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The Distribution of Specialist Hand Surgeons Across the United States
Arturo J. Rios Diaz, MD; David Metcalfe, LLB, MBChB; Mansher Singh, MD; Olubode Olufajo, MD, MPH; Cheryl K. Zogg, MSPH; Margarita S. Ramos2, Edward J. Caterson, MD, PhD; Simon G. Talbot, MD
Brigham and Women's Hospital. Harvard Medical School & Harvard T.H. Chan School of Public Health, Boston, MA

Background: Unequal access to hospital specialists for emergency care is an issue in the United States (US). The objective of this study was to describe the geographical distribution of surgeons with a Subspecialty Certificate in Surgery of the Hand (SCSH) and associated factors in the US.

Methods: Geographic distributions of surgeons holding a SCSH (2013) and hand surgery fellowship positions (2013) were identified from the American Board of Medical Specialties Database and the literature, respectively. State-level population (2012) and median per capita income (2009-2013) were ascertained using US census data. Variations in hand trauma admissions were determined using ICD-9-CM diagnosis codes in Healthcare Cost Utilization Project (HCUP) national/state inpatient databases (2012). Pearson correlations examined state-level associations between the density (per 100,000 population) of hand surgeons and fellowship positions, per capita income, and hand trauma admissions.

Results: Among 2,019 specialist hand surgeons identified; 72.1% were orthopedic (OS), 18.3% plastic (PS), and 9.6% general (GS) surgeons. There were 157 hand surgery fellowship positions nationwide; 82.8% run by OS, 12.1% PS, and 5.1% GS. There were 149,295 annual hand trauma admissions. The national hand surgeon density was 0.6 per 100,000 population and there were 47.6 hand trauma admissions per 100,000 population. At the state-level, the density of specialist hand surgeons and fellowship positions varied to a significantly greater extent than the density of hand trauma admissions (Figure 1). State-level variations in density correlated with the number of fellowship positions (r2=0.41; p=0.011) and strongly with median per capita income (r2=0.66; p<0.001). There was no correlation between density of subspecialist hand surgeons and the density of trauma-related admissions (r2=0.19; p=0.273); and, per capita income and density of trauma-related admissions (r2=0.054; p=0.751).

Conclusion: Specialist hand surgeons are distributed unevenly across the US. State-level analyses suggest that states with lower per-capita incomes may be particularly underserved, which may contribute to regional disparities in access to emergency hand trauma care.

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