Abstract
Medically underserved areas (MUA) or health professional shortage areas (HPSA) designations are based on primary care health services availability. These designations are used in recruiting international medical graduates (IMGs) trained in primary care or subspecialty (e.g., oncology) to areas of need. Whether the MUA/HPSA designation correlates with Oncologist Density (OD) and supports IMG oncologists’ recruitment to areas of need is unknown. We evaluated the concordance of OD with the designation of MUAs/HPSAs and evaluated the impact of OD and MUA/HPSA status on overall survival. We conducted a retrospective cohort study of patients diagnosed with hematological malignancies or metastatic solid tumors in 2011 from the Surveillance Epidemiology and End Results (SEER) database. SEER was linked to the American Medical Association Masterfile to calculate OD, defined as the number of oncologists per 100,000 population at the county level. We calculated the proportion of counties with MUA or HPSA designation for each OD category. Overall survival was estimated using the Kaplan-Meier method and compared between the OD category using a log-rank test. We identified 68,699 adult patients with hematologic malignancies or metastatic solid cancers in 609 counties. The proportion of MUA/HPSA designation was similar across counties categorized by OD (93.2%, 95.4%, 90.3%, and 91.7% in counties with <2.9, 2.9–6.5, 6.5–8.4 and >8.4 oncologists per 100K population, p = 0.7). Patients’ median survival in counties with the lowest OD was significantly lower compared to counties with the highest OD (8 vs. 11 months, p<0.0001). The difference remained statistically significant in multivariate and subgroup analysis. MUA/HPSA status was not associated with survival (HR 1.03, 95%CI 0.97–1.09, p = 0.3). MUA/HPSA designation based on primary care services is not concordant with OD. Patients in counties with lower OD correlated with inferior survival. Federal programs designed to recruit physicians in high-need areas should consider the availability of health care services beyond primary care.
Highlights
The American Association of Medical Colleges (AAMC) recent report predicts a shortfall of between 42,600 and 121,300 physicians, including 33,800 to 72,700 non-primary care physicians by 2030 [1]
The Conrad-30 program was established to allow state departments of health to sponsor a waiver of the home residency requirement in return for the international medical graduates (IMGs) service in medically underserved areas (MUAs) or health professional shortage areas (HPSAs) [8]
Patients were located within 609 US Federal Information Processing Standards (FIPS) code areas, and 3,983 oncologists were identified to be working in these areas
Summary
The American Association of Medical Colleges (AAMC) recent report predicts a shortfall of between 42,600 and 121,300 physicians, including 33,800 to 72,700 non-primary care physicians by 2030 [1]. One strategy to reduce this disparity is requiring non-US citizen international medical graduates (IMGs) to work in underserved areas [8]. Every year at least 3500 non-US citizen IMGs match into a residency or fellowship program using a J1 visa [9]. The Conrad-30 program was established to allow state departments of health to sponsor a waiver of the home residency requirement in return for the IMGs service in medically underserved areas (MUAs) or health professional shortage areas (HPSAs) [8]. The designation of MUA or HPSA is based on a shortage of PCPs, percent of the population below the federal poverty level, infant health, and travel time to the nearest source of care; but it does not consider disparities in specialty care such as medical oncology [12,13]
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