Randall Zuckerman

Perforated appendicitis among rural and urban patients: implications of access to care.

Objective:To determine whether rural patients are more likely to present with perforated appendicitis compared with urban patients. Background:Appendiceal perforation has been associated with increased morbidity, length of hospital stay, and overall health care costs. Recent arguments suggest that high rates of appendiceal rupture may be unrelated to the quality of hospital care, and rather associated with inadequate access to surgical care. Methods:We performed a retrospective cohort study of 122,990 patients with acute appendicitis from the Nationwide Inpatient Sample from 2003 to 2004. International Classification of Diseases diagnosis 9 (ICD-9) codes were used to determine appendiceal perforation. Urban influence codes from the US Department of Agriculture were used to determine rural versus urban status. Univariate and multivariate analyses were used to determine patient and hospital factors associated with perforation. Results:Overall, 32.07% of patients presented with perforation. Rural patients were more likely than urban patients to present with perforation (35.76% vs. 31.48%). Factors associated with perforation in multivariate analysis were age more than 40 years, male gender, transfer from another facility, black race, poorest 25th percentile, Charlson score of 3 or higher, and rural residence. Thirty percent of rural patients were treated in urban hospitals. Rural patients treated at urban hospitals were more likely to present with perforation compared with rural patients treated at rural hospitals (OR = 1.23). Conclusions:Patients from rural areas have higher rates of perforation with acute appendicitis than urban patients. This difference persists when accounting for other factors associated with perforation. These differences in perforation rates suggest disparities in access to timely surgical care.

The pineal gland hormone melatonin improves survival in a rat model of sepsis/shock induced by zymosan A

BACKGROUND Melatonin has demonstrated protective effects in severe sepsis/shock in the animal model. Zymosan A causes inflammation and shock leading to death in rats. We hypothesized that daily afternoon melatonin administration would improve rat survival after an intraperitoneal (IP) zymosan injection. METHODS Adult male rats, maintained on a 12L:12D photoperiod, received a single IP injection of either zymosan (500 mg/kg) or paraffin vehicle at 1200 hours. At 1700 hours and daily thereafter, zymosan-injected rats received subcutaneous injections of either melatonin (0.8 mg/kg) or saline (SAL). Any surviving animals were killed on day 10 to obtain wet organ weights. RESULTS Three independent experiments produced similar results. In each zymosan+SAL group, all animals died by day 4. In the melatonin-treated groups combined, 33/45 rats survived (73.33%, P<.00002). Posthumous body weight was greater in melatonin-treated animals compared with the zymosan+SAL groups (P<.001). Mean splenic weight in the melatonin-treated groups was twice that of the control groups (P<.001). CONCLUSION Melatonin administered in the late afternoon after a lethal dose of zymosan significantly improved animal survival. Melatonin has no known adverse effects in humans and may represent a novel treatment for sepsis/shock.

Is a Broadly Based Surgical Residency Program More Likely to Place Graduates in Rural Practice

BackgroundThere is a shortage of general surgeons practicing in rural America. Rural surgical practices differ from those in urban settings encompassing a broader case mix with a larger percentage of time spent performing abdominal, alimentary, gynecological, genitourinary, and orthopedic procedures. Present graduates of many general surgical residencies do not obtain the range of experience necessary to practice effectively in this environment. We hypothesize that general surgical residents undergoing broadly based training are more likely to practice in a rural location.Methods and MaterialsWe conducted a survey of graduates from the Mary Imogene Bassett Hospital’s (MIBH) broadly based surgical residency program in 2004. Additionally, the surgical resident logs from the Accreditation Council for Graduate Medical Education (ACGME) and the residency program were reviewed for years 2001–2004.ResultsOf the 56 surveys sent out, 42 (75%) were completed and used in the analysis. A majority of the general surgeons who were raised in a rural environment reported that they are residing and practicing in a rural setting. Graduates of the MIBH residency program, on average, performed more cases as residents in the following subspecialty areas: genitourinary, plastics/hand, gynecology, neurosurgery, and orthopedics than national residency graduates.ConclusionsBased on our findings, surgical residents graduating from a broadly based training program appear more likely to practice in a rural setting.

How does degree of rurality impact the provision of surgical services at rural hospitals

CONTEXT Rural residents frequently have decreased access to surgical services. Consequences of this situation include increased travel time and financial costs for patients. There are also economic implications for hospitals as they may lose revenue when patients leave the area in order to obtain surgical services. Rural communities vary in size and distance from more populated centers. Since rural hospitals are located in varying types of rural communities, they likely differ with regard to the provision of surgical care. PURPOSE To describe the differences between hospitals located in smaller versus larger rural areas regarding the provision of surgical care. METHODS A 12-item survey instrument based on one previously used in a pilot study was mailed to a national random sample of rural hospital administrators (n = 233). Rural location was determined using rural-urban commuting area codes. FINDINGS One hundred and eleven surveys were received, yielding a 48% response rate. Hospitals in larger rural areas had an average of 9 surgeons compared to 1 at hospitals in smaller rural areas. More administrators at hospitals located in larger rural areas viewed the ability to provide surgical care as very important to the financial viability of their hospital. CONCLUSIONS Among rural hospitals located in communities of varying sizes there are significant differences in how surgical services are delivered and the financial importance of providing surgical care. Administrators at hospitals located in larger rural areas, more than in smaller ones, report financial reliance on their ability to offer surgical care and have significantly more resources available to do so.

The Impact of Laparoscopy on the Volume of Open Cases in General Surgery Training

OBJECTIVE The purpose of this study was to evaluate the impact of laparoscopy on the volume of open cases in general surgery residency training over the past 10 years. DESIGN The Accreditation Council for Graduate Medical Education (ACGME) database (1999-2008), which records all cases (by Current Procedural Terminology code) performed by graduating general surgery trainees, was retrospectively analyzed. SETTING ACGME database (1999-2008). MAIN OUTCOME MEASURES Trends were compared regarding the average number of the most common laparoscopic and open procedures (colectomy, hernia, and appendectomy) performed by graduating general surgery trainees during the reporting period. RESULTS Across all procedures, an increase was noted in laparoscopic approaches with a reciprocal decrease in open cases. The number of open appendectomies decreased by 29% (30.7 to 21.7), whereas the number of laparoscopic appendectomies increased by 278% (8.5 to 32.1). Similarly, open inguinal hernia cases decreased by 12.5% (51.9 to 45.4) and open colectomy cases decreased by 10.4% (48 to 43). Conversely, laparoscopic hernia repair and laparoscopic colectomy increased by 87.5% (7.6 to 15.8) and 550% (2 to 13), respectively. CONCLUSIONS In addition to the limitations placed on residency training by other factors (including work hour restrictions), changing practice patterns within the field of general surgery have a significant impact on the exposure of residents to open surgery cases. This trend might have far-reaching implications with regard to the overall competency of graduating residents and raises concerns for the future direction of surgical education.

Are General Surgery Residency Programs Likely to Prepare Future Rural Surgeons

BACKGROUND Too few surgeons practice in small rural areas of the United States. Many newly graduating surgeons choose not to practice rurally because they feel unprepared for rural practice. Family medicine residencies have a track record of placing graduates in rural settings. Their experience shows that having a stated interest in training rural physicians, a rural-focused curriculum, and rural practice exposure opportunities are successful elements for graduating physicians who practice rurally. OBJECTIVE To describe the extent to which general surgery residency training is likely to prepare future rural surgeons using criteria cited in reviews of rural family medicine residency programs. METHODS Three criteria were used to assess whether general surgery residency programs are positioned to produce rural surgeons: rural location, rural-focused curriculum, and self-identified interest in rural training. Several search strategies were employed to identify residency programs that meet the criteria. Additionally, data extracted from the American Medical Associations Physician Masterfile was used to determine demographic characteristics of residency programs that have trained surgeons who currently practice rurally. RESULTS Overall, 25 general surgery residency programs meet at least 1 of the 3 criteria. This finding represents approximately 10% of all residency programs in the United States. Residency programs located in the Midwest and the South have generally been more successful in graduating surgeons who are practicing rurally than those situated in the Northeast and West. CONCLUSIONS Although a few general surgery residency programs have been successful in graduating surgeons who practice rurally, there has not been a coordinated effort among programs to accomplish this goal. Our findings suggest a need for organization and coordination among those programs committed to training surgeons for rural practice. The creation of a consortium of general surgical residency programs with an interest in training rural surgeons could be a useful first step in this process.

Rural surgery: framing the issues.

Many rural residents have limited access to surgical care. Although this problem has been ongoing for the past few decades, several factors threaten to exacerbate the situation. The narrowing of general surgery practice, workforce shortages and inappropriate distribution of surgeons, changes in how surgeons are trained, and increasing health care costs contribute to the problem. Creative approaches to address these issues are needed to provide high-quality surgical services to the approximately 50 million Americans living in rural communities.

A rural, community-based program can train surgical residents in advanced laparoscopy

BACKGROUND Advanced laparoscopy requires mastery of complex surgical skills. A steep learning curve, lack of an adequate number of cases, and a shortage of experienced staff are reasons cited as barriers to the acquisition of these skills by surgical residents. We hypothesize that advanced laparoscopy can be taught during residency without additional fellowship training. STUDY DESIGN ast surgical residents who completed training at our rural, community-based, 140-bed hospital from 1992 to 2000 were contacted by mailed surveys and a followup telephone interview. Advanced laparoscopy was defined as cases other than cholecystectomy, appendectomy, and diagnostic laparoscopy. Five attending surgeons routinely perform advanced laparoscopy. RESULTS The response rate to the survey was 93.3% with 15 of 18 graduates currently practicing general surgery and 100% of the surgeons performing advanced laparoscopy. Laparoscopic herniorrhaphy, splenectomy, colectomy, Nissen fundoplication, and adrenalectomy were performed by 12 (85.7%), 10 (71.4%), 11 (78.6%), 13 (92.9%), and 9 (64.3%) surgeons, respectively. Eight (57.1%) surgeons reported confidence to perform advanced laparoscopy immediately after residency. All graduating chief residents from the last 3 years expressed this confidence. On average each of two chief residents from the past 3 academic years graduated with 99 basic and 50 advanced laparoscopic cases. CONCLUSIONS A rural, community-based program can train residents to perform advanced laparoscopy. Increasing the volume of advanced cases handled by resident correlates with increasing confidence in graduates.

General Surgery Contributes to the Financial Health of Rural Hospitals and Communities

Rural hospitals and communities often profit from the ability to provide surgical services. There can also be substantial financial costs for individuals, hospitals, and communities associated with not having access to surgical care in rural areas. Despite these advantages, limitations that include a shortage of rural general surgeons and other surgical staff and financial constraints prevent some rural institutions from offering surgical services. Few concrete data are available on this subject, and more research is needed to confirm anecdotal reports regarding the positive economic impact derived from general surgical services. It is especially important to examine and quantify the direct and indirect financial contribution that a general surgeon makes to a rural hospital and community.

State of rural general surgery programs: A national survey of rural hospital administrators

INTRODUCTION: Rural hospitals provide healthcare for residents and are central to the economic stability of their regions. Many rural hospitals, however, are financially vulnerable. Surgical practices generate valuable revenue for rural hospitals from inpatient and outpatient procedures. Rural surgeons provide surgical services, trauma care, and critical care in small hospitals. Without a surgeon, patient access to these services is limited. The purpose of this project is to describe rural hospital administrators’ perceptions regarding the state of their general surgery programs and the impact that providing surgical services has on their hospitals’ financial viability.