Primary Care Shortages Associated With Higher Surgical Emergencies, Complications

In a cross-sectional, retrospective study, researchers found that Medicare beneficiaries located in federally designated primary care Health Professional Shortage Areas (HPSAs) had higher rates of emergency surgery, serious complications, and readmissions compared with rates in the least severe shortage areas

“Although primary care physicians are essential in treating common and chronic medical conditions, they also serve as front-line providers to identify surgical conditions that require initial screening and timely referral,” the authors wrote in their study. “This may be particularly true for access-sensitive surgical conditions—diagnoses requiring surgery that is ideally treated in the elective setting but, when access is limited, have a natural history that often results in emergency surgery if they are left untreated.”

The study objective was to evaluate and compare the rates of elective vs emergency surgery for Medicare beneficiaries undergoing access-sensitive surgical procedures, which researchers then stratified by primary care HPSA severity score (ranging from 0 to 25, with a higher score representing the greater primary care need).

To do this, Schaefer and colleagues obtained Medicare beneficiary data using the Medicare Provider Analysis and Review file for those beneficiaries who underwent one of three access-sensitive surgical procedures while living in primary care shortage areas between 2015 and 2019 (n = 228,204). The three procedures, colectomy to remove a cancerous area of the colon (33.4%), hernia repair (38.5%), and repair of aneurysms in the aorta wall (28.2%), were chosen because when the symptoms for these conditions are not detected, they could lead to emergency surgery.

Data from Schaefer et al. doi:10.1377/hlthaff.2023.00843

Regarding the characteristics of the beneficiaries, the mean age was 76.3 years, 49.2% were men, and 85.7% were White, while 10.5% were Black. Those 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). The authors also noted that the beneficiaries traveled similar distances (median distance = 31.7 vs 28.2 miles; p = 0.52) for a similar amount of time (median time = 38.7 vs 38.4 minutes; p = 0.99) whether they lived in areas with the most or least severe primary care shortages.

The researchers’ study results showed that Medicare beneficiaries in more severe primary care HPSAs had higher rates of emergency surgery (37.8%) compared with rates in the least severe HPSAs (29.9%). They were also more likely to have serious complications (14.9% vs 11.7%) and readmissions (15.7% vs 13.5%), respectively.

“Our findings underscore the value of primary care physicians to a broad range of health conditions,” the authors wrote.

The study has limitations. For example, the study could not address all the socioeconomic factors that impact access, or the lack of access, to surgical care. Additionally, while the study evaluated data from Medicare beneficiaries, it did not examine those covered by Medicaid, the US Department of Veterans Affairs, or private insurance.

“Overall, our findings suggest both that primary care HPSAs may meaningfully identify areas that are in need of better access to surgical care and that addressing primary care access may have a meaningful impact on access to surgical care,” the authors concluded. “Importantly, improving resources in primary care shortage areas may lead to better health outcomes in the Medicare population across the continuum of ambulatory and inpatient services.”

Reference:
Schaefer SL, Dualeh SHA, Kunnath N, Scott JW, Ibrahim AM. Higher rates of emergency surgery, serious complications, and readmissions in primary care shortage areas, 2015-19. Health Aff (Millwood). 2024;43(3):363-371. doi:10.1377/hlthaff.2023.00843