Previous investigations have shown that there are disparities in healthcare services provided to rural and urban residents. Removing these disparities has become a national priority because good healthcare shouldn’t depend on where people live. Disparities in care to rural residents can have important implications for how healthcare resources are allocated. For example, patient outcomes are typically better with hospitals and surgeons performing higher volumes of given procedures. Outlying rural hospitals may be performing lower volumes of these procedures, but it’s important to balance this with the need for these procedures if there are no nearby hospitals and surgeons.

Rural Vs Urban Settings

In an effort to better understand the association between receipt of greater and lesser discretionary surgeries among residents in rural versus urban settings, my colleagues and I conducted an analysis that was published in the May 2011 Archives of Surgery. In this analysis, we analyzed disparities between settings by looking at the incidences of several elective procedures (lumbar spine fusion, total hip and knee replacement surgery, and prostatectomy) as well as that of less discretionary procedures (abdominal aortic aneurysm repair [AAA], aortic valve replacement, non-incidental appendectomy, open reduction and internal fixation of the femur, and carotid endarterectomy [CEA]).

According to our findings, rural Medicare beneficiaries were significantly more likely than their urban counterparts to undergo a wide variety of surgical procedures. These procedures ranged from those that were generally more discretionary, especially total joint replacement surgery and lumbar spine fusion, to those that were generally less discretionary, including CEA and appendectomy. The magnitude of this difference was also important to note. Rural patients were at least 20% more likely to undergo five of the nine procedures studied in the analysis (CEA, lumbar spine fusion, knee replacement surgery, AAA repair, and prostatectomy). Several factors—race, household income, and gender—can significantly influence whether patients undergo surgery. After adjusting for these variables, as well as age and state of residence, rural Medicare beneficiaries remained much more likely to undergo any of the nine surgeries evaluated. We concluded that rurality was associated with the increased likelihood of rural Medicare beneficiaries undergoing a wide variety of surgical procedures.

Ramifications of Rurality Disparity

The uniformity of the results suggests there is a general difference in rural areas that appears to be driving the increased use of surgical procedures in rural areas rather than individual risk factors for each of the various diseases that lead to these procedures. The most important question raised by the results of our study is whether or not rural residents have significantly poorer health than urban residents. Is the frequency of the underlying diseases equal between rural and urban populations? If so, these findings could suggest that cultural and other differences among these populations drive their decisions for undergoing surgery. Interventions would then need to be tailored toward improving overall health in these regions. Another possibility is that access problems are more severe in urban rather than rural areas. Or, these results could suggest that rural beneficiaries have a higher burden of the underlying diseases that lead to these surgeries.

It’s clear that more studies are needed to determine the driving forces of this surprising disparity. As more information unfolds, the hope is that healthcare systems will then establish strategies to help reduce the surgical burden of rural residents and improve their overall health.



Francis ML, Scaife SL, Zahnd WE. Rural-urban differences in surgical procedures for Medicare beneficiaries. Arch Surg. 2011;146:579-583. Available at:

Francis ML, Scaife SL, Zahnd WE, Cook EF, Schneeweiss S. Joint replacement surgeries among Medicare beneficiaries in rural compared with urban areas. Arthritis Rheum. 2009;60:3554-3562.

Axelrod DA, Guidinger MK, Finlayson S; et al. Rates of solid-organ wait-listing, transplantation, and survival among residents of rural and urban areas. JAMA. 2008;299:202-207.

Institute of Medicine. Quality through collaboration: the future of rural Accessed June 3, 2011.