乌鸦传媒

Rates of emergency surgery, serious complications, and hospital readmissions were higher among Medicare patients living in primary care shortage areas, according to a cross-sectional retrospective cohort study of data from 2015 to 2019.

Medicare beneficiaries living in areas with the most severe primary care shortages had higher rates of three types of emergency surgeries compared with those living in areas with the least severe shortages (37.8% vs 29.9%; risk ratio [RR] 1.26, 95% CI 1.17-1.37, P<0.001), reported Sara Schaefer, MD, of the University of Michigan in Ann Arbor, and co-authors.

Those in areas with the most severe shortages were also more likely to have serious complications (14.9% vs 11.7%; adjusted RR 1.27, 95% CI 1.12-1.44, P<0.001) and readmissions (15.7% vs 13.5%; adjusted RR 1.16, 95% CI 1.01-1.33, P=0.03), they noted in .

However, beneficiaries in areas with the most and least severe shortages had similar rates of 30-day mortality (5.6% vs 4.8%; adjusted RR 1.17, 95% CI 0.93-1.47, P=0.17) and any complications (25.9% vs 24.5%; adjusted RR 1.05, 95% CI 0.97-1.15, P=0.21).

Schaefer told 乌鸦传媒 that what surprised her most about the study was the strength of the association for the primary endpoint. Across multiple iterations of analyses, the trend remained consistent, she said.

Findings were similar when Schaefer and team accounted for areas with a shortage of surgeons.

Approximately 74 million Americans lack adequate access to primary care, the authors noted. "In response, primary care Health Professional Shortage Areas (HPSAs) were designated by the federal government to create incentives for primary care providers to practice in areas with the greatest need. These areas are of particular importance, as areas with lower primary care physician density are associated with increased mortality," they wrote.

During her residency, Schaefer said she spent time in a rural Idaho community with only six primary care providers. She saw patients who hadn't seen a doctor in a decade flown to her hospital from remote parts of the state because of hernias. Now very sick, they needed emergency operations. Had their conditions been detected during a wellness visit, the procedure could have been planned.

"We all anecdotally know, if you see a primary care provider, you get screened for these things, you catch them early and that's better. But I think seeing that in the data ... really highlights again that connection between outpatient primary care and the really important role that it plays in downstream specialty care for patients," she said.

The study leveraged the to identify beneficiaries with "access-sensitive surgical conditions" who underwent surgeries. They then compared the rates of emergency versus planned operations stratified by primary care HPSA severity scores, a composite measure that includes provider density, infant mortality, and distance to care, among other elements. HPSA scores range from 0 to 25, with a higher score indicating greater primary care need.

The surgical procedures included in the study -- colectomy for cancer (33.4% of patients), abdominal aortic aneurysm repair (28.2%), and incisional hernia repair (38.5%) -- were all for conditions for which a patient might have mild symptoms or even be asymptomatic over a certain period of time. However, when not detected, these conditions could lead to emergency surgeries.

The study cohort included 228,204 Medicare beneficiaries who underwent one of these surgeries from 2015 to 2019. Mean age was 76.3, 49.2% were men, 85.7% were white, and 10.5% were Black. Beneficiaries living in areas with the highest levels of primary care shortages were more often Black compared with those living in areas with the least severe shortages (33% vs 3.2% P<0.001).

Beneficiaries, whether they lived in the most or the least severe primary care shortage areas, traveled similar distances for care (median distance 31.7 vs 28.2 miles) and spent similar amounts of time traveling (median time 38.7 vs 38.4 minutes).

Schaefer said that one of the main limitations of the study was "the complex relationship between some of the socioeconomic factors and social vulnerability, and how that plays into patients' access to surgery." The team applied a "risk-adjusted model with known risk factors for poor surgical outcomes" to address potential confounders and conducted multiple sensitivity analyses, she added.

The study may also have underestimated potential sources of primary care, because the current HPSA designation excludes advanced practice clinicians.

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