Derangements of the Heart

Despite worry from medical schools and organized medicine, some scholars doubt that physician shortages are real phenomenon. Instead, issues of access to care can be blamed on maldistribution of physicians and specialists.

With the increased prevalence of cardiovascular disease and obesity, the authors of this study sought to look at the geographic distribution of cardiologists over the past decade.  Elderly populations over age 65 possess a high prevalence of cardiovascular disease and use a large portion of cardiovascular services.  Data were derived from the Area Resource File published by the Health Resources and Services Administration.

Across 306 previously defined “Hospital Referral Regions” they calculated the cardiologist-to-elderly population ratios in both 1995 and 2007 and compared that to total physician and primary care physician ratios as reference groups.

In comparison to a 28.6 percent increase in the total physician workforce and a 26.3 percent increase in the primary care workforce over these twelve years, there was a modest 19.2 percent increase in the cardiology workforce.  Between 1995 and 2007, per capita ratios for cardiologists were consistently lower in rural areas and the Midwest, with higher per capita cardiologist ratios observed in the Northeast*; over the same 12 year period, there was a decreasing cardiologist ratio in the western part of the country.  The overall United States population increased by nearly 15 percent in these twelve years.

Utilizing a measure known as the Gini coefficient, primary care physicians were the most evenly distributed group, followed by the total physician workforce, and then lastly cardiologists.  Sixty-percent of the elderly population lived in areas of the country with access to cardiologists limited to only 38 percent of the cardiology workforce.  Over the twelve year period, despite the fact that the cardiology workforce was most unevenly distributed, evidence from the Gini coefficients suggested the greatest improvements towards evenness occurred among the cardiologist ratio compared with primary care physicians and the total physician workforce.

Multivariate analysis was used to determine which social factors influenced the cardiologist ratio. Household income was related to increased cardiologist-to-population ratios (p<0.001). Negative associations existed for population unemployment rate (p<0.001) and the percentage of white race within the community (p<0.001).  Viewed another way, cardiologist ratios were higher in Hospital Referral Regions that had higher proportions of minorities, fewer unemployed people, and higher incomes.

Commentary

While there is a strong focus on the growth of the primary care workforce due to its potential to address multiple health concerns, there remains the need to assure that appropriate specialty care is available throughout the nation.  As the authors recognize, cardiovascular disease is a significant and highly prevalent morbidity with increasing complexities that would benefit from additional input from non-primary care physicians.

We must promote the role of specialists such as cardiologists within the medical home through increased communication and coordination of care. Without the appropriate growth of these specialist workforces, the medical community will remain at a loss to appropriately care for an aging population. With the recent emphasis on the maldistribution of physicians – especially specialists – it is remarkable to note that the move towards equalizing geographic distribution has occurred best among the cardiologist workforce (the authors unfortunately do not include that data in the article itself). However, an appraisal of the overall distribution of cardiologists still reveals appalling difficulties with access to care: out of 3,187 counties across the nation and its territories, 63 percent do not have a single cardiologist available for consultation.

Aneja, S. et al. US cardiologist workforce from 1995 To 2007: modest growth, lasting geographic maldistribution especially in rural areas. Health Affairs. 2011; 30 (12): 2301-9.

by

Kameron Matthews, MD, Esq.

*A correction has been entered regarding higher cardiologist ratios in the “Northeast” not the Northwest (1/10/12)

** The image source for this graphic representation of cardiologists per 10,000 population (65+) comes from the CDC 2010 Heart Atlas. [Greer SA, Nwaise IA, Casper ML. Atlas of Heart Disease Hospitalizations Among Medicare Beneficiaries. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2010.]