Routes to Rural Readiness: Enhancing Clinical Training Experiences for Physician Assistants.

PURPOSE: The purpose of this study was to describe practices and experiences of rurally oriented physician assistant (PA) training programs in providing rural clinical training to PA students. METHODS: A survey of PA program directors (PDs) included questions about program characteristics, student and clinical preceptor (CP) recruitment in rural areas, and barriers to, and facilitators of, rural clinical training. Programs that considered rural training "very important" to their goals were identified. We interviewed PDs from rurally oriented programs about their rural clinical training and rural CPs about their experiences training PA students for rural practice. We identified key themes through content analysis. RESULTS: Of 178 programs surveyed, 113 (63.5%) responded, 61 (54.0%) of which were rurally oriented and more likely than other programs to recruit rural students or those with rural practice interests and to address rural issues in didactic curriculum. The 13 PDs interviewed linked successful rural training to finding and supporting rural preceptors who enjoy teaching and helping students understand rural communities. The 13 rural CPs identified enthusiastic and rurally interested students as key elements to successful rural training. Interviewees identified systemic barriers to rural training, including student housing, decreased productivity, competition for training slots, and administrative burden. CONCLUSIONS: Physician assistant students can be coached to capitalize on their rural clinical experiences. Knowing how to "jump in" to rotations and having genuine interest in the community are particularly important. Student housing, competition for training slots, and lack of financial incentives are major system-level challenges for sustaining and increasing the availability of PA rural clinical training.

Pipelines to Pathways: Medical School Commitment to Producing a Rural Workforce.

PURPOSE: Despite the efforts of numerous medical schools to produce rural physicians, many rural communities in the United States still experience physician shortages. This study describes the current landscape of rural efforts in US undergraduate medical education and catalogs medical school characteristics and activities that evidence has suggested, and that many experts in rural medical education believe, may result in more graduates choosing rural practice. METHODS: This is a descriptive study of publicly available and rurally relevant characteristics of all 182 allopathic and osteopathic medical schools operating in the 50 states and the District of Columbia in 2016, with rural program information for these schools updated in 2019. The authors constructed a "rural program" definition in order to systematically catalog coordinated and strategic medical school efforts to produce a rural physician workforce. FINDINGS: Few (8.2%) medical schools expressed an explicit commitment to producing rural physicians in public mission statements. However, most (64.8%) provided rural clinical experiences and many demonstrated their commitment in other ways. Only 39 (21.4%) did so through a formal rural program. CONCLUSIONS: In establishing an explicit rural program definition and documenting other markers of rural commitment, this paper provides a baseline for future studies of rural workforce production and medical school investment in these programs, activities, and personnel. Demonstrating the effectiveness of schools' rural physician education efforts will require collaboration across institutions and more intensive evaluations of programs involving students who, though relatively few in number, have great potential for contributing to the health of rural communities across the nation.

Comparing the Health Workforce Provider Mix and the Distance Travelled for Mental Health Services by Rural and Urban Medicare Beneficiaries.

PURPOSE: To describe the mix of health professionals who care for rural and urban seniors suffering from mood and/or anxiety disorders, the quantity of services they receive, and to understand where beneficiaries receive care for mood and/or anxiety disorders and the distance and time they travel for care. METHODS: We used 2014 Medicare administrative claims data to examine access to health care for fee-for-service Medicare beneficiaries aged ≥ 65 years who received outpatient services for mood and anxiety disorders. We classified providers into 9 categories: (1) family physicians/general practice, (2) internists, (3) nurse practitioners (NPs) and physician assistants (PAs), (4) psychiatrists, (5) psychologists, (6) clinical social workers, (7) emergency medicine physicians, (8) other physicians, and (9) other providers. We calculated the 1-way driving distance and travel time between the beneficiary residence and provider location. We classified beneficiaries into 1 of 4 geographic categories based on their residence ZIP Code. FINDINGS: Urban beneficiaries had an average of 2.7 visits for mood and anxiety disorders, while rural beneficiaries had 2.4. Generalist physicians and NPs/PAs provided 50.8% of all visits. Urban beneficiaries saw more behavioral health specialists (34.3%) than rural beneficiaries (16.1%). NPs and PAs provided more than twice as much of the care for rural beneficiaries (14.8%) as for urban beneficiaries (6.4%). Rural beneficiaries travelled about twice as far as urban beneficiaries. CONCLUSIONS: Rural and urban Medicare beneficiaries received care for mood/anxiety disorders from different mixes of health care providers, and ensuring access for rural populations will require innovative solutions.

Projected Contributions of Nurse Practitioners and Physicians Assistant to Buprenorphine Treatment Services for Opioid Use Disorder in Rural Areas.

The United States is experiencing an opioid use disorder epidemic. The Comprehensive Addiction and Recovery Act allows nurse practitioners (NPs) and physician assistants (PAs) to obtain a Drug Enforcement Administration waiver to prescribe medication-assisted treatment (MAT) for opioid use disorder. This study projected the potential increase in MAT availability provided by NPs and PAs for rural patients. Using workforce and survey data, and state scope of practice regulations, the number of treatment slots that could be provided by NPs and PAs was estimated for rural areas. NPs and PAs are projected to increase the number of rural patients treated with buprenorphine by 10,777 (15.2%). Census Divisions varied substantially in the number of projected new treatment slots per 10,000 population (0.8-10.6). The New England and East South Central Census Divisions are projected to have the largest population-adjusted increase. NPs and PAs have considerable potential to reduce substantial MAT access disparities.

Characteristics of Physician Assistant Students Planning to Work in Primary Care: A National Study.

PURPOSE: While the number of physician assistants (PAs) participating in the primary care workforce continues to rise, the proportion of PAs practicing in primary care rather than other specialties has decreased. The purpose of this study was to identify the characteristics of matriculating PA students planning to enter primary care specialties and compare them with students planning on entering other specialties. METHODS: Data from the Physician Assistant Education Association Matriculating Student Survey (MSS) from 2013 and 2014 were analyzed. In a series of bivariate analyses, demographic characteristics, educational backgrounds, clinical experiences, and practice expectations of students intending to enter primary care practice were compared with those of their counterparts who did not intend to enter primary care. Logistic regression was used to assess the overall importance of demographic, background, and practice expectations variables on practice intentions. RESULTS: A total of 9283 students responded to the MSS from 2013 and 2014. More than half (58.3%) stated an intention to practice in primary care upon graduation. Those students were more likely than their counterparts to be married, to be Hispanic or Asian, and to have participated in community service prior to starting PA training. They were also less likely to view high income as essential to their careers and more likely to view practicing in rural or underserved areas favorably. CONCLUSIONS: The findings of this study could be used to identify student characteristics associated with an interest in primary care and could contribute to more successful student recruitment and PA curriculum design, especially for PA training programs with a mission focused on producing primary care PAs.

Geographic Distribution of Providers With a DEA Waiver to Prescribe Buprenorphine for the Treatment of Opioid Use Disorder: A 5-Year Update.

PURPOSE: Opioid use disorder (OUD) is a substantial public health problem. Buprenorphine is an effective medication-assisted treatment (MAT) for OUD, but access is difficult for patients, especially in rural locations. To improve access, the Comprehensive Addiction and Recovery Act of 2016 extended the ability to get a Drug Enforcement Administration (DEA) waiver to prescribe buprenorphine to treat OUD to nurse practitioners (NPs) and physician assistants (PAs). This study summarizes the geographic distribution of waivered physicians, NPs, and PAs at the end of 2017 and compares it to the distribution of waivered physicians 5 years earlier. METHODS: Using the DEA list of providers with a waiver to prescribe buprenorphine to treat OUD and the Area Health Resources File, we assigned waivered providers to counties in 1 of 4 geographic categories. We calculated the number of counties in each category that did not have a waivered provider and county provider to population ratios and then compared our results to the waivered workforce in 2012. FINDINGS: The availability of a physician with a DEA waiver to provide office-based MAT has increased across all geographic categories since 2012. More than half of all rural counties (56.3%) still lack a provider, down from 67.1% in 2012. Almost one-third (29.8%) of rural Americans compared to 2.2% of urban Americans live in a county without a buprenorphine provider. NPs and PAs add otherwise lacking treatment availability in 56 counties (43 rural). CONCLUSIONS: Overall, MAT access has improved, but rural communities still experience treatment disparities.

Service provision and quality outcomes in home health for rural Medicare beneficiaries at high risk for unplanned care.

Multiple barriers exist to providing home health care in rural areas. This study examined relationships between service provision and quality outcomes among rural, fee-for-service Medicare beneficiaries who received home health care between 2011 and 2013 for conditions associated with high-risk for unplanned care. More skilled nursing visits, visits by more types of providers, more timely care, and shorter lengths of stay were associated with significantly higher odds of hospital readmission and emergency department use and significantly lower odds of community discharge. Results may indicate unmeasured clinical severity and care needs among this population. Additional research regarding the accuracy of current severity measures and adequacy of case-mix adjustment for quality metrics is warranted, especially given the continued focus on value-based payment policies.

Geographic Variation in the Supply of Selected Behavioral Health Providers.

INTRODUCTION: In 2015, an estimated 43.4 million Americans aged 18 and older suffered from a behavioral health issue. Accurate estimates of the number of psychiatrists, psychologists, and psychiatric nurse practitioners are needed as demand for behavioral health care grows. METHODS: The National Plan and Provider Enumeration System National Provider Identifier data (October 2015) was used to examine the supply of psychiatrists, psychologists, and psychiatric nurse practitioners. Providers were classified into three geographic categories based on their practicing county (metropolitan, micropolitan, and non-core). Claritas 2014 U.S. population data were used to calculate provider-to-population ratios for each provider type. Analysis was completed in 2016. RESULTS: Substantial variation exists across Census Divisions in the per capita supply of psychiatrists, psychologists, and psychiatric nurse practitioners. The New England Census Division had the highest per capita supply and the West South Central Census Division had among the lowest supply of all three provider types. Nationally, the per capita supply of these providers was substantially lower in non-metropolitan counties than in metropolitan counties, but Census Division disparities persisted across geographic categories. There was a more than tenfold difference in the percentage of counties lacking a psychiatrist between the New England Census Division (6%) and the West North Central Census Division (69%). Higher percentages of non-metropolitan counties lacked a psychiatrist. CONCLUSIONS: Psychiatrists, psychologists, and psychiatric nurse practitioners are unequally distributed throughout the U.S. Disparities exist across Census Divisions and geographic categories. Understanding this unequal distribution is necessary for developing approaches to improving access to behavioral health services for underserved populations. SUPPLEMENT INFORMATION: This article is part of a supplement entitled The Behavioral Health Workforce: Planning, Practice, and Preparation, which is sponsored by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration of the U.S. Department of Health and Human Services.

The Use of Simulation in Physician Assistant Programs: A National Survey.

PURPOSE: The purpose of this study was to develop a national-level description of the current use of simulation activities in physician assistant (PA) education and to assess the degree to which the use of simulation varies by PA program size and institutional type. METHODS: An electronic survey on medical simulation was sent to 177 PA program directors or to a designated simulation activities coordinator, using the directory on the Physician Assistant Education Association website. The survey addressed program characteristics, types of simulation modalities in use, and frequency of use of those modalities in PA training. The specific content areas addressed were error disclosure, medical knowledge, patient care, and psychomotor skills. RESULTS: The survey was emailed 3 times from early April to mid-May 2014, with a follow-up call to nonrespondents in August 2014. Of the 177 PA programs contacted, 63 completed the survey, for a response rate of 35.6%. Results indicate widespread use of simulation by survey respondents, especially in teaching, assessment of medical knowledge, and clinical skills, with somewhat lower levels of use in content areas such as error disclosure, delivery of bad news, and team training. CONCLUSIONS: Although barriers exist to its use in training health care professionals, simulation has become an important tool for training PAs in a variety of medical and interpersonal skills. It is also clear that simulation is an important tool for conducting interprofessional training. More research is needed to identify optimal approaches to the use of simulation in health care professions training.

Barriers Rural Physicians Face Prescribing Buprenorphine for Opioid Use Disorder.

Opioid use disorder is a serious public health problem. Management with buprenorphine is an effective, office-based, medication-assisted treatment, but 60.1% of rural counties in the United States lack a physician with a Drug Enforcement Agency waiver to prescribe buprenorphine. This national study surveyed all rural physicians who have received a waiver in the United States and found that those who were not actively prescribing buprenorphine reported significantly more barriers than those who were, regardless of whether they were treating the maximum number of patients their waiver allowed. These findings suggest the need for tailored strategies to address barriers to providing buprenorphine for opioid use disorder and to support physicians who are adding or maintaining this service.

What Is the Potential of Community Paramedicine to Fill Rural Health Care Gaps?

Community paramedicine (CP) uses emergency medical services (EMS) providers to help rural communities increase access to primary care and public health services. This study examined goals, activities, and outcomes of 31 rural-serving CP programs through structured interviews of program leaders and document review. Common goals included managing chronic disease (90.3%); and reducing emergency department visits (83.9%), hospital admissions/readmissions (83.9%), and costs (83.9%). Target populations included the chronically ill (90.3%), post-hospital discharge patients (80.6%), and frequent EMS users (64.5%). Community paramedicine programs engaged in bi-directional referrals most often with primary care facilities (67.7%), hospitals (54.8%), and home health (38.7%). Programs provided assessment, testing, preventive care, and post-discharge services. Reported outcomes were promising, but few programs used rigorous evaluation methods. Rural-serving CP programs provided services to shift costs to less expensive settings and provide appropriate care where vulnerable patients live, but more evidence is needed that care is safe, effective, and economical.

Geographic and specialty distribution of US physicians trained to treat opioid use disorder.

PURPOSE: The United States is experiencing an epidemic of opioid-related deaths driven by excessive prescribing of opioids, misuse of prescription drugs, and increased use of heroin. Buprenorphine-naloxone is an effective treatment for opioid use disorder and can be provided in office-based settings, but this treatment is unavailable to many patients who could benefit. We sought to describe the geographic distribution and specialties of physicians obtaining waivers from the Drug Enforcement Administration (DEA) to prescribe buprenorphine-naloxone to treat opioid use disorder and to identify potential shortages of physicians. METHODS: We linked physicians authorized to prescribe buprenorphine on the July 2012 DEA Drug Addiction Treatment Act (DATA) Waived Physician List to the American Medical Association Physician Masterfile to determine their age, specialty, rural-urban status, and location. We then mapped the location of these physicians and determined their supply for all US counties. RESULTS: Sixteen percent of psychiatrists had received a DEA DATA waiver (41.6% of all physicians with waivers) but practiced primarily in urban areas. Only 3.0% of primary care physicians, the largest group of physicians in rural America, had received waivers. Most US counties therefore had no physicians who had obtained waivers to prescribe buprenorphine-naloxone, resulting in more than 30 million persons who were living in counties without access to buprenorphine treatment. CONCLUSIONS: In the United States opioid use and related unintentional lethal overdoses continue to rise, particularly in rural areas. Increasing access to office-based treatment of opioid use disorder--particularly in rural America--is a promising strategy to address rising rates of opioid use disorder and unintentional lethal overdoses.

Physician assistants in orthopedic practice. A national study.

UNLABELLED: Orthopedics is the third most common specialty practiced by physician assistants (PAs), but little is known at a national level about PAs backgrounds or specific contributions to orthopedic practices. We sought to describe, from a nationally representative sample, the demographic and practice characteristics of PAs working in orthopedics. METHODS: Surveys were sent to 1,200 PAs, identified from American Academy of Physician Assistants data, who reported orthopedics as their specialty between 2005 and 2007. Information was collected on demographic and educational background, PA training, current practice characteristics, clinical activities, and physician supervision. RESULTS: After three mailings, the adjusted response rate was 55.8%. Of respondents, 45% reported working in general orthopedics, and the remainder in orthopedic specialties. A majority (76.5%) completed a 4- to 8-week rotation in orthopedic surgery during PA school, but most did not complete any advanced postgraduate orthopedic training. Orthopedic group practices were the most commonly reported employer type (57.6% of respondents). Respondents performed an average of 59 outpatient visits per week and 16 inpatient visits per week. A large proportion (87.6%) participated in surgery on a regular basis, most often working as first assistants. Many orthopedic generalists and specialists performed a broad range of clinical activities, including ones suggestive of general, rather than close and direct, physician supervision such as closing surgical incisions independently and taking first call. CONCLUSIONS: PAs contribute to orthopedic care in many inpatient and outpatient settings and perform a wide variety of clinical tasks, often with only general supervision and little or no formal postgraduate training. Health workforce planning and the development of appropriate training models for PAs in orthopedics and other medical and surgical specialties require understanding the content of PA specialty practice.

Workforce issues in rural surgery.

Almost one quarter of America's population and one third of its landmass are defined as rural and served by approximately 20% of the nation's general surgeons. General surgeons are the backbone of the rural health workforce. There is significant maldistribution of general surgeons across regions and different types of rural areas. Rural areas have markedly fewer surgeons per population than the national average. The demography of the rural general surgery workforce differs substantially from the urban general surgery workforce, raising concerns about the extent to which general surgical services can be maintained in rural areas of the United States.

Trends in perinatal and infant health disparities between rural American Indians and Alaska natives and rural Whites.

OBJECTIVES: We examined disparities in perinatal care, birth outcomes, and infant health between rural American Indian and Alaska Native (AIAN) persons and rural Whites over time. METHODS: We compared perinatal and infant health measures for 217 064 rural AIAN births and 5 032 533 rural non-Hispanic White births. RESULTS: Among American Indians and Alaska Natives, unadjusted rates of inadequate prenatal care (1985-1987, 36.3%; 1995-1997, 26.3%) and postneonatal death (1985-1987, 7.1 per 1000; 1995-1997, 4.8 per 1000) improved significantly. However, disparities between American Indians and Alaska Natives and Whites in adjusted odds ratios (AORs) of postneonatal death (1985-1987, AOR = 1.55; 95% confidence interval [CI] = 1.41, 1.71; 1995-1997, AOR = 1.46; 95% CI = 1.31, 1.64) and adjusted risk ratios (ARRs) of inadequate prenatal care (1985-1987, ARR = 1.67; 95% CI = 1.65, 1.69; 1995-1997, ARR = 1.84; 95% CI = 1.81, 1.87) persisted. CONCLUSIONS: Despite significant decreases in inadequate prenatal care and postneonatal death among American Indians and Alaska Natives, additional measures are needed to close persistent health gaps for this group.

Access to cancer services for rural colorectal cancer patients.

CONTEXT: Cancer care requires specialty surgical and medical resources that are less likely to be found in rural areas. PURPOSE: To examine the travel patterns and distances of rural and urban colorectal cancer (CRC) patients to 3 types of specialty cancer care services--surgery, medical oncology consultation, and radiation oncology consultation. METHODS: Descriptive cross-sectional study using linked Surveillance, Epidemiology, and End Results (SEER) cancer registry and Medicare claims data for 27,143 individuals ages 66 and older diagnosed with stages I through III CRC between 1992 and 1996. FINDINGS: Over 90% of rural CRC patients lived within 30 miles of a surgical hospital offering CRC surgery, but less than 50% of CRC patients living in small and isolated small rural areas had a medical or radiation oncologist within 30 miles. Rural CRC patients who traveled outside their geographic areas for their cancer care often went great distances. The median distance traveled by rural cancer patients who traveled to urban cancer care providers was 47.8 miles or more. A substantial proportion (between 19.4% and 26.0%) of all rural patients bypassed their closest medical and radiation oncology services by at least 30 miles. CONCLUSIONS: Rural CRC patients often travel long distances for their CRC care, with potential associated burdens of time, cost, and discomfort. Better understanding of whether this travel investment is paid off in improved quality of care would help rural cancer patients, most of whom are elderly, make informed decisions about how to use their resources during their cancer treatment.

Access to specialty health care for rural American Indians in two states.

CONTEXT: The Indian Health Service (IHS), whose per capita expenditure for American Indian and Alaska Native (AI/AN) health services is about half that of the US civilian population, is the only source of health care funding for many rural AI/ANs. Specialty services, largely funded through contracts with outside practitioners, may be limited by low IHS funding levels. PURPOSE: To examine specialty service access among rural Indian populations in two states. METHODS: A 31-item mail survey addressing perceived access to specialty physicians, barriers to access, and access to non-physician clinical services was sent to 106 primary care providers in rural Indian health clinics in Montana and New Mexico (overall response rate 60.4%) and 95 primary care providers in rural non-Indian clinics within 25 miles of the Indian clinics (overall response rate 57.9%). FINDINGS: Substantial proportions of rural Indian clinic providers in both states reported fair or poor non-emergent specialty service access for their patients. Montana's rural Indian clinic providers reported poorer patient access to specialty care than rural non-Indian clinic providers, while New Mexico's rural Indian and non-Indian providers reported comparable access. Indian clinic providers in both states most frequently cited financial barriers to specialty care. Indian clinic providers reported better access to most non-physician services than non-Indian clinic providers. CONCLUSIONS: Reported limitations in specialty care access for rural Indian clinic patients appear to be influenced by financial constraints. Health care systems factors may play a role in perceived differences in specialty access between rural Indian and non-Indian clinic patients.

A longitudinal analysis of the general surgery workforce in the United States, 1981-2005.

HYPOTHESIS: The overall supply of general surgeons per 100 000 population has declined in the past 2 decades, and small and isolated rural areas of the United States continue to have relatively fewer general surgeons per 100 000 population than urban areas. DESIGN: Retrospective longitudinal analysis. SETTING: Clinically active general surgeons in the United States. PARTICIPANTS: The American Medical Association's Physician Masterfiles from 1981, 1991, 2001, and 2005 were used to identify all clinically active general surgeons in the United States. MAIN OUTCOME MEASURES: Number of general surgeons per 100 000 population and the age, sex, and locale of these surgeons. RESULTS: General surgeon to population ratios declined steadily across the study period, from 7.68 per 100 000 in 1981 to 5.69 per 100 000 in 2005. The overall urban ratio dropped from 8.04 to 5.85 (-27.24%) across the study period, and the overall rural ratio dropped from 6.36 to 5.02 (-21.07%). The average age of rural surgeons increased compared with their urban counterparts, and women were disproportionately concentrated in urban areas. CONCLUSIONS: The overall number of general surgeons per 100 000 population has declined by 25.91% during the past 25 years. The decline has been most marked in urban areas. However, more remote rural areas continue to have significantly fewer general surgeons per 100 000 population. These findings have implications for training, recruiting, and retaining general surgeons.

Growth and change in the physician assistant workforce in the United States, 1967-2000.

The physician assistant (PA) profession grew rapidly in the 1970s and 1990s. As acceptance of PAs in the health care system increased, roles for PAs in specialty care took shape and the scope of PA practice became more clearly defined. This report describes key elements of change in the demography and distribution of the PA population between 1967 and 2000, as well as the spread of PA training programs. Individual-level data from the American Academy of Physician Assistants, supplemented with county-level aggregate data from the Area Resource File, were used to describe the emergence of the PA profession between 1967 and 2000. Data on 49,641 PAs who had completed training by 2000 were analyzed. More than half (52.4%) of PAs active in 2000 were women. PA participation in the rural workforce remains high, with more than 18% of PAs practicing in rural settings, compared with about 20% in 1980. Primary care participation appears to have stabilized at about 47% among active PAs for whom specialty is known. By 2000, 51.5% of practicing PAs had been trained in the states where they worked. The profession has grown rapidly; 56% of all PAs were trained between 1991 and 2000. In 2000, more than 42% of accredited PA programs offered a master's degree, compared to master's degree programs in 1986. Although many critical issues of scope of practice and patient and physician acceptance of PAs have been resolved, the PA profession remains young and continues to evolve. Whether the historical contribution of PAs to primary care for rural and underserved populations can be sustained in the face of increasing specialization and higher-level academic credentialing is not clear.

Predictors of comprehensive surgical treatment in patients with ovarian cancer.

BACKGROUND: Providing appropriate surgical treatment for women with ovarian cancer is one of the most effective ways to improve ovarian cancer outcomes. In this study, the authors identified factors that were associated with a measure of comprehensive surgery, so that interventions may be targeted appropriately to improve surgical care. METHODS: Using Healthcare Cost and Utilization Project hospital discharge data from 1999 to 2002 for 9 states, the authors identified 10,432 admissions of women who had an International Classification of Disease, 9th Revision (ICD-9) primary diagnosis of ovarian cancer and who had undergone oophorectomy. Based on National Institutes of Health Consensus Panel recommendations, surgeries were categorized as comprehensive by using ICD-9 diagnosis and procedure codes. Logistic regression analysis using data from 5 states with a full set of variables (n = 6854 patients)was used to identify factors that were associated with the receipt of comprehensive surgical care. RESULTS: Overall, 66.9% of admissions (range, 46.3-80.8% of admissions) received comprehensive surgery. Factors that were associated independently with comprehensive surgical care included age (ages 21-50 years vs ages 71-80 years or > or = 81 years), race (Caucasian vs African American or Hispanic), payer (private insurance vs Medicaid), cancer stage (advanced vs early), annual surgeon volume (low/medium [2-9 surgeries per year] or high [>10 surgeries per year] vs very low [1 surgery per year]), and surgeon specialty (gynecologic oncologists vs obstetrician gynecologists or general surgeons). Among nonteaching hospitals, medium-volume hospitals (10-19 ovarian cancer surgeries per year) and high-volume hospitals (> or = 20 surgeries per year) had significantly higher comprehensive surgery rates than low-volume facilities (1-9 surgeries per year). Volume did not influence comprehensive surgery rates in teaching hospitals. CONCLUSIONS: Many women with ovarian cancer, especially those in poor, elderly, or minority groups, are not receiving recommended comprehensive surgery. Efforts should be made to ensure that all women with ovarian cancer, especially those in vulnerable populations, have the opportunity to receive care from centers or surgeons with higher comprehensive surgery rates.