People living in rural areas were more likely to get nine different surgical procedures - including both elective and non-elective surgeries - compared to people living in urban areas, in a study of all Medicare beneficiaries.

On the surface, the finding seems to question the assumption that people in rural areas have less access to medical care, and that their health suffers because of it, the authors say.

The results “really ran counter to the expectations of myself and my colleagues,” Dr. Mark Francis, of the Texas Tech University Health Sciences Center, and lead author on the study, told Reuters Health.

The surgery trend could still reflect poorer health among rural residents, however.

Previous research has suggested that people living in rural areas have worse health overall than city dwellers. Rural residents are also less likely to have health insurance, Alana Knudson, co-director of the Walsh Center for Rural Health Analysis in Bethesda, Marylan, told Reuters Health.

Because living in a rural area generally requires a longer trip to a hospital or doctor’s office than it does for those in the city, doctors and researchers worry about gaps in care for rural residents.

Medicare’s federally funded health insurance typically covers only those aged 65 or older, and some younger people with disabilities or severe kidney disease.

In the current study, Francis and his colleagues examined data for nine different procedures billed by 45.5 million Medicare beneficiaries in 2006. Those procedures included some that were elective, including knee and hip replacement, and others that were not elective, such as appendectomies. Also included were a range of surgeries on the spine, prostate, legs and the heart and blood vessels.

People living in rural areas were between 15 percent and 35 percent more likely to undergo every procedure than those in urban areas, according to the findings published in the journal Archives of Surgery.

When the authors took into account that the rural population was generally poorer and more likely to be white and male than the urban population, the differences were smaller - between 4 percent and 18 percent - but still prevailed across the board.

The results have a few possible explanations, Francis said, and this study on its own can’t determine which one is correct. It could be that people in rural areas are less healthy in general than people in urban areas, and so require more surgeries, he said. Or a lack of access to primary care might cause health problems to stack up in rural residents by the time they’re 65 and old enough to qualify for Medicare.

Finally, Francis said, it could be that people in rural areas are just as healthy as people in urban areas, but something about rural culture makes rural residents more likely to choose surgery over other kinds of medical care when they have the option.

Dr. David Goodman, director of The Center for Health Policy Research at The Dartmouth Institute for Health Policy & Clinical Practice, said he was not surprised by the results. “Rates of surgery are quite a bit different from place to place and are driven by different levels of surgeons’ enthusiasm for a surgical solution,” Goodman, who was not involved in the study, told Reuters Health.

Many conditions, Goodman said, can be addressed with surgery or with a different treatment method. Rural hospitals may be more likely to lean toward surgeries, he said, because they are dependent on the money that those procedures bring in. In urban hospitals with a bigger and more diverse patient base, “although surgery can still help subsidize other operations in the hospital, they’re not so singularly dependent” on it, he said.

Knudson, who was not involved in the current study, said she was also not surprised by its results - but for different reasons. They reflect a lack of good primary care options early in life, she said. “People perhaps delay care and are not accessing care when they’re younger,” Knudson said. “They may not have had adequate insurance or coverage to be able to seek care earlier. Once they become Medicare-eligible, they seek that surgical intervention.”