Comment for article “Predictors of Hospital Bypass for Rural Residents Seeking Common Elective Surgery”

Access to care in rural America faces significant challenges. These have been worsened by financial instability of rural hospitals leading to an unabating trend of rural hospital closures. Zhang et al addressed a possible contributing factor to rural hospital financial strain—the bypass of paying surgical patients from rural to urban hospitals. The authors used statewide inpatient data from 13 states to evaluate the rate of surgical bypass for 30 operative procedures and associated patient and hospital characteristics. They found that almost 66% of rural patients bypass their local hospitals in favor of urban hospitals. Their work added to the existing literature that has shown that rural bypass is common by including relevant factors such as procedure type, procedure risk, demographics, and individual hospital characteristics. By breaking procedures down, they were able to identify that bypass rates were highest for higher-risk operations. They also found that bypass is more common for those with private insurance and is lowest for Medicaid patients, supporting the scientific premise that bypass has the potential to affect hospital margin. Although the authors nicely highlighted these disparities and associated factors, questions remain as to why bypass occurs and, just as importantly, whether high bypass rates reflect an inappropriate matching of needs to resources.

Understanding rural surgical bypass requires that a broad range of variables are considered that can be broadly grouped into those that are within versus outside of a patient’s control. There is an underlying assumption in this study (and others) that patients who bypass their closest rural hospital have elected to do so. Certainly, patient choice likely plays a role. This assumption is supported by the fact that those with private insurance and those who are potentially more mobile (eg, of a younger age) are more likely to skip over their local hospitals. However, there are other factors outside of patients’ control that are also likely to be contributing. For example, although a hospital might technically have the capability to perform an operation (defined as having evidence that a particular procedure has been performed at least once), this does not sufficiently describe accessibility. Many US rural hospitals struggle to maintain surgical call coverage for their emergency departments.^, For those patients who present to an emergency department with surgical conditions, immediate surgical care may not be available or may be only intermittently available. If this is the case, then going to an urban center for care is not “bypass” but instead appropriate resource matching. In the case of elective operations, if there are only a limited number of surgeons performing procedures, it may be that there is a long waiting time for a procedure. In that case, “bypass” might more accurately represent overflow due to high demand. Finally, although the current study addressed the complexity of surgical procedures, it did not address the medical complexity of the patient. There are cases where a patient’s comorbidities would warrant tertiary care or resources not available at a rural hospital, such as need for advanced intensive care unit services or cardiac anesthesiologists. In these cases, rural surgeons and primary care physicians may be referring their patients to urban institutions that can have the resources to support higher levels of care. It is not clear if nonpatient explanations represent a small or a significant portion of the decision for bypass, but it is critical to characterize these factors to gain a broader understanding of bypass.

As for those drivers for bypass that pertains to a patient’s choice, a more granular analysis is required. For example, there are patients who receive specialty care for other conditions at urban hospitals given the fact that specialists may not be available in their regions. If those patients require an operation, they may elect to have their procedures at the same hospital so that there is continuity of care. Other factors may make local hospitals less attractive to rural patients. There are also concerns with compromising privacy given the possible stigma associated with conditions in rural communities. In this case, going to the nearest urban center provides the anonymity a patient may feel is needed. Finally, perceptions about the quality of care are important to explore. There will be times when this is true and other times when it is not true. Taken these factors into consideration, the patient’s decision to bypass may be grounded in valid need and/or accurate perception and therefore appropriate.

Until we truly understand the current drivers for bypass, it is not appropriate to assume that the entirety of the 65% bypass rate reflects inappropriate decision making or even a bias against rural hospitals. The financial implications of surgical bypass also require further study. A question that was raised by the current study and others is whether the business case exists to retain surgical cases locally. Given the shortage of specialty surgeons in rural areas, the cost to recruit surgeons may be sufficiently high, leading to narrow financial margins unless a certain threshold of cases can be met. Given the fact that rural communities are small, achieving the threshold for all these procedures might not be possible or may change over time. What also must be taken into consideration are reimbursement dynamics that expose rural hospitals to risk. Rural hospitals have been shown to have low margins and are at risk with any changes to policy, demographics, or population size.^, How we create stable access to quality care in rural areas is critically important, and there are signs that in the current environment we are not doing a good job. But this is a question that is larger than surgical bypass, as it is intimately tied to policy. Bypass may be making rural hospitals weaker by exacerbating existing financial strain, or, alternatively, it might a symptom of the larger problem.