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Keywords:

  • Pediatric rheumatology;
  • Physician workforce;
  • Access to care

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

Objective

To describe rheumatology providers, depict their availability, and determine the extent to which internist rheumatologists may expand access to care for children with rheumatic diseases.

Methods

Using data from the American College of Rheumatology and the Bureau of Health Professions Area Resource File, we generated a national map of providers' practice locations and calculated distances between each county and the nearest rheumatologist. We also performed a logit analysis to identify provider and county characteristics that were associated with internist rheumatologists' willingness to treat children.

Results

Approximately 50% of the under 18 population in the United States live within 50 miles of a pediatric rheumatologist and nearly 90% live within 50 miles of a pediatric rheumatologist or an internist rheumatologist who treats children. Internist rheumatologists in private practice were 3 times as likely as those in medical schools to treat children (P < 0.001). Likewise, internist rheumatologists who live 200 or more miles from a pediatric rheumatologist were more than twice as likely to treat children as those who lived within 10 miles of a pediatric rheumatologist (P < 0.001).

Conclusions

Our analysis suggests that internist rheumatologists are more geographically diffuse than pediatric rheumatologists and act as substitutes for pediatric rheumatologists in those regions that lack such providers. Research is needed to understand the role of internist rheumatologists in caring for children with rheumatic diseases and the quality of the care that they provide to this population.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

Although access to primary pediatric care providers has been explored and discussed extensively in the literature, access to pediatric specialists has not been widely investigated. Consequently, we know little about patients' access to pediatric subspecialty providers. Pediatric rheumatology provides a sentinel example of the limited availability of pediatric specialty care. Approximately 174 board-certified pediatric rheumatologists practice in the United States (1). Only these physicians have been specifically trained to treat the multitude of complex, severe, and sometimes life-threatening rheumatic diseases of childhood. Pediatric rheumatic diseases affect approximately 285,000 children in the United States (2). The most common form of juvenile arthritis, juvenile rheumatoid arthritis (JRA), affects 148–167 children per 100,000 (3). The overall prevalence of pediatric rheumatic disease is relatively low; collectively, however, these conditions are among the most common chronic illnesses of childhood and involve considerable disease burden and disability. Furthermore, some studies suggest that JRA is more common than other chronic pediatric conditions, such as diabetes mellitus (4, 5). Unlike acute conditions that may require use of specialists for short periods of time, pediatric rheumatic diseases require frequent and ongoing medical care. The treatment of these illnesses often requires physician visits, lab work, infusion therapy, and physical and occupational therapy. Thus, long travel distances between the patient and the caregiver can impede continuity of care and access to important ancillary healthcare services.

A recent study of primary and subspecialty care use among Supplemental Security Income (SSI) eligible Medicaid children with JRA found that 18% saw any relevant pediatric subspecialist (i.e., pediatric rheumatologist, orthopedic surgeon, allergist/immunologist, or infectious disease specialist) (6). Among Medicaid eligible children without SSI, only 5% saw a relevant pediatric subspecialist. Another study of pauciarticular JRA patients at 1 tertiary referral center found that primary care providers referred a majority of these patients to orthopedic surgeons prior to their referral to pediatric rheumatologists (7). Children initially referred to orthopedic surgeons did not differ clinically from those first referred to pediatric rheumatologists. Although this study cannot explain the reasons for the failure of these primary care providers to refer to pediatric rheumatologists, the authors speculate that access to and availability of providers of pediatric rheumatology care may play a role.

The geographic locations of American Board of Pediatrics-certified pediatric rheumatologists have never been depicted in the literature; however, studies indicate that a large number of these providers practice in academic settings (8, 9). Of the first-time subspecialty candidates who applied to take the certifying exam in pediatric rheumatology in 1994 and 1995, 89% were practicing at an academic medical center, suggesting a continued trend toward academic practice in this specialty (8). Thus, the distribution of pediatric rheumatologists may be concentrated in a limited number of geographic areas, restricting access for a segment of the at-risk population.

One possible solution to this access problem involves the use of internist rheumatologists to provide care to pediatric rheumatology patients. The larger number of internist rheumatologists may lead to a more diffuse geographic distribution of these providers and, potentially, increased access to care for pediatric patients. Past studies suggest that internist rheumatologists already play an important role in the treatment of children with rheumatic diseases (10, 11). In 1996, the American College of Rheumatology (ACR) surveyed all members who listed pediatric rheumatology and patient care in their membership profile (n = 1,386) (10). Of the 574 physicians (41.4%) who responded, only 18.3% completed a pediatric residency and 12.0% completed a pediatric rheumatology fellowship. The overwhelming majority of respondents completed internal medicine residencies (77.4%) and rheumatology fellowships (79.3%). Only 73 (12.7%) respondents were board certified in pediatric rheumatology. A study of private practice internist rheumatologists in Washington found that the majority (62%) saw pediatric patients (11). These 2 studies suggest that a substantial number of internist rheumatologists already treat children with rheumatic diseases.

Because internist rheumatologists have experience treating some of the illnesses that affect pediatric rheumatology patients, they offer a potentially high quality alternative to pediatric rheumatologists. The extent to which the services of internist rheumatologists, in terms of their geographic availability relative to pediatric rheumatologists, are available to pediatric patients has not been demonstrated. If internist rheumatologists offer sufficient geographic access to pediatric rheumatology patients and a willingness to treat pediatric patients, educational efforts should be directed at increasing the ability of these providers to give effective care to this patient population.

This study describes selected characteristics of rheumatology providers who are currently members of the ACR and uses these characteristics to classify providers according to their involvement in the treatment of children. We also use geographic information systems software to depict the practice locations of pediatric and internist rheumatologists. Using county level data, we determine the percentages of the pediatric population living within 10, 50, 100, 200, and > 200 miles of a provider of pediatric rheumatology care. We explore the relationship between county characteristics and the likelihood that an internist rheumatologist treats children. We hypothesize that internist rheumatologists are geographically more diffuse than pediatric rheumatologists and, in areas where the services of pediatric rheumatologists are not available, such providers substitute for pediatric rheumatologists.

METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

We obtained physician membership data from the ACR. The ACR data include practice zip code, provider specialty, practice location, and professional activities; sex and race are not available on this file. Providers could list up to 3 responses to each for the following variables: practice location, professional activity, and discipline. For each of these variables, we considered the first response listed to be primary and second and third responses to be secondary. For example, we assume that the first practice location listed was the provider's primary practice location. Our analysis includes those physicians who currently practice in the United States and list adult or pediatric rheumatology as a primary or secondary discipline (n = 4,673).

To identify providers of patient care, we used data from the professional activities and practice location variables. We defined providers of patient care as physicians who listed patient care as a primary or secondary professional activity or those who listed a solo or group practice as a practice location. We restricted our sample to physicians who provide at least some patient care (n = 4,306).

We classified providers into 3 categories: internist rheumatologists who treated adult patients only, pediatric-only providers who treated primarily pediatric patients, and internist rheumatologists who also treated pediatric patients. Adult-only providers were those providers who reported adult rheumatology as a primary or secondary discipline and did not report pediatric rheumatology as a discipline. Pediatric-only providers were those who reported a primary discipline of pediatric rheumatology or pediatrics as a primary discipline and pediatric rheumatology as a secondary discipline. Finally, providers who listed adult rheumatology as a primary discipline and pediatric rheumatology as a secondary discipline were classified as internist rheumatologists who treated children. Two additional providers were excluded at this stage because their listed disciplines did not allow them to be classified into 1 of these 3 categories. Our final sample size was 4,304.

We performed 3 analyses. We described the characteristics of the 3 different types of rheumatology providers using the limited information available from the ACR file. We contrasted practice locations and professional activities across these 3 classifications. The second analysis used county-level latitude and longitude data from the Bureau of Health Professions Area Resource File (ARF) (12) and practice zip code data to generate a national map depicting the practice locations of rheumatology providers and to estimate the distance from each county in the United States to the nearest provider of pediatric rheumatology care. This analysis was performed using 3 different definitions of pediatric rheumatology provider: pediatric-only rheumatologist, pediatric rheumatologist or internist rheumatologist who treats children, and any rheumatologist (i.e., regardless of their involvement in treating children). We combined population data from the ARF and the distance data described above to estimate the percentage of the pediatric population living within 10, 50, 100, 200, or > 200 miles of a rheumatology provider. Poor zip code data prevented 18 observations from being merged to county level data; these observations were excluded from mapping, distance, and regression analyses.

We used chi-square analyses and 2-sided t-tests to compare internist rheumatologists who treated children with those who did not. Finally, we performed a logit analysis to determine the independent effect of practice and county level characteristics on the likelihood that an internist rheumatologist treats children. County level variables of interest from the ARF include 1999 metropolitan status (Office of Management and Budget), 1999 population estimates (Bureau of the Census), physician counts (American Medical Association Masterfile), per capita income (Regional Economic Information System), and hospital membership in the Council of Teaching Hospitals and Health Systems (COTH). Physician counts and population estimates were used to generate 2 ratios: the subspecialist to population ratio and the pediatric subspecialist to population under 18 ratio. The omitted group for the logit analysis was internist rheumatologists in a medical school who lived within 10 miles of a pediatric rheumatologist. Pediatric-only rheumatology providers were excluded from bivariate and logit analyses. All statistical analyses were performed in Stata 7 (Stata Corp., College Station, TX).

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

Practice characteristics by provider type

Of the 4,304 providers in our analysis, we classified 224 as pediatric-only providers, 3,030 as internist rheumatologists who treat adults only, and 1,050 as internist rheumatologists who also treat children. Thus, one-quarter of internist rheumatologist members of the ACR are currently involved in patient care and treat children. In all 3 provider groups, the most common professional activity listed in the membership file is patient care. Internist rheumatologists who treat children are the most likely to report patient care as their primary professional activity (91.9%). Adult-only providers are significantly more likely than pediatric-only providers to list patient care as their primary professional activity (84.2% versus 74.1%; P < 0.001).

Providers could report up to 2 additional professional activities. Compared with providers who treat adults only and those who treat both adults and children, providers who treat primarily pediatric patients are significantly more likely to be involved in basic research and clinical research as a secondary professional activity (Table 1). These providers are also the most likely to be involved in teaching activities as a secondary activity and the least likely to report having no other professional activities besides their primary professional activities (8%).

Table 1. Selected secondary professional activities of rheumatology providers by provider type
Selected secondary professional activitiesAdult only n = 3,030 %Pediatric only n = 224 %Adult and pediatric n = 1,051 %
  • *

    Chi-square analyses significant versus pediatric rheumatology at P < 0.001.

  • Significant at P < 0.01.

Basic research6.3*11.63.2*
Clinical research32.1*48.742.4
Patient care13.7*23.76.6*
Teaching59.970.567.5

Both rheumatologists who treat adults only and those who treat both adult and pediatric patients are significantly less likely to practice in a medical school setting than pediatric rheumatologists (Table 2). Only 20% of pediatric-only providers report practicing in a solo or group setting. In contrast, more than 60% of adult-only providers are located in a solo or group practice and 80% of providers who treat both adult and pediatric patients are located in solo or group practices.

Table 2. Primary practice location of rheumatology providers by provider type
Primary locationAdult only n = 3,030 %Pediatric only n = 224 %Adult and pediatric n = 1,051 %
  • *

    Chi-square analyses significant versus pediatric rheumatology at P < 0.001.

  • Significant at P < 0.05.

  • HMO = health maintenance organization.

Medical school24.9*67.49.6*
Solo practice22*830.6*
Group practice39.1*12.549.6*
Hospital2.95.42.3
Staff model HMO2.10.91.7
Other5.53.14
None3.42.72.2

Practice location and distance to care

Six states in the United States have no pediatric rheumatologist practicing within their borders: Arkansas, Idaho, New Hampshire, North Dakota, Nevada, and Wyoming. Of the 3,141 counties in the United States, 623 have an internist or pediatric rheumatologist involved in patient care on at least a part-time basis (Figure 1). Rheumatologists are heavily concentrated in metropolitan areas: 95.6% of adult-only providers, 98.7% of pediatric-only providers, and 93.6% of adult and pediatric providers are located in a metropolitan county. It is notable that significantly more providers who treat both adult and pediatric patients practice in nonmetropolitan counties than did providers who treat only adult or only pediatric patients (P < 0.03). Eighty percent of the counties in the United States do not have any rheumatologist available. Ninety counties, 3% of all counties in the United States, have a pediatric rheumatologist practicing within the county. More than 99% of these counties also have an adult rheumatologist in practice. An additional 317 counties have at least 1 adult rheumatologist who treats children available: 202 of these counties also have an adult rheumatologist who does not treat children available. Finally, 216 additional counties have an adult rheumatologist who does not treat children, but have no rheumatology provider who treats children.

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Figure 1. Access to rheumatology care: pediatric rheumatologists and internist rheumatologists by county.

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Despite the small number of counties with a pediatric rheumatologist, nearly one-quarter of the pediatric population in the United States lives within 10 miles of a pediatric rheumatologist (Table 3). When the definition of pediatric rheumatology provider includes internist rheumatologists who treat children, the percentage of the pediatric population living proximal to these providers more than doubles. More than half of the pediatric population in the United States lives within 10 miles of a pediatric rheumatologist or an adult rheumatologist who treats children. Only 3% of the pediatric population in the United States needs to travel more than 100 miles to obtain care from a provider of pediatric rheumatology care (i.e., adult or pediatric rheumatologist who treats children).

Table 3. Percent of the population living within selected distance of rheumatology providers by rheumatology provider type
Miles to nearest providerPercent of pediatric populationPercent of US population
Pediatric-only rheumatologistPediatric rheumatologist or internist rheumatologist who treats childrenAny rheumatologistAny rheumatologist
<1022.753.269.370.4
10–5031.434.926.225.2
51–10019.48.73.83.7
101–20018.42.50.70.5
>2008.00.70.10.01

Factors associated with internist rheumatologists involvement in treating children: bivariate results

Compared with internist rheumatologists who do not treat children, internist rheumatologists who treat children are significantly more likely to work in private practice and significantly less likely to practice in medical schools (Table 4). Internist rheumatologists who treat children are significantly more likely to report patient care as their primary professional activity than those who do not treat children. Internist rheumatologists who treat children practice in counties with significantly lower specialist and pediatric subspecialist to population ratios and significantly lower per capita incomes than internist rheumatologists who do not treat children. Internist rheumatologist who treat children have significantly fewer pediatric rheumatologists within their practice county, are significantly more likely to live in a county without a pediatric rheumatologist, and live significantly greater distances from pediatric rheumatologist than internist rheumatologists who do not treat children.

Table 4. Bivariate comparisons of internist rheumatologists who treat children and those who do not*
 Treat childrenDo not treat childrenP
  • *

    Analyses performed using chi-square analyses for dichotomous variables and 2-sided t-test for continuous variables. HMO = health maintenance organization; COTH = Council of Teaching Hospitals and Health Systems.

Practice location, %   
 Medical school9.624.8<0.001
 Private practice80.261.2<0.001
 HMO1.72.1 
Patient care primary professional activity, %92.084.3<0.001
Other professional activities, %   
 Basic research3.36.3<0.001
 Clinical research42.232.1<0.001
 Teaching64.360.0<0.001
Secondary practice location: medical school, %12.712.3 
Specialist physician per 1,000 persons, mean0.91.2<0.001
Specialist pediatricians per 1,000 persons <18, mean0.20.3<0.001
Practice in county with a COTH member hospital, %52.970.3<0.001
Per capita income in practice county, $ mean29,413.831,995.3<0.01
Practice county in 1999 metro area, %93.695.6<0.01
Number of pediatric rheumatologists in practice county, mean1.22.5<0.001
No pediatric rheumatologist in practice county, %63.043.0<0.001
Distance to the nearest pediatric rheumatologist, miles, mean70.947.9<0.001

Factors associated with internist rheumatologists involvement in treating children: logistic regression results

Compared with rheumatologists practicing in medical schools, those who work in private practice are 3 times more likely to report pediatric rheumatology as 1 of their practice disciplines. Internist rheumatologists in health maintenance organizations were also significantly more likely to treat children than those located in medical schools. Internist rheumatologists who list clinical research or teaching as a secondary professional activity are two-thirds and three-fourths more likely to treat children than their counterparts who are not engaged in these secondary activities, respectively. Internist rheumatologists who practice in a county where a hospital with membership in the COTH was located were significantly less likely to treat pediatric rheumatology patients (Table 5).

Table 5. Likelihood an internist rheumatologist treated children, logit results*
 Odds ratio95% CIP
  • *

    Models also includes county per capita income (significant at P < 0.001), subspecialist to population ratio (not significant [NS]), and pediatric subspecialist to under 18 population ratio (NS). HMO = health maintenance organization; COTH = Council of Teaching Hospitals and Health Systems.

Practice location   
 Private practice3.222.48–4.19<0.001
 HMO2.601.44–4.69<0.01
 Other2.281.58–3.28<0.001
 None listed1.821.09–3.05<0.05
Patient care primary professional activity0.870.66–1.16 
Other professional activities   
 Basic research1.090.73–1.63 
 Clinical research1.631.39–1.92<0.001
 Teaching1.741.47–2.06<0.001
Secondary practice location: medical school0.800.63–1.01 
Practice in county with a COTH member hospital0.740.61–0.90<0.001
Practice county in 1999 metro area1.130.80–1.58 
Distance to the nearest pediatric rheumatologist   
 10–50 miles1.491.22–1.84<0.001
 51–100 miles1.671.29–2.15<0.001
 101–200 miles1.931.50–2.47<0.001
 >200 miles2.251.62–3.12<0.001

Among internist rheumatologists who lived farther from pediatric rheumatologists, the odds of treating children were higher. Compared with providers who lived within 10 miles of a pediatric rheumatologist, those who lived 10–50 miles from a pediatric rheumatologist were 50% more likely to treat children. The odds of treating children increased as distance from the nearest pediatric rheumatologist increased. Internist rheumatologists who lived more than 200 miles from the nearest pediatric rheumatologist were more than twice as likely as those living near pediatric rheumatologists to treat children.

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

Despite the limited data available on the ACR membership file, we are able to make important observations about the availability of pediatric rheumatologists, as well as the extent to which internist rheumatologists who treat children increase the geographic availability of rheumatology care. Our findings suggest that few pediatric rheumatologists devote 100% of their effort to patient care; in fact, one-quarter of pediatric rheumatologists do not list patient care as their primary activity. Our findings also suggest that providers who primarily treat pediatric patients have substantial research and teaching commitments and, therefore, less time available for patient care. As such, access may be limited even in regions where pediatric rheumatologists practice.

Several states have no pediatric rheumatologist within their border and only 3% of US counties have a pediatric rheumatologist practicing there. Fortunately, the pediatric population is concentrated in areas proximal to these providers. Our results show that more than half of the under 18 population in the US lives within reasonable driving distance (i.e., less than 50 miles) of a pediatric rheumatologist. Yet, a recent study of Medicaid enrollees found that very few children with JRA receive care from pediatric subspecialists and that this population relied heavily on internist subspecialists and generalist pediatricians for their care (6). Clearly, geographic accessibility is only 1 factor in the overall accessibility of pediatric rheumatologists. More research is needed to understand the nongeographic barriers, such as provider availability, insurance, and transportation, to receipt of pediatric rheumatology care for this population.

In addition to these pediatric rheumatology providers, one-quarter of internist rheumatologists also provide services to children. Although access to pediatric rheumatologists is somewhat more limited, the availability of internist rheumatologists who treat children yields a geographic distribution of providers that affords similar access to care for children as it does for adults. Our findings also show that internist rheumatologists who treat children are more geographically diffuse than pediatric rheumatologists and may be able to expand access geographically. Internist rheumatologists who treat children substantially reduce the distances that children with rheumatic conditions must travel to obtain care from a rheumatologist.

Results from bivariate and logit analyses suggest that internist rheumatologists who treat children act as substitutes for pediatric rheumatologists in areas without easy geographic access to such providers. Compared with internist rheumatologists who do not treat children, internist rheumatologists who treat children live in counties with fewer pediatric rheumatologists and live significantly greater distances from such providers. They are also significantly more likely to live in a county with no pediatric rheumatologist than are internist rheumatologists who do not treat children. Our logit analysis found a positive and significant relationship between distance to the nearest pediatric rheumatologists and the likelihood that an internist rheumatologist treated children, controlling for other factors. These findings suggest that the absence of a nearby pediatric rheumatologist may influence internist rheumatologists' willingness to treat children.

The validity of many of our findings depends on the accuracy of the ACR data, which has not been substantiated. The ACR data lists 50 more pediatric rheumatologists than the American Board of Medical Specialties currently reports. It is unclear whether these providers are board eligible but not yet certified. It is possible that some of the 50 providers are pediatricians who treat pediatric rheumatic diseases without having completed a rheumatology fellowship. Thus, our estimate of the number of pediatric rheumatologists may be overstated. Furthermore, the Washington state study done by Sherry et al (11) found that many internist rheumatologists who reported treating children on his survey did not indicate pediatric rheumatology as a discipline in the ACR membership record. Furthermore, internist rheumatologists who treat adolescents may not consider them to be children and, as such, not report pediatric rheumatology as a secondary discipline. Thus, our estimate of the number of internist rheumatologists currently treating children may be low.

Our logistic model explains a small proportion of the variance. Future analyses that include more detailed data on personal, training, and practice characteristics and their relationship to internist rheumatologists' involvement in the care of children will require survey data. Such analyses will likely identify factors related to internist rheumatologists' involvement in the care of children. As shown in 1 previous study, a potentially important determinant of internist rheumatologists' willingness to treat children may be exposure to pediatric rheumatology during fellowship (11). At present, the Accreditation Council for Graduate Medical Education Program Requirements for Residency Education in Rheumatology encourage but do not require adult rheumatology fellowship programs to provide training in pediatric rheumatology (13). Given the substantial involvement of internist rheumatologists in the treatment of children as demonstrated in our study as well as others (11), more research is need to understand the relationship between exposure to clinical pediatric rheumatology in fellowship and subsequent involvement in the care of children with rheumatic diseases. Such analyses will have important implications for graduate medical education requirements.

The small number of pediatric rheumatologists, as well as their concentration in urban areas and academic medical centers, potentially limits access to care for certain pediatric populations. Pediatric rheumatology is a small, geographically concentrated subspecialty. Because the conditions treated by pediatric rheumatologists are relatively rare, their concentration in population-dense areas is reasonable in that these regions are likely to have sufficient demand to support a pediatric rheumatology provider. Nonetheless, it remains unclear whether the current number and distribution of pediatric rheumatologists is adequate. We have shown that the overwhelming majority of pediatric rheumatologists are engaged in other professional activities in addition to patient care. To understand the extent to which the current supply of pediatric rheumatologists is adequate, future studies need to consider not only the current level of patient demand but also the volume of patient care that these pediatric rheumatologists currently provide.

Finally, our results show that a substantial minority of internist rheumatologists are involved in the care of children with rheumatic diseases and that these providers may act as substitutes for pediatric rheumatologists in regions that lack pediatric rheumatology providers. Although all adult rheumatologists may not be willing or capable of expanding their practice to treat children, increased involvement of adult rheumatologists in the treatment of children would nearly guarantee geographic access to care. Future studies are needed to determine the volume of care provided, the types of disease treated, and the quality of care delivered by internist rheumatologists who treat children. Such research efforts can facilitate the development of a system of care that insures access to quality care for children with rheumatic diseases while minimizing the financial and nonfinancial burdens imposed on their families by obtaining treatment.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES