Transfers to tertiary acute care surgery service point to shortage of rural general surgeons


Nearly half of all transfer patients admitted to a tertiary facility’s acute care surgery service over a 12-month period underwent only basic surgical procedures or required no intervention after the transfer, according to a retrospective chart review.

The 161 patients transferred through the acute care surgery system during the 2014 study period were in need of the services for which they were transferred; thus, the findings highlight a “concerning lack of general surgery resources” in the community, Brittany Misercola, MD, and her colleagues at Maine Medical Center, Portland, reported in the Journal of Surgical Research.

Acute care surgery (ACS) is a relatively new paradigm – borne in part out of a heavy call burden for trauma and general surgeons – for managing patients in need of non–trauma-related emergency surgery, the investigators explained.

“At the same time as the ACS paradigm has developed, rural areas are suffering worsening shortages of physicians, especially specialists like surgeons. Another change has been regionalization of sick, complex, and resource-intensive patients to larger hospitals with more specialized care. However, no one has yet examined the effect of an ACS service in a predominantly rural area, given these changes in health care,” they wrote (J Surg Res. 2016. [doi:10.106/j.jss.2016.06.090]).

Patients included all adults aged 18 and older admitted between Jan. 1 and Dec. 31, 2014, excluding elective surgical and trauma patients. Transfer patients were admitted from 29 different institutions. The hospital is the largest in Maine, with a wide and rural catchment area. Transfer patients came from every county in the state, with a few from outside the state; 18% were transferred from a Maine Critical Access Hospital.

Compared with 611 local patients admitted through the emergency department or from local long-term care facilities, the transfer patients were older (61.2 years vs. 54.7 years), had more comorbidities (Charlson Comorbidity Index, or CCI, of 4 vs. 3.1), and required more resources (length of stay, 8.2 vs. 3.4 days; intensive care unit admission, 24% vs. 6%), the investigators reported.

Stratification by CCI showed that the difference in length of stay between transfer and local patients was largest in those with a low CCI (0-3), compared with those with a higher CCI.

The admission diagnosis was similar in the transferred and local patients, with pancreaticobiliary and small bowel complaints being the most common (29% and 30%, and 25% and 23%, respectively, for the two diagnoses). The most common interventions were laparoscopic cholecystectomy in both groups (29% and 25%, respectively). Subspecialty interventions were also similar in the groups, and were performed in 10% and 8%, respectively.

However, the transfer patients were more likely than the local patients to not require any intervention, including subspecialty care (32% vs. 23%), they said, noting that the most common reason for admission without operative intervention was “small bowel obstruction, followed by diverticulitis without drainable abscess and mesenteric ischemia.”

The transfer patients also were more likely to have Medicare (55% vs. 24%) and less likely to be privately insured (26% vs. 45%).

The discharge destination differed significantly between the groups, with local patients being more likely to be discharged directly to home (76% vs. 46%), and transfer patients more often discharged home with services (46% vs. 12%) or to acute rehabilitation or skilled nursing facilities (12% vs. 9%). In-hospital mortality and discharge to hospice care also were more likely among transfer patients (6% vs. 2%).

“If changes are not made to support rural hospitals in caring for these patients, tertiary centers in larger cities will see increasing volume of basic surgical emergencies. As such, investing in community hospitals is important to improve patient outcomes not only locally but also after transfer to tertiary referral centers,” they wrote, adding that additional research on the populations most affected is needed.

The authors reported having no relevant financial disclosures.