title: Rural hospitals and volume standards in surgery.
abstract: BACKGROUND
  We sought to understand the potential impact of volume-based referral policy on rural hospitals by estimating the proportion of low-volume operations occurring in rural versus urban hospitals.
  
  
  METHODS
  We performed an observational study using the national Medicare population who underwent one of 12 high-risk operations from 1999-2001. Low-volume hospitals were considered those in the 2 lowest quintiles for each procedure. Hospitals were assigned to 1 of 3 types of geographic locations on the basis of Rural-Urban Commuting Area Codes: urban areas, rural large towns, or rural small towns. For each of the 12 operations, we estimated the proportion of patients undergoing operation in low-volume hospitals within each type of geographic area.
  
  
  RESULTS
  For all 12 operations, the majority of surgical cases were performed in urban areas (ranging from a low of 76% for colectomy to 96% for heart valve operations). Evaluation of only operations performed in low-volume hospitals showed that the majority of surgical cases were still located in urban areas (varying from a low of 55% for colectomy to a high of 94% for heart valve operations). Operations with a stronger effect of volume on outcome (eg, pancreatic and esophageal resection) were more concentrated in urban areas, compared with operations with a weaker effect (eg, colectomy).
  
  
  CONCLUSIONS
  Most low-volume operations take place in urban hospitals. Efforts to direct patients to high-volume hospitals can exempt rural hospitals and still realize most of the potential benefits.
authors.affiliation: VA Outcomes Group, Department of Veterans Affairs Medical Center, White River Junction, VT 05009, USA. Justin.B.Dimick@Dartmouth.edu
authors.forename: Justin B
authors.initials: JB
authors.lastname: Dimick
authors.forename: Samuel R G
authors.initials: SR
authors.lastname: Finlayson
mesh_terms: D000368:Aged; D003082:Colectomy / Q000706:statistics & numerical data; D019918:Heart Valve Prosthesis Implantation / Q000706:statistics & numerical data; D006780:Hospitals, Rural / Q000706:statistics & numerical data*; D006786:Hospitals, Urban / Q000706:statistics & numerical data*; D006801:Humans; D006278:Medicare / Q000706:statistics & numerical data / Q000639:trends; D012017:Referral and Consultation / Q000706:statistics & numerical data; D013503:Surgery Department, Hospital / Q000706:statistics & numerical data*; D013514:Surgical Procedures, Operative / Q000706:statistics & numerical data*; D014481:United States