Nearly Half of US Counties Lack Practicing Cardiologists

Haider J. Warraich, MD

Credit: Brigham and Women's Hospital

Nearly half of US counties do not have a practicing cardiologist, particularly in more rural and socioeconomically disadvantaged areas already experiencing a greater burden of cardiovascular disease (CVD), according to new research published in The Journal of the American College of Cardiology (JACC).¹

Counties affected by these disparities were more likely to experience preventable hospitalizations, have lower household income and lack insurance, and have worse access to healthy food and primary care.

“While cardiologists are not the only determinants of cardiovascular outcomes, the lack of access to cardiologists in areas with greater prevalence of heart disease and mortality is incredibly concerning,” said senior author Haider J. Warraich, MD, director of the heart failure program at VA Boston Healthcare and associate physician at Brigham and Women’s Hospital.²

Disparities in CVD outcomes continue to widen between urban and rural areas, but it remains ambiguous how these gaps affect access in areas with greater need.³ The current analysis evaluated differences in characteristics of county-level access to cardiologists across the US, using data from the HealthLink Dimensions database.¹

Driving distance from a census tract’s population center to the nearest cardiologist was summarized at the county level as the average distance across all census tracts. Urban or rural status was determined via the 2020 Census and median household income, insurance status, food environment, and life expectancy were collected from the 2023 County Health Rankings.

For each county, a composite cardiovascular index was created using 5 CVD risk factors (diabetes, obesity, smoking, hypertension, and hypercholesterolemia) obtained from the CDC PLACES 2022 and 2023 database. A sum of 5 binary scores for each county determined the composite cardiovascular index, from 0 (low risk) to 5 (high risk).

Analysis of all 3143 US counties revealed that 1454 counties (46.3%) with 22 million residents had no cardiologists, while the other 1689 (53.7%) had an average of 24 cardiologists each. Notably, 86.2% of rural counties (n = 952 of 1105) had no cardiologists.

By driving distance, the average round-trip distance to the closest cardiologist was 16.3 miles versus 87.1 miles, in counties with and without cardiologists, respectively.

Counties without cardiologists experienced a 31% higher cardiovascular risk index (2.8 vs. 2.1), an increased prevalence of all risk factors, higher age-adjusted cardiovascular mortality rates (281.6 vs. 269.1 per 100,000), and 1-year shorter life expectancy on average.

Overall, counties without cardiologists were more likely to be rural with lower household incomes, lack insurance, be without access to healthy food and primary care clinicians, and experience preventable hospitalizations.

Native Americans experienced the highest within-group likelihood of living in a county without cardiologists. Counties lacking cardiologists were infrequent on the coasts of the US, while those in the South exhibited the highest cardiovascular risk factor index.

“Our findings really highlight the critical need to find ways to mitigate deep disparities to improve cardiovascular disease outcomes for Americans living in rural and disadvantaged areas,” Warraich added.²

In the release, investigators called for broad policy interventions to tackle severe geographic disparities in access to cardiovascular care in the US.² These included wider broadband access to increase digital literacy, better access to adequate health insurance, and a reduction in the prevalence of modifiable risk factors.

“This study underscores the urgent need for policy reforms and innovative solutions, such as financial incentives for clinicians and the expanded use of telemedicine, to bridge this gap,” said Harlan M. Krumholz, MD, editor-in-chief of JACC.² “Ensuring equitable access to cardiovascular care is a crucial step towards improving overall public health outcomes and reducing preventable cardiovascular mortality.”

References

1. _{Geographic Disparities in Access to Cardiologists in the United States. JACC. July 2024. Accessed July 10, 2024. https://www.jacc.org/doi/full/10.1016/j.jacc.2024.04.054.}
2. _{ACCmediacenter. Almost half of US counties have no cardiologists despite higher prevalence of CV risk factors, mortality. EurekAlert! July 8, 2024. Accessed July 10, 2024. https://www.eurekalert.org/news-releases/1050246.}
3. _{Kyalwazi AN, Loccoh EC, Brewer LC, et al. Disparities in Cardiovascular Mortality Between Black and White Adults in the United States, 1999 to 2019. Circulation. 2022;146(3):211-228. doi:10.1161/CIRCULATIONAHA.122.060199}