In Reply:-I am pleased that the Drs. Aldrete share the interest in and concern for the adequacy of anesthesia care in the rural United States expressed in my editorial. They note an apparent discrepancy between their assessment of the availability of anesthesiologists in their Florida panhandle region and that depicted in Figure 1. That illustration is a map of the geographic distribution of anesthesiologists across the United States, which was developed from the data and “viewer” software in the CD-ROM accompanying The Dartmouth Atlas of Health Care 1998. Although not involved in that mapping project, I can offer some reasons for the discrepancy, as well as comment on the Aldretes' other unrelated concerns.
The Aldretes' assessment of anesthesiologists' availability in their region relates presumably to the current situation (i.e., 1998), whereas the Atlas is based on the latest available national data (1996) collected in the American Medical Association and American Osteopathic Association surveys, unique data sources used widely for public and private physician workforce analyses. In contrast to the Aldretes' tabulations of hospital-associated personnel, these data sources also include physicians working in non-hospital settings (e.g., hospital-independent, freestanding surgery center; pain management office practice). More important, the Aldretes' assessment relates to their region's seven rural (and nine total) counties, whereas an early finding of the Atlas project was that geopolitical areas (e.g., counties) correspond poorly to where patients actually receive their medical care. The areas mapped in Figure 1are the hospital referral regions that are defined by where Medicare patients were hospitalized for major cardiovascular and neurosurgical procedures. The Florida panhandle region overlaps with four such hospital referral regions, one of which has its greatest land coverage in neighboring Alabama: Pensacola (9.7 anesthesiologists/100,000 population), Panama City (7.2), Tallahassee (7.6), and Dothan (7.6). Hence, comparing the Aldretes' assessment and what is mapped in Figure 1is much like comparing apples and oranges.
The Aldretes also seem to impugn physician data obtained in the American Hospital Association's Annual Survey mailed to hospital administrators. In years in which AHA has inquired about physicians, the survey has specified medical staff membership at the time of the survey, leaving little subjectivity. The administrator has also been a most appropriate person to complete the form in relation to studies of anesthesiologists' availability, given that so many hospitals lack anesthesiologists (e.g., about one third nationally, [3-6]69% in rural Washington and Montana, and 71% in rural counties of the Florida panhandle according to the Aldretes). Thus, AHA Annual Survey data have enjoyed usage in ASA, [3,4]personal, [5,6]and other anesthesia-related studies in which the hospital is the unit of analysis.
Like the Aldretes, I would encourage anesthesiologists to consider rural sites, even though the challenges of developing a physician-directed anesthesia practice de novo may be substantial.
Frederick K. Orkin, M.D., M.B.A.
Department of Health Evaluation Sciences; The Milton S. Hershey Medical Center; 500 University Drive, H173; Hershey, Pennsylvania;firstname.lastname@example.org
(Accepted for publication July 9, 1998.)