Nearly half of counties in the United States have no cardiologists at all, according to a new study that maps decades of rural health care crisis in sharp focus.
Researchers from 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 that lead author Haider J. Warraich called “truly shocking.”
To compound the problem, researchers found that heart disease risk factors such as smoking, diabetes, obesity and high blood pressure “were actually more prevalent in the counties that didn’t have a cardiologist,” said Warraich, who moonlighted as the only cardiologist in rural Randolph County, N.C., for several months in 2019.
Warraich said his work in Randolph County, which at the time had a population of more than 143,000, was “a powerful experience” that inspired the study published in the Journal of the American College of Cardiology.
“I was basically the only one there for those people,” he said.
The lack of cardiologists in many provinces puts a greater burden on primary care physicians. But those same provinces with a shortage of cardiologists also often have fewer primary care physicians, Warraich said.
In districts without cardiologists, there are 41 general practitioners per 100,000 inhabitants, compared to 63 per 100,000 inhabitants in districts with cardiologists.
Warraich, who no longer works at Brigham and Women’s Hospital, said the study was not designed to determine whether the lack of cardiologists in certain areas leads to an increase in cardiovascular health. lead to premature deaths, but “it cannot help,” he said.
Some studies show that the lack of cardiologists in rural areas is associated with higher rates of serious illness and death.
“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 about the rural health care crisis. A 2021 study in JAMA, an influential medical journal, found that the gap between urban and rural mortality rates widened significantly between 1999 and 2019, 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 ― do not have a cardiologist.
The struggle to provide adequate health care in rural America is not new.
Since January 2005, 192 rural hospitals across the country have closed or converted to nonclinical care facilities, according to the North Carolina Rural Health Research Program. George H. Pink, the program’s deputy director, said many factors contributed to the hospital closures, including declining populations in certain areas, large numbers of uninsured patients, outdated medical technology and severe financial problems.
“There’s a saying, 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 true in rural America.”
In few areas of medicine is the disparity more acutely felt than in heart disease. Nearly half of all Americans have some form of cardiovascular disease, but many can receive effective treatments, such as statin medications.
“Most cardiovascular disease and deaths are preventable, and that’s very different from many other conditions,” Warraich said. “For example, for dementia we don’t have great treatments, but for cardiovascular disease we have great treatments and many of them are inexpensive.”
Santa Monica, California-based healthcare company GoodRx collected data and conducted statistical analyses for the new study.
The ongoing shortage of physicians specialized in cardiovascular diseases poses a burden for both patients and physicians.
Stephen Sigal is one of two full-time cardiologists in Titus County, Texas serving a four-county area of about 3,000 square miles. Those four counties are part of a larger area in the northeast corner of Texas that is plagued by some of the highest rates of heart disease in the country. If this corner of Texas were a state, it would rank last for respiratory disease, next to last for stroke, and near the bottom for heart disease.
“It’s rare that I work less than 12 hours a day,” Sigal said. “It’s not uncommon for me to work 16 to 18 hours a day.”
His hospital, Titus Regional Medical Center, is trying to recruit two additional cardiologists. “I don’t know of any hospital in our area that isn’t recruiting cardiologists,” he said.
The new study found that patients in counties without a cardiologist had to drive an average of 140 kilometers (87 miles) round trip to see one, much longer than the average 25-kilometer (16-mile) round trip for patients in counties with at least one cardiologist.
Eldrin Lewis, professor and chief of the Division of Cardiovascular Medicine at Stanford University, says patients have to travel four hours to reach him. This problem is even greater when it comes to referrals for follow-up treatments.
“I felt helpless yesterday when I had a patient three hours away who needed physical therapy,” Lewis said. “The patient said, ‘There’s literally no one who does physical therapy near my house.’ ”
One of Lewis’ long-distance patients, 72-year-old Lenore Tate, lives in Sacramento. Even in a city of more than half a million people, Tate said, there aren’t enough cardiologists to meet the need. Tate, who has congestive heart failure, said it’s difficult to get an appointment with a cardiologist, and if you do need to reschedule, the wait can be up to six months.
“It’s more than an ordeal,” she said of the three-hour drive from her home to Lewis’ office. “There have been times when 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, Mississippi, a city of about 34,000, said there are 11 other cardiologists in surrounding Lauderdale County. But there are none in the neighboring counties, which together have a population of about 100,000.
“It’s definitely a challenge,” Salahuddin said, explaining that even at Meridian, “we don’t have cardiothoracic surgery or electrophysiology, which are specialties within cardiology. So we do the initial triage assessment and then we have to refer them,” as far away as Hattiesburg, an hour and a half away, or even New Orleans, about a three-hour drive away. Electrophysiologists identify and treat irregular heart rhythms.
“When I tell the family we need to refer the patient to, say, Birmingham or New Orleans,” he said, “you can see them thinking, ‘Oh, how am I going to logistically get there?’”
Salahuddin, who attended medical school in his native Pakistan, said he was given a special visa to train in the United States, which required him to work as a doctor in an underserved area for three years. That’s how he ended up at Meridian.
The visa program has helped officials address health care shortages specialists in rural and other disadvantaged areas.
To his surprise, Salahuddin stayed a year longer than he could have left. He has received his permanent residency and said he enjoys being able to dine in a smaller community and being approached by a patient or family who is pleased with the care he has provided.
Salahuddin and others said the rise of telemedicine has helped ease the shortage of cardiologists in rural counties. A neurologist in New Orleans can use a laptop to see a stroke patient and a primary care doctor in a more remote area to determine whether the patient needs clot-busting drugs.
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 and take additional steps to reach rural communities. Cardiology practices that serve these areas, he said, could consider extending their hours or creating mobile testing units.
“We need to invest and provide resources to these communities,” Razavi said.
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