Nearest Rheumatologist 200 Miles Away for Some Patients

Larry Hand

November 27, 2013

In some geographic areas of the United States with populations of fewer than 50,000 people, adults might have to travel 200 miles to see a rheumatologist, according to an article published online November 27 and in the December issue of Arthritis & Rheumatism.

Of 3920 practicing rheumatologists registered with the American College of Rheumatology (ACR) in 2010, 90% practiced in metropolitan areas, 7% practiced in rural areas, and 3% practiced in micropolitan areas with populations more than 10,000 but less than 50,000.

John D. FitzGerald, MD, PhD, a rheumatologist at the University of California at Los Angeles Rheumatology Rehabilition Center in Los Angeles, and colleagues analyzed ACR data on adult rheumatologists according to 2010 US Census Core Based Statistical Area for the 48 contiguous states and the District of Columbia. They then mapped practice locations according to metropolitan area (n = 360) and micropolitan area (n = 573).

"While only 31 metropolitan areas (9%) did not have a practicing rheumatologist, the majority of micropolitan areas (84%) did not have a rheumatologist," the researchers write. Patients in almost 100 (16%) micropolitan areas had travel distances of more than 75 miles to the nearest rheumatologist, with some in low-population areas having distances more than 200 miles.

No Surprise

"To patients and physicians, this won't come as a surprise. Patients in areas that don't have a rheumatologist or where they're waiting 6 months to see a rheumatologist, this would be self-evident," Dr. FitzGerald told Medscape Medical News. "I hope this brings attention to agencies that can help bring about changes. Studies like this are important not just in rheumatology but in other specialties, so that the public policy makers can be aware of this and possibly provide assistance for those [rheumatologists] who would want to try and go to these areas."

It is actually in the other specialty areas, he said, where any data exist that point out the consequences of having physician shortages. For instance, in areas with fewer cardiologists, less cholesterol-lowering medicine is prescribed, he said.

For rheumatology, specifically, he added, in areas with fewer dual-energy X-ray absorptiometry bone-density scanning machines, patients are less often screened for osteoporosis. Rheumatologists are also more likely than internists to prescribe disease-modifying drugs for rheumatoid conditions, he added.

"Because we're just starting to identify these [impact] areas, we don't have the data to show what the impact would be. Those would be the next steps. It's hard to quantify at this point," Dr. FitzGerald explained.

Showing effect may come down to 2 problems. "One is getting an accurate diagnosis, and another is getting a patient on the right treatment," he said. Diagnosing rheumatoid conditions is often not straightforward. "Lupus and scleroderma often take years to figure out," he explained. "Complaints of some rheumatology patients can be quite nonspecific, such as 'I feel achy,' or 'I'm tired.' "

Potential Interventions

In the article, the researchers offer potential interventions to address the distribution of rheumatology practices. For example, getting up-to-date information on shortage areas to rheumatologists could prompt some to expand practices with second offices or attract graduating rheumatologists. In addition, committing more money to training programs in underserved areas could increase the number of rheumatologists practicing there.

In an accompanying editorial, Chad L. Deal, MD, director of the Center for Osteoporosis and Metabolic Bone Disease at the Cleveland Clinic in Ohio, points out that physician assistants (PAs) and nurse practitioners (NPs) could be of help.

"Studies have shown that use of NPs and PAs is productive, cost effective, and accepted by patients, and NPs and PAs are more likely to practice in areas where there are doctor shortages. NPs and PAs have been employed in rheumatology settings for more than 30 years, but there have been few studies to delineate their roles," Dr. Deal writes.

He concludes, "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 [Committee on Rheumatology Training and Workforce Issues] data as the start of the process. Since many rheumatology graduates are seeking hospital employment, the ACR should also survey hospitals in rural areas that are interested in investing in a rheumatologist for their residents."

As for anything clinicians can do today to minimize the negative effect of rheumatologist shortages, Dr. FitzGerald encourages any patients or physicians to search the ACR Web site for experts to consult and to look for guidelines issued on how to manage rheumatoid conditions.

"Those guidelines can be very helpful to physicians in shortage areas, or even to patients in shortage areas, where they can get access to the knowledge in a nice, single source of information," he said.

Arthritis Rheum. Published online November 27, 2013. Article abstract

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