And with a majority of parents choosing a pediatrician rather than a family doctor for their children's general primary care, and more children seeing specially trained pediatric specialists for diseases such as asthma, diabetes and cancer, the new findings have major implications for access to care among children in poorer states.
In a new paper published in the June issue of the Journal of Pediatrics, a team led by a University of Michigan Health System researcher reports that the number of pediatricians in the United States rose by 140 percent between 1978 and 2000, while the number of children ages 14 and under rose more slowly. As a result, the number of pediatricians per 100,000 children aged 14 and younger more than doubled in that period, from 49.8 to 106.2 pediatricians.
"American children have greater access to pediatricians and pediatric sub-specialists than ever before," says Gary Freed, M.D., M.P.H., the U-M pediatrician who led the study for the research advisory committee of the American Board of Pediatrics. "The demand for care is there, as we've shown in previous research, and it appears that the growing number of physicians is better at meeting that demand."
But when the researchers mapped the number of pediatricians per 100,000 children in each state, they noticed a stark trend: much higher concentrations, as many as 165 pediatricians per 100,000 children in some states, and concentrations as low as 28 pediatricians per 100,000 children in others.
Then, they compared those concentrations with each state's personal per capita income, in constant dollars. In 1980, they found, there was some association between income and pediatrician supply -- but the effect was much stronger in 2000.
In other words, in 20 years the supply of pediatricians may have doubled, but they became far more concentrated in wealthier states than in poorer ones.
"Better economic opportunities in some states may create a draw for physicians, but we need to make sure that society provides incentives for physicians to locate and practice in areas that may offer less economic opportunity," says Freed.
For instance, he says, the study might be useful to policy makers who may want to provide incentives and opportunities for pediatricians and other health professionals to operate in shortage areas, or protect existing programs from funding changes.
The new study found that Massachusetts has the highest concentration of pediatricians per 100,000 children, at 165. Other northern states, including New York (154), Connecticut (127), Maryland and the District of Columbia (160), and New Jersey (131) had high distributions. The plains and western states, except California, had the lowest concentrations, with Montana (43), South Dakota (41), Wyoming (35) and Idaho (28) at the bottom. When income was added in, the states with the highest concentrations of pediatricians per capita also tended to have the highest per capita incomes.
"We need to better understand where we are to know where we need to go, and this study is the first step. As a society, we need to make sure we prioritize the health of our children," says Freed, who leads the Child Health Evaluation and Research group in the U-M Department of Pediatrics and Communicable Diseases and C.S. Mott Children's Hospital. In 2001, the U-M team won the contract to lead pediatrician workforce supply research for the American Board of Pediatrics, which examines and certifies doctors who specialize in the care of children from birth to adolescence.
The newly published study is the latest in a series of papers stemming from that research. It's based on data from the American Medical Association that includes both AMA and non-AMA member physicians, the U.S. Census and the U.S. Bureau of Economic Analysis.
Earlier this year, the U-M team published a paper in the Archives of Pediatric and Adolescent Medicine showing that a growing majority of non-surgical doctor's office visits by American children are with pediatricians (64 percent) and that the percentage of visits to family physicians, who treat both adults and children, is declining.
Parents, especially those of children born since the mid-1990s, appear to be choosing pediatricians. And the steady number of older patients making more visits to family physicians, combined with a decreasing proportion of family physicians who deliver their patients' babies and then care for them, appears to be leaving less room for children in family physicians' schedules.
"Meanwhile, the ability of our health care system to provide preventive care to children has increased dramatically, and the type of care that pediatricians provide is changing," Freed notes, adding that more vaccinations and screening tests, and more counseling about behavioral and mental health issues have all been added to the standard list of child health care.
Other studies have found differences between pediatricians and family physicians in patterns of vaccination, infection care, asthma care, depression care and other practices. More studies are needed to determine if these differences have any major impact on children's overall health.
During this same period, the number of pediatric sub-specialists, such as pediatric cardiologists and pediatric neurologists, has risen sharply, and treatments for children with chronic or severe diseases have expanded. About 4.5 percent of children's doctor visits nationwide are with pediatric sub-specialists, up from 1.6 percent in 1980. The new study doesn't distinguish between the distribution of general pediatricians who provide primary care, and pediatric sub-specialists; Freed notes that a study examining the distribution and use of sub-specialists is forthcoming.
The new study also echoes findings of a 2002 study published in Health Affairs that examined the overall distribution of physicians in the United States; it found that as the nation's gross domestic product has increased, so has the supply of physicians as a proportion of population. This phenomenon has been dubbed "white follows green."
In addition to Freed, the study's authors include Tammie H. Nahra, Ph.D., and John Wheeler, Ph.D.
Journal
The Journal of Pediatrics