DIN White Paper #4
Bridging the Urban-Rural Divide in Hospital-Based Microsurgery
An Analysis of Operating Room Utilization in Ophthalmology, ENT, Dermatology, and Urology (2019–2024)
Authored and reviewed by the DIN team, June 2025
Introduction
The divide between rural and urban access to specialty surgical care in the U.S. has grown sharper in the past five years. This paper explores the utilization of hospital-based operating rooms (ORs) for outpatient microsurgical procedures in ophthalmology, ENT, dermatology, and urology—anchored in Medicare data and supported by all-payer datasets—to better understand where surgical resources are underused and why. By examining trends across five U.S. regions (Northeast, Southeast, Midwest, Southwest, and West), we highlight key gaps and propose strategies to improve surgical access in rural areas.
Background & Context
Outpatient microsurgery has become the norm for many procedures thanks to advances in technology and anesthesia. Cataract surgery, sinus procedures, Mohs surgery, and cystoscopies are routinely performed outside inpatient settings. In 2019, more than 11.9 million ambulatory surgeries were performed in hospital-based outpatient settings, with cataract surgery alone representing over 3 million cases (AHRQ, 2021).
While urban areas benefit from both hospital outpatient departments and ambulatory surgery centers (ASCs), rural communities rely almost entirely on hospital-based ORs. However, from 2010 to 2020, the number of rural hospitals offering surgical services declined by over 14% (UNC Sheps Center, 2023). Over 140 rural hospitals have closed since 2010, with more than 50% of rural counties now lacking even a single full-time surgeon (GAO, 2020).
Key Findings
1. National Trends in Microsurgical Volume
Hospital-based outpatient surgery volumes dipped sharply in 2020 due to COVID-19, with a 45% decline reported nationally between March and May 2020 (FAIR Health, 2021). Volumes have only partially rebounded. Cataract surgery remains the most common outpatient microsurgery, with nearly 8% of all ambulatory procedures falling into this category (AHRQ, 2021). Yet many rural residents must travel over 30 miles for access (Lee et al., 2017).
2. Regional Disparities
Southeast: Highest demand, lowest rural OR access. The Southeast accounts for 44% of all rural hospital closures between 2010 and 2023 (UNC Sheps Center, 2023). States like Alabama, Georgia, and Mississippi show the largest gaps between surgical need and OR access.
Southwest: Texas alone has experienced over 25 rural hospital closures. Rural OR access is limited in West Texas and tribal regions of New Mexico and Arizona.
Midwest: Kansas and Nebraska face extreme specialist shortages. Half of rural counties in the Great Plains region have no local surgeon (GAO, 2020).
West: Montana, Wyoming, and Nevada are home to some of the longest travel distances for cataract and ENT surgeries, often exceeding 50 miles (Lee et al., 2017).
Northeast: Although rural areas are smaller and denser, states like Maine and Vermont still face low OR utilization due to difficulty recruiting surgical specialists.
3. Urban-Rural Gap in OR Utilization
While rural residents have higher per-capita surgical rates due to age-related need, the procedures often occur in distant urban centers. In 2019, rural Medicare beneficiaries underwent 51 ambulatory surgeries per 1,000 people, versus 30–37 per 1,000 for urban counterparts (AHRQ, 2021). Yet many rural ORs remain underused or inactive due to staffing and equipment limitations.
4. Specialty-Level Disparities
Ophthalmology: Only 5.6% of ophthalmologists practice in rural areas, despite 17.4% of the population living there (AAO, 2022). Cataract surgery rates vary fivefold across states, with rural communities in the Southeast and West most underserved.
ENT: ENT services are concentrated in urban ASCs; rural ENT surgery rates are lowest in the Appalachian and Deep South regions (Otolaryngology Clinics of NA, 2020).
Dermatology: Urban areas have 40x more dermatologists per capita than rural counties, delaying access to Mohs surgery and other cancer-related procedures (JAMA Dermatol, 2019).
Urology: Rural patients with prostate cancer are 40% less likely to receive surgical treatment compared to urban peers (Renal & Urology News, 2020).
Implications
Underutilization of rural hospital ORs represents a missed opportunity to meet existing demand with existing infrastructure.
Delayed or forgone care results in worse outcomes, especially for progressive conditions like cataracts or cancers.
Financial instability of rural hospitals is worsened by underused ORs, as outpatient procedures are a key revenue driver.
Strategies for Improvement
Rotating Specialist Networks
DIN’s model coordinates rotating surgeons to rural hospitals based on OR availability and community need—reviving underused surgical infrastructure without the burden of full-time staffing.Telehealth as an Enabler
Remote consultations and pre-op/post-op care coordination allow for better triaging and planning, reducing patient burden while optimizing OR scheduling.Data-Driven Expansion
Policymakers and health systems should use CMS and all-payer data to identify surgical deserts and invest in flexible care delivery models that activate existing rural OR capacity.
Conclusion
Rural communities across the U.S. face an urgent mismatch: significant need for outpatient microsurgery and declining access to local hospital-based ORs. This underutilization isn't due to lack of demand—it's the result of a fractured system unable to connect surgical capacity with patients. By deploying rotating specialist models and reinforcing rural surgical networks, we can close these gaps and bring high-value care back to where it’s needed most.
Works Cited
Agency for Healthcare Research and Quality (AHRQ). (2021). Overview of Major Ambulatory Surgeries in 2019. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb286-Ambulatory-Surgery-Overview-2019.pdf
UNC Sheps Center. (2023). Rural Hospital Closures. https://www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital-closures/
Government Accountability Office (GAO). (2020). Rural Hospital Closures. https://www.gao.gov/assets/gao-21-93.pdf
FAIR Health. (2021). COVID-19 and Outpatient Trends. https://s3.amazonaws.com/media2.fairhealth.org/whitepaper/asset/COVID-19%20Outpatient%20Trends%20-%20A%20FAIR%20Health%20White%20Paper.pdf
Lee, P.P., Hoskins, H.D., & Parke, D.W. (2017). Disparities in delivery of ophthalmic care: An exploration of public Medicare data. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5487266/
American Academy of Ophthalmology (AAO). (2022). Ophthalmology Workforce Projections. https://www.aao.org/newsroom/news-releases/detail/ophthalmologist-shortage-report
Otolaryngologic Clinics of North America. (2020). ENT Workforce Data. https://www.oto.theclinics.com/
JAMA Dermatology. (2019). Urban vs Rural Dermatologist Access. https://jamanetwork.com/journals/jamadermatology/fullarticle/2737188
Renal & Urology News. (2020). Geographic Disparities in Prostate Cancer Care. https://www.renalandurologynews.com/view/increase-in-percentage-of-rural-patients-traveling-more-than-an-hour-for-surgical-care