Rural Family Medicine–General Surgery Dyads and Health Outcomes

Importance: Despite a 43% higher age-adjusted mortality rate among rural working-age adults and a 29.1% decline in general surgeon supply between 2001 and 2019, the public health impact of the family medicine-general surgery (FM-GS) specialty dyad remains understudied. Objective: To examine longitudinal changes in access to FM-GS dyads and their association with health outcomes in rural US counties. Design, Setting, and Participants: This longitudinal, repeated cross-sectional analysis used linked county-level data to conduct a population-based study of rural US counties. Rural US counties with available workforce and mortality data were eligible for inclusion. Exposure: Duration of access to an FM-GS dyad, derived from annual county physician counts and classified as no dyad, continuous access, newly gained, lost, or intermittent. Main Outcomes and Measures: Primary outcomes included age-adjusted annual mortality rates for cancer and ischemic heart disease (IHD) per 100 000 population and years of potential life lost (YPLL; age-adjusted rate per 100 000 population under age 75 years). Results: A total of 1871 counties were linked to outcome and covariate data, and 1428 to 1644 counties contributed to each outcome model. Among 1871 rural counties, dyad access declined from 997 counties (53.3%) in 2010 to 914 counties (48.9%) in 2021, with 176 counties losing and 93 gaining access. Formation and loss of dyads was almost entirely attributable to general surgery: of counties gaining a dyad, 66 gained a general surgeon and 1 gained a family physician. After adjusting for baseline county population, no exposure category was significantly associated with any outcome. This conclusion was robust to 2 sensitivity analyses that tested inverse probability of treatment weighting and different regression link functions. Conclusions and Relevance: Per the results of this cross-sectional study, rural FM-GS dyads experienced a net decline between 2010 and 2021, driven primarily by the loss of general surgeons, and after adjusting for confounding, dyad availability was not independently associated with population-level mortality outcomes. Because dyad presence alone did not directly alter short-term mortality outcomes independent of structural factors, such as county population and health system infrastructure, policy efforts-including Rural Health Transformation funding-should target hospital viability and structural equity alongside workforce recruitment.