Abstract
This cross-sectional study examines the surgical workforce in all counties across the US from 2010 to 2020.
Access to lifesaving surgical interventions is dependent on surgeon availability.1 In response to evidence indicating a decreasing general surgeon supply in the early 2000s,2 several federal efforts (eg, 2011 Surgical Incentive Payment Program under the Affordable Care Act3) have aimed to more equitably distribute surgeons across the US. Yet, it remains unclear how surgeon supply has evolved since implementation of these policies or whether county-level disparities in surgeon supply have narrowed. Thus, we evaluated trends in per-capita surgeon supply over the past decade and assessed whether these trends varied across county-level rurality and social vulnerability.
Methods
We conducted a population-based serial cross-sectional study of all US counties from 2010 to 2020. Numbers of all active nonfederal general, colorectal, neurologic, orthopedic, otolaryngologic, plastic, thoracic, and urologic surgeons in each county were obtained from the Area Health Resources Files. Annual county supply of surgeons was calculated per 100 000 population. Counties were characterized as urban (codes 1-3) or rural (codes 4-9) using the 2013 Rural-Urban Continuum Codes. High social vulnerability counties were defined as those in the top quartile of the Social Vulnerability Index. In accordance with the Common Rule, this study was exempt from ethics review and informed consent because it was not human participant research.
Trends in surgeon supply were visualized by county-level rurality and social vulnerability. Adjusted differences in surgeon supply by county-level characteristics were estimated using generalized estimating equations with these parameters: age, sex, US Census region, rurality, social vulnerability, and year. To evaluate changes in differences in surgeon supply by county-level rurality and social vulnerability from 2010 to 2020, we added interaction terms between rurality × year and social vulnerability × year to the models (eMethods in Supplement 1). Analyses were performed using R 4.1.2 (R Foundation for Statistical Computing), with a 2-sided α = .05.
Results
Between 2010 and 2020, surgeon supply per 100 000 population decreased in rural counties (9.97 vs 9.03; adjusted difference, −0.98 [95% CI, −1.41 to −0.55]) and increased in urban counties (22.7 vs 23.6; adjusted difference, 0.80 [95% CI, 0.18-1.42]) (Figure). Consequently, the rural-urban disparity in surgeon supply widened over time (difference-in-difference, −1.78; 95% CI, −2.51 to −1.05) (Table). The rural-urban disparity in supply remained unchanged for 3 and widened for 5 surgical specialties, of which general surgery experienced the greatest widening over the past decade (difference-in-difference, −0.95; 95% CI, −1.31 to −0.59).
Figure. Trends in Surgeon Supply by County-Level Rurality and Social Vulnerability From 2010 to 2020.
Urban (n = 1166) and rural (n = 1976) counties were characterized using the 2013 Rural-Urban Continuum Codes. Socially vulnerable counties (n = 787) were characterized as those in the top quartile of the Social Vulnerability Index.
Table. Difference in Adjusted Differences in Surgeon Supply Between Rural and Urban Counties and Between Socially Vulnerable and Other Countiesa.
| Surgical specialty | Adjusted difference in surgeon supply between rural and urban counties per 100 000 population | Adjusted difference in surgeon supply between socially vulnerable and other counties per 100 000 population | ||||||
|---|---|---|---|---|---|---|---|---|
| 2010 | 2020 | Difference-in-difference (95% CI) | P value | 2010 | 2020 | Difference-in-difference (95% CI) | P value | |
| All | −11.43 | −13.21 | −1.78 (−2.51 to −1.05) | <.01 | −0.51 | −1.38 | −0.87 (−1.60 to −0.13) | .02 |
| General | −2.49 | −3.44 | −0.95 (−1.31 to −0.59) | <.01 | 0.15 | −0.41 | −0.56 (−0.97 to −0.15) | <.01 |
| Colorectal | −0.22 | −0.28 | −0.06 (−0.11 to −0.02) | <.01 | 0.02 | 0.02 | −0.01 (−0.05 to 0.04) | .77 |
| Neurology | −1.08 | −1.22 | −0.14 (−0.25 to −0.02) | .02 | 0.07 | −0.04 | −0.11 (−0.19 to −0.02) | .01 |
| Orthopedic | −2.88 | −3.17 | −0.29 (−0.55 to −0.03) | .03 | −0.64 | −0.64 | 0.01 (−0.26 to 0.27) | .97 |
| Otolaryngology | −1.44 | −1.52 | −0.08 (−0.22 to 0.06) | .25 | −0.02 | −0.07 | −0.06 (−0.20 to 0.09) | .44 |
| Plastic | −1.18 | −1.18 | 0 (−0.09 to 0.09) | .98 | −0.15 | −0.16 | 0 (−0.08 to 0.08) | .98 |
| Thoracic | −0.73 | −0.74 | −0.01 (−0.09 to 0.07) | .82 | −0.01 | 0.01 | 0.01 (−0.06 to 0.09) | .72 |
| Urology | −1.18 | −1.4 | −0.22 (−0.38 to −0.06) | <.01 | 0.04 | −0.11 | −0.16 (−0.32 to 0.01) | .06 |
Differences in surgeon supply were derived from generalized estimating equation models with the following parameters: age composition, sex composition, US Census Bureau region, rurality, social vulnerability, year, and interaction terms between (rurality × year) and (social vulnerability × year). Difference in differences in surgeon supply were estimated using marginal contrasts.
The number of surgeons per 100 000 population decreased between 2010 and 2020 in socially vulnerable counties (12.4 vs 11.5; adjusted difference, −0.8 [95% CI, −1.41 to −0.19]) and remained unchanged in other counties (15.4 vs 15.4; adjusted difference, 0.06 [95% CI, −0.35 to 0.48]). Thus, the disparity in surgeon supply between these groups also widened over the study period (difference-in-difference, −0.87; 95% CI, −1.60 to −0.13). The difference in supply between socially vulnerable and other counties remained unchanged for 6 and widened for 2 surgical specialties, including general surgery (difference-in-difference, −0.56; 95% CI, −0.97 to −0.15).
Discussion
Over the past decade, disparities in surgeon supply between rural and urban counties and between socially vulnerable and other counties have widened in the US. The largest widening was observed among general surgeons. One study limitation was the inability to fully account for diverse surgical needs within each county, although evaluation of overall and subspecialty surgeon supply revealed similar trends. Future research should assess geographic variations in estimated surgical needs and their associations with surgeon supply.
These findings suggest that existing federal programs have not addressed the unequal distribution of the surgical workforce. This implication is particularly concerning for rural and underserved communities, as limited access to surgical care has been associated with poor outcomes and will perpetuate health inequities if unaddressed.4,5 Therefore, policy solutions are needed to reduce health inequities and mitigate underlying factors of surgical workforce disparities, including unequal compensation, working conditions, and access to training.6
eMethods. Construction and Specification of Statistical Model
Data Sharing Statement
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eMethods. Construction and Specification of Statistical Model
Data Sharing Statement