Already a Shortage in Cardiology

[task]

From HeartWire, Mar 15, 2002, "Critical shortage of cardiology specialists looms"

Aging baby boomers with their increasingly failing hearts, plus the recent explosion in cardiovascular technical advances, equal a pressing need for more cardiovascular specialists. The shortage of cardiologists, particularly interventionalists and electrophysiologists, is not on the horizon; it is right at our front door, American College of Cardiology (ACC) president-elect Dr W Bruce Fye (Mayo Clinic) says.

"Changing technology, epidemiology and demographic factors, the decrease in the number of people being trained as interventional and electrophysiology cardiology specialists, are all conspiring to increase the potential pool of patients who require highly specialized services," Fye told heartwire.

Unfortunately, the supply is not keeping up with the demand. Fye predicts a "significant" shortage of cardiovascular specialists, which "isn't going to happen in 20 years. It's happening now. We are going to see evidence of it very quickly."

In a recent report in Business First, staff writer Jennifer Gordon writes that the incidence of cardiovascular problems in the US is rising by 13% a year, but the number of cardiologists is not keeping pace with the demand.

Over the next 5 years, the need for in-hospital cardiovascular services are expected to increase 44% more than other hospital services, according to a report by Solucient (Evanston, IL), a health care research and information company, Gordon writes.

"The report is very accurate," she quotes Michael Esposito (Norton Healthcare Inc, Louisville, KY). Currently in the Louisville area, there are 70 adult and 16 pediatric cardiologists, but in the next few years, 16 additional cardiologists will be needed, both to meet increased demand and to replace physicians who retire or relocate, according to Business First.

Increasingly rigorous training requirements as a result of new technological developments are a major obstacle to the production of new cardiovascular specialists, says Fye.

Clinton health plan got it wrong
"The electrophysiologists and NASPE [North American Society of Pacing and Electrophysiology] have articulated their thoughts about this. As in all of the technical areas of cardiology, there has been an extraordinary explosion of technical innovation and growth. The implantable cardioverter defibrillator, although it is not brand new, has certainly become the procedure of choice in a number of areas. This leaves us with the knowledge that the population that requires these specialized procedures is growing and also with the recognition that more and more, there are specific cardiovascular conditions - such as the risk for sudden death - where devices like ICDs are proven to reduce this risk," he said in an interview.

Back in the mid-1990s, during the Clinton years, it was widely thought that there would be too many cardiovascular specialists within a few years. Such a surplus has not materialized, says Fye.

"Back in 1994, as part of the Clinton health plan, there were many voices articulating such a view. But we are now seeing how the natural history of the intrusive and very heavy-handed managed care organizations, which were preaching fewer specialists and more family physicians, have been forced to modulate their rhetoric. Clearly, we are not all living under a heavily managed-care model, where there are very few specialists and many primary care physicians."

The future is "problematic" if no action taken
Fye told heartwire that one of his main goals as ACC president will be to persuade government and health officials to address this important issue. To this end, the ACC will be launching a formal work force study, which will be having its first meeting at the ACC annual meeting in Atlanta.

"I would like to see us put together a compelling argument that makes it crystal clear that the future is problematic if we do not provide the American people with an increased number of cardiovascular specialists. Hopefully we will have the ear of health policy people and government official legislators."

US President George W Bush "is very interested in these matters," adds Fye, who, with current ACC president Dr Douglas P Zipes, has already met the President to discuss the Patients' Bill of Rights legislation. "The meeting was supposed to last for 20 minutes and in fact lasted 45 minutes. Bush was very interested in the whole issue of whether patients are able to get access to specialty care."

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[Voxel]

I think this about the Nth time I will say this. Looking back to the year 1994-5, the Pew commission concluded that there will be an oversupply in many specialties based upon current supply of physicians and assumed a steady/constant demand of services. This was a big mistake.

When predicting the equilibrium point on the supply vs demand curve, on must take into account that event though the supply can be fixed (IE medicare residency funding), but the demand for specialty services by an aging baby boomer popultion CANNOT be held constant.

Looking back at the time, one can seen that the healthcare system was becoming more effecient (due to managed care pressures) and specialists had to take jobs outside major metropolitan areas in droves or continue with fellowship training. However, this effeciency cannot overshadow the increasing elderly population the likes of which we have not seen in a long time. By the year 2020, atleast 1/3 of the population will be over 55+. People over 55+ spend 2-4X as much on healthcare services as those under than 55.

So what does all this mean? There may be shortages of specialists in areas that have the highest incidence of disease/demand, if nothing is done to increase their # of residents training in those fields.

#1) Coronary Artery Disease
Cardiologists and CT surgeons, PM&R. And their related support specialists, Anesthesiologists. ? Cardiac MRI/CT and radiologists role.

#2) Oncology/Cancer.
Heme/Onc, Rad Onc, Gen Surgy, Pulm and GI Medicine, CT Surgeons, Onc Surgeons, and Gyn/Onc, to a lesser extent Interventional Rads. And their related support specialists, Anesthesiologists, Radiologists, and Pathologists.

#3) Cerebrovascular and Perpheral (excluding CAD) Vascular Disease.
Neurologists, Neurosurgeons, Neurointerventional rads, Vascular Surgeons, Interventional Rads, PM&R And their related support specialists, Anesthesiologists, Radiologists, and to a lesser extent Pathologists.

#4) Orthopaedic/Rheumatologic.
Orthopaedists, Rheumatologists, PM&Rs. And their related support specialists, Anesthesiologists, Radiologists, and to a lesser extent Pathologists.

#5) Beauty, hearing and Eye Sight.
Plastic surgeons, dermatologists, audiologists( and hearing aid manufacturers), dentists, opthamologists, and their related support specialists, Anesthesiologists.

One can never be sure about specific advances in technology and pharmaceutical products that will shift patients from one specialty to another. However one can say with fair confidence that healthcare consumers will prefer treatments/diagnosis that while equally effective/accurate, are less invasive and have more tolerable side effect profiles.

 

[jargon124]

Voxel,

I bet we could add Psychiatry to the list of those specialties that will benefit from the aging baby-boomers.

 

[Goofy]

EVERY medical discipline will benefit.

 

[jargon124]

Well, maybe not Peds. :wink:

 

[droliver]

I'm not so sure about where we'll stand with the number of interventional cardiologists stand. As I understand it, radiated & antibiotic impregnated stents have shown tremendous improvements in restenosis rates vs. traditional stenting. I would think this would decrease the number of stents done over time. Also MRA coronary angiograms could dramtically decrease the need for traditional diagnostic caths, and likewise decrease the # of cardiologists needed for these. In addition, its likely @ some point in the not too distant future that athersclerosis will be a medically treated or prevented disease, again a variable which would lower the demand for some of these specialists.

Just my observations

 

[droliver]

•••quote:•••Originally posted by droliver:
•I'm not so sure about where we'll stand with the number of interventional cardiologists needed. As I understand it, radiated & antibiotic impregnated stents have shown tremendous improvements in restenosis rates vs. traditional stenting. I would think this would decrease the number of stents done over time. Also MRA coronary angiograms could dramtically decrease the need for traditional diagnostic caths, and likewise decrease the # of cardiologists needed for these. In addition, its likely @ some point in the not too distant future that atherosclerosis will be a medically treated or prevented disease, again a variable which would lower the demand for some of these specialists.

Just my observations•••••

 

[Voxel]

Yes, but the interventional cardiologists will be the ones placing the stents. Lower restenosis rates will mean wider acceptance and maybe even prophylactic stent placement. Thus not a decrease in demand for stents but an increase.

MRA of the coronary arteries to r/o infarction and/or acute thrombosis/stenosis would be nice. However, if the MRA is positive, the patient will still go to diagnostic angio cath and stent placement by the interventional cardiologist.

Medical prevention/dramatic absolute risk reduction of MI would be a spectacular advance, but far off on the horizon as cv disease is a multi-factorial/complex disease. In the mean time we will need CHF and electrophysiology cardiologists.

As CAD tends to be a disease of the elderly and the absolute risk goes up after the age of 40 and increases as the patient gets older and with the aging baby boomer patient population, I'd say there will be shortage of cardiologists not glut or equilibrium if nothing is done to increase the number of cardiology training positions.

 

[Voxel]

Jargon,

Yes we can add psychiatry to the list, but dealing with demented Alzheimers patients is probably not appealing to those entering/practicing psychiatry/ neurology.

 

[droliver]

voxel,

I think you underestimate how many fewer interventions could be realized with MRA if the technology pans out. As far as prophylactic stenting of CAD, that in effects is already routinely done for any signifigant CAD on angiogram. Broadening indications for this are not even being discussed as far as I know, it would be hard to demonstrate much benefit from disease specific mortality gains for lower grade lesions as well as being prohibitively expensive.

I also think atherosclerosis is much closer to being treated with directed medical tx. than you do.

 

[task]

I'd have to respectfully disagree with droliver with regards to future decrease in the number of percutaneous coronary interventions.

While a medical therapy to treat atherosclerotic disease would be amazing, from what I understand we are nowhere near that step. As you well know, we are talking about acute plaque rupture causing thrombosis due to platelet aggregation, not the situation of a chronic blockage (which would be less likely to cause infarct due to formation of collaterals anyway). From that standpoint, we are not close to a therapy to dissolve plaque and to repair the underlying damage to the endothelium.

The published studies comparing PTCA with CABG were done before the advent of GP IIb/IIIa inhibitors, stents, and even before the widespread use of aspirin in the peri-infarct period. New studies with the new platelet inhibitors, let alone aspirin, in conjunction with PTCA/stenting are still underway. Empirically, the fact is that more patients with CAD are being managed with PCI rather than being referred for CABG, and this trend continues. CABG is still definitive therapy, but I think this will change sooner than we all think. There are cowboys at MGH/BW doing unprotected left-main PTCA and we've all read about the percutaneous bypass procedure in patients that the surgeons won't touch.

In this day and age, the number of primary PTCAs done already far outnumbers the number of repeat PTCAs. The rate of in-stent stenosis is highest in the first 2-6 months post procedure for coronary stenting. While the advent of coronary irradiation and antibiotic impregnated stents has made headway in reducing the need for repeat PTCA/stent, I think the most important advance in the field of coronary stenting which will have the most impact on instent stenosis are the new drug eluting stents like those impreganted with tacrolimus and sirolimus (these are chemotherapeutic agents that target endothelial cells to prevent neointimal proliferation after the trauma of ballooning and stenting). A lot of new data shows this is rapidly becoming the way to go with stenting/preventing in-stent stenosis. These are actually cheaper and logistically much easier to deploy than the radioactive stents, and you don't need a Radiation Oncologist to do dosimetry (costs further reduced). One of the deterrents to doing PTCA/stent is the worry that an inappropriately done/placed stent will restenose so you might as well send the patient for surgery. Now, that worry is rapidly becoming a thing of the past.

Another factor contributing to what will actually be an increase in the number of primary PTCAs done is evidence that the narrower the stent is, the lower the restenosis rate. With continued advances in techniques/technology surrounding PTCA, and more experienced operators in the cath lab, the ability to deploy these smaller stents is becoming much more common. Today, even vessels with difficult anatomy are much more amenable to stenting than in the recent past, and many patients once referred for surgery are being managed with PCI primarily more and more.

Bottom line -- there is benefit (less angina, less progression to MI, less progression to HF) to intervening (CABG or PTCA) on lesions with 60% or greater stenosis, with no significant benefit from intervening on lesions smaller than this. No one is talking about intervening prophylactically on smaller grade lesions. The object is to have better interventional technology to intervene on the lesions we know can cause problems down the road, and prevent patients from going to the OR if they don't have to.

With regards to the development of MRI coronary angio and medical advances in the treatment of CAD, the ACC has already established two "new" subspecialties of Cardiology, Vascular Medicine and Cardiac MRI (also from the HeartWire article on theheart.org that I originally posted). To do a therapeutic cath, one must do a diagnostic cath anyway, right? Cardiac MRI is another screening tool, and regardless of who reads them (Cardiologists or Radiologists) in the end the net result will be more patients going for intervention because more silent but potentially critical (60% or greater) lesions will be found in otherwise healthy patients who don't have significant contraindications for an intervention. Anyway, that big NEJM article only talked about the utility of Coronary MRI in 3VD. Data for single vessel lesions have yet to be published.

Don't forget the EP arena either. As we all know, the number one reason for hospitalization in the US is CHF. Arrhythmic complications of CHF are the number one reason for death in these patients. The data concerning ICD therapy for the secondary prevention of sudden death is irrefutable, and their is now mounting evidence supporting their use in primary prevention as well. Hence, as Voxel said, more ICDs that need to be placed. Trust me, all the EP guys I know are up to their ears in ICD placement, and it's only going to get worse.

 

[task]

Sorry, I forgot to mention the role of statins in the acute infarct period as a way to "cool-down" the lesion as well in conjunction with intervention.

 

[Offshore]

Apparently one of the problems encountered with the anti-neoplastic agent implanted stents, is that there is no re-epithelialization of the lesion, leaving exposed stent in the intimal wall. Patients may need lifelong anti-coagulation if this can't be corrected. Another issue that I have heard raised talking to both cardiologists and pathologists, is the long-term consequences of implating anti-neoplastic or radiologically active stents in the coronaries themselves. Rare mesenchymal cancers may result, or may increase in frequency. Overall though, I agree with the assessment that interventional cardiology will be in incredibly high demand in the next 10+ years. As for medical therapy for atherosclerosis, that's one of the reasons we use statins. Stents and CABG relieve high-grade, fixed stenostic lesions which cause angina. They do not address the unstable smaller plaques that are responsible for AMI. Statins reduce the formation of new anterosclerotic plaques and stabilize and reduce existing ones, through a combination of lowering oxidized cholesterol and anti-inflammatory action within the plaques themselves. This anti-inflammatory may be an indirect result of the lowered oxidized LDL, which is one of the prime movers of inflammation within the plaque. I'm sure as our understanding of these processes increases, our ability to offer better medical treatments will also benefit. Good luck tomorrow and Thursday!