washingtonpost.com
Almost half the counties in the United States lack a single cardiologist, according to a new study that puts the decades-long rural health-carecrisis into sharp relief.
Researchers at Brigham and Women’s Hospital in Boston looked at all 3,143 U.S. counties and found that just over 46 percent had no cardiologist, a finding senior author Haider J. Warraich called “truly shocking.”
Compounding the problem, researchers discovered that risk factors for cardiovascular disease such as smoking, diabetes, obesity and high blood pressure “were actually more prevalent in the counties that did not have a cardiologist,” said Warraich, who spent several months in 2019 moonlighting as the only cardiologist in rural Randolph County, N.C.
Warraich said his work in Randolph County, which had a population then of more than 143,000, was “a powerful experience” that provided the impetus for the study published in the Journal of the American College of Cardiology.
“I was essentially the only person there for those people,” he said.
The lack of cardiologists in many counties places a greater burden on primary care doctors. But those same counties with a dearth of cardiologists also tend to have fewer primary care physicians, Warraich said.
Counties without cardiologists have 41 primary care doctors for every 100,000 people, compared with 63 per 100,000 in counties with cardiologists.
Warraich, who no longer works for Brigham and Women’s Hospital, said the study was not designed to determine whether the lack of cardiologists in areas translatesinto premature deaths, but “it can’t help,” he said.
And some lines of evidence suggest that the lack of cardiologists in rural areas correlates with higher rates of severe disease and deaths.
“There’s no question that the health statistics of rural America are worse than the health statistics of more urban America,” said Robert A. Harrington, dean of Weill Cornell Medicine, who has written on the crisis in rural health care. A 2021 study in JAMA, influential medical journal, showed the gap between urban and rural mortality rates widened considerably between 1999 and 2019, increasing by more than 170 percent.
One reason for the mortality gap, experts suspect, is the lack of cardiologists and other specialists in rural areas. The new study found that the vast majority of rural counties ― 86 percent ― have no cardiologist.
The struggle to provide sufficient health care in rural America is not new.
Since January 2005, 192 rural hospitals nationwide have closed or converted to facilities that do not provide inpatient care, according to the North Carolina Rural Health Research Program. George H. Pink, the program’s deputy director, said many factors have been driving the hospital closures, including declining populations in certain areas, large numbers of uninsured patients, outdated medical technology and severe financial struggles.
“There’s a statement and I don’t know who said it, but I use it all the time: ‘Your Zip code tells more about your health outcomes than your genetic code,’ ” Harrington said. “And that’s certainly the case with rural America.”
In few areas of medicine is the disparity as acutely felt as in heart disease. Almost half of all Americans have some form of cardiovascular disease, but many can be placed on effective treatments such as statin medications.
“Most cardiovascular disease and death is preventable, and that is very different from a lot of other conditions,” Warraich said. “For example, with dementia, we don’t have great treatments, but with cardiovascular disease, we’ve got amazing treatments and many of them are cheap.”
The Santa Monica, Calif., health-care company GoodRx acquired data and performed statistical analysis for the new study.
The persistent shortage of doctors specializing in heart and blood vessel diseases burdens both patients and doctors.
Stephen Sigal is one of two full-time cardiologists in Texas’s Titus Countywho serve a four-county area of about 3,000 square miles. Those four counties are part of a larger region in the northeast corner of Texas that is burdened by some of the highest levels of heart illnesses in the country. If this corner of Texas were a state, it would rank dead last in respiratory disease, second to last in strokes and near the bottom in heart disease.
“It’s rare that I work less than 12 hours a day,” Sigal said. “It’s not uncommon that I work 16 to 18 hours in a day.”
His hospital, Titus Regional Medical Center, is trying to recruit two more cardiologists. “I don’t know of any hospital in our region that isn’t recruiting cardiologists,” he said.
The new study found that in counties with no cardiologist, patients averaged an 87-mile round-trip drive when they needed to see one — far longer than the average 16-mile round trip for patients in counties with at least one cardiologist.
Eldrin Lewis, a professor and chief of cardiovascular medicine at Stanford University, said he has patients who travel four hours one way just to reach him, a problem that’s magnified when it comes to referrals for follow-up care.
“I felt helpless yesterday when I had a patient who was three hours away and needed physical therapy,” Lewis said. “The patient said, ‘There’s literally no one who does physical therapy near my home.’ ”
One of Lewis’s long-distance patients, 72-year-old Lenore Tate, lives in Sacramento. Even in a city of more than half a million, Tate said, there are not enough cardiologists to meet the need. Tate, who has congestive heart failure, said it is hard to make an appointment with a cardiologist, and if you have to reschedule, the wait can be up to six months.
“It’s more than a hardship,” she said of the three-hour drive from her home to Lewis’s office. “There are times I’ve had other illnesses and injuries that have made it difficult for me to get in my car and drive.”
Usman Salahuddin, a cardiologist for Ochsner Rush Health in Meridian, Miss., a city of about 34,000 people, said surrounding Lauderdale County has 11 other cardiologists. But there are none in the adjacent counties, which have a combined population of about 100,000.
“It’s definitely challenging,” Salahuddin said, explaining that even in Meridian, “we don’t have cardiothoracic surgery or electrophysiology, specialty fields within cardiology. So we do the first triage assessment and then we, in turn, have to refer them out,” as far as Hattiesburg an hour and a half away, or even New Orleans, about three hours away. Electrophysiologists identify and treat irregular heart rhythms.
“When I tell the family we have to refer the patient to, say Birmingham or New Orleans,” he said, “you can see them starting to think, ‘Oh, how will I logistically get there?’ ”
Salahuddin, who went to medical school in his native Pakistan, said he received a special visa to train in the United States, which required that he spend three years working as a doctor in an underserved area. That’s how he came to Meridian.
The visa program has helped officials begin to address the shortage of health-carespecialists in rural and other underserved areas.
To his surprise, Salahuddin has stayed a year beyond when he could have left. He has received his permanent residency card and said he enjoys being able to dine in a smaller community and find himself approached by a patient or family pleased with the care he provided.
Salahuddin and others said the rise of telemedicine has mitigated to some degree the shortage of cardiologists in rural counties. A neurologist in New Orleans can use a laptop to view a stroke patient and family practitioner in a more remote area and determine whether the patient should receive clot-busters.
But inconsistent broadband internet access limits access to telemedicine in some areas.
Alexander Razavi, a cardiology fellow at Emory University School of Medicine in Atlanta, said cardiologists may need to look beyond telemedicine to additional measures to reach rural communities. Cardiology practices that serve these areas, he said, might consider extending their hours or creating mobile examination units.
“We need to invest and provide resources to these communities,” Razavi said.