Trends in Rural Outreach by Orthopedic Surgeons

Abstract

Background

Sixty million rural residents have limited access to orthopedic care due to a small rural orthopedic surgery workforce. Increases in specialized training add to the challenge of attracting orthopedic surgeons to rural communities. Answering the call for research on models to meet the needs of rural orthopedic patients, we examine long-term trends in visiting consultant clinics (VCCs) in Iowa, a state with a large rural population.

Methods

The Office of Statewide Clinical Education Programs (Carver College of Medicine) compiles an annual report of outreach clinic locations, frequencies and participating physicians. Trends in the total number of VCCs, days and locations (1989-2018) were analysed using joinpoint analysis.

Results

Total clinic days grew rapidly from 1992-1997 (Average Percent Change: 19.7%) before a decline ending in 2009 (APC: -4.1%). A new growth period (2009-2013, APC: 7.5%) preceded another decline (APC: -3.6%) ending in 2018. The number of cities hosting a VCC grew from 56 (1989) to a peak of 90 (1999) and fell an average of 0.9% a year thereafter. More than 80% of all VCCs in the last ten years were offered 2 or more times per month. The average participation rate for Iowa-based orthopedic surgeons was 44%. The mean number of VCCs staffed by a single physician was 1.32 (std. dev. = 0.53) with a median of 1. The average number of VCC days per month for a participating physician was 3.22 (std. dev. = 2.41) with a median of 2.66.

Conclusion

The VCC model of rural outreach is sustainable (30+ year history) and self-funded. Most clinics occur with sufficient frequency to allow timely follow-up care. This model of rural outreach is supported by the participation of a large segment (44%) of Iowa’s orthopedic surgeons. Visiting orthopedic surgeons provide access to care in 65 of the 76 Critical Access Hospitals in Iowa offering orthopedic services compared to 8 staffed by a local orthopedic surgeon.

Level of Evidence: V

Introduction

Providing access to orthopedic surgery in rural areas has been recognized as a challenge for decades.^1-2 Comparatively few orthopedic surgeons practice in rural areas of the US^3-4 and their average age is higher than that of their urban counterparts.⁴ Unfortunately, recent trends militate against expanding (or even maintaining) the number of orthopedic surgeons practicing in rural areas. The country as a whole is facing a shortage of orthopedic surgeons^5-6 at a time when the Baby Boom generation is moving into older age. A coincident increase in obesity in the general population is leading to further increases in the demand for orthopedic care.⁷

Within the profession, the trend towards increased specialization results in fewer new physicians with the more generalized training associated with a rural practice.^8-9 There are few concrete solutions to some of the perceived personal and professional limitations associated with practicing in a rural community, e.g., spousal employment opportunities, lower pay, call coverage, etc. Finally, some studies suggest that patient outcomes for some complex procedures are better in large volume hospitals.^10-12

Recent articles in academic¹³ and professional¹⁴ outlets highlight the challenges facing the orthopedics profession in providing care for rural patients in the US and other countries. An AOA Critical Issues Symposium was held in 2016 to stimulate a national conversation about the issues surrounding orthopedic care in underserved areas.¹³ One focus of his discussion involves, “which model of orthopedic care in rural areas will best serve our profession and fulfill our foundational obligation to society.”¹³ This study intends to contribute to this conversation by describing the long-term experience of Iowa, a state with a large rural population, with the visiting consultant clinic (VCC) model of providing access to orthopedic care in rural communities.

An orthopedic surgery VCC is a joint arrangement between a visiting orthopedic surgeon (or group practice) and an outreach location, usually a rural hospital or clinic.^15-17 A formal contract stipulates the frequency of the clinics, services offered in the outreach clinic location, payments for the space used by the visiting orthopedic surgeon, etc.^15-17 Initiating a VCC agreement includes a review of the visiting physicians’ credentials and malpractice insurance.¹⁵ These agreements are reviewed annually by both parties and may be amended, for example, to accommodate new physicians to staff the clinics.

Almost all orthopedic VCC sites are rural communities that are too small to support a full-time orthopedic surgeon. While the majority of physicians staffing these outreach clinics are from urban areas, some have their primary practice locations in rural areas.^14,17 Like their urban counterparts.¹⁸ rural orthopedists use VCCs to expand their catchment area while serving patients in underserved rural locations.¹⁴ The VCC model for orthopedic surgery outreach has been established in Iowa for more than 30 years.¹⁵ In addition to Iowa, cross-sectional studies have documented the presence of orthopedic surgery VCCs in Kansas¹⁹ and 38% of rural hospitals in Florida, Nebraska, West Virginia, Arizona and Montana surveyed in 2011.²⁰

Despite their long history and presence in several states with large rural populations, orthopedic VCCs are still not well understood. For example, a recent article equates VCCs with a “fly in-fly out” model for surgery apparently used in isolated areas of Australia.¹³ It is suggested that both models of rural outreach suffer from a lack of follow-up care, questionable results, etc. However, such a comparison reveals a fundamental misunderstanding about orthopedic surgery VCCs in rural areas of the U.S. To illustrate a most salient difference, consider that the Australian Orthopedic Association “does not support” the fly-in fly-out model¹³ whereas 45% of Iowa-based orthopedic surgeons¹⁷ were involved in rural outreach through a VCC in 2014.

Prior research on orthopedic VCCs shows their positive effect on access to orthopedic care.¹⁷ However, there are no longitudinal studies on how this model of rural outreach has evolved over time. To better understand this model of serving rural patients, it may be helpful to see how it has changed over the decades. For this study, we utilize information from a unique state-wide database that has been tracking orthopedic surgery VCCs since 1989. Using data from 1989-2018, we modeled how the number of VCCs, clinic days and VCC locations have changed over time. We also analyzed the trends in the frequency of VCCs since clinic frequency affects the timeliness of follow-up care after major procedures. Since VCCs transfer some of the travel burden from rural patients to orthopedic surgeons, we analyzed trends of the average number of VCC sites visited by a participating surgeon, the average days spent on rural outreach and the accompanying travel burden in terms of total miles traveled to outreach clinic sites

Materials and Methods

Data Sources

The primary data source was the Annual Report on Iowa’s Visiting Medical Consultant Activity for the years 1989-2018. This report is compiled by the Office of Statewide Clinical Education Programs within the Carver College of Medicine (University of Iowa). This report is compiled using information from the Iowa Physician Information System, a statewide registry of practicing physicians in Iowa. It is updated continuously using multiple data sources including a twice-yearly census of all work sites in Iowa employing licensed health professionals.

The information on each orthopedic surgery VCC includes the location (site and city) and frequency. The names of participating orthopedic surgeons, their primary practice locations and group practice associations, if any, are also included.

All driving distances were estimated between the primary practice city of the participating orthopedic surgeon and VCC location using the Google Distance Matrix API.

To estimate the travel burden for an individual orthopedic surgeon, the total days staffed by a given group practice at a VCC location were allocated equally across all physicians associated with that site.

Statistical Analysis

Trends in the total number of clinic days and VCC locations were modeled using join-point regression.²¹ There were at least three annual observations between joinpoints or between a joinpoint and either end of the data series. Count data were log (base 10) transformed. The joinpoint models were fit using the grid-search method. Confidence intervals for average percentage change (APC) were estimated using the empirical quantile method. Significant results are reported for the p < 0.05 level.

Results

Growth in VCC Days and Locations

The number of VCC days and locations, by year, are presented in Figure 1. A separate dashed line indicates the number of VCC days staffed by Iowa-based orthopedic surgeons. Joinpoint analyses are presented in Table 1.

Figure 1.

Orthopedic surgery visiting consultant clinic (VCC) days in Iowa (1989-2018).

Table 1.

Joinpoint Analyses of Trends in Orthopedic Surgery VCC Days, Counts and Cities: 1989-2018

	Trend 1		Trend 2		Trend 3		Trend 4		Trend 5
	Years	APC	Years	APC	Years	APC	Years	APC	Years	APC
Orthopedic surgery VCC days in Iowa	1989-1992	-1.3%	1992-1997	19.5%*	1997-2009	-4.1%*	2009-2013	7.5%*	2013-2018	-3.6%*
Orthopedic surgery VCCs in Iowa	1989-1998	8.3%*	1998-2010	-3.2%*	2010-2013	7.9%*	2013-2018	-6.0%*
Iowa cities with an Orthopedic Surgery VCC	1989-1997	5.1%*	1997-2018	-0.9%*

Abbreviations: APC, annual percent change; VCC, visiting consultant clinic. (*) Significant at p < 0.05

Starting in 1992, the number of clinic days grew rapidly (APC = 19.5%, 95% C.I. = 15.3, 25.3) until 1997. The number of VCC days fell between 1998 and 2009 at am average rate of 4.1% per year (APC 95% C.I. = -3.5%, -5%). A short growth period from 2009-2013 (APC = 7.9%, 95% C.I. = 3.6%, 12.5%) was followed by a contraction averaging 3.6% per year (95% C.I. = -1.5, -8.5).

The total number of orthopedic surgery VCC clinics offered in each year is presented in Figure 2 (solid black line) along with the number of cities hosting a VCC (dashed black line). The differences between these lines shows that, in every year, some rural cities hosted more than one VCC. The average number of VCCs per city over all the years was 1.39 with an initial peak of 1.58 in 1999 and a second peak of 1.49 in 2013. As might be expected, the repeated pattern of growth and contraction in the number of orthopedic VCCs was consistent with that of the overall clinic days (see Table 1). The number of cities hosting an orthopedic VCC (Figure 2) grew steadily from 1989 until 1997 (APC 5%, 95% C.I. = 3.3%, 7.8%). After peaking in 1999, the number of cities continued to fall on average 0.9 per year (95% C.I. = -0.5, -1.4) until the end of our study period.

Figure 2.

Number of orthopedic surgery VCCs and locations in Iowa (1989-2018).

Across the entire study period (1989-2018), 115 different cities in Iowa hosted an orthopedic VCC for at least one year. The average number of years a community hosted a VCC is 19.97 (std. dev. = 9.52) out of the 30 yearly observations (Median = 23). More than 60% of communities hosted an orthopedic VCC for more than 20 of the last 30 years. At the other end of the distribution, 17 cities (15%) hosted a VCC for 5 or fewer years.

Trends in Clinic Frequency

Our sample includes 3209 VCC-year observations. Of these, few (1.2%) are offered less than once a month. About 20% (19.6%) are clinics offered once a month. Across all VCC-year observations, we find that 79% of orthopedic VCCs are offered 2 times a month or more frequently. Figure 3 shows that percentage of all VCCs with a frequency of 2 or more times per month. Since 2007, the proportion of at least twice-monthly VCCs has been consistently higher than 80%.

Figure 3.

Proportion of orthopedic surgery VCCs in Iowa offered 2 or more times per month (1989-2018).

Orthopedic Surgeon Participation

A total of 282 different Iowa-based orthopedic surgeons staffed one or more VCCs during our study period. The number of participating orthopedic surgeons varied from 47 in 1989 to 109 in 1998. Using the data from the Iowa Physician Information System, we computed the proportion of participating orthopedic surgeons as a total of all Iowa-based orthopedic surgeons. The resulting proportions are presented in Figure 4. The average participation rate across all 30 years is 44% (std. dev. = 6.5%). The median participation rate is 43%. Over the last 10 years (2009-2018), the average participation rate is 41% (std. dev. = 2.5%).

Figure 4.

Proportion of Iowa orthopedic surgeons participating in VCC outreach (1989-2018).

Outreach Involvement of Individual Orthopedic Surgeons

While an orthopedic surgeon may staff more than one VCC location, 50.3% of Iowa-based orthopedic surgeons are associated with only one VCC location in a given year. The average number of VCC locations staffed by an individual physician is 1.32 (std. dev. = 0.53) The median is 1.

The average number of days per month that an orthopedic surgeon dedicates to VCC outreach varies somewhat depending on the year (Figure 4). The overall average across all years is 3.58 (std. dev. = 3.10) days per month. The median number of days is 2.66. In the last 10 years, the average number of days is 3.41 (std. dev. = 2.80) and the median is 2.25.

Travel is associated with rural outreach. The average monthly travel burden for a participating orthopedic surgeon is 279.08 (Median = 193.4) miles. The standard deviation of 269.1 miles per month reflects high variation in the number of VCCs staffed by a given physician as well as differences in clinic frequency and distance from one’s primary practice location. In the last ten years, the average travel burden is comparable at 280.46 miles (std. dev. = 269.83).

Discussion

As in many rural states, the orthopedic surgery workforce is primarily concentrated in urban areas.¹⁷ However, through the mechanism of the visiting consultant clinic model of rural outreach, patients in more than 70 rural locations (on average) have been able to receive orthopedic care in their own communities. It is important to note that the impact of VCCs on access to orthopedic care in Iowa is “hidden in plain sight.” Consider that 76 Critical Access Hospitals (CAHs) in Iowa offer orthopedic services.²³ Of these, 65 are staffed by visiting orthopedic surgeons while 8 are associated with a local, rural-based orthopedic surgeon. The staffing in the remaining 3 CAHs is unknown.

In contrast to centrally planned (and funded) rural outreach programs in other countries,²² orthopedic VCCs in Iowa are organized by individual physician groups and rural hospitals or clinics. Their “market-based” nature is best illustrated in the 30-year repeated pattern of high growth followed by retrenchment illustrated in Figure 1. From the changes in the number of locations reported in Figure 2, some of the original expansion (1992-1997) included sites that turned out to be not economically feasible. We also note that the second wave of growth in the number of clinic days coincided with the onset of the Affordable Care Act in 2010. However, as before, some of the expansion was apparently not sustainable in the longer term. Despite all of these changes over time, a majority (60%) of rural locations were served by an orthopedic surgery VCC for 20 or more of the 30 years covered by our study, suggesting that the participating physicians found this core set of rural locations to be sustainable in the long run.

While the VCC model does not meet the needs of rural communities for emergency or trauma care, they are held frequently in most communities (80% occurring twice a month or more often). This level of frequency allows for timely follow-up care for elective procedures. For example, a survey of Hip Society members in 2011 found that the average time for the first follow-up visit after a total hip replacement was 4.9 weeks with only 1.2% of respondents following up in a week.²⁴ A twice-monthly VCC schedule would accommodate the follow-up practice patterns of more than 98% of this sample of orthopedic surgeons.

The support of Iowa’s orthopedic surgery workforce has been high and consistent for decades. More than 4 in 10 orthopedic surgeons in Iowa staff a VCC in a given year. Over the 30 years covered by this study, 282 Iowa-based orthopedic surgeons and 68 out of state orthopedic surgeons staffed rural outreach clinics in Iowa. We limited much of our analysis to Iowa-based physicians since we have no information on other possible outreach activities by non-Iowa orthopedic surgeons.

The benefits of VCC outreach for rural patients come at a cost. While there are wide variations across individuals, most (50.3%) orthopedic surgeons staff only a single VCC site each year. The monthly average commitment by an individual physician in terms of clinic days is 3.41 (over the last 10 years) and miles traveled is 280 (in the last 10 years). [Of course, depending on the individual physician, these time and travel burdens may be much higher.] Due to travel time, travel costs, space rental costs, etc., there is a considerable economic expense associated with rural outreach.¹⁵ These costs have been absorbed by the participating physicians. New models of reimbursement for procedural orthopedic care should be reviewed for their ability to support rural outreach whether through a VCC model or some other system. Without accounting for these “hidden” costs of serving rural patients in their own communities, payment reform may worsen rather than improve access to orthopedic care for rural patients.

This study is subject to limitations due to its focus on a single rural state. Differences in geography, demographics, insurance coverage, history, etc. between Iowa and other rural states may reduce the appropriateness of the VCC model for other situations. Our data is limited to measurements of the participation of physicians in rural outreach and, therefore, does not inform us about the quality of the care being provided in the VCC setting. Furthermore, while the in-person VCC model of rural outreach has a long legacy, the future for follow-up care, for example, may lie in telemedicine.²⁵

Conclusion

As a model for rural outreach, VCCs offer potential benefits to patients as well as participating providers. Rural patients can meet in-person with an orthopedic surgeon in one’s own community. Furthermore, VCCs can improve coordination of care for patients with primary care providers.¹⁵ What is unknown is how well this model fulfills the needs of patients for “local” care when major procedures are often referred to larger, nearby urban hospitals.

In their concluding remarks on “Orthopedic Care in Underserved Areas,”¹³ the authors called for, “providers who see the value in and are willing to practice in rural communities.” While most of the Iowa-based orthopedic surgeons who participate in VCC outreach reside in urban areas, they apparently see value in maintaining these relationships for years. However, with changes in provider reimbursement and other health system reforms, the viability of this type of rural outreach may be reduced. Therefore, in addition to studying the option of training and financially supporting an orthopedic surgeon to work in a rural area, further research is needed on how to maintain and possibly expand currently working models of rural outreach.