Health and healthcare in rural America are in crisis, including musculoskeletal care. People living in rural areas tend to be older, with more than 20 percent of individuals in rural America aged 65 years or older. And they are more likely to be living in poverty. Compared with urban areas, individuals in rural America are more likely to be uninsured or covered by Medicaid; if they have other insurance options, those typically come with higher deductibles.

Because of increased age and lack of local resources, including readily available or affordable healthcare, people living in rural areas tend to be sicker, with higher rates of obesity, diabetes, osteoarthritis (OA), and OA-related functional limitations. There are also higher rates of death related to a variety of health conditions, including after hip fractures.

Due to the higher rate of OA, people living in rural areas are more likely to undergo joint arthroplasty. Although joint arthroplasty outcomes have not been reported to differ based on patients’ geographical regions, one of the key reported differences between rural and urban experiences is difficulty accessing orthopaedic care. There is a noted trend of fewer arthroplasties being performed in rural hospitals. This trend is not surprising; given the economic challenges in rural areas, there are limited healthcare resources, including orthopaedic surgeons.

Although the density of orthopaedic surgeons in metropolitan areas continues to rise, the number in rural areas is decreasing. In numerous counties, particularly in rural areas, there is no local access to an orthopaedic surgeon. Density of orthopaedic surgeons has been found to correlate with median home value and percentage of noninsured people, both of which are issues in rural areas.

Issues with access to care in rural areas are multifaceted. Healthcare facilities, including hospitals, in rural areas are closing at unprecedented rates due to general economic issues. This is exacerbated by physicians, especially surgeons—who are often the economic engines for hospitals—aging out of practice and younger, typically subspecialty-trained orthopaedic surgeons being less likely to fill the voids. The issues recruiting new orthopaedic surgeons in rural areas is a vicious cycle: Hospitals, by and large, lack the financial and infrastructure resources to attract surgeons to rural areas, which leads to decreased billing, directly impacting hospital bottom lines and the available resources with which to attract surgeons.

Until recently, the specific issues with orthopaedic care in rural areas have received less attention. This lack of focus may be due to issues with defining “rurality” and knowing how many orthopaedic surgeons provide care in rural areas and where. According to the U.S. Census Bureau, rurality can be defined based on population (less than 50,000) or population density (no more than 35 people per square mile), land use, or distance from known metropolitan areas. “Rural” has also been defined as any area that is not metropolitan. With the continuing expansion of urban and suburban areas, the line between what is rural and what is not is continuing to blur. However, using the above definitions, rural areas include 70 percent of the land mass in the United States but only 20 percent of the population. This population density, and what it means in terms of economic resources in rural areas, partially explains the issue with building and sustaining healthcare infrastructure in these areas.

It is unclear how many orthopaedic surgeons provide care in rural communities. Care for patients living in rural areas is provided through a variety of models, including patient travel to more metropolitan areas for care, outreach from orthopaedic surgeons with periodic rural clinics as visiting consultants (particularly among academic surgeons), or locum tenens surgeons. Orthopaedic surgeons who reside in a rural area may provide care at multiple rural sites. Unfortunately, there are limited to no data that demonstrate how many orthopaedic surgeons provide care in rural communities (as opposed to care for rural patients who travel to urban areas) and to what degree (e.g., full-time, part-time, outreach clinics, locum tenens). Available data either do not include reference to rural practice or do not differentiate between practicing surgeons and those in training (or retired). The lack of data on orthopaedic care in rural America cripples advocacy efforts. Partnerships among AAOS, state orthopaedic societies, and state medical associations could produce more reliable data, including types of practices in rural areas.

Although all of the listed models provide needed care, models that require patients to travel can be a strain on patients and their families, and models that require surgeons to travel can be impacted by weather, illness, and other uncontrollable factors. It has been estimated that patients in rural areas travel 20 to 250 miles (mean of 50 miles) for emergent musculoskeletal care and 20 to 135 miles (mean of 45 miles) for elective care. Given the health and financial resources of these patients, travel is not always feasible or sustainable. The rise in use of virtual healthcare visits, especially since the COVID-19 pandemic, can address this issue in part—but telemedicine does not address how to provide surgical services.

Having orthopaedic care provided locally would be ideal. However, rural orthopaedic surgeons tend to be older than those practicing in urban areas, and younger orthopaedic surgeons, especially those who have completed a subspecialty fellowship, are less likely to choose to practice in rural areas. This trend has led to an increase in other healthcare professionals, including chiropractors and podiatrists, stepping in to fill the void. From 2000 to 2010, the density of chiropractors increased significantly more in rural areas (6.42 to 21.18 per 100,000) versus urban areas (from 20.34 to 26.64 per 100,000). More than half of chiropractors work in areas with fewer than 50,000 people in the population. During the same decade, the total density of podiatrists increased 45 percent in urban areas and 280 percent in rural areas.

Another solution to supplement orthopaedic care is training family physicians and emergency medicine physicians to manage minor orthopaedic conditions and provide initial management for more complex conditions. Orthopaedic-trained nonphysician clinicians, such as physician assistants and nurse practitioners, can extend the reach of rural orthopaedic surgeons in the community and hospital; however, current data would indicate that it is unlikely that an advanced practice professional would provide orthopaedic care in a county in which there is no orthopaedic surgeon. Thus, relying solely on advanced practice providers to provide rural orthopaedic care is likely not going to adequately address the demand and gap in care. In addition, the perils of scope creep and suboptimal training and supervision of non-physician providers must be considered.

Kim Templeton, MD, FAAOS, FAOA, is professor, vice chair, and former residency program director in the Department of Orthopaedic Surgery at the University of Kansas Medical Center in Kansas City; codirector of the University of Kansas Rural Health Council; and a member of the Accreditation Council for Graduate Medical Education orthopaedic residency review committee.

References

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