Completing the Picture – AANS 2006 Workforce Survey Assesses Neurosurgical ER Coverage

Completing the picture of neurosurgical emergency coverage in the United States is the aim of a new survey conducted by the American Association of Neurological Surgeons. The AANS 2006 Workforce Survey shows that while the overall participation of neurosurgeons in the nation’s emergency medical system remains strong, there is room for improvement in neurosurgical call coverage and, more broadly, in the emergency medical system itself.

Figure 1. Percentage of  Neurosurgeons Taking Emergency  Call  Percentages are rounded. Source 2006 Data.  AANS 2006 Workforce Survey:2004 Data, 2004  AANS/CNS Neurosurgical Emergency and Trauma  Services Survey.

The emergency medical system has been the subject of intense scrutiny, most recently by the Institute of Medicine which released three reports June 14 that conjure an image of an unraveling system. The three reports—Emergency Care for Children: Growing Pains, Emergency Medical Services at the Crossroads, and Hospital-Based Emergency Care: At the Breaking Point—depict what the IOM characterizes as an “overburdened, underfunded, and highly fragmented” U.S. emergency medical system.

The IOM reports are the product of the Committee on the Future of Emergency Care in the U.S. Health System, a group commissioned in September 2003 to perform extensive study of emergency care issues. In announcing the reports, committee chair Gail L. Warden observed that “the system’s capacity is not keeping pace with the increasing demands being placed on it” and called for “a comprehensive effort to shore up America’s emergency medical care resources and fix problems that can threaten the health and lives of people in the midst of a crisis.”

Inadequate reimbursement, increased liability, and unintended consequences of the Emergency Medical Treatment and Labor Act, all cited in the IOM report on hospital-based care as factors contributing to inadequate coverage by specialists in the ER, have been among organized neurosurgery’s premier concerns in recent years. These issues were also among the threads comprising the complex fabric that characterizes the delivery of emergency neurosurgical care, described by Alex Valadka, MD, in the cover story of the Winter 2004 Bulletin. Also in that issue, results of the 2004 AANS/CNS Neurosurgical ER and Trauma Services Survey were released.

The 2004 ER survey was clear in its finding that a solid majority, 83 percent, of neurosurgeons or their practices were providing full (24/7/365) emergency coverage. However, as summarized in the Bulletin by AANS Executive Committee member James R. Bean, MD, the survey also showed that “some neurosurgeons [were] straining to provide emergency coverage, particularly those in private practice and in small group settings, and that some patients, particularly trauma victims and children distant from a level 1 trauma center, may be at risk for not receiving timely and appropriate neurosurgical emergency care.”

Figure 2. Compensation for Neurosurgical On-Call Service

That neurosurgeons were interested in and concerned about neurosurgical emergency coverage was demonstrated by the 2004 survey’s robust response rate of 32 percent, coupled with the more than 350 comments offered and the more than half of respondents who volunteered themselves for follow-up discussion of neurosurgical emergency care in their areas.

Neurosurgeons Are Participating in the Emergency Care System
Rather than waning, neurosurgeons’ concern regarding appropriate, quality neurosurgical emergency care has intensified. The AANS Task Force on Neurosurgical Care and Physician Workforce Issues commissioned the 2006 Workforce Survey to help AANS leadership identify and quantify problems in neurosurgical emergency coverage and in other areas of the workforce. Although this survey was broader in scope than the 2004 survey, results of a few key questions regarding emergency neurosurgical care could be compared, though some caveats apply.

The AANS 2006 Workforce Survey was conducted online by Perception Solutions, an independent market research company. E-mail invitations were delivered in January to 2,562 neurosurgeon members of the AANS. The demographics of survey respondents tracked closely with those of AANS members as well as participants in the 2004 survey, with the great majority of respondents ranging from 36 to 55 years of age, in private practice, and practicing in small groups of two to five neurosurgeons or medium groups of six to 20 neurosurgeons.

A total of 770 surveys were completed, resulting in a 30 percent return comparable to that of the 2004 survey. Results are accurate plus or minus 5 percent or better, meaning that the same survey conducted 100 times would yield the same results 95 times.

Figure 3. Services Covered by On-Call Neurosurgeons

The 2006 Workforce Survey reaffirmed that the vast majority of neurosurgeons are taking emergency call. As shown in Figure 1, 94 percent responded affirmatively to the question, Do you take ER call? It is unclear whether the increase in neurosurgical emergency call coverage of 11 percentage points over the 2004 survey result is attributable to broader phrasing of the question in the 2006 survey or to some other factor or factors.

The 2006 survey also indicated a 17 percent increase in the number of neurosurgeons who receive a stipend for emergency call coverage: 50 percent in 2006 compared with 33 percent in 2004, as shown in Figure 2. The distribution of stipend amount remained fairly constant, with the areas of greatest change reported in the $1,001 to $1,500 per diem range (8 percent reduction between 2004 and 2006) and in the number of neurosurgeons who have an arrangement for emergency call other than per diem payment (10 percent increase between 2004 and 2006). However, differences in question design between the 2006 and 2004 surveys may account for some variation in results.

As shown in Figure 4, most on-call neurosurgeons, 59 percent, practiced in a community hospital setting, while 38 percent practiced in an academic medical center and 6 percent selected “other.” As expected, the majority of on-call neurosurgeons practiced at level 1 or level 2 trauma centers, both of which are defined by the American College of Surgeons Committee on Trauma as requiring neurosurgical coverage. Most on-call neurosurgeons also covered call at two or more hospitals (57 percent) with another 43 percent covering call at only one facility, and almost all respondents, 95 percent, said that some or all of their hospitals require them to cover call. About 57 percent of on-call neurosurgeons took call two or three days per week, though nearly equal percentages took call more or less frequently: 22 percent took call four or more days per week, and 21 percent, one day per week or less.

Figure 4. Where On-Call Neurosurgeons Are Practicing   Percentages are rounded. Participants could select more than one   response. Source: AANS 2006 Workforce Survey.

On-call neurosurgeons worked an average of 70 hours per week, with 56 hours devoted to direct patient care. Administrative work absorbed eight hours per week, and 6 hours were spent on research or education, while four hours were allocated to unspecified “other” tasks.

The majority of survey respondents said they provided all types of neurosurgical services. Of the neurosurgeons who took emergency call, 61 percent covered all neurosurgical services in 2006, compared with 54 percent who did so in 2004. Additional results are shown in Figure 3.

In the 2006 survey, the service coverage question also was put to all neurosurgeons participating in the survey, inclusive of those who took emergency call and those who did not. When asked, Have you limited the type of procedures performed by your practice, 62 percent affirmed that they had not. The 38 percent who had limited their practices were asked to identify any procedures they had completely eliminated. The greatest number, 57 percent, had eliminated pediatric cases, while 13 percent had eliminated trauma cases, and 11 percent had eliminated cranial cases. Only 5 percent had eliminated spinal cases, although research by Richard Wohns, MD, published in the Bulletin, indicated that elective spinal cases are the primary source of medical malpractice lawsuits. Another 55 percent selected “other” and offered a variety of explanations, frequently citing aneurysms, neurovascular cases (a lack of available interventionists was noted several times), subarachnoid hemorrhages, and complex cranial and spinal cases as the types of cases eliminated from practice.

Of the scant six percent of neurosurgeons who did not take emergency call, 48 percent selected as their reason “other,” and the great majority of these respondents specified age-related exemptions such as recent retirement or senior partner status. Other reasons this group reported for not taking call included insufficient pay for emergency services (17 percent), disruption of routine practice schedule (15 percent), lifestyle interference (13 percent), malpractice insurer’s premium discount for eliminating trauma or other emergency services (6 percent), and malpractice insurer’s discontinuance of coverage for emergency services (2 percent).

Figure 5. Age Distribution and Year Expected to Stop   Taking Call   *Responses of those not currently taking call may have been included.   Percentages are rounded. Source: AANS 2006 Workforce Survey

For neurosurgeons who said they were planning to stop taking call, the most influential factor was retirement; the great majority of those planning to retire said they had intended to do so anyway, but other factors reported were excessive on-call demands and high malpractice insurance premiums. The second-ranked factor for those planning to discontinue call was lifestyle interference, followed by insufficient pay for emergency services, disruption of routine practice schedule, and “other” unspecified factors. All of these factors outranked the insurer’s elimination of malpractice insurance coverage for call services or insurance premium reduction in return for elimination of trauma or other emergency services. Only 2 percent of all survey respondents reported receiving malpractice insurance premium reductions for not taking call, but of that small group 71 percent received a substantial premium discount of 11 percent or more.

All survey participants also were asked when they expected to stop taking call. As shown in Figure 5, response distribution among the selections was fairly equal. The two top-ranking selections, “2010 or sooner” and “don’t know,” may include responses of those not currently taking call.

Call Coverage, ER System Concern Neurosurgeons
In addition to providing data that help to complete the picture of neurosurgeons’ participation in the emergency medical system, the 2006 Workforce Survey offered insight into neurosurgeons’ perceptions of how the system is working. The survey clearly shows that neurosurgeons think there is plenty of room for improvement in the emergency system and that they are willing to join in the effort.

Fully 76 percent of respondents identified call coverage as a problem in their geographic areas, and most neurosurgeons, 60 percent, disagreed with the statement that the emergency system allows them enough time off call. Of even greater concern are the data that only about half of respondents believe the call system either works in the best interest of patients (52 percent) or is effective (52 percent).

Less than one fifth of respondents (18 percent) reported that their practice group had been involved in development of a hospital’s plan for going “offline,” meaning that ambulances are diverted from a hospital’s emergency department, and nearly one third (32 percent) reported that a plan for going offline doesn’t exist at any of the hospitals for which they cover call. When asked if their group had been involved in developing a hospital’s plan for transfer of patients, less than half (43 percent) responded affirmatively, and 19 percent said there was no transfer plan at any of the hospitals they cover. Only 9 percent of neurosurgeons, a number roughly equivalent to the number of survey participants not taking call, said they would decline to participate in the planning process for handling offline events or patient transfers at their hospitals.

What Is the Complete Picture?
What is an accurate depiction of neurosurgeons’ participation in the emergency care system? The 2006 AANS Workforce Survey clearly shows that by far most neurosurgeons are answering when the nation’s ERs call, attending to people in need of neurosurgical emergency care. But despite evidence that the vast majority of neurosurgeons are covering all types of emergency services and are doing so chiefly in community-based ERs at level 1 or level 2 trauma centers, it is just as apparent that neurosurgeons share many of the concerns articulated by the IOM and others regarding the functioning of the U.S. emergency medical system and the provision of their vital services within it.

Evidence that demonstrates exactly where the problems lie is less clear. While the survey’s initial findings provide a broad outline of neurosurgeons’ participation in the emergency medical system, additional analysis of survey data could fill in the detail and better complete the picture. For example, the responses of those who identified call coverage as a problem could be examined for demographic commonalities such as practice type or setting, or for geographic correlations such as practice within a state that lacks effective medical liability reforms or a coordinated emergency medical system. Conversely, similar additional data analysis for the 24 percent of respondents who reported no problem with call coverage in their areas might lead to identification of specific factors that in turn would generate strategies or a model that could be applied in other locales to alleviate problems with call coverage.

Additional meaningful data optimally would illuminate the path toward productive change and aid the many neurosurgeons who want to improve of the delivery of neurosurgical emergency services to those who need them.

Manda J. Seaver is staff editor of the AANS Bulletin

For More Information
• Seaver MJ: Baseline ER survey explores system’s cracks: 2004 AANS/CNS neurosurgical emergency and trauma services survey. AANS Bulletin 13(4): 19–24, 2004. www.AANS.org, Article ID 26367

• Valadka AB: The ER: Who is answering call? In some hospitals, not neurosurgeons. AANS Bulletin 13(4): 6–12, 2004. www.AANS.org, Article ID 26358

• Wohns RN: Liability is rooted in elective spine cases. AANS Bulletin, 14(2): 18–19, 2005. www.AANS.org, Article ID 37060

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