Areas with primary care shortages face greater rates of emergency surgery, readmissions

Key takeaways:

• Areas with severe primary care shortages saw higher rates of several negative surgical outcomes.
• The study highlighted opportunities to improve quality across the continuum of inpatient and outpatient care.

Adults undergoing surgical procedures in areas with severe primary care shortages had higher rates of emergency surgery, serious complications and readmission, a study showed.

According to Sara L. Schaefer, MD, a surgical resident from the University of Michigan, one of the major takeaways is “the link between a need for primary care doctors and the downstream impacts on access to other specialties such as surgery.”

“If there are fewer primary care doctors... those patients are more likely to have emergency surgery,” she told Healio. “Instead of having a planned operation for a hernia, for example... the [patient’s] hernia gets so big or so stuck [after not seeing a primary care provider] that they have an emergency, and that’s a higher risk procedure inherently.”

Schaefer and colleagues pointed out how PCPs, in addition to treating common medical conditions, serve as front-line providers “to identify surgical conditions that require initial screening and timely referral.”

Despite this, however, “little is known about the relationship between primary care shortage areas and access-sensitive surgical care,” they wrote in Health Affairs.

In the study, the researchers evaluated the rates of elective surgery vs. emergency surgery among Medicare beneficiaries (n = 228,204) undergoing one of three access-sensitive surgical procedures — colectomy for cancer, abdominal aortic aneurysm repair and incisional hernia repair — and who lived in primary care Health Professional Shortage Areas from 2015 to 2019.

The researchers analyzed data from CMS’ Medicare Provider Analysis and Review file. The cohort had a mean age of 76 years, half were men (49.2%) and 87.5% were white.

Overall, Medicare beneficiaries in areas with the most severe primary care shortages, compared with those in areas with the least severe shortages, had:

• higher rates of emergency surgeries (37.8% vs. 29.9%; RR = 1.26; 95% CI, 1.17-1.37);
• a greater likelihood of developing serious complications (14.9% vs. 11.7%; adjusted RR = 1.27; 95% CI, 1.12-1.44); and
• higher odds of readmissions (15.7% vs. 13.5%; aRR = 1.16; 95% CI, 1.01-1.33).

Medicare beneficiaries in both areas had similar rates of 30-day mortality and risk for any complications. The findings were similar when the researchers adjusted for a shortage of surgeons.

Schaefer and colleagues used just one measure of primary care shortage and could not address all the factors that influence access to surgical care — two limitations of the study, they said.

Still, the findings have important implications for health systems struggling to allocate resources, the researchers noted.

"Although surgical quality improvement has traditionally focused on inpatient providers and care, these findings underscore the opportunity to improve quality across the continuum of inpatient and outpatient care,” they wrote. “By focusing on access-sensitive surgical conditions that are initially screened and identified in the primary care setting and then treated in the inpatient setting, health systems may have more opportunities to explicitly collaborate across care settings.”

Schaefer said that future research should focus on other metrics of primary care quality, like Medicare metrics, and “ways of how to get to good surgical care.”