1. Characteristics of Practice Rural and Urban General Surgeons in North Carolina Jennifer King Erin Fraher, MPP, Thomas C. Ricketts, PhD, Anthony Charles, MD, George F. Sheldon, MD, Anthony Meyer, MD PhD Funding provided by American College of Surgeons Health Policy Institute and NC AHEC

2. Background

3. Integrating practice patterns in workforce analyses Medical practice varies between individual physicians –Volume –Content –Breadth Still, many supply assessments rely on head counts –Sometimes adjusted for hours in clinical care

4. General Surgery Indications of increasing specialization –Over 70% of general surgeons pursue fellowship training –ABS now offers primary certification in vascular surgery –“Natural” narrowing of practice over career? Rural practice may be broader Debate over “right” breadth of training for general surgeons

5. Research Questions  What is the: –Content of general surgery practices? –Volume of procedures performed? –Breadth of procedures performed?  How much do these characteristics vary from surgeon to surgeon?  How do these practice characteristics vary by rural and urban location?

6. Data & Methods

7. Data NC Health Professions Data System, 2004 –Data on all licensed physicians –Specialty, practice location, demographics NC Inpatient Discharge Database & Ambulatory Surgery Database, 2004 –ICD-9 procedure codes for all discharges and ambulatory surgery encounters –Attending physician UPIN

8. Analysis File Active non-federal general surgeons 648 UPIN 601 Any procedures 544 No procedures 57 No UPIN 47

9. Methods: Collapse ICD-9 Codes Clinical Classification Software (CCS) - AHRQ –231 Procedure Categories, such as: Cholecystectomy and common duct exploration (CCS 84) Inguinal and femoral hernia repair (CCS 85) –4 Procedure Types Major Therapeutic: Cholecystectomy (ICD-9 5122) Minor Therapeutic: Skin incision & foreign body removal (ICD-9 8605) Major Diagnostic: Intraoperative cholangiogram (ICD-9 8753) Minor Diagnostic: Colonoscopy (ICD-9 4523) Group CCS Procedure Categories into American Board of Surgery content areas

10. Methods: Analysis Descriptive statistics by county type –Core Based Statistical Area designations Metropolitan: county with an urbanized area with 50,000 or more population Micropolitan: county with urban cluster of 10,000 to < 50,000 population Rural OLS regression to examine rural-urban differences in breadth of practice controlling for individual characteristics

11. Results

12. Procedures Performed by CCS Type N=301,294N=213,176N=64,263N=23,855 Source: North Carolina Health Professions Data System and NC Hospital Inpatient and Ambulatory Surgery Discharge Data, 2004. Data include active, in-state, non-federal physicians who report a primary specialty of general surgery and had at least one procedure in 2004.

13. Procedures Performed by Content Area N=301,294N=213,176N=64,263N=23,855 Source: North Carolina Health Professions Data System and NC Hospital Inpatient and Ambulatory Surgery Discharge Data, 2004. Data include active, in-state, non-federal physicians who report a primary specialty of general surgery and had at least one procedure in 2004.

14. Total Procedures = 511 Dr. Jones Fictional Surgeon

15. Variation in Procedure Volume 25% performed >700 25% performed < 356 Average = 554 Source: North Carolina Health Professions Data System and NC Hospital Inpatient and Ambulatory Surgery Discharge Data, 2004. Data include active, in-state, non-federal physicians who report a primary specialty of general surgery and had at least one procedure in 2004. Metro: 24% Micro: 27% Rural: 31% Metro: 25% Micro: 23% Rural: 31%

16. Total Procedures = 511 Dr. Jones Fictional Surgeon Types of Procedures = 30

17. Variation in Types of Procedures Performed Average = 61 Source: North Carolina Health Professions Data System and NC Hospital Inpatient and Ambulatory Surgery Discharge Data, 2004. Data include active, in-state, non-federal physicians who report a primary specialty of general surgery and had at least 50 procedures in 2004. 15% performed < 44 15% performed > 79 Metro: 14% Micro: 8% Rural: 7% Metro: 13% Micro: 13% Rural: 31%

18. Total Procedures = 511 Dr. Jones Fictional Surgeon Types of Procedures = 30 Share in Top 10 = 406 / 511 = 79%

19. Variation in Share of All Procedures Accounted for by Top 10 Procedure Types Average =.67 13% of surgeons were > 80% focused on 10 procedures Source: North Carolina Health Professions Data System and NC Hospital Inpatient and Ambulatory Surgery Discharge Data, 2004. Data include active, in-state, non-federal physicians who report a primary specialty of general surgery and had at least 50 procedures in 2004. Metro: 13% Micro: 10% Rural: 14% 15% of surgeons were < 55% focused on 10 procedures Metro: 17% Micro: 13% Rural: 0%

20. Some rural-urban differences smaller after controlling for individual characteristics Percent of Total Procedures Performed Accounted For by Top 10 Procedures MetropolitanMicropolitanRural Average61.959.353.7 Simple Difference -2.6 -8.2** OLS Coefficient -1.2 (-4.5, 2.2) -3.6 (-9.4, 2.1) Number of Different Types of Procedures Performed MetropolitanMicropolitanRural Average66.3%67.2%72.2% Simple Difference 0.95.9** OLS Coefficient-0.5 (-2.9, 1.9) 3.9* (0.9, 6.9) Source: North Carolina Health Professions Data System and NC Hospital Inpatient and Ambulatory Surgery Discharge Data, 2004. Data include active, in-state, non-federal physicians who report a primary specialty of general surgery and had at least 50 procedures in 2004 (N=517). OLS results control for years since medical school graduation, hours per week in clinical care, gender, and second specialty.

21. Conclusions

22. Key Findings Rural-urban differences in content Wide variation in volume and breadth between individual surgeons No large rural-urban differences in breadth –Many urban surgeons have practices as broad or broader than rural counterparts

23. Limitations Missing UPIN for some surgeons Self-reported specialty –No information on board certification Possible measurement error –If attending surgeon is not performing surgeon –If incorrect ICD-9 codes Limited information on hospital characteristics

24. Extensions of Analysis Strategy: Future Work More detail on differences between rural and urban practice Effect of formal sub-specialization on scope of practice Changes in scope of practice over career trajectory