Improving Access to Healthcare in Rural Communities

The World Health Organization identifies anesthesia and surgical services as part of a universal right to health [1]. While an important issue is the challenges to anesthesia in lower- and middle-income countries (LMICs), similar challenges to access exist in high-income countries, as well. As a result of staffing shortages and declining investment in rural hospitals, many rural areas in affluent countries such as United States, Canada, and Australia have limited access to safe anesthesia. At the same time, a study by Smith et al found that rural populations are largely older and sicker than urban populations, leading to a greater demand for anesthesia and surgical services [2]. However, several initiatives to improve access to safe anesthesia in rural communities are making strides toward assuaging these issues.

The lack of timely access to anesthesia in rural communities is largely due to a shortage of workers. Staffing shortages are a problem across the U.S., according to a study by Daugherty et al that predicted a shortage of 4,500 anesthesiologists by 2020. However, the same study found that 95% of anesthesiologists live in urban areas, meaning that this shortage will be felt most acutely in rural areas [3]. Canada has also seen similar staffing shortages. A study by Pong and Pitblado found that rural areas, which account for 21.1% of the total population, only have 2.4% of the country’s specialists [4].

The effects of staffing shortages are compounded by the attrition of small hospitals, a mainstay of rural healthcare. According to the American Hospital Association, rural “critical access” hospitals account for 57% of all hospitals in the United States [5]. However, these hospitals are closing at an alarming rate. A study by Hsia and Shen that tracked this decline found that 30% of the rural population now lives more than 30 miles from a hospital [6].  The resulting loss in specialized services such as anesthesia, is extremely dangerous as it raises risks when patients must travel further for care.

One of the most popular methods for improving access to safe anesthesia involves distributing care to other medical professionals, usually anesthesia-adjacent personnel or family physicians. While shortages of CRNAs across the U.S. also impact rural areas, a study by Fallacaro and Ruiz-Law found that 18.6% of CRNAs reside in rural areas, more than double the number of anesthesiologists [7]. As a result, in the rural United States, anesthesia is normally performed by certified registered nurse anesthetists (CRNAs) or assistants [8]. In Canada, however, this work is most often done by family practitioners (GPs) who receive additional training in anesthesia. A study of hospitals in rural western Canada by Chiasson and Roy found that 80% of facilities surveyed used GPs for anesthesia care, while 67% rely solely on GPs to provide anesthesia to patients [9]. For its part, Australia has chosen to invest in professional development initiatives. The Joint Consultative Committee Anesthesia develops training and educational resources for rural practitioners and helps standardize procedures across the country [10].

Telemedicine, a more recent introduction, has the potential to offer remote access to specialists and is particularly promising when it comes to consultations. A study of medical literature by Schoen and Prater found that telemedicine is particularly useful in rural areas [11]. Indeed, Smith et al found that telemedicine has had significant success improving care in rural Australia [12]. And, a pilot study by Applegate in the U.S. found that telemedicine worked particularly well for pre-anesthetic consultations [13]. While these applications are recent and often still in pilot stages, they have shown promise in delivering safe anesthesia care to rural communities.

References

[1] “Strengthening Emergency and Essential Surgical Care and Anaesthesia as a Component of Universal Health Coverage.” World Health Assembly, World Health Organization, 26 May 2015, apps.who.int/medicinedocs/documents/s21904en/s21904en.pdf.

[2] Smith, Karly B., et al. “Addressing the Health Disadvantage of Rural Populations: How Does Epidemiological Evidence Inform Rural Health Policies and Research?” Australian Journal of Rural Health, vol. 16, no. 2, Apr. 2008, pp. 56–66., doi:10.1111/j.1440-1584.2008.00953.x.

[3] Daugherty, Lindsay, et al. “United States Faces a Shortage of Anesthesia Providers.” RAND Corporation, 7 July 2010, www.rand.org/pubs/research_briefs/RB9541.html.

[4] Pong, Raymond W, and J. Roger Pitblado. Geographic Distribution of Physicians in Canada: Beyond How Many and Where. Canadian Institute for Health Information, 2005.

[5] “Fast Facts on US Hospitals.” AHA Resource Center, American Hospital Association, Jan. 2019, www.aha.org/system/files/2019-01/2019-aha-hospital-fast-facts.pdf.

[6] Hsia, Renee Yuen-Jan, and Yu-Chu Shen. “Rising Closures Of Hospital Trauma Centers Disproportionately Burden Vulnerable Populations.” Health Affairs, vol. 30, no. 10, Oct. 2011, pp. 1912–1920., doi:10.1377/hlthaff.2011.0510.

[7] Fallacaro, Michael D, and Theresa Ruiz-Law. “Distribution of US Anesthesia Providers and Services.” AANA Journal, vol. 72, no. 1, Feb. 2004, pp. 9–14.

[8] Orser, Beverley A., et al. “Improving Access to Safe Anesthetic Care in Rural and Remote Communities in Affluent Countries.” Anesthesia & Analgesia, vol. 129, no. 1, 2019, pp. 294–300., doi:10.1213/ane.0000000000004083.

[9] Chiasson, Patrick M, and Peter D Roy. “Role of the General Practitioner in the Delivery of Surgical and Anesthesia Services in Rural Western Canada.” Canadian Medical Association Journal, vol. 153, no. 10, 15 Nov. 1995, pp. 1447–1452.

[10] Davie, M. J. “General Practitioner Anaesthesia Survey 2006.” Anaesthesia and Intensive Care, vol. 34, no. 6, 2006, pp. 770–775., doi:10.1177/0310057×0603400612.

[11] Schoen, Diane C, and Katherine Prater. “Role of Telehealth in Pre-Anesthetic Evaluations.” AANA Journal, vol. 87, no. 1, Feb. 2019, pp. 43–49.

[12] Smith, Anthony C, et al. “Telemedicine and Rural Health Care Applications.” Journal of Postgraduate Medicine, vol. 51, no. 4, 2005, pp. 286–293.

[13] Applegate, Richard L., et al. “Telemedicine Pre-Anesthesia Evaluation: A Randomized Pilot Trial.” Telemedicine and e-Health, vol. 19, no. 3, 5 Feb. 2013, pp. 211–216., doi:10.1089/tmj.2012.0132.