Rheumatologists Scarce Outside Big Cities

28 November 2013 10:46 PM

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U.S. rheumatologists tend to gravitate toward metropolitan areas, with many less populous locales having little if any access to specialty rheumatology care, researchers reported.

In 2010, 90% of rheumatologists were practicing in metropolitan areas, which were defined as having populations of at least 50,000 centered in an urban core, while 3% were in "micropolitan" areas, with populations between 10,000 and 50,000, and 7% were located in rural districts, according to John D. FitzGerald, MD, PhD, of the University of California Los Angeles, and colleagues.

Furthermore, only 9% of metropolitan areas didn't have a practicing rheumatologist, compared with 84% of micropolitan areas, the researchers reported online in Arthritis & Rheumatism.

In 2005, the American College of Rheumatology surveyed its national workforce, identifying 4,908 practicing rheumatologists in the country, which represented 1.67 per 100,000 persons, and concluded that supply and demand were in balance.

But the report noted that the aging of the population and a lack of growth in the number of rheumatologists could lead to a shortfall of 2,500 by 2025.

That report led to ACR's increased funding for training, but it didn't take into account the possibility of regional clustering and shortages, as have been recognized for primary care physicians and general surgeons.

In those so-called medically underserved areas, "researchers have documented poor quality of care as noted by lower use of statins and restricted access to specialists (for cardiovascular disease) than in nonshortage areas," FitzGerald and colleagues noted.

And while federal efforts have begun to address the needs of those underserved areas through qualified health centers, specialists haven't been included in these programs.

To gain a snapshot of the nationwide distribution of rheumatologists, the researchers consulted the ACR's member database for participants' addresses.

Geocoding was done using ArcView software, and regional analysis was done according to the census bureau's Core Based Statistical Areas (CBSAs) of metropolitan, micropolitan, and rural districts.

They identified 3,920 rheumatologists practicing in 2010, according to ACR.

The concentration of rheumatologists identified in metropolitan areas was greater than could be explained by population density alone (P<0.001), the researchers found.

They then attempted to identify specific underserved areas by determining which CBSAs had fewer than 1.67 per 100,000 from the 2005 report, and found that 85% of the areas would be considered as having inadequate rheumatology service.

Moreover, for CBSAs with no rheumatologists, only 1% of metropolitan residents would have to travel more than 75 miles for rheumatology treatment, but in 16% of micropolitan areas a 75-mile distance of travel would be needed.

An additional analysis of unmet need involved plotting distance to the nearest rheumatology office according to the population of the CBSA, which showed that even in some large CBSAs that had populations exceeding 200,000, the distance required for travel could be up to 94 miles.

And for some small micropolitan districts, travel distance exceeded 200 miles.

Then in a multivariate analysis, factors that were associated with having greater numbers of rheumatologists included size of the population, a greater number of residents being female, young, and white or Asian, as well as the presence of an active training program (P<0.05 for all).

The researchers noted that their findings should be considered "preliminary and exploratory," particularly because there may be an unknown number of practicing rheumatologists who aren't members of ACR.

Nonetheless, they suggested several strategies that could be implemented to alleviate the potential shortage and imbalance of rheumatologists.

"Simply providing up-to-date information about the local supply of rheumatologists could attract more rheumatologists to underserved regions through migration, expansion (opening of a second practice site) or attraction of new rheumatologists (graduating fellows)," they wrote.

Increasing and filling training programs in areas lacking practicing rheumatologists also could help, particularly if funding could be provided.

Novel strategies also could be evaluated, such as video consultations and traveling clinics, as well as increasing the participation of nonphysician providers such as nurse practitioners.

In an editorial accompanying the study, Chad L. Deal, MD, of the Cleveland Clinic noted that proximity to care has acquired greater importance as treatment of rheumatologic diseases has become so much more successful -- and complex.

"We can have a huge impact with biologic therapies, reducing joint damage, and improving long-term outcomes in patients with inflammatory arthritis," he wrote.

He pointed out that a study in the Netherlands found that patients who experienced delays in seeking treatment had a hazard ratio of 1.87 for not reaching remission.

"Delays in initiation of treatment are multifactorial, but availability and ease of access to a trained specialist in the care of inflammatory arthritis is essential," Deal stated.

"I believe the ACR should commit to providing up-to-date information on supply by region, and apprise fellows in training and early career rheumatologists, using the FitzGerald data as the start of the process," he concluded.

Source: medpagetoday.com

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