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Shortage of general surgeons ups probability of ruptured appendix

Major finding: The probability of rupture was 4.8 percentage points higher for patients in surgical service areas having fewer than 3 general surgeons per 100,000 people versus those in areas having at least 5 general surgeons per 100,000 people.

Data source: A cross-sectional observational study of 29,403 patients with acute appendicitis.

Disclosures: The investigators disclosed no relevant conflicts of interest.


 

FROM ANNALS OF SURGERY

Patients with appendicitis who live in areas having a critical shortage of general surgeons are at increased risk for appendiceal rupture, finds a cross-sectional, observational study published in the Annals of Surgery.

Investigators used discharge data to identify 29,403 patients with acute appendicitis seen in acute care and ambulatory surgery facilities in North Carolina between 2007 and 2009. Diagnostic codes indicated that 24.6% overall had experienced rupture.

In multivariate analyses, the probability of rupture was a significant 4.8 percentage points higher for patients in surgical service areas having a critical shortage of general surgeons (fewer than 3 per 100,000 people) than for patients in areas not having any shortage (at least 5 per 100,000 people), the investigators report (Ann Surg. 2014;259:910-15). Patients living in areas having lesser shortages did not have significantly elevated risk.

In contrast, the primary care physician supply in a given surgical service area did not predict rupture on its own, although it did show an interaction with area, with greater supply increasing the probability of rupture in some areas having a general surgeon shortage and decreasing it in others.

"Although rupture risk also depends on several other determinants of access, the density of the local general surgery workforce may be the most important determinant of access for timely appendicitis care. The independent effect of living in a critical surgery shortage area was greater than that of race, insurance status, rural status, and admission source," the investigators note.

"Enhancing supply in critical shortage areas could reduce appendiceal rupture and improve surgical access more generally," they maintain.

At the same time, the findings regarding primary care physician supply also have implications for policies aimed at improving general surgeon supply, according to the investigators.

"These results underscore the need for an effectively targeted HPSA (health professional shortage area) surgical incentive payments policy," which currently provides a 10% bonus payment to general surgeons operating in primary care health professional shortage areas, they note. "The current rule for designation of a surgical HPSA assumes that they coincide with current primary care HPSAs and designates them accordingly. This assumption is not supported by our analysis."

The investigators disclosed no relevant conflicts of interest.

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