Kornelsen Jude, Av-Gay Gal, Parajulee Anshu, Humber Nancy, Ebert Sean, Skinner Tom, Stoll Kathrin
From the Centre for Rural Health Research, Department of Family Practice, University of British Columbia, Vancouver, BC (Kornelsen, Av-Gay, Parajulee, Stoll) and the Rural Coordination Centre of British Columbia, Vancouver, BC (Humber, Ebert, Skinner).
Can J Surg. 2025 Jun 10;68(3):E221-E234. doi: 10.1503/cjs.003423. Print 2025 May-Jun.
Many rural communities have lost local access to procedural care, and although rural surgical services have endured in some regions, questions regarding quality and safety of care have persisted. Using retrospective observational data, we sought to compare adverse outcomes of the most common surgical procedures performed at rural facilities in British Columbia and outcomes by provider specialty. Our objective was to show whether the efficacy of surgical care at rural facilities is comparable to that of larger referral facilities and whether family physicians with enhanced surgical skills (FPESS) have outcomes comparable to those of specialists at referral facilities for low-morbidity patients.
We included patients who had a colonoscopy, hernia repair, appendectomy, or cesarean delivery at 1 of 7 rural hospitals in BC that participated in the Rural Surgical and Obstetrics Networks of BC and corresponding referral facilities between 2016 and 2021. To control for differences in the acuity of patients between facility types, we risk stratified data by patient comorbidity level, in addition to adjusting for other demographic differences using multivariable Firth logistic regression analysis. We also compared the outcomes of FPESS with those of regional specialists for low-acuity patients in a similar manner. We calculated adjusted odds ratios (ORs), used tests of noninferiority to obtain values for the adjusted ORs, and calculated E-values to estimate the extent to which our findings could be due to other unmeasured confounding.
Most surgical procedures at rural hospitals were performed by FPESS ( = 4403, 34.9%) and visiting general surgeons ( = 7317, 57.9%). We found that the quality of care at rural facilities was at least equivalent to the quality at referral facilities in rural BC for colonoscopy, hernia repair, and appendectomy, and that FPESS had outcomes at least equivalent to those of specialists for low-acuity patients.
Our findings provide evidence in favour of the efficacy of rural procedural care at BC facilities, and although these results are not inherently generalizable to other populations, we believe they illustrate the potential for high-quality rural care for low-acuity procedures in similar settings. These findings are an important step toward documenting rural-specific outcomes and creating attendant benchmarks for rural practice.
许多农村社区已无法在当地获得程序性医疗服务，尽管农村外科服务在一些地区得以存续，但有关医疗质量和安全性的问题依然存在。我们利用回顾性观察数据，比较了不列颠哥伦比亚省农村医疗机构最常见外科手术的不良结局以及不同医疗服务提供者专业的手术结局。我们的目的是表明农村医疗机构的外科医疗效果是否与大型转诊机构相当，以及具备增强手术技能的家庭医生（FPESS）对低发病率患者的手术结局是否与转诊机构的专科医生相当。
我们纳入了2016年至2021年间在不列颠哥伦比亚省参与农村外科和产科网络的7家农村医院之一以及相应转诊机构接受结肠镜检查、疝气修补术、阑尾切除术或剖宫产的患者。为控制不同类型医疗机构中患者病情严重程度的差异，我们除了使用多变量费思逻辑回归分析调整其他人口统计学差异外，还按患者合并症水平对数据进行风险分层。我们还以类似方式比较了FPESS和区域专科医生对低病情严重程度患者的手术结局。我们计算了调整后的比值比（OR），使用非劣效性检验获得调整后OR的 值，并计算E值以估计我们的研究结果可能因其他未测量的混杂因素而产生的程度。
农村医院的大多数外科手术由FPESS（n = 4403，34.9%）和来访的普通外科医生（n = 7317，57.9%）实施。我们发现，农村医疗机构的医疗质量在结肠镜检查、疝气修补术和阑尾切除方面至少与不列颠哥伦比亚省农村转诊机构的质量相当，并且FPESS对低病情严重程度患者的手术结局至少与专科医生相当。
我们的研究结果为不列颠哥伦比亚省农村程序性医疗的疗效提供了证据支持，尽管这些结果并非必然适用于其他人群，但我们认为它们说明了在类似环境中对低病情严重程度手术提供高质量农村医疗服务的潜力。这些研究结果是记录农村特定结局并为农村医疗实践创建相关基准的重要一步。
