An Examination of General Surgery Residency Programs with a Rural Track.

BACKGROUND: There is a steady decline in the general surgery workforce in rural areas of the United States. In response, some surgery residency programs have developed rural tracks to encourage rural practice and adequately prepare trainees for this setting. OBJECTIVE: To compare the practice type and location of graduates from general surgery residency programs with and without a dedicated rural track between 2011-2020. METHODS: General surgery residency programs with and without a rural track were identified using the American Medical Association Residency and Fellowship Electronic Interactive Database and the Rural Surgery Program list from the American College of Surgeons. Graduates of these programs who entered general surgery practice between 2011-2020 were subsequently identified from individual residency program websites and tracked to their current practice setting using a Google search of first and last name and residency affiliation. Practice location was identified by zip code or county name and coded by Rural-Urban Continuum Codes (RUCC, Economic Research Service, USDA). RESULTS: We identified 2,582 general surgery residency graduates from 2011 to 2020 across 66 residency programs. Of these graduates from programs without a rural track, 23.6% entered general surgery practice without additional fellowship training, compared to 34.0% from residency programs with a rural track (p = 0.019). Community or University-based program designation was not associated with decision to enter general surgery practice over fellowship training (p = 0.420). Proportion of graduates entering rural practice as defined by RUCC groups 7-9 was not associated with having a rural program track or with community or university-based program status. CONCLUSION: Residency programs with a rural track produce a higher proportion of graduates entering general surgery compared to fellowship, though they are no more likely than programs without a rural track to produce graduates who ultimately practice in rural areas.

A Cross-Sectional Analysis of High-Acuity Professional Services Performed by Urban and Rural Emergency Care Physicians Across the United States.

STUDY OBJECTIVE: We seek to examine differences in the provision of high-acuity professional services between rural and urban physicians receiving reimbursement for emergency care evaluation and management services from Medicare fee-for-service Part B. METHODS: Using the 2017 Medicare Public Use Files, we performed a cross-sectional analysis and defined the primary outcome, the proportion of high-acuity charts (PHAC), at the physician level as the proportion of services provided as 99285 and 99291 emergency care evaluation and management service codes relative to all such codes. After accounting for unique clinician-level characteristics, we categorized individual physicians by PHAC quintiles and conducted ordered logistic regression analyses reporting adjusted marginal probabilities to examine associations with rurality. RESULTS: A total of 34,256 physicians providing emergency care had a median PHAC of 66.8% (interquartile range 55.6% to 75.7%), with 89.2% practicing in an urban setting. Urban and rural physicians had respective median PHACs of 67.6% (interquartile range 57.1% to 76.2%) and 57.9% (interquartile range 42.7% to 69.4%). Urban and rural physicians had respective adjusted marginal probabilities of 15.2% and 11.8% of being in the highest PHAC quintile, and respective adjusted marginal probabilities of 14.3% and 18.2% of being in the lowest PHAC quintile. CONCLUSION: In comparison with rural physicians, urban physicians providing emergency care received reimbursements for a greater PHAC when caring for Medicare fee-for-service beneficiaries. Policymakers must consider these differences in the design and implementation of new emergency care payment policies.

Unscheduled Care Access in the United States-A Tale of Two Emergency Departments.

BACKGROUND: Rural communities face challenges in accessing healthcare services due to physician shortages and limited unscheduled care capabilities in office settings. As a result, rural hospital-based Emergency Departments (ED) may disproportionately provide acute, unscheduled care needs. We sought to examine differences in ED utilization and the relative role of the ED in providing access to unscheduled care between rural and urban communities. METHODS: Using a 20% sample of the 2012 Medicare Chronic Condition Warehouse, we studied the overall ED visit rate and the unscheduled care rate by geography using the Dartmouth Atlas' hospital referral regions (HRR). We calculated HRR urbanicity as the proportion of beneficiaries residing in an urban zip code within each HRR. We report descriptive statistics and utilize K-means clustering based on the ED visit rates and unscheduled care rates. RESULTS: We found rural ED use is more common and disproportionately the site of unscheduled care delivery when compared to urban communities. The ED visit and. unscheduled care proportions were negatively correlated with increased urbanicity (r =. -0.48, p < 0.001; r = -0.58, p < 0.001). CONCLUSION: The use and role of EDs by Medicare beneficiaries appears to be substantially different between urban and rural areas. This suggests that the ED may play a distinct role within the healthcare delivery system of rural communities that face disproportionate barriers to care access.

Are Rural and Urban Emergency Departments Equally Prepared to Reduce Avoidable Hospitalizations?

INTRODUCTION: Attempts to reduce low-value hospital care often focus on emergency department (ED) hospitalizations. We compared rural and urban EDs in Michigan on resources designed to reduce avoidable admissions. METHODS: A cross-sectional, web-based survey was emailed to medical directors and/or nurse managers of the 135 hospital-based EDs in Michigan. Questions included presence of clinical pathways, services to reduce admissions, and barriers to connecting patients to outpatient services. We performed chi-squared comparisons, regression modeling, and predictive margins. RESULTS: Of 135 EDs, 64 (47%) responded with 33 in urban and 31 in rural counties. Clinical pathways were equally present in urban and rural EDs (67% vs 74%, p=0.5). Compared with urban EDs, rural EDs reported greater access to extended care facilities (21% vs 52%, p=0.02) but less access to observation units (52% vs 35%, p=0.04). Common barriers to connecting ED patients to outpatient services exist in both settings, including lack of social support (88% and 76%, p=0.20), and patient/family preference (68% and 68%, p=1.0). However, rural EDs were more likely to report time required for care coordination (88% vs 66%, p=0.05) and less likely to report limitations to home care (21% vs 48%, p=0.05) as barriers. In regression modeling, ED volume was predictive of the presence of clinical pathways rather than rurality. CONCLUSION: While rural-urban differences in resources and barriers exist, ED size rather than rurality may be a more important indicator of ability to reduce avoidable hospitalizations.

Trends in Emergency Department Use by Rural and Urban Populations in the United States.

Importance: Patterns in emergency department (ED) use by rural populations may be an important indicator of the health care needs of individuals in the rural United States and may critically affect rural hospital finances. Objective: To describe urban and rural differences in ED use over a 12-year period by demographic characteristics, payers, and characteristics of care, including trends in ambulatory care-sensitive conditions and ED safety-net status. Design, Setting, and Participants: This cross-sectional study of ED visit data from the nationally representative National Hospital Ambulatory Medical Care Survey examined ED visit rates from January 2005 to December 2016. Visits were divided by urban and rural classification and stratified by age, sex, race/ethnicity, and payer. Emergency departments were categorized as urban or rural in accordance with the US Office of Management and Budget classification. Codes from the International Classification of Diseases, Ninth Revision (ICD-9), were used to extract visits related to ambulatory care-sensitive conditions. Safety-net status was determined by the Centers for Disease Control and Prevention definition. Visit rates were calculated using annual US Census Bureau estimates. National Hospital Ambulatory Medical Care Survey estimates were generated using provided survey weights and served as the numerator, yielding an annual, population-adjusted rate. Data were analyzed from June 2017 to November 2018. Main Outcomes and Measures: Emergency department visit rates for 2005 and 2016 with 95% confidence intervals, accompanying rate differences (RDs) comparing the 2 years, and annual rate change (RC) with accompanying trend tests using weighted linear regression models. Results: During the period examined, rural ED visit estimates increased from 16.7 million to 28.4 million, and urban visits increased from 98.6 million to 117.2 million. Rural ED visits increased for non-Hispanic white patients (13.5 million to 22.5 million), Medicaid beneficiaries (4.4 million to 9.7 million), those aged 18 to 64 years (9.6 million to 16.7 million), and patients without insurance (2.7 million to 3.4 million). Rural ED visit rates increased by more than 50%, from 36.5 to 64.5 visits per 100 persons (RD, 28.9; RC, 2.2; 95% CI, 1.2 to 3.3), outpacing urban ED visit rates, which increased from 40.2 to 42.8 visits per 100 persons (RD, 2.6; RC, 0.2; 95% CI, -0.1 to 0.6). By 2016, nearly one-fifth of all ED visits occurred in the rural setting. From 2005 to 2016, rural ED utilization rates increased for non-Hispanic white patients (RD, 26.1; RC, 1.6; 95% CI, 0.4 to 2.8), Medicaid beneficiaries (RD, 56.4; RC, 4.1; 95% CI, 2.1 to 6.1), those aged 18 to 44 years (46.9 to 81.6 visits per 100 persons; RD, 34.7; RC, 2.3; 95% CI, 1.1 to 3.5) as well as those aged 45 to 64 years (27.5 to 53.9 visits per 100 persons; RD, 26.5; RC, 1.6; 95% CI, 0.7 to 2.5), and patients without insurance (44.0 to 66.6 visits per 100 persons per year; RD, 22.6; RC, 2.7; 95% CI, 0.2 to 5.2), with a larger proportion of rural EDs categorized as safety-net status. Conclusions and Relevance: Rural EDs are experiencing important changes in utilization rates, increasingly serving a larger proportion of traditionally disadvantaged groups and with greater pressure as safety-net hospitals.

Urban and Rural Emergency Department Performance on National Quality Metrics for Sepsis Care in the United States.

PURPOSE: The Centers for Medicare and Medicaid Services (CMS) and the American College of Emergency Physicians (ACEP) developed national quality measures for emergency department (ED) sepsis care. Like care for many conditions, meeting sepsis quality metrics can vary between settings. We sought to examine and compare sepsis care quality in rural vs urban hospital-based EDs. METHODS: We analyzed data from EDs participating in the national Emergency Quality Network (E-QUAL). We collected preliminary performance data on both the CMS measure (SEP-1) and the ACEP measures via manual chart review. We analyzed SEP-1 data at the hospital level based on existing CMS definitions and analyzed ACEP measure data at the patient level. We report descriptive statistics of performance variation in rural and urban EDs. FINDINGS: Rural EDs comprised 58 of the EDs reporting SEP-1 results and 405 rural patient charts in the manual review. Of sites reporting SEP-1 results, 44% were rural and demonstrated better aggregate SEP-1 bundle adherence than urban EDs (79% vs 71%; P = .049). Both urban and rural hospitals reported high levels of compliance with the ACEP recommended initial actions of obtaining lactate and blood cultures, with urban EDs outperforming rural EDs on metrics of IV fluid administration and antibiotics (74% urban vs 60% rural; P ≤  .001; 91% urban vs 84% rural; P ≤  .001, respectively). CONCLUSIONS: Sepsis care at both rural and urban EDs often achieves success with national metrics. However, performance on individual components of ED sepsis care demonstrates opportunities for improved processes of care at rural EDs.

An Emergency Medicine-Primary Care Partnership to Improve Rural Population Health: Expanding the Role of Emergency Medicine.

The health of rural America is failing and our traditional approaches have proved ineffective at improving health in rural communities. Rural populations are now a health disparity population, facing higher mortality rates for the 5 leading causes of death compared with their urban counterparts. We must generate novel, rural-specific approaches to solve this challenge-and there is a clear role for the field of emergency medicine. Building on emergency departments' (EDs') expanding role in health care delivery and emergency medicine's increasing involvement in population health, we propose a new health care delivery model for rural population health based on partnership between emergency medicine and primary care that embraces the important role that EDs play in rural areas.

Trends in Hospital Admission and Surgical Procedures Following ED visits for Diverticulitis.

INTRODUCTION: Diverticulitis is a common diagnosis in the emergency department (ED). Outpatient management of diverticulitis is safe in selected patients, yet the rates of admission and surgical procedures following ED visits for diverticulitis are unknown, as are the predictive patient characteristics. Our goal is to describe trends in admission and surgical procedures following ED visits for diverticulitis, and to determine which patient characteristics predict admission. METHODS: : We performed a cross-sectional descriptive analysis using data on ED visits from 2006-2011 to determine change in admission and surgical patterns over time. The Nationwide Emergency Department Sample database, a nationally representative administrative claims dataset, was used to analyze ED visits for diverticulitis. We included patients with a principal diagnosis of diverticulitis (ICD-9 codes 562.11, 562.13). We analyzed the rate of admission and surgery in all admitted patients and in low-risk patients, defined as age <50 with no comorbidities (Elixhauser). We used hierarchical multivariate logistic regression to identify patient characteristics associated with admission for diverticulitis. RESULTS: Fryom 2006 to 2011 ED visits for diverticulitis increased by 21.3% from 238,248 to 302,612, while the admission rate decreased from 55.7% to 48.5% (-7.2%, 95% CI [-7.78 to -6.62]; p<0.001 for trend). The admission rate among low-risk patients decreased from 35.2% in 2006 to 26.8% in 2011 (-8.4%, 95% CI [-9.6 to -7.2]; p<0.001 for trend). Admission for diverticulitis was independently associated with male gender, comorbid illnesses, higher income and commercial health insurance. The surgical rate decreased from 6.5% in 2006 to 4.7% in 2011 (-1.8%, 95% CI [-2.1 to -1.5]; p<0.001 for trend), and among low-risk patients decreased from 4.0% to 2.2% (-1.8%, 95% CI [-4.5 to -1.7]; p<0.001 for trend). CONCLUSION: From 2006 to 2011 ED visits for diverticulitis increased, while ED admission rates and surgical rates declined, with comorbidity, sociodemographic factors predicting hospitalization. Future work should focus on determining if these differences reflect increased disease prevalence, increased diagnosis, or changes in management.

Usability of the Massachusetts Prescription Drug Monitoring Program in the Emergency Department: A Mixed-methods Study.

OBJECTIVES: Prescription drug monitoring programs (PDMPs) are underutilized, despite evidence showing that they may reduce the epidemic of opioid-related addiction, diversion, and overdose. We evaluated the usability of the Massachusetts (MA) PDMP by emergency medicine providers (EPs), as a system's usability may affect how often it is used. METHODS: This was a mixed-methods study of 17 EPs. We compared the time and number of clicks required to review one patient's record in the PDMP to three other commonly performed computer-based tasks in the emergency department (ED: ordering a computed tomography [CT] scan, writing a prescription, and searching a medication history service integrated within the electronic medical record [EMR]). We performed semistructured interviews and analyzed participant comments and responses regarding their experience using the MA PDMP. RESULTS: The PDMP task took a longer time to complete (mean = 4.22 minutes) and greater number of mouse clicks to complete (mean = 50.3 clicks) than the three other tasks (CT-pulmonary embolism = 1.42 minutes, 24.8 clicks; prescription = 1.30 minutes, 19.5 clicks; SureScripts = 1.45 minutes, 9.5 clicks). Qualitative analysis yielded four main themes about PDMP usability, three negative and one positive: 1) difficulty accessing the PDMP, 2) cumbersome acquiring patient medication history information within the PDMP, 3) nonintuitive display of patient medication history information within the PDMP, and 4) overall perceived value of the PDMP despite an inefficient interface. CONCLUSIONS: The complicated processes of gaining access to, logging in, and using the MA PDMP are barriers to preventing its more frequent use. All states should evaluate the PDMP usability in multiple practice settings including the ED and work to improve provider enrollment, login procedures, patient information input, prescription data display, and ultimately, PDMP data integration into EMRs.

Best Practices for Prescription Drug Monitoring Programs in the Emergency Department Setting: Results of an Expert Panel.

Prescription drug monitoring programs are generally underused in emergency departments (ED) and nationwide enrollment is low among emergency physicians. We aimed to develop consensus recommendations for prescription drug monitoring program policy and design to optimize their functionality and use in the ED. We assembled a technical expert panel with key stakeholders in emergency medicine, public health, and public policy. The panel included academic and community-based emergency physicians, a pediatric fellowship-trained emergency physician, a medical toxicologist, a public health expert, a patient advocate, a legal expert, and two state prescription drug monitoring program administrators. We compiled prescription drug monitoring program policies and characteristics and organized them into domains based on user-prescription drug monitoring program interaction. The panel convened for 3 rounds in which the policies and characteristics were introduced, discussed, and modified in an iterative fashion to achieve consensus. The process yielded policy recommendations and design features, with majority agreement. The panel made 18 policy recommendations within these main themes: enrollment should be mandatory, with an automatic process to mitigate the workload; registration should be open to all prescribers; delegates should have access to prescription drug monitoring program to alleviate work flow burdens; prescription drug monitoring program data should be pushed into hospital electronic health records; prescription drug monitoring program review should be mandatory for patients receiving opioid prescriptions and based on objective criteria; the prescription drug monitoring program content should be standardized and updated in a timely manner; and states should encourage interstate data sharing. An expert panel identified 18 recommendations that can be used by states and policymakers to improve prescription drug monitoring program design to increase use in the ED setting.

Development, implementation, and effects of community-based diabetes prevention program for obese latino youth.

OBJECTIVE: Obesity and type 2 diabetes have emerged as critical health issues among Latino youth. Although both conditions manifest early in life, very few diabetes prevention programs have been developed to specifically meet the needs of this population. The authors describe the development, implementation, and metabolic impact of a culturally informed, community-based diabetes prevention program for obese Latino youth. METHODS: A lifestyle education program was developed to address the health needs of Latino youth served by a community-based medical clinic. The program consisted of group education sessions delivered to children and their families to address nutrition, physical activity, family roles and responsibilities, and self-esteem. The metabolic impact of the program was evaluated by assessing body mass index (BMI), high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, total cholesterol, triglycerides, glucose, and insulin. RESULTS: On entry, the prevalence of risk factors among the 102 youth (mean BMI, 30.4 ± 4.9 kg/m(2)) was substantial (68.6% with low HDL cholesterol, 32.1% with elevated triglycerides, 9.4% with impaired fasting glucose, 39.4% with elevated total cholesterol, 43.0% with elevated LDL cholesterol, and 60.6% with hyperinsulinemia). The 50 youth who returned after the program for follow-up measurements exhibited significant health improvements, including a 3.8% reduction in BMI; 5.4% and 8.6% decreases in total and LDL cholesterol, respectively; a 9.3% increase in HDL cholesterol; and a 24.0% decrease in fasting insulin (all P values < .05). CONCLUSIONS: These promising findings suggest that a community-based diabetes prevention program for obese Latino youth is a feasible strategy for improving health in this high-risk population. Further studies are warranted to examine whether similar programs can be implemented in diverse communities and settings.

Sustainability of a culturally informed community-based diabetes prevention program for obese latino youth.

Latino youth are disproportionately impacted by obesity and type 2 diabetes; however, few lifestyle interventions have targeted this population. Therefore, the purpose of this study was to assess the impact of a culturally informed lifestyle education program on nutrition and physical activity behaviors among obese Latino youth. A retrospective chart review of 67 youths was conducted with self-reported nutrition and physical activity assessed both immediately following the program and after long-term follow-up. Body mass index (BMI) was evaluated to determine the impact of behavior changes on adiposity. Healthy nutrition and physical activity changes were reported by 20%-59% of youths immediately following the program. However, most of these changes were attenuated over the 261 ± 49 day follow-up with reported walking (25.4%) and sports participation (34.3%) sustained to a greater extent than dietary changes (3.4-14.9%). Nonetheless, children who continued walking at follow-up exhibited significantly larger reductions in BMI compared with those who did not (-1.63 ± 0.56 vs. 0.44 ± 0.30 kg/m(2), P < .05). Based on our pilot study, we conclude that community-based lifestyle education programs can support behavior modification and weight management in obese Latino youth. Ongoing support may be necessary to encourage sustained behavior change to facilitate greater weight loss.