title: The impact of general surgeon supply on the risk of appendiceal rupture in North Carolina.
abstract: OBJECTIVE
  To determine whether individuals from surgery-specific service areas with a low supply of general surgeons (GSs) are at increased risk for ruptured appendicitis (ruptured appendicitis is an indicator of surgical access).
  
  
  BACKGROUND
  The increased health care costs and morbidity linked to appendiceal rupture are considered preventable in most cases with timely access to surgery. Among the factors thought to affect an individual's access to surgery for appendicitis is the relative supply of GSs. The maldistribution of GSs is targeted by a Medicare bonus payment although the impact of GS supply on surgical access has yet to be fully described.
  
  
  METHODS
  Patients discharged from acute care and ambulatory surgery facilities in North Carolina from 2007 to 2009 were pooled for observational analysis. Using ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) codes, cases were identified as ruptured or unruptured. GS shortage levels based on supply were calculated at the surgical service area level and tested for an association with an individual's risk of rupture using logistic regression.
  
  
  RESULTS
  Living in a service area with less than 3 GSs per 100,000 people significantly increases the probability of rupture in individuals with appendicitis, compared with living in a service area with at least 5 GSs per 100,000.
  
  
  CONCLUSIONS
  The supply of GSs does affect access to surgical services for appendicitis. Expanding on this finding, the recently instituted HPSA (health professional shortage area) surgical incentive payment from the Affordable Care Act should be evaluated closely for its effectiveness. Enhancing supply in critical shortage areas could reduce appendiceal rupture and improve surgical access more generally.
authors.affiliation: From the American College of Surgeons Health Policy Research Institute; Department of Health Policy and Management, University of North Carolina; and Cecil G. Sheps Center for Health Services Research, Chapel Hill, NC.
authors.forename: Simon
authors.initials: S
authors.lastname: Neuwahl
authors.forename: Thomas
authors.initials: T
authors.lastname: Ricketts
authors.forename: Mark
authors.initials: M
authors.lastname: Holmes
mesh_terms: D000208:Acute Disease; D000328:Adult; D001062:Appendectomy / Q000706:statistics & numerical data*; D001064:Appendicitis / Q000175:diagnosis / Q000601:surgery*; D003695:Delivery of Health Care / Q000458:organization & administration*; D005260:Female; D013502:General Surgery; D006801:Humans; D008297:Male; D008507:Medically Underserved Area; D009657:North Carolina; D010820:Physicians / Q000600:supply & distribution*; D012307:Risk Factors; D012422:Rupture, Spontaneous; D000078329:Workforce