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. 2018 Feb 1;153(2):150-159.
doi: 10.1001/jamasurg.2017.3799.

Geographic Diffusion and Implementation of Acute Care Surgery: An Uneven Solution to the National Emergency General Surgery Crisis

Jasmine A Khubchandani  1 , Angela M Ingraham  2 , Vijaya T Daniel  3 , Didem Ayturk  3 , Catarina I Kiefe  4 , Heena P Santry  3   4
Affiliations

Geographic Diffusion and Implementation of Acute Care Surgery: An Uneven Solution to the National Emergency General Surgery Crisis

Jasmine A Khubchandani et al. JAMA Surg. .

Abstract

Importance: Owing to lack of adequate emergency care infrastructure and decline in general surgery workforce, the United States faces a crisis in access to emergency general surgery (EGS) care. Acute care surgery (ACS), an organized system of trauma, general surgery, and critical care, is a proposed solution; however, ACS diffusion remains poorly understood.

Objective: To investigate geographic diffusion of ACS models of care and characterize the communities in which ACS implementation is lagging.

Design, setting, and participants: A national survey on EGS practices was developed, tested, and administered at all 2811 US acute care hospitals providing EGS to adults between August 2015 and October 2015. Surgeons responsible for EGS coverage at these hospitals were approached. If these surgeons failed to respond to the initial survey implementation, secondary surgeons or chief medical officers at hospitals with only 1 general surgeon were approached.

Interventions: Survey responses on ACS implementation were linked with geocoded hospital data and national census data to determine geographic diffusion of and access to ACS.

Main outcomes and measures: We measured the distribution of hospitals with ACS models of care vs those without over time (diffusion) and by US counties characterized by sociodemographic characteristics of county residents (access).

Results: Survey response rate was 60% (n = 1690); 272 responding hospitals had implemented ACS by 2015, steadily increasing from 34 in 2001 to 125 in 2010. Acute care surgery implementation has not been uniform. Rural regions have limited ACS access, with hospitals in counties with greater than the 75th percentile population having 5.4 times higher odds (95% CI, 1.66-7.35) of implementing ACS than hospitals in counties with less than 25th percentile population. Communities with greater percentages of adults without a college degree also have limited ACS access (OR, 3.43; 95% CI, 1.81-6.48). However, incorporating EGS into ACS models may be a potential equalizer for poor, black, and Hispanic communities.

Conclusions and relevance: Understanding and addressing gaps in ACS implementation across communities will be crucial to ensuring health equity for US residents experiencing general surgery emergencies.

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Conflict of interest statement

Conflict of Interest Disclosures: None reported.

Figures

Figure 1.
Figure 1.. Acute Care Surgery (ACS) Implementation Diffusion
Total ACS hospitals by year among 1690 survey respondents (ACS hospital based on self-report in national survey). Twenty-eight hospitals that reported uptake of ACS did not report what year the model was implemented.
Figure 2.
Figure 2.. Distribution of Hospitals With Acute Care Surgery (ACS) vs Hospitals That Have Not Implemented ACS Across the United States
This map shows the distribution of ACS (272) vs non-ACS (1324) hospitals in the continental United States by county population density in 2015.
Figure 3.
Figure 3.. Access to Hospitals With Acute Care Surgery (ACS) Based on Race and Ethnicity in 2015
A, ACS hospitals (272) mapped over US county percentage of African American population. B, ACS hospitals (272) mapped over US county percentage of Hispanic population. C, ACS hospitals (272) mapped over US county percentage of white population (ACS hospital based on self-report in national survey).
Figure 4.
Figure 4.. Access to Hospitals Providing Acute Care Surgery (ACS) Based on Socioeconomic Characteristics in 2015
A, ACS hospitals (272) mapped over US county percentage of uninsured population. B, ACS hospitals (272) mapped over US county percentage of population living less than 200% below federal poverty level. C, ACS hospitals (272) mapped over US county percentage of adults older than 25 years with at least a bachelor’s degree (ACS hospital based on self-report in national survey).
See this image and copyright information in PMC

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