Declining Endoscopic Care by Family Physicians in Both Rural and Urban Areas

• Endoscopy
• Family Physicians
• Geography
• Health Policy
• Rural Health

The scope of practice of family physicians (FPs) has been decreasing over the past decade in core aspects of family medicine such as maternity care,^1,2 care of children,³ and women's health.⁴ During this decline, rural FPs continue to have a broader scope of practice than urban FPs across multiple clinical services.⁴ What remains unknown is whether the declines in care that may be considered a core aspect of family medicine are evenly distributed between rural and urban areas and whether it extends to services outside of the usual training and competency of FPs, with endoscopic services being one such example. One study from a single residency network found a precipitous decline in provision of sigmoidoscopy from 2000 to 2012 by residency graduates from 42% to 4% while the provision of colonoscopies remained around 5%.² Our objective was to determine if the percentage of FPs providing endoscopic services is declining in both rural and urban areas.

We used data from the 2014 through 2016 American Board of Family Medicine Family Medicine Certification Examination registration questionnaire.⁶ If physicians registered for the examination multiple times, their most recent data were included. A representative subset of these FPs answered questions about whether they provided colonoscopy, flexible sigmoidoscopy, or endoscopy.⁶ Primary practice address was geocoded and rural or urban status assigned using the Rural Urban Continuum Codes.⁷ We conducted Cochran-Armitage tests for trend for each service by rural/urban status. The American Academy of Family Physicians Institutional Review Board approved this study.

The response rate was 100%. After excluding physicians living outside the United States and those without geocoded addresses (n = 18), our final sample size was 6317. The sample was concentrated in urban areas: 82.9% urban and 17.1% rural. Rural FPs provided each of the 3 endoscopic services more commonly than urban FPs (Figure 1). For all 3 services, the relative percentage of rural FPs providing each declined by nearly half. Only colonoscopies by urban FPs did not have a statistically significant decline over time.

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Figure 1.

Percentage of family physicians performing endoscopic procedures by urban/rural location from 2014 through 2016 (n = 6,317). Error bars are standard error.

The decline in the provision of endoscopic services by FPs has 2 notable implications on the experience of patients. On one hand, this decrease may increase patient safety if low-volume FPs are no longer providing services. Low procedural volume is independently associated with complications,⁸ and past work found that the decline in FPs delivering babies was mostly from low-volume physicians.⁹ However, our data did not capture volume. On the other hand, our study may indicate declining access to endoscopic services, since the decrease in the scope of practice of FPs is borne not only by FPs in urban areas, where other physicians may provide services, but also by rural FPs, who are crucial for access to health care. Our results also confirm that the erosion of comprehensive care by FPs extends to services beyond the usual training of FPs. Health care systems and FPs should find ways to safely provide endoscopic care for all Americans.

• Received for publication February 19, 2019.
• Revision received May 7, 2019.
• Accepted for publication May 7, 2019.