The differences between densely and sparsely populated areas is a common awareness in society, and the general public tends to label communities broadly as being either urban or rural. However, the degree of rurality falls along a wide spectrum. The definition of rurality depends on the scale used to define it.1,2 Therefore, a dichotomous labeling of urban vs rural is overly simplistic and inaccurate. The determination of rurality of a community is important because it has consequences regarding the allocation of funding, as well as the implementation of federal policies and benefits to rural residents. Moreover, this impacts clinical research, quality of care, and outcome measures initiatives.1–3 The factors used to determine and classify rurality include population density, urbanization, and daily commuting classification.4
Regardless of the system used to classify rurality in geographic areas, providing health care in rural communities is challenging for general practitioners and patients alike. Specialist providers have added hurdles in providing care to such patients. This article reviews some of the challenges facing appropriate and timely orthopedic care delivery in the rural setting and outlines available strategies to address such challenges.
Although rural communities occupy 72% of the US land area, approximately one-sixth of the US population (46 million people) live there.1,5–8 The rural population has been decreasing since 20106–8 and, with population loss, poverty rates have increased and educational attainment has decreased compared with urban areas.8
The rural poverty rate was an estimated 18.1% in 2014, whereas the urban rate was 15.1%.8 Median earnings are substantially lower in rural areas than in urban areas, although this shortfall is mitigated by rural-urban differences in living costs.6 The educational attainment in rural areas is significantly lower than in urban areas; this gap has increased over time. In 2014, 19% of rural young adults had a bachelor's degree compared with 35% of urban young adults.8 This lower educational achievement contributes to lower rates of health care literacy and a decreased understanding of their health conditions, their significance, and the importance of compliance with treatment.1
Rural populations are less likely to have adequate health care insurance coverage,1 and they are aging and becoming more ill much more quickly than urban populations.9 They have higher rates of chronic illnesses, such as high blood pressure, chronic obstructive pulmonary disease, cancer, diabetes mellitus, and obesity, as well as higher rates of smoking, alcohol and drug abuse, and lack of exercise.1
Due to this plurality of problems, rural populations experience accelerated effects of aging as compared with urban dwellers, which in turns impacts their orthopedic health.9 Unfortunately, only approximately 30% of hospitals in rural areas have a full-time orthopedic surgeon on staff.9
Health Care Delivery in the Rural Setting
Rural areas experience a disproportionate lack of health care services, including a paucity of primary care physicians; many rural residents have difficulty accessing health care.3,10,11 Rural hospitals are small with fewer services and may be admitting no more than 60% of their service area's hospitalized patient population.5,12 They are also less likely to offer surgeries and procedures than their urban counterparts.12 Rural hospitals and practices face increased difficulties in recruiting and retaining medical staff.1,4,10,13 One-third of surveyed hospitals continue to actively recruit general and/or orthopedic surgeons.4,10 Even with financial incentives, certain specialties do not thrive in rural settings.1,4,10,13 Therefore, despite adequate provider-to-rural ratios, it is much less likely to have specialists and subspecialists available in rural communities.4,10
Rural communities prefer to receive medical services locally.10,11 Still, 30% of rural Medicare beneficiaries travel to visit urban providers.14 Rural patients with private insurance are even more likely to visit urban providers.5 Rural Medicare beneficiaries are less likely to have regular outpatient follow-up care, which may explain the increased likelihood of visiting an emergency department after discharge from the hospital.15
One study examined patient-borne expenses in Canada.16 They included costs not covered by health insurance, including food, transportation, and lodging. They estimated that a rural patient's out-of-pocket expenses for an outpatient carpal tunnel release would be more than $2000 higher than an urban patient's costs.16 Other expenses include childcare costs, possession of a driver's license, car ownership and maintenance, and lost work time.17 For a population that is already jeopardized financially, these added monetary burdens lead to expenditure conflict, forcing patients to choose between buying food or gas.4 Patients who have no personal means of transportation must enlist the help of others, creating another source of scheduling conflict and financial burden on a third party.
Beyond cost of travel, patients face other commuting challenges; rural areas are less likely to have well-maintained transportation infrastructures or adequate public transportation. The lack of reliable transportation makes the rural patient particularly vulnerable to weather conditions, as clearing snow and ice in winter is slow and costly for small, rural towns. Moreover, with limited transportation resources, scheduling conflicts force patients to choose between an already established, yet difficult-to-reschedule appointment and a conflicting but also urgent appointment.
Access to Orthopedics in Rural Communities
Information on the delivery of orthopedic services in US rural hospitals is limited.4,18 Approximately 30,000 orthopedic surgeons currently practice in the United States.19 The orthopedic surgeon density averages 9.2 per 100,000 (range, 7.2–15.2) on the state level.19 This number decreases to as little as 3.9 per 100,000 inside individual states.9
Weichel4 surveyed 145 rural hospital administrators. Those hospitals had a median of 25 beds and a service area population of 15,000. Twenty-five percent of the hospitals provided no orthopedic care, and 40% relied on itinerant (locum) orthopedic surgeons. Eighty-six percent of rural hospitals had limited or no orthopedic emergency department coverage. Thirty-three percent were actively recruiting for orthopedic surgeons, and the median estimated time needed to recruit an orthopedic surgeon was 12 months. Recruiting orthopedic surgeons was considered more difficult than recruiting general surgeons and primary care physicians according to 52% and 78% of administrators, respectively. Seventy-seven percent of the surveyed hospitals provided inpatient orthopedic surgery, 10% provided outpatient surgery only, and 13% provided no surgical services. When no orthopedic service was available, patients had to travel a median distance of 50 miles (range, 20–250 miles) one way.4 Another study showed a travel distance of 25 miles, on average.9
Factors Affecting Delivery of Orthopedic Care
Several variables challenge the delivery of adequate orthopedic care in the rural setting. They include delay in presentation, inadequate determination of orthopedic urgencies, limited orthopedic knowledge of local providers, need for subspecialty services, and deficiencies in local support services.
Delay in Presentation
The most common factor affecting orthopedic care is delay in reaching the definitive provider, which starts with delay in presentation to any health care provider. Faced with scheduling, transportation, and financial constraints, patients may neglect or underestimate the extent and/or urgency of the problem. Once it is determined that the condition needs evaluation, the initial provider is usually a general practitioner, an urgent care facility, or an emergency department. Although serious emergencies are typically transferred immediately when recognized, both nonurgent and urgent conditions are referred to the local orthopedic surgeon or the patient's primary care physician. By the time the patient reaches the treating specialist or subspecialist, the time for optimal treatment may have passed, leading to less-than-ideal outcomes.
The determination of orthopedic urgency is not an exact science for the nonorthopedist and is highly dependent on the initial provider's background, training, and experience, as well as access for a peer-to-peer consultation with an orthopedic surgeon. This determination is the first major preventable source of delay for definitive treatment. From this point on, each added referral goes through an administrative process and adds more steps to definitive care. For injuries with surgical indications that are not recognized early on, patients may spend 2 or more weeks between initial contact with the health care system and evaluation by a treating surgeon. Typical examples include surgical fractures and soft tissue injuries sent home as chip fractures and sprains (Figure 1).
Anteroposterior (A) and lateral (B) views of a proximal interphalangeal joint fracture dislocation. Five providers saw the patient on 5 different visits over 4 weeks prior to evaluation by a hand surgeon.
Lack of understanding of what requires orthopedic consultation contributes to delay and can lead to serious consequences, such as admitting a patient with musculoskeletal infections to a facility for intravenous antibiotics with no available orthopedic services. Lack of understanding of what the local orthopedic surgeon is capable of leads to wasted time and resources, as well as increased complexity of care. Examples include admitting patients with injuries requiring subspecialty experience overnight to the local hospital assuming that the local general orthopedic surgeon can take care of it next day, thereby converting a straightforward emergency department-to-emergency department transfer into a more difficult hospital-to-hospital transfer (Figure 2).
Photograph of a 28-year-old pregnant patient who presented with an abscess. She was admitted to the local hospital over the weekend without consulting with the local orthopedic surgeon. On evaluation 3 days later, the orthopedic surgeon determined that she needed to be transferred for surgical evaluation and treatment due to her pregnancy.
Need for Subspecialty
Conditions requiring subspecialty expertise are particularly vulnerable to delay in treatment. Articular fractures, surgical infections, tendon and nerve lacerations, and ligament tears are time sensitive by nature, and the presenting condition progresses from an acute process amenable to primary intervention to delayed surgery, late reconstruction, or salvage procedures. Figure 3 provides a good example of this situation. In particular, pre-established referral patterns can interfere with appropriate and timely orthopedic care. Referral to the local general orthopedist or to the affiliate regional institution by default can waste valuable time and transportation resources if the receiving orthopedist is not qualified to take care of the referral. These multistep referrals deteriorate the outlook for timely and successful recovery for the rural orthopedic patient. The current authors have seen patients with surgical injuries after as many as 5 other providers were unable to provide the appropriate care.
A 50-year-old patient with an anterior shoulder dislocation 2 months previously. She had a reduction in the emergency department on the day of injury but reported re-dislocation after she was released. She was instructed to follow up with the local orthopedic surgeon. Early evaluation would have led to reduction and stabilization; however, 2 months later, she underwent delayed open reduction and graft reconstruction.
Deficiency of the Local Support System
Even when the local orthopedic surgeon is comfortable and qualified to take care of certain conditions, the rural facilities may not have the human resources, equipment, or supplies needed for a successful outcome. Sixty percent to 80% of surveyed rural hospitals provided anesthesia services through a certified registered nurse anesthetist with no supervising anesthesiologist.4,10 Limited anesthesia services may influence the surgical cases these orthopedic surgeons choose to do and the types of patients on which these surgeons choose to operate.4 Moreover, with limited or absent ancillary services, such as physical and hand therapy, orthotics and prosthetics, and wound care, surgeons avoid procedures whose outcomes are dependent on those services. One example is flexor tendon repair, for which outcomes are highly dependent on appropriate and timely supervised hand therapy. Even when available, delay in evaluation and initiation of therapy affects postoperative outcomes significantly.
The rural hospital may also not be able to fully support the local orthopedic surgeon to the extent of the surgeon's capabilities. The US Government has several programs to help fill physician shortages in rural areas.20 Some of those programs place highly skilled, fellowship-trained subspecialists in rural communities. However, due to economies of scale, rural hospitals are less likely to acquire the specialty-specific instruments and implants required to make use of their surgeons' abilities,5,21 leading to an unfortunate waste of subspecialist orthopedic surgeon experience.
Compliance is directly related to health care literacy and adds to the patient's financial and transportation constraints. Patients with a driver's license had 2 times as many visits, and those who had family or friends providing transportation had 1.6 times more nonurgent visits than those who did not.17 By the same token, some patients underestimate the value of pre- and postoperative compliance.
Optimizing Rural Orthopedic Care
Several strategies can be pursued to improve care for rural patients. These include collaboration efforts, peer-to-peer consultations, outreach clinics, virtual consults, electronic consults, and telemedicine. Other support programs include transportation assistance, as well as treatment choice and patient education programs. Some of these may be limited by the level of available technology in rural areas.
Direct coordination of care between the initial provider and the definitive provider is the most efficient way to deliver appropriate care to patients. It improves patient triage on initial presentation, avoids multilevel referrals, and prevents unnecessary transfers.
Several regional and national tertiary care centers provide physician-to-physician consultation services on a 24/7 basis.22 The call center transfers calls from community providers directly to the appropriate subspecialist when requested for consults, appointments, admissions, transfers, and patient information.
Outreach clinics bring specialists to rural areas.9 These clinics are usually based in community hospitals. A Cochrane review found that specialist outreach combined with collaboration with primary care and patient education was associated with improved health outcomes, more efficient and guideline-consistent care, and less use of inpatient services.23 This approach increases the service area of the orthopedic surgeon significantly and limits the travel distance for patients.9 Advantages include improved connection with local physicians and improved transition of care. One limitation of this approach is its inability to accommodate emergency orthopedic care.
Several strategies rely on technology to limit the burden on patients. In 2016, 39% of rural Americans lacked access to adequate internet access—benchmarked at 25 Mbps—in contrast to only 4% of urban Americans.24 This rate increases to 68% in rural tribal lands and 98% of those living in rural territorial areas.24 When and where available, high-quality telecommunication can be pursued to improve care for rural patients. These include electronic consult (e-consult), telemedicine, and virtual clinic programs.
E-consults rely on screening the electronic records of health care systems and identifying patients at risk. A specialist reviews the medical records of eligible patients and sends a note to the patient's primary care provider that highlights guideline-based recommendations for further evaluation and management. This program was successful in the Veterans Health Administration and helped 117 rural patients with osteoporotic fractures save a total of 11,917 miles of travel.25
One way to provide orthopedic care to rural patients is telemedicine.18,26 With telemedicine, the consulting physician evaluates the patient through web-based, live video conference. Telemedicine encounters for rural Medicare patients in general increased 15-fold between 2004 and 2013.27 Telemedicine requires good quality equipment and internet access.13 Poor quality images make accurate diagnosis difficult.28 One study of 400 patients found that it is safe to offer video-assisted consultations for selected orthopedic patients.26 Physical examination is limited, and the consultation is highly dependent on high-quality video equipment and the internet connection, as well as access to available imaging. Telemedicine is evolving rapidly with respect to reimbursement, licensing, liability, and legislation.9,27
Virtual clinics are similar to telemedicine but are run by a local provider under supervision of a remote specialist. Project ECHO (Extension for Community Health care Outcomes) was started in 2003 to share specialty knowledge with primary care physicians through a weekly virtual clinic run by academic subspecialists and executed by community providers.29 Current programs include bone health and rheumatology.30,31 One limitation is the reliance on the primary care provider for physical examination. The primary care physician may be deficient in orthopedic-specific tests, especially provocative maneuvers and joint stability tests.
Transportation assistance includes travel reimbursement and community-based transportation services, such as those provided by senior citizens' centers. Transportation is probably the weakest link in health care delivery; travel assistance helps improve compliance with follow-up and limits less favorable outcomes.
Treatment Choice and Patient Education
Adapting the treatment strategy is frequently necessary together with proper and thorough patient education and depends on the patient's understanding and goals. One must consider the patient as a whole and not just the patient's orthopedic condition. It makes little sense to choose a treatment option requiring complex rehabilitation when the patient is unwilling or unable to travel or be compliant with the treatment plan. Patient education and home exercise programs can be useful, especially when local physical therapy is not available. Educating the patient regarding the nature of the diagnosis, treatment, and rehabilitation is important, as is stressing the need for follow-up. Deferring follow-up to local providers when appropriate also limits the burden on the patient and community.
The World Health Organization opines that adequate access to health care in rural communities is a human right to health and a matter of social justice.32 It is included in the United Nations' Millennium Development Goals. Access to health care in rural America has been under increased attention in the past few years as the government and public continue to debate health care reform.3 Other countries, such as Australia, face similar geographic challenges in health care.13
Orthopedic surgery carries a high impact on rural communities. Rural hospital administrators strongly believe that a full-time orthopedic surgeon (1) significantly improves the hospital's finances, (2) is viewed positively by the community, and (3) affects the quality of care provided in the community.4 Unfortunately, many rural communities do not have any orthopedic surgeons, whereas others rely on locum orthopedic surgeons.4,33 Rural orthopedic emergency department coverage is deficient as well. The distance traveled to obtain orthopedic care out of town can be as far as 250 miles one way. Thirty-three percent of the rural hospitals in the United States are actively recruiting orthopedic surgeons.4 According to the American Academy of Orthopaedic Surgeons, orthopedic surgeon availability in the United States improved from 1 for every 14,000 people in 2008 to 1 for every 11,000 people in 2016.4 Still, there is a 2-fold discrepancy between states,19 which may be much higher at the county level.
Coordination of care between the initial provider and definitive provider is the most efficient way to deliver appropriate care to patients. It improves patient triage on initial presentation, avoids multilevel referrals, and prevents unnecessary transfers. There are other methods used to improve rural patients' access to orthopedic care. Several regional and national tertiary care centers provide physician-to-physician consultation services directly to the appropriate subspecialist when requested. Outreach clinics bring specialists to rural areas periodically, increase the service area of the orthopedic surgeon significantly, and limit the travel distance for patients. Other methods use technology, such as e-consults, telemedicine, and virtual clinics to benefit patients. Lack of ancillary services also necessitates alternative treatment plans and the need to educate patients.
Orthopedic surgery is in high demand in rural communities. Timely and appropriate referral must be improved and altered to accommodate the financial, travel, and educational needs of the rural population. Orthopedic surgeons and specialists should consider local follow-up when appropriate. They should avoid treatment options that require intensive follow-up when possible.
Many challenges are faced in the care of rural patients. These challenges are well-recognized in many countries. The first goal of improving orthopedic care in rural areas is to improve access. Ideally, more providers and resources would be allocated to rural areas. However, given that this may not be possible, it is incumbent upon health care delivery systems to improve other methods of access such as collaboration between primary and specialist services, peer-to-peer consultations, out-reach clinics, and technology-based services.
- Snyder JE, Jensen M, Nguyen NX, Filice CE, Joynt KE. Defining rurality in Medicare administrative data. Med Care. 2017;55(12):e164–e169. doi:10.1097/MLR.0000000000000607 [CrossRef]
- Cromartie J, Parker T. Rural classification: overview. https://www.ers.usda.gov/topics/rural-economy-population/rural-classifications. Accessed May 31, 2019.
- Douthit N, Kiv S, Dwolatzky T, Biswas S. Exposing some important barriers to health care access in the rural USA. Public Health. 2015;129(6):611–620. doi:10.1016/j.puhe.2015.04.001 [CrossRef]
- Weichel D. Orthopedic surgery in rural American hospitals: a survey of rural hospital administrators. J Rural Health. 2012;28(2):137–141. doi:10.1111/j.1748-0361.2011.00379.x [CrossRef]
- Hall MJ, Owings MF. Rural residents who are hospitalized in rural and urban hospitals: United States, 2010. NCHS Data Brief. 2014;159:1–8.
- Kusmin L. Rural America at a Glance, 2016 Edition. Washington, DC: US Department of Agriculture; 2016.
- Cromartie J. How is rural America changing? https://www.census.gov/newsroom/cspan/rural_america/20130524_rural_america_slides.pdf. Accessed May 31, 2019.
- Kusmin L. Rural America at a Glance, 2015 Edition. Washington, DC: US Department of Agriculture; 2015.
- Gruca TS, Pyo TH, Nelson GC. Improving rural access to orthopaedic care through visiting consultant clinics. J Bone Joint Surg Am. 2016;98(9):768–774. doi:10.2106/JBJS.15.00946 [CrossRef]
- Doty B, Zuckerman R, Finlayson S, Jenkins P, Rieb N, Heneghan S. How does degree of rurality impact the provision of surgical services at rural hospitals?J Rural Health. 2008;24(3):306–310. doi:10.1111/j.1748-0361.2008.00173.x [CrossRef]
- Finlayson SR, Birkmeyer JD, Tosteson AN, Nease RF Jr, . Patient preferences for location of care: implications for regionalization. Med Care. 1999;37(2):204–209. doi:10.1097/00005650-199902000-00010 [CrossRef]
- Hall MJ, Owings M. Rural and urban hospitals' role in providing inpatient care, 2010. NCHS Data Brief. 2014;147:1–8.
- Rankin SL, Hughes-Anderson W, House AK, Heath DI, Aitken RJ, House J. Costs of accessing surgical specialists by rural and remote residents. ANZ J Surg. 2001;71(9):544–547. doi:10.1046/j.1440-1622.2001.02188.x [CrossRef]
- Medicare Payment Advisory Commission. Serving rural Medicare beneficiaries. http://www.medpac.gov/docs/default-source/reports/chapter-5-serving-rural-medicare-beneficiaries-june-2012-report-.pdf. Accessed May 31, 2019.
- Toth M, Holmes M, Van Houtven C, Toles M, Weinberger M, Silberman P. Rural Medicare beneficiaries have fewer follow-up visits and greater emergency department use postdischarge. Med Care. 2015;53(9):800–808. doi:10.1097/MLR.0000000000000401 [CrossRef]
- Robb JL, Clapson BJ. The unfunded costs incurred by patients accessing plastic surgical care in Northern Saskatchewan. Plast Surg (Oakv). 2014;22(2):88–90. doi:10.1177/229255031402200215 [CrossRef]
- Arcury TA, Preisser JS, Gesler WM, Powers JM. Access to transportation and health care utilization in a rural region. J Rural Health. 2005;21(1):31–38. doi:10.1111/j.1748-0361.2005.tb00059.x [CrossRef]
- Lambrecht CJ, Canham WD, Gattey PH, McKenzie GM. Telemedicine and orthopaedic care: a review of 2 years of experience. Clin Orthop Relat Res. 1998;348:228–232. doi:10.1097/00003086-199803000-00034 [CrossRef]
- Project ECHO. http://echo.unm.edu/about-echo. Accessed May 31, 2019.
- US Citizenship and Immigration Services. Conrad 30 Waiver Program. https://www.uscis.gov/working-united-states/students-and-exchange-visitors/conrad-30-waiver-program. Accessed May 31, 2019.
- Radcliff TA, Brasure M, Moscovice IS, Stensland JT. Understanding rural hospital bypass behavior. J Rural Health. 2003;19(3):252–259. doi:10.1111/j.1748-0361.2003.tb00571.x [CrossRef]
- WVU Medicine Children's. Medical Access and Referral System (MARS). https://wvu-medicine.org/childrens/for-health-professionals/medical-access-and-referral-system-mars. Accessed May 31, 2019.
- Gruen RL, Weeramanthri TS, Knight SE, Bailie RS. Specialist outreach clinics in primary care and rural hospital settings. Cochrane Database Syst Rev. 2004;1:CD003798.
- Federal Communications Commission. 2016 Broadband Progress Report. https://www.fcc.gov/reports-research/reports/broadband-progress-reports/2016-broadband-progress-report. Accessed May 31, 2019.
- Lee RH, Pearson M, Lyles KW, Jenkins PW, Colon-Emeric C. Geographic scope and accessibility of a centralized, electronic consult program for patients with recent fracture. Rural Remote Health. 2016;16(1):3440.
- Buvik A, Bugge E, Knutsen G, Småbrekke A, Wilsgaard T. Quality of care for remote orthopaedic consultations using telemedicine: a randomised controlled trial. BMC Health Serv Res. 2016;16:483. doi:10.1186/s12913-016-1717-7 [CrossRef]
- Mehrotra A, Jena AB, Busch AB, Souza J, Uscher-Pines L, Landon BE. Utilization of telemedicine among rural Medicare beneficiaries. JAMA. 2016;315(18):2015–2016. doi:10.1001/jama.2016.2186 [CrossRef]
- Johansson AM, Lindberg I, Söderberg S. Patients' experiences with specialist care via video consultation in primary health care in rural areas. Int J Telemed Appl. 2014;2014:143824.
- Project ECHO. Our story. http://echo.unm.edu/about-echo/our-story. Accessed May 31, 2019.
- Project ECHO. Bone health. http://echo.unm.edu/bone-health. Accessed May 31, 2019.
- Project ECHO. Rheumatology. http://echo.unm.edu/nm-teleecho-clinics/rheumatology-clinic. Accessed May 31, 2019.
- Chen LC. Striking the right balance: health workforce retention in remote and rural areas. Bull World Health Organ. 2010;88(5):323. doi:10.2471/BLT.10.078477 [CrossRef]
- Kellerman R, Ast T, Dorsch J, Frisch L. Itinerant surgical and medical specialist care in Kansas: report of a survey of rural hospital administrators. J Rural Health. 2001;17(2):127–130. doi:10.1111/j.1748-0361.2001.tb00269.x [CrossRef]