More than 22 million Americans living in rural and socioeconomically disadvantaged counties have no access to cardiologists, despite having a greater burden of cardiovascular disease, according to data reported in a new research letter. The research letter, published online Monday and in the July 16 issue of the Journal of the American College of Cardiology (JACC), noted that disparities in cardiovascular disease outcomes between urban and rural areas continue to widen, reporting that, out of 3,143 U.S. counties analyzed, 1,454 counties (46.3%) with 22 million residents had no cardiologists while the other 1,689 counties had 24 cardiologists each, on average. Led by Jeong Hwan Kim, MD, from the Brigham and Women’s Hospital, Boston, and the VA Boston Healthcare System, Boston, the team behind the letter warned that the findings highlight a deep geographic disparity in access to cardiovascular 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 the study’s senior author Haider J. Warraich, MD. Research methods Kim and colleagues examined differences in characteristics of 3,143 counties with and without cardiologists across the United States. County-level estimates of practicing cardiologists were determined using data from HealthLink Dimensions, while driving distance from a census tract’s center of population to the nearest cardiologist was determined and summarized at the county level (as the average distance across all census tracts in a county). The team also obtained population estimates by race/ethnicity from the American Community Survey (2017-2021), while median household income, percent uninsured, food environment index, and life expectancy were obtained from 2023 County Health Rankings. A composite cardiovascular index was then constructed for each county by summing 5 CVD risk factors—diabetes, obesity, smoking, hypertension and hypercholesterolemia—whose prevalence was obtained from CDC PLACES (2022 and 2023), said the team. “For a given risk factor, a binary score of 0 or 1 was assigned to each county: a score of 1 for a given risk factor if the prevalence of the risk factor was higher than the national average, and 0 otherwise,” they said. “The sum of 5 binary scores for each county was used as the composite cardiovascular index, with a range of scores from 0 (low risk) to 5 (high risk).” Key findings The authors reported that out of all 3,143 U.S. counties analyzed, 1,454 counties (46.3%) had no cardiologists while the other 1,689 counties had on average 24 cardiologists each. The average round-trip distance to the nearest cardiologist was 16.3 vs 87.1 miles in counties with and without cardiologists, they added, noting that counties without cardiologists had 31% higher cardiovascular risk index (2.8 vs 2.1), greater 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 than those with cardiologists. Furthermore, they found that 86.2% of rural counties (n = 952 of 1,105) had no cardiologists. The team concluded that counties without cardiologists were more likely to be rural, with lower household incomes, greater uninsured levels, worse access to healthy food and primary care clinicians and experienced more preventable hospitalizations. They added that of all the racial-ethnic groups examined, Native Americans were the most likely to be living in a county without a cardiologist. Critical need “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 said. “Policy reforms, such as financial incentives to clinicians to practice in areas with marginal access or better leveraging telemedicine are potential options. The integration and coordination of cardiovascular care—especially with regard to prevention and risk modification—with the primary care is crucial.” According to the researchers, broader policy interventions to widen broadband access and increase digital literacy, increase access to adequate health insurance coverage and reducing prevalence of modifiable risk factors would also have a sustainable impact. “The findings of this study are both enlightening and alarming, shedding light on the severe geographic disparities in access to cardiovascular care across the United States,” said JACC Editor-in-Chief Harlan M. Krumholz, MD, SM, FACC. “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. Ensuring equitable access to cardiovascular care is a crucial step towards improving overall public health outcomes and reducing preventable cardiovascular mortality.” Source: Kim JH, Cisneros T, Nguyen A, et al. Geographic Disparities in Access to Cardiologists in the United States: Research Letter. J Am Coll Cardiol 2024;84:315-316. Image Credit: alenamozhjer – stock.adobe.com