Rural Surgery Research Articles

Racial disparities in treatment of high grade endometrial cancer in the Medicare population

OBJECTIVE To examine the patterns of care and survival for African American and white women with high-grade endometrial cancer. METHODS The linked Surveillance, Epidemiology, and End Results and Medicare databases were queried to identify patients diagnosed with grade 3 endometrioid endometrial adenocarcinoma, uterine carcinosarcoma, uterine clear cell carcinoma, and uterine serous carcinoma between 1992 and 2009. The effect of treatment modality on survival was analyzed using the Kaplan-Meier method. Factors predictive of outcome were compared using the Cox proportional hazards model. RESULTS A total of 9,042 patients met study eligibility criteria. African Americans had definitive surgery (76.8% compared with 88.7%; P<.001) less frequently. There was no difference in the rate of adjuvant treatment between the groups. In the crude models for both all-cause mortality and cancer-specific mortality, African American women had an increased overall and disease-specific hazard of death compared with white women. The overall hazard ratio for African American women was 1.6 (95% confidence interval [CI] 1.5-1.7), and the disease-specific hazard ratio was 1.5 (95% CI 1.3-1.6). Over the entire study period, after adjusting for stage, age, period of diagnosis, registry region, urban compared with rural setting, marital status, treatment, surgery, socioeconomic status, and comorbidities, there was no association between race and lower disease-specific survival (hazard ratio 1.1, 95% CI 1-1.2; P=.06). CONCLUSION African American women had lower cancer-specific and all-cause survival compared with white women. Controlling for treatment, sociodemographics, comorbidities, and histopathologic variables eliminated the difference between African American and white women in the disease-specific analysis.

(144) Chronic pain and prescription opioid use in rural bariatric surgery patients

(144) Chronic pain and prescription opioid use in rural bariatric surgery patients

Comments on Rural Pediatric Surgery

<i>Comments on Rural Pediatric Surgery</i>

Does surgery residency prepare residents to work at critical access hospitals?

BackgroundOperations performed by surgeons working at Critical Access Hospitals (CAHs) and surgery residents have not been compared. MethodsProcedure codes logged by general surgery residents graduating from our institution in 2013 and 2014 were obtained. Procedure codes were obtained for all CAHs in our state for 2012 to 2013. Clinically relevant categories were compared among residents and general surgeons at CAHs. ResultsA total of 34,246 procedures logged by general surgeons at CAHs were compared with 31,977 procedures logged by surgery residents. Endoscopy comprised 56.1% of cases done by general surgeons versus 9.1% of cases by residents (P < .001). Excluding endoscopy, rural surgeons had higher percentages in hernia, skin/soft tissue, cholecystectomy/common bile duct, rectal/anal, and breast cases. Residents who completed a rural surgery rotation had higher numbers in small/large bowel, hernia, breast, and endoscopy. ConclusionsSurgery residency provides less exposure to endoscopy compared with a general surgery practice at CAHs. A rural rotation increases endoscopic exposure.

Innovative bridging of the rural-urban divide: comparison of scope, safety, and impact of collaborative rural surgery camps and an urban surgical program.

In medically under-resourced regions worldwide, non-permanent surgery programs or camps have been conducted to expand access to surgical services. Surgery camp programs have been reported in rural India, primarily in the ophthalmic and obstetric fields; however, the provision of general surgical services in these settings is largely unknown. A 12-month retrospective review of non-ambulatory procedures performed at a rural hospital surgery camp program and at an urban hospital in Maharashtra, India, was completed to characterize relative differences in procedural activity, frequency and severity of perioperative complications, and to evaluate efficacy of care. A total of 449 cases performed in rural hospital surgery camps were compared with 344 cases performed in an urban hospital during the course of the study period. The majority of rural surgical cases were elective and of intermediate complexity. Approximately 4% of rural cases were complex-major compared to 17% of urban cases. Intraoperative complications occurred in 0.2% rural cases compared to 5.5% of urban cases; p = 0.01. Postoperative complications were predominantly low grade in both groups. The postoperative complication rate was higher among rural surgical patients (43.4%; 23.5%; p < 0.01), though the Surgical Risk Score was significantly lower in this group (p < 0. 01). Rural surgery camp activity over 12 months achieved diagnostic and/or therapeutic goals in 92.2% of procedures and rendered 1.74-2.69 disability-adjusted life-years (DALYs) averted per patient. Rural general surgery camps can safely and effectively provide a wide range of surgical services under appropriate collaborative and clinical conditions. Surgery camps may be a safe, temporizing solution to unmet needs until substantial gains in rural healthcare are realized.

Issues that face rural surgery in the United States.

The social and economic issues that encumber rural communities in the United States threaten surgical practices that serve them. The term rural surgery refers to the practice of surgery serving people in rural communities and geographically remote areas. The myriad issues fall into 3 broad areas that parallel the tectonic pressures on rural America and medical economics: the demographic and economic decline of rural communities; a change in surgery in America brought on by the workforce shortage in general surgery; and a shift in the structure of surgical practice from an independent practitioner single hospital relationship to an employed corporate model. Each challenges relationships among the hospital, surgeon, and the community. Solutions lie in not considering each group in isolation, but considering the triad as a whole. A central task is to improve the quality of surgical care in rural America, a measure that will both drive caseloads to rural surgeons and hospitals and improve the care they provide to their communities.

Hand injuries from cassava milling machine in sub-urban Nigeria

Background: Nigeria is the highest cassava producer in the world. The processing of cassava tubers into a valuable product involves grinding in locally fabricated machines. This process exposes the hand to injuries. Aim: The aim of this study is to investigate the pattern of presentation and outcome of hand injury from locally fabricated cassava milling machines in our rural plastic surgery practice. Materials and Methods: This is a prospective clinical audit of patients with hand injuries from cassava milling machines managed in Irrua Specialist Teaching Hospital from January 2010 to December 2011. Demographic data, type of injury and outcome were documented and analyzed. Result: There were 33 patients who had injuries from locally fabricated cassava milling machines. Females in the second decade of life were mostly affected. Mutilating injury involving digits 2, 3, 4 and 5 of the dominant hand was the main finding. Although, no amputation was recorded, stiffness was a major complication. Conclusion: We observed that the dominant hand of female teenagers is mostly at risk in locally fabricated cassava milling machine hand injuries. This injury is preventable.

Rural Surgery in Niger: A Multicentric Study in 21 District Hospitals.

The purpose of the study was to evaluate the qualitative aspect and global impact of surgery in a district hospital (DH) since the launching of the surgery at the district level. Surgical care was provided by general practitioners (GP) who received 12-month training in surgery, certified by a "Capacity of District Surgery" (CDS) diploma. It was a prospective study during 4years from 2007 to 2010. Of the 34 DHs, only 21 were functional and included in this study. Most of the DHs had two or more CDS (n = 15). The majority of the DHs had one nurse surgical aid (n = 16) and one nurse anesthetist (n = 17). The total number of surgical operations was 18,441 cases; emergency cases represented 51.8% and elective surgery 48.2%. Regarding emergency surgery, cesarean sections revealed the most common surgical procedure (37.21%), followed by wound debridement (19.42%). In elective surgery, hernia repair and hydrocelectomy were the most common surgical procedures (69.60%), followed by gynecologic procedures in 12.74% of the cases. The global complication rate was 4.34%. The global mortality rate was 1.04% (n = 192), 102 deaths following cesarean section (2.87%). No death was encountered in elective surgery. Nine hundred and fifty-five patients (5.17%) were transferred to a higher-level facility of whom 598 patients (62.61%) were admitted for fracture treatment. The concept of district surgery has proven to be an effective tool to counter skilled medical manpower shortage to perform emergency and elective basic surgery at the rural level and could be adopted by developing countries facing similar health challenges.

Rural surgical workforce and care of colorectal disease

Over the past several years, increasing attention has been focused on the challenges associated with surgical care delivery in rural settings. These challenges include the relative scarcity of surgeons in rural America, professional isolation, rural case mix, regionalization, and financial issues surrounding rural surgery. This article will summarize these issues and describe the implications for the care of patients with colorectal diseases in rural settings.

Association Between Dedicated Rural Training Year and the Likelihood of Becoming a General Surgeon in a Small Town

Although projections of surgical workforce predict an increased need for general surgeons, especially in rural areas, graduates of residency programs increasingly enter urban or metropolitan specialty practice. To determine whether fourth-year residents at a hospital in a rural setting were more likely to enter general surgery practice than a specialty. In 2002, we initiated a year-long program for fourth-year residents. The records of all surgical residents (n = 70) who completed our general surgical residency and entered practice since the rural rotation began were divided into those completing the rural surgery program (rural) and those who did not (other). Demographic characteristics of the 2 groups and initial intent to practice rural general surgery were compared. Critical end points included completion of a fellowship, general surgery practice, and practice setting population of less than 50,000. As an additional control group, we compared these residents with those who completed residency just before our rural program began (1993-2002) with regard to fellowship and practice characteristics. Age, sex, and initial practice plans. Age, sex, and initial practice plans of the 2 groups did not differ. Residents who completed the rural year were more likely to enter general surgery practice (10 of 11 [91%]) than those who did not (28 of 59 [47%]; P = .009). They were also more likely to practice in a site of population less than 50,000 (4 of 11 [36%] vs 4 of 59 [7%]; P = .02). The practice type and fellowship completion rate of the residents who finished all training years at Oregon Health and Science University during 1993-2002 and 2003-2012 did not differ. Most residents who completed the rural year (6 of 11 [55%]) entered residency with a desire to practice general surgery. All of them are practicing general surgery. Of the residents who entered training with a specialty career in mind, 4 of 5 (80%) who completed the rural year are practicing general surgery, while only 13 of 45 (29%) who stayed at our university program for the entire 5 years are in general surgery practice (P = .04). Providing residents a dedicated and significant experience in a rural setting increases the likelihood that they will practice general surgery in a similar setting despite initial specialty plans. Implementing such programs might help alleviate the increasing gap in workforce needs of small towns and rural hospitals.

Five‐year results of surgical colorectal cancer treatment in rural Australia

The incidence of colorectal cancer in Australia is among the highest worldwide. We investigate whether similar treatment results for colorectal cancer can be achieved in rural surgery as reported from metropolitan centres. Retrospective analysis of prospectively collected follow-up data in a rural surgical centre in South Australia has been carried out. Results of all patients undergoing surgical treatment for colorectal cancer are analysed, and all cancer stages and interventions over a 5-year period are included. Five-year survival of all patients (n = 194) treated for colorectal cancer independent of stage and cause of death was 56%, cancer-specific 5-year survival was 64%. Perioperative mortality was 1.7%. Overall survival was 96% in stage 1, 92% in stage 2, 58% in stage 3 and 0% for patients with metastatic disease at the time of diagnosis. Cancer-specific survival ranged from 100% in stage 1 to 0% for patients with metastatic disease. Assessment of overall and cancer-specific survival of all patients undergoing surgery for colorectal cancer over a 5-year time period in a rural South Australian centre shows that good long-term results can be achieved with low perioperative mortality. These findings compare well with the results of other groups.

Assessment of the Role of a Student-Led Surgical Interest Group in Surgical Education

We describe the development of a medical student surgical interest group, its initial evaluation, and future plans. The Surgical Students Society of Melbourne was formed in August 2008 by a group of senior medical students from the University of Melbourne. The Surgical Students Society of Melbourne seeks to provide additional surgical teaching and professional development for students interested in a career in surgery. It also aims to provide junior doctors with leadership and teaching opportunities to meet the requirements of the Royal Australasian College of Surgeons for application to the Surgical Education and Training program. Its program also addresses contemporary workforce issues, such as women in surgery and rural surgery. The society runs a weekly teaching program during the semester and procedural and careers workshops throughout the year. A survey of students attending the teaching program was conducted by means of written and online questionnaires. The results suggest that the society has been successful in augmenting surgical education and providing opportunities to improve procedural skills, but also highlighted areas of the program that may be improved, including aspects of surgical professional development and role modeling. The Surgical Students Society initiative was generally very well received by students and shows great potential as a means for augmenting surgical education at the medical student level.

Surgical specialty procedures in rural surgery practices: implications for rural surgery training

BackgroundSpecialty procedures constitute one eighth of rural surgery practice. Currently, general surgeons intending to practice in rural hospitals may not get adequate training for specialty procedures, which they will be expected to perform. Better definition of these procedures will help guide rural surgery training. MethodsCurrent Procedural Terminology codes for all surgical procedures for 81% of North Dakota and South Dakota rural surgeons were entered into the Dakota Database for Rural Surgery. Specialty procedures were analyzed and compared with the Surgical Council on Resident Education curriculum to determine whether general surgery training is adequate preparation for rural surgery practice. ResultsThe Dakota Database for Rural Surgery included 46,052 procedures, of which 5,666 (12.3%) were specialty procedures. Highest volume specialty categories included vascular, obstetrics and gynecology, orthopedics, cardiothoracic, urology, and otolaryngology. Common procedures in cardiothoracic and vascular surgery are taught in general surgical residency, while common procedures in obstetrics and gynecology, orthopedics, urology, and otolaryngology are usually not taught in general surgery training. ConclusionsOptimal training for rural surgery practice should include experience in specialty procedures in obstetrics and gynecology, orthopedics, urology, and otolaryngology.

Contemporary Issues in Rural Surgery

Contemporary Issues in Rural Surgery

Rural General Surgery: A Review of the Current Situation and Realities from a Rural Community Practice in Central Nebraska

Purpose: To examine the reasons fewer students and residents are entering general surgery, to educate residents about the realities of rural general surgery based on the experience of three general surgeons in central Nebraska, and to suggest a strategy for individual general surgeons and for residency programs to maintain the rural surgical workforce. Methods: A systematic literature review of surveys, review articles, and editorials through PUBMED was performed. Relevant studies were included in a review of the current literature on the rural general surgery workforce, general surgery residency, fellowship training, and rural surgery education. Findings: There is an insufficient supply of general surgeons in many parts of the country, particularly in rural settings. More general surgery residents are entering into subspecialty fellowship training and fewer are practicing general surgery than in the past. Residents may have inaccurate perceptions about rural general surgery practice. Those residency programs with dedicated rural and community surgery rotations have had more success in producing rural general surgeons. Conclusions: Although specialization in surgery has many positive effects, maintenance of a general surgical workforce in rural America is crucial to the health care of many citizens. Increasing the numbers of mentoring and training programs could provide medical students and general surgery residents with more educational opportunities that may lead to increased interest in rural surgery.

The Scope and Challenges of Rural Surgical Practice in Nigeria

Background: Rural surgical practice is the practice of Surgery under conditions of limited resources which brings surgical services to the doorsteps of the rural Populace, majority of whom are poor. Aims: The aim of this paper is to highlight rural surgical practice in Nigeria. Materials and Methods: A review of personal experiences in rural surgery and interaction with other practitioners in the field as well information gathered at Rural Surgery conferences in Nigeria and abroad. Results: Scope of surgery performed is commonly usually limited by infrastructure, manpower and funding. Procedures include fields as Obstetrics and Gynaecology, Urology, Orthopaedics, Ear Nose and throat, Anaesthesia as well as General Surgery. A high proportion is contributed by emergencies especially Caesarian Sections, removal of foreign bodies from the ear, nose and throat, initial management of simple fractures, Hip-pinning, appendectomies, relief of intestinal obstruction, suprapubiccystostomies, catheterization and management of ruptured ectopic tubal pregnancies. The procedures are carried out by General Duty doctors with only a few surgeons in established self-owned practices. Challenges include poor living conditions, poor accessibility, lack of infrastructure and equipment, lack of suitably trained assistants, inadequate schools for their children, lack of suitable jobs for spouses. In spite of difficulties Rural Surgery in Nigeria has come to stay and is growing especially with formation of Rural Surgical Practitioners in Nigeria. Conclusion: Rural surgical practice is feasible in Nigeria and should be encouraged by the Government as it forms an important arm of Healthcare delivery in Nigeria. Key Words: Rural, Surgery, Scope, Challenges, Limited resources, Poverty

Rural surgery: a new specialty?

Alan J Grant and colleagues argue that the skill mix needed for rural surgery demands a unique specialty

Rural surgeons’ attitudes towards and usage of evidence‐based medicine in rural surgical practice

Rural and remote surgical practice presents unique barriers to the uptake of the evidence-based medicine (EBM) paradigm. As medical and education institutions around Australia develop practices and support for EBM, there are growing questions about how EBM is situated in the rural and remote context. The Monash University Department of Surgery at Monash Medical Centre implemented a study to explore the current understandings, attitudes and practices of rural surgeons towards the EBM paradigm. Descriptive survey of rural surgeons based in a tertiary care environment. The overall results of the survey demonstrate that: (1) rural surgeons have a good understanding of EBM; (2) EBM evidence is somewhat useful but not very important to clinical decision making; and (3) while rural surgeons are relatively confident in most sources listed, they are most confident in their own judgment and clinical practice guidelines, and least confident in telephone contact with colleagues. Rural surgeons' understanding, usage and confidence in EBM purports that rural surgeons have contradictory, ambivalent and complex views of the EBM paradigm and its place in rural surgical practice. Professional isolation and context specificity are important to consider when extending the EBM paradigm to rural surgical practice and understanding the EBM uptake in the rural surgery context.

Rural Surgery Program Abstracts

ANZ Journal of SurgeryVolume 81, Issue s1 p. A61-A61 Rural Surgery Program Abstracts First published: 21 April 2011 https://doi.org/10.1111/j.1445-2197.2011.05741.xAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume81, Issues1Special Issue: The Royal Australasian College of Surgeons Annual Scientific Congress Adelaide, SA, 3‐6 May 2011May 2011Pages A61-A61 RelatedInformation

Choledocholithiasis Management in Rural America: Health Disparity or Health Opportunity?

Choledocholithiasis (CDL) management is dictated by local expertise, individual training, and availability of appropriate staff. This study evaluates the management of CDL between urban and rural communities. Patients undergoing inpatient management of CDL were identified from the 2007 Healthcare Cost and Utilization Project. Availability of endoscopic retrograde cholangiopancreatography (ERCP) was determined from the 2007 American Hospital Association survey. The proportion of common bile duct exploration (CBDE), ERCP, or percutaneous (PERC) interventions were compared across census regions and National Centers for Health Statistics (NCHS) urban-rural classes. The NCHS urban-ruralclassification scheme divides counties from most populous (NCHS 1) to rural (NCHS 6). Proportions were compared using the 95% confidence interval (95%CI) approach. We estimated 111,021 CDL hospitalizations in the U.S. in 2007. Of these, 67% had a coded intervention. Intervention frequencies were similar across census regions. Comparisons across NCHS classes revealed higher proportions of ERCP in urban areas (NCHS 1-4) while a higher proportion of CBDE was seen in rural areas (NCHS 5-6). ERCP availability was high in metropolitan areas (available in 35%-44% of hospitals NCHS 1-4) and low in rural areas (25% of NCHS 5 hospitals and 5% NCHS 6). PERC management was similar across NCHS classes. Rural hospitals and communities need surgeons trained in CBDE, where ERCP expertise may not be readily available. Feasible ways of expanding ERCP coverage to the nation's rural areas need to be explored. These observations may impact surgical training at least for those targeting careers in rural surgery.