Disparity in Availability of Vascular Specialists in Florida and its Effect on Differential Rates of Major Lower Extremity Amputation
Kelly E Arnold, Khayree Butler, Trevan D Fischer, Michael S Hong, Peter R Nelson
University of Florida College of Medicine, Gainesville, FL
INTRODUCTION: Physician maldistribution is an increasing problem, with a greater number of providers in high population urban centers than in rural areas. Previous studies have demonstrated this concept in primary care and general surgery. However, the extent of maldistribuion of vascular providers (vascular surgeons, interventional radiologists, interventional cardiologists), or more importantly, the impact of this maldistribution on patient outcomes, is unknown. We hypothesize (1) that there is a significant specialist physician maldistribution in Florida, (2) that patients from counties with fewer vascular specialists will present with a greater severity of atherosclerosis compared to those from counties with more vascular specialists, and (3) that these underserved patients will have a higher rate of amputation than those who have access to care in their home county.
METHODS: Using 2009 annual data from the Florida Agency for Healthcare Administration inpatient database, we identified patients with peripheral arterial disease (PAD) presenting with either ulceration or gangrene by ICD9 codes 440.23 and 440.24. We identified those patients undergoing either lower extremity revascularization or amputation using codes 39.25 - 39.70, and 84.10 - 84.17, respectively. Next, we examined whether or not these patients received care in or out of their county of residence. These two groups were then analyzed using a chi square test comparing the proportions of patients in each group based on disease severity and treatment received. Finally, using physician specialty data from the Florida Department of Health and physician distribution data from American Medical Association Physician Related Resources database, we reconciled the above analysis based on availability of vascular providers in all patients’ home county.
RESULTS: The data query provided 3,544 PAD patients (86.3%) who stayed in county for their procedure to 562 patients (13.7%) who traveled out of county for care. It was found that 86.7% of the patients who traveled out of county for care presented with gangrene compared to only 68.9 % from those who stayed in county (p=.0001). In addition, the amputation rate in patients having to travel was 46.4% compared to only 39.3% for those receiving treatment in their home county (p=.002). Of the patients who had received an amputation, there were 19 home counties in which 100% of the patients had to travel to a different county in order to receive treatment. In these counties, the average number of vascular providers per 100,000 people was 4.27 compared to all other counties which had an average number of 14.01.
CONCLUSIONS: The majority of patients in Florida with PAD get care near home, however, nearly 14% had to travel to get care. In those who had to travel, there was a significantly higher proportion of gangrene at presentation and a significantly higher amputation rate. In addition, we identified at least 19 counties in which the number of vascular providers was not enough to adequately serve the patients with severe atherosclerosis. This data suggests the presence of significant maldistribution of vascular providers in Florida leading to worse outcomes.
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