Imbalance Between the Supply and Demand for Cardiologists in Spain. Analysis of the Current...

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Planning cardiology provision in Spain requiresknowledge of the resources available and the demand,both now and in the future. In this report, we present theresults of a study carried out by the Spanish Society ofCardiology on the availability of and demand forcardiologists in the country. The current situation ischaracterized by an imbalance of around 14% betweenthe number of active cardiologists and the estimatednumber required. The demographic distribution ofcardiologists shows that they are predominantly male andmiddle-aged. Expectations are that the situation will getworse until the year 2020. To correct this imbalance,alternative forms of training or clinical departmentorganization, or both, are required. Some possiblealternatives are presented in the final part of thisdocument, as proposals for open discussion.

Key words: Cardiologists. Planning. Supply. Demand.

INTRODUCTION

Cardiovascular diseases are still the leading cause ofdeath in Spain and also represent an important causeof morbidity and invalidity.1 This situation does notseem set to change much in the future; in fact, it mayget worse if the growth in the prevalence of some riskfactors (obesity, diabetes) does not slow down.2 It is

Imbalance Between the Supply and Demand for Cardiologistsin Spain. Analysis of the Current Situation, Future Prospects,and Possible SolutionsEduardo de Teresa Galván, Luis Alonso-Pulpón, Patricia Barber,* Ramón Bover Freire, Alfonso Castro Beiras, José María Cruz Fernández, Francisco Fernández Avilés, Juan García de Lara,Beatriz González Valcárcel,* Cándido Martín Luengo, Leandro Plaza Celemín, Fernando del Pozo Crespo, and Miguel Triola Fort

*Grupo de Investigación en Economía de la Salud de la Universidad de Las Palmas, Spain.

SPECIAL ARTICLE

Document drafted by the Working Group on Cardiologists in Spain. ThisWorking Group was set up by a mandate from the Executive Committee ofthe Spanish Society of Cardiology with the sole aim of producing thepresent document.

Correspondence: Dr. E. de Teresa.Servicio de Cardiología. Hospital Clínico Virgen de la Victoria. Campus de Teatinos, s/n. 29010 Málaga. España. E-mail: [email protected]

Desequilibrio entre la oferta y las necesidadesde cardiólogos en España. Análisis de la situación actual, previsiones futuras y propuestas de solución

La planificación de la cardiología en España requiere elconocimiento de los recursos disponibles y las necesida-des, no sólo presentes, sino también futuras. En el pre-sente informe se recogen los resultados de un estudio lle-vado a cabo por la Sociedad Española de Cardiologíasobre la necesidad y la disponibilidad de cardiólogos. Lasituación actual en España presenta un desequilibrio entreel número de cardiólogos en activo y los que serían nece-sarios, desequilibrio que oscila en torno al 14%. La pirámi-de poblacional refleja una población envejecida y mayori-tariamente masculina. Las previsiones futuras indican quela situación empeorará desde ahora hasta el año 2020. Lacorrección de este desequilibrio requiere el desarrollo dealternativas diferentes de las actuales en formación y/o or-ganización de los servicios asistenciales. Algunas de es-tas alternativas se recogen en la parte final de este docu-mento, en forma de propuestas abiertas al debate.

Palabras clave: Cardiólogos. Planificación. Oferta. De-manda.

also true that medical science has made spectacularadvances in recent years. Not only has cardiology beeninvolved in such changes, it has often been at theforefront of progress. These advances have introducedinto clinical practice an impressive battery ofdiagnostic tests and therapeutic options, which,without doubt, will help to alleviate the effects ofcardiovascular disease. Society too has undergonechanges, not only in its demographic profile but alsoin the expectations and demands of the public. Thismakes for a complex situation that requires newstrategies to be drawn up and more efficient use ofthose resources best suited for dealing withcardiovascular disease. Such strategies should takeinto account not only the current situation, but shouldalso try to anticipate future needs.

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Although many different types of health professionalare involved in the fight against cardiovasculardiseases, the cardiologist is still a cornerstone ofinvestigation and clinical practice. Therefore, anyanalysis of needs and resources must take into accountthe availability and requirements of appropriatelytrained cardiologists given that the relationshipbetween resources and cardiologists will play a leadingpart in shaping the health care models forcardiovascular disease. At the same time, prediction ofpossible scenarios may help the adoption of measuresto successfully provide for these future needs.

The Spanish Society of Cardiology (SEC), inaccordance with its role as a reference in the fightagainst cardiovascular diseases, understands that it hasthe responsibility to provide data that help clarify thecurrent situation and that allow the most appropriateapproaches for the future to be chosen.

In 2003, the SEC commissioned a study on thecurrent supply and demand for cardiologists in Spain,including predictions for the coming years. The studywas done by Beatriz González Valcárcel and PatriciaBarber, who belong to the Group for HealthEconomics Research of Las Palmas University, Spain.3

After receiving the final report, the ExecutiveCommittee of the SEC decided to set up a workinggroup to draft a document, based on the report, thatincluded possible actions to deal with the predictionsmade therein. This group, whose members arepresented at the beginning of this article, includedmembers of the National Cardiology Commission (forInternal Physicians and Residents) of the SpanishNational Board of Medical Specialties under theauspices of the Ministry of Health and ConsumerAffairs, J.M. Cruz, the past president of thiscommission and the person who proposed the study,and the authors of the aforementioned report. Dr. E. deTeresa coordinated this working group and wasresponsible for drafting this document, whichsummarizes the results of the report drawn up by theGroup for Health Economics Research of Las PalmasUniversity, Spain, and discusses possible futureactions. The document aims to serve as a framework toestablish a broad debate about the future of cardiology.

PREDICTING THE FUTURE-AN ARDUOUSTASK

Any prediction of the needs of health professionalsis fraught with a number of problems, especially whenthose predictions look beyond the short term. In 1965,for example, the Commission on Heart Disease,Cancer, and Stroke, set up by the then United StatesPresident, L.B. Johnson, concluded that the countrywould be faced with a critical shortage ofcardiologists.4 Years later, in 1981, a report by theGraduate Medical Education National Advisory

Committee in the United States of America predictedthe opposite and concluded that there would be a 94%excess of cardiologists by the year 1990.5 When 1990arrived, this excess never materialized. Shortlyafterwards in 1993, the American College ofCardiology sponsored the 25th Bethesda Conferenceon the “Future needs in human resources forcardiovascular health care.” The conclusions of theresulting 54-page document were that the UnitedStates of America had too many cardiologists, that thisexcess was going to be accentuated by existingAmerican private and public health policies, and that,consequently, the number of cardiologists in trainingshould be reduced. The excess, according to thedocument, occurred mainly in the field ofinterventional cardiology.6 As a result, the number ofcardiology residents decreased by between 11% and13%. Finally, the 35th Bethesda Conference, whoseresults were published in 2004, concluded that theUnited States of America was faced with a serious andgrowing shortage of cardiologists.7

These shifts, not only in the actual situation but alsoin the analysis, reveal how difficult it is to predictfuture scenarios for an activity that is subject to manyinfluences, some of which are changing rapidly. Theseproblems also illustrate the risks of making suddencorrections to the supply of new cardiologists giventhat the effects-because specialist training takes a longtime-are felt many years later when the circumstancesmay have changed substantially.

NEED AND AVAILABILITY OF CARDIOLOGISTS IN SPAIN:CURRENT SITUATION, PROSPECTS,AND RECOMMENDATIONS FOR HUMANRESOURCE POLICIES

This section briefly covers the report commissionedby the SEC. The full document is available from theSEC web page.3

The labor market for health professionals ischaracterized in that supply cannot be self-regulatingbecause of stronger intervention from the public sectorthan in other markets and because the market must beable to adapt quickly to accommodate changes arisingfrom new technologies, which in turn are becomingincreasingly specialized (overspecialization). The labormarket for health professionals operates against abackdrop of continually increasing demand for healthcare, both in quantity (extent of development, longevity,access, etc) and quality (development, technologies, etc).

Objectives

To compare the current reality and trends inprovisions for cardiology in Spain with needs. Theelements of this comparison are:

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De Teresa Galván et al E. Imbalance Between Supply and Demand for Cardiologists in Spain


1. Provisions (supply). Human resources currentlyavailable and those available in the future. Expectedchanges according to different hypotheses for thefuture and according to different options of publicintervention in the market.

2. Needs (demand). To assess the needs, it is alsonecessary to lay down some assumptions about whatprofessionals are responsible for what tasks and aboutregulation in the workplace. Alternatively, the needscan be established by comparison with other similarcountries with supposedly good provision(benchmarking method), or using an epidemiologicalprofile of the population and application of standardworkloads generated by such a population.

The specific objectives of the study were:

1. To estimate the current deficit or excess ofcardiologists in Spain for a reference datecorresponding to the year of the study, 2004, with aconfidence interval that takes into account theelements of uncertainty in the model, including errorsin measuring the data.

2. To provide a dynamic, year-on-year, estimate ofthe deficit or excess for 2004-20.

3. To propose recommendations for policies orinterventions to control variables to minimize theimbalances between supply and demand (that is,between needs and provisions).

Evaluation of the Current Situation

Supply: Availability of Cardiologists in Spain

In this section, we provide numbers for thepopulation of cardiologists in Spain in the referenceyear (2004), discuss the reliability of the dataavailable, and present the age pyramid on which oursimulation of the future dynamics of this population isbased.

Data Sources and Problems Associated WithThese Sources

There are no “official” figures for the total numberof practicing cardiologists (with an officialqualification who are working as cardiologists or whoare prepared to do so). Basically, there are 3information sources for the number of specialists, andan additional information source for cardiologists intraining. The Ministry of Health and Consumer Affairsdrafted and published a survey of specialists in theresident training system through to 1990, and sincethen has recorded the number newly qualified residentphysicians each year.8 Professional bodies and theirGeneral Council of the Association of SpanishProfessional Medical Bodies have data on members

who are accredited with the qualification ofcardiologist, but there is no way of knowing which ofthese have retired, which have several differentspecialist qualifications, and which are currently notpracticing or have never practiced as cardiologists.The SEC is an alternative source with a register of itsmembers. Although this underestimates the size of thepopulation because membership is voluntary, theregister provides realistic information on sex, age, andplace of residence and work. The SEC also hassurveys of specific working conditions of thecardiologists.9

The different sources provide a different number ofqualified cardiologists (Table 1). Legislation whichbecame law in December 2003 lowered the age ofretirement of health professionals from 70 years to 65years and established the need to explicitly request avoluntary extension to the working life, up to a limit of70 years.10 The request for such an extension was to beassessed according to physical and intellectualcapacity and health care needs (article 26). Table 1presents the number of cardiologists under 65 years ofage, that is, potentially active.11-14

The figure from the Association of SpanishProfessional Medical Bodies represents an upper limitbecause it includes member cardiologists who are nowretired and classifies as cardiologists physicians who,prior to the introduction of the current resident trainingsystem, registered for more than one specialty(including cardiology) but who have never practicedand never will. The figure for the study of resources incardiology only includes cardiologists who work inthe public health system (specialist care).

In February 1996, the General Council of theAssociation of Spanish Professional Medical Bodieshad 1904 member cardiologists registered in Spain. In January 2005, there were 2287 membercardiologists.11 This corresponds to an increase of20%, considerably greater than Spanish populationgrowth over the same period (7%). According to the


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TABLE 1. Discrepancies in the Sources for TotalNumber of Cardiologists in Spain in 2004

Total Number of Cardiologists Source Number of of Working Age

Cardiologists (<65 Years)

SEC* 1903 1537ASPMD† 2287CESM Study 2005‡ – 1713Cardiology Resources Study 1999§ – 1177

*Members of the Spanish Society of Cardiology in October 2004.12

†Members of the Association of Spanish Professional Medical Bodies withspecialist qualification in 2005. Source: ASPMD.11

‡tAmaya C, García MA. Demografía Médica en España. Fundación CESM; 2005.§Study of the resources of the Spanish National Health System performed bythe Spanish Society of Cardiology. The data only include cardiologists emplo-yed as specialists in the Spanish National Health System, excluding residentphysicians in training.14


figures from the SEC registry, the number ofcardiologists in October 2004 was 1903, of whom1537 were under 65 years of age.12 The number ofcardiologists of working age per 100 000 inhabitantsin Spain varies from 3.6 to 4.0 according to the source.Regardless of the source used, there are relatively fewcardiologists in Spain compared to other Europeancountries15 (Table 2).

Population of Cardiologists: Number and Profileof Cardiologists Belonging to the Spanish Societyof Cardiology

An analysis of the database of SEC members shouldrepresent a true reflection of the profile anddemographic structure of cardiologists in Spain, withthe necessary provisos arising from the discussion inthe previous section about discrepancies between datasources. The database contains the age, sex, and placeof residence and work of 1903 cardiologists, and alsowhether they are practicing and, if so, whether theywork in the private sector.

The mean age of SEC members is 55 years, but thisage decreases to 51 years if we include only those agedunder 65 years. One out of every 5 members is over 65years. The age pyramid clearly shows that the agedistribution is centered between 50 years and 60 yearsand reflects the high proportion of members aged over

65 years. Despite more women becoming qualified andalso more women specializing in cardiology, only15.3% of members on the SEC database are women.The proportion of female cardiologists bears an inverserelationship to age (Table 3). In the last 2 rounds ofapplications for the resident training program (2002-03and 2003-04), the percentages of women who startedtraining to become a cardiologist was 46.5% and 42%,respectively.

Age Pyramid of Cardiologists in Spain

We only took into account potentially activephysicians and therefore excluded those aged over 65years, who represent 17.4% of the SEC membership.

To establish the age pyramid in 2004, we appliedthe age distribution of the SEC members to the totalnumber of members of the Association of SpanishProfessional Medical Bodies, subtracting 17.4% toaccount for those who, supposedly, have passed thelegal age for retirement.

From these data, and following the proceduredescribed, we estimated the total number of potentiallyactive physicians (<65 years) in 2004 to be 1926cardiologists.

The estimated age pyramid for the reference year2004 (Figure 1) shows an ageing population ofcardiologists, in which 39% are aged between 50 yearsand 59 years and only 21% are under 40 years (Table4). More than half (51%) are aged over 50 years.Given that the age of retirement has dropped to 65years, around 669 specialists (more than a third of thetotal, 33.2%) will retire in the coming 10 years. Asshown in Figure 1, the population has aged slightlysince 1996.

Future Supply of Cardiologists: Recent Changesand the Current Number of ResidentCardiologists in Training

The main function of the resident training programis to train specialist physicians in a range of fields in

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TABLE 3. Percentage of Female Cardiologists WithRespect to the Total Number of CardiologistsBelonging to the Spanish Society for Cardiology, by Age Range (2004)

Age, Y Percentage

30-34 31.735-39 28.640-44 23.245-49 16.650-54 16.155-59 9.760-64 6.065-69 0.8

TABLE 2. Number of Cardiologists in Europe, the United States of America, and Canada

CountryNumber in 2002 per Percentage Increase 100 000 inhabitants in 1990-2002

Ireland 0.7Turkey 1.2 140%Finland 2.1 110%United Kingdom 3.1 158%Slovakia 3.6Germany 3.7Czech Republic 3.9 290%Denmark 4.1 86%Netherlands 4.2 5%Switzerland 5.5 57%Latvia 5.7 27%United States of America* 6Portugal 7 49%Luxembourg 7.4Belgium 8.6 91%Iceland* 8.6France 9.6 19%Lithuania 9.6 20%Estonia 9.8 72%Bulgaria 10.4Cyprus* 11.2Greece* 21.7

*Figure for year 2000.Source: Eurostat.15


sufficient numbers to meet Spain’s needs. The trainingof physicians is affected by education, health, andlabor policies, and so represents a particularlyattractive and complex topic.

In the 2002-03 round of applications, a total of 5417resident positions were awarded compared to 5661 inthe 2003-04 round of applications. Of the positionsawarded in 2003 to 2004, 2%, that is 114,corresponded to the specialty of cardiology.16

The percentage growth in the number of trainingpositions advertised in the specialties of cardiology andcardiovascular surgery through to 1996 was 17.52%and 142%, respectively, whereas the increase over thesame period in the total number of training positionson offer was 24.97%. This increase is 69.16% if weinclude family and community medicine. In thisperiod, cardiology has been one of the specialties withthe lowest increase in training positions advertised andits relative share has also declined. In the 1997-98round of applications, with family and communitymedicine included, 2.9% of the training positions werein the specialty of cardiology, whereas in the last roundof applications in 2003 to 2004, that share was 2%. Ifwe exclude family medicine, the corresponding shareswere 3.2% and 3%, respectively. Cardiology is one ofthe preferred specialties when choosing a residenttraining position, occupying third place in the last 2rounds of applications, with a median ranking of 318in 2003 to 2004 and 284 in 2002 to 2003, and arelatively narrow distribution.16

Cardiology is an eminently “male” specialty, but itis following the same trends as the rest of the medicalprofession; indeed, 40% of the new cardiologists intraining are women.

Labor Market: Employment of Cardiologists in Spain

The National Survey of Cardiology Resources from1991 to 19929 was sent to 127 hospitals, of which, 94responded. Cardiologists tended to be concentrated inlarge hospitals (in fact, none of the hospitals thatresponded to the survey had fewer than 200 beds).Overall, 37% of the hospitals had more than 700 bedsand 35% had between 400 and 700 beds. In 1992,


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19962004

60

55

50

45

40

35

30

0 50 100 150 200

Years

Cardiologists Under 65 Years

Figure 1. Age pyramid of Spanishcardiologists up to 65 years of age.The absolute numbers for each agegroup are presented along the x-axisand the age groups are shown on they-axis. Data drawn up from the lawgoverning health professionals,10

Association of Spanish ProfessionalMedical Bodies,11 and the SpanishSociety of Cardiology.12

TABLE 4. Age Distribution of Cardiologists in Spain,2004

Age, Y Number in 2004 Percentage in 2004

30-34 200 9.935-39 227 11.240-44 172 8.545-49 271 13.450-54 387 19.255-59 401 19.960-64 268 13.3Total 1926 100


these 94 hospitals employed 700 cardiologists (plus173 residents), an increase of 7% with respect to theprevious year. More than half of the cardiologists(54%) worked in hospitals with more than 700 beds.These hospitals also accounted for 73% of thecardiology residents. The hospitals with between 200and 400 beds employed only 17.6% of thecardiologists and 5% of the residents.

The concentration of human resources in largehospitals is becoming less marked. As subspecializationbecomes more widespread in medical practice,community hospitals tend to assign beds to cardiologyand employ at least one cardiologist, even if he or sheworks within the internal medicine service.

In 1997 to 1998, 3% of the physicians in the publichospital system were cardiologists.14 Of these, 8.7%were under 34 years old.

More than a quarter of the cardiologists who weremembers of the SEC worked in hospitals with morethan 20 cardiologists, but a considerable number ofprofessionals (more than 10%) were the onlyrepresentatives of their specialty in the hospital wherethey worked. Medium-sized community hospitals arehiring cardiologists and this trend is expected tobecome more marked.

Demand and Need: How Many Cardiologists AreRequired?

Where one specialty ends and another begins. Theassignment of the professional duties of thecardiologists is a key aspect when quantifying the futureneeds for specialists. The distribution of professionalduties changes over time and from place to place. Forexample, in Canada, half of the patients admitted tohospital for congestive heart failure are attended by ageneral or family physician, and 65% of the patientsadmitted to hospital for acute myocardial infarction(AMI) are treated by a cardiologists.17 In Canada, 12%of the patients seek medical attention in general clinicsfor cardiovascular disease and undiagnosed chest pain.18

In Spain, the medical culture tends to favorspecialization and burdens the cardiologists with greaterresponsibility, although, as in other countries, internistsattend to more than 50% of hospital patients with heartfailure, particularly if they are elderly with otherconcurrent diseases. On the other hand, a coronaryservice run by a specialist other than a cardiologist isnot unheard of, even in large hospitals.

The division of duties among specialties alsodepends of course on the availability of professionals.So although it might be desirable that, for example,interventionist cardiologists attend cases of stroke,19

this is often not possible because of the lack of suchprofessionals. The exact definition of the training needsof professionals implicated in attending cardiovascularpatients is a complex topic that changes over time.

Faced with the need for teamwork in thecardiovascular field, there is a trend towardssubspecialization (general cardiologists,interventionists, and electrophysiologists in theUSA). Recently, the SEC set in motion the process toset up qualifications in electrophysiology andarrhythmias and in catheterization and interventionalcardiology. The European Society of Cardiology hassubsequently followed suit. As the professionbecomes more subdivided, there will be a tendencytowards a heightened perceived need for moreprofessionals because a minimum number of eachsubspecialist will be required in each clinical unit. Atthe other extreme, active collaboration betweencardiologists and family physicians is encouraged tohelp manage the cardiovascular problems of thepatients.

In search of references for the number ofcardiologists. It is an extremely complex task toestablish how many cardiologists are needed. Too fewcardiologists is of course not desirable, but neither istoo many, as the use of invasive cardiac procedures andcardiac catheterization is largely dependent on theavailability of cardiovascular resources (catheterizationlaboratories). This is reflected in a number of studieson the variability of medical practice, such as the studyby Wennberg et al20 for example. The Organization forEconomic Cooperation and Development (OECD) hasfound that usage of interventional cardiac proceduresvaries greatly from country to country and followsdifferent trends. The position of Spain in the ranking ofusage is relatively low, although the growth in thenumber of these techniques used has been spectacularover the last decade.21 Within Spain, variation fromautonomous region to autonomous region is alsonoteworthy-2.5 more angioplasty procedures areperformed in the autonomous region with mostprocedures compared to the one with least.22,23

The number of cardiac procedures in Spain might beexpected to increase until it comes in to line with othercountries. In 2002, Spain was the third from thebottom of a ranking of 22 countries according to thenumber of coronary angioplasty procedures and thecountry that performed the least number of coronarybypass grafts (out of 19 countries).21 Bothcardiologists and cardiovascular surgeons would havemore work to do if the number of procedures in Spainwas more in line with other members of the OECD.According to the Integral Plan for Ischemic HeartDisease, patients with coronary artery disease shouldhave access to cardiac rehabilitation programs-anothersign of the need for cardiologists is the fact that accessis limited to only 2% to 3% of such patients.

On the other hand, treatment of myocardialinfarction by a cardiologist is associated with a 17%decrease in in-hospital mortality in the United States of

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America.24 Sufficient empirical evidence hasaccumulated to suggest that the availability ofcardiologists in a zone is significantly associated withgreater usage of angioplasty procedures,catheterization, or coronary stenting25 and thatcardiologists and other physicians (mainly internists)differ in their clinical practice.26,27 Moreover, betterhealth outcomes have been reported (greater survivalafter myocardial infarction,28 lower in-hospitalmortality29) for patients treated by cardiologists thanfor those attended by other physicians. Thesedifferences have also been reported in Europe. Thecardiologists who treat patients with congestive heartfailure seem to adhere more closely to clinicalguidelines.30 A study in Germany highlights theadvantages of having cardiologists on hand becausepostinfarction mortality is lower in hospitals with acardiology department compared to those that lacksuch a service.31 In Spain, cardiologists resort tointerventions shown to be useful more often than otherspecialists, both for acute coronary syndrome32 andheart failure,33 and adhere more closely to clinicalguidelines.

Reference standard. From the arguments presentedabove, it follows that the appropriate number ofcardiologists depends on the how professional dutiesare defined and the “need” for cardiology services inorder to improve the health of the population. Someexercises in planning human resources set an optimumor desired number for comparison (benchmarking).Thus, the planning office of Ontario, Canada, sets thenumber in the region with best coverage (3.8 per100 000 inhabitants) as the goal to aim for.17

In both the United States of America and Canada,general practitioners and internists take on many of theprofessional responsibilities and tasks that, in Spain,would correspond to cardiologists. Therefore, theAmerican reference values should not be applied toSpain. In fact, as has been observed, almost allEuropean countries exceed the optimum number forNorth America. This is probably not because there isan excess of cardiologists in other countries, butbecause they have more extensive clinical duties.

Evaluation according to “needs” criteria. Thetechnical definition of need is the capacity of patientsor population to benefit from the possibilities offeredby medicine to improve their state of health, lengthentheir lives, or improve their quality of life. The needfor cardiologists is therefore dependent on normativecriteria (how much can cardiologists do and how longdoes it take?) The Integral Plan for Ischemic HeartDisease has found a number of large areas in whichthe health system could be improved to reducemortality and improve the state of health of patientswith cardiovascular diseases.21 Many of these areas

represent technically feasible options that would needmore professionals. However, the number ofcardiologists required is not evaluated or quantified inthe Plan.

Ever since the 1970s, epidemiological studies haveinvestigated unnecessarily early and avoidable deathswhere the health system could assign more resourcesor better use existing resources. The list of causes ofsuch deaths includes:

– Cerebrovascular disease and hypertension (35-64years), codes ICD-9: 430-438, 401-405.

– Ischemic heart disease (all ages), codes ICD-9:410-414.

– Rheumatic heart disease (5-44 years), codes ICD-9: 393-398.

The mortality rate for ischemic heart disease per100 000 inhabitants varies from 67.9 to 178.7 in menand from 35.3 to 97.4 in women according to Spanishautonomous region.34 Nationally, this rate has droppedin the last 10 years, although an increase has beenreported in 7 autonomous regions. Some cardiovascularrisk factors, such as high concentrations of cholesterol,increased smoking among women, and high-caloriediets might lead to an increase in this type of mortalityin the coming years.

Although it might seem paradoxical, the need forcardiologists tends to increase when the health systemmanages to lower cardiovascular mortality (deaths dueto unexpected infarction avoided thanks to rapidaction). This is because someone who has suffered aninfarction becomes a cardiology patient for the rest ofhis or her life so and the decreases in mortality gohand in hand with an increased prevalence ofcardiovascular conditions. These problems tend tooccur after a certain age and ageing of the Spanishpopulation will therefore be a factor that increases theneed for cardiologists.

Evaluation by benchmarking: what is the optimumreference number? In this study, the basic modelconsiders the following numbers of cardiologistsnecessary for every 100 000 inhabitants (basicscenario), divided into 4 age groups:

– 0-14 years, 1 cardiologist.– 15-44 years, 4 cardiologists.– 45-64 years, 7 cardiologists.– ≥65 years, 9 cardiologists.

These figures are assigned in accordance with theprecedents for Spain and for other countries aftercomparing morbidity, the use of resources, and humanresources available. These numbers are those thatwere inputted into the basic simulation model. Wealso performed a sensitivity analysis by varying the


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benchmarks. The parameters of the model are set sothat it runs automatically on changing thebenchmarks.

Evaluation by demand indicators: waiting lists andaccess to services. Demand is the expression of theneed felt by the public who use the health services.Medications are becoming more widely used insociety, and cardiovascular drugs are no exception.This is reflected in national health surveys-comparisonof the last 2, from 1993 and 2001, shows a significantincrease in the perceived cardiovascular disease in allSpanish autonomous regions except Valencia andCastile-León (where it decreased) and in the CanaryIsles and Navarre (which showed no significantchanges).34 There are factors that “catalyze” demandin Spain and in other countries. A recent report by theAmerican Society of Cardiology6 described catalystsin demand for cardiologists in the coming decades inthe United States of America. The list, presentedbelow, is applicable to Spain, except for the pointreferring to the disappearance in the United States ofAmerica of the role of the “gatekeeper” in generalclinics (catalyst number 4 of the list):

1. Elderly population, with more chronic diseases,that lives longer.

2. Epidemics of obesity and noninsulin dependentdiabetes that enhance cardiovascular problems.

3. Improved outcomes for patients when attended bya cardiologist.

4. Disappearance of the model of indirect access tothe specialist (only with referral by the familyphysician) and improved access to the cardiologist.

5. Better informed population with growing healthcare expectations.

6. More women aware that they are more likely todie of cardiovascular disease than cancer.

7. Continuous innovations in procedures andtechniques, which spread rapidly.

8. Growing use of cardiovascular screening tests,which in turn lead to more tests and procedures.

9. Progressive subspecialization amongcardiologists, so increasing the number of referralsfrom within the specialty.

An indirect indicator of the current imbalancebetween supply and demand is the number of cardiologypositions that are advertised. In March 2005, there were17 cardiology positions advertised on the web site of theSpanish Society of Cardiology that were unfilled.35 InFebruary 2006, this number had risen to 41, althoughthe number of unfilled positions was actually muchhigher because the web site is by no means exhaustive.In 2004, 40% of the hospitals in the United States ofAmerica with more than 100 beds were seeking to hirecardiologists, and half of these recognized havingdifficulties to find qualified personnel.6

Waiting lists are another sign or indicator of theimbalance between supply and demand, but there is aproblem associated with using them to quantify thedeficit in resources: providers (cardiology services)can readily manipulate them. Waiting lists are themain reason for dissatisfaction among the public andthey have got longer in recent years.22 After a reportissued by the national ombudsman at the end of 2002which made recommendations on waiting lists in theSpanish National Health System, the state hasregulated and guaranteed waiting times (Act 605/2003,Spanish Official Gazette dated May 23, 2003), withmeasures introduced to ensure that information aboutwaiting lists in the health system is reliable. As aresult, the criteria, indicators, and requirements forinformation on waiting lists in some autonomousregions have started to become standardized, and itcould be expected that the demand for cardiologistsincreases dramatically in the short term as a result.According to the state figures for waiting lists,somewhat more than 400 000 patients were awaitingsurgery on December 31, 2003.36

The demand (and need) for resources depends to alarge extent on demographic changes and the ageingprocess. In our reference year (2004), drugs to treatcardiovascular diseases were mainly consumed bypatients aged over 65 years.37

Evaluation of the Deficit/Excess of Cardiologistsin Spain in 2004

In 2004, there were 1926 potentially activecardiologists in Spain, whereas 2185 would be neededaccording to our estimates based on the benchmarkcriteria discussed above.

In 2004, Spain had 259 cardiologists less than thenumber necessary, that is, the number of practicingcardiologists would have to be increased by 13.4%.

Future Prospects: Simulation Model

Factors That Influence Change: Hypothesis of the Dynamics of Supply and Demand Throughto 2020

As with all dynamic simulation models, futurechanges in the variables included in the model depend inturn on dynamic changes in other elements of the model.

The hypothesized changes are those that ultimatelywill determine to a large extent the quality of theresults obtained. For this reason, in this study, the mostplausible hypotheses were used in that we erred on theside of caution and tried to avoid excessive errors.Thus, when other preferably official predictive models(such as those of the Spanish National Institute ofStatistics for the population) were available, thehypothesized changes in these models was

710 Rev Esp Cardiol. 2006;59(7):703-17



incorporated, and when no such models wereavailable, hypotheses were established based on pastbehavior of the variable in question. Nobody canignore the impact that immigration is having on theSpanish population. In fact, a look at the predictionsfor the population made by several studies in recentyears shows that the future population has beenconsistently underestimated. The foreign populationliving in Spain has gone from 1.6% in 1998 to 6.24%in 2003 according to the electoral role for 2003, and to8% according to the electoral role for 200538; in thelast 5 years, the number of foreigners living in Spainhas increased 4-fold. However, the arrival of

foreigners has not only affected the overall number ofpeople but also the age structure and regionaldistribution. The incoming population is generallyyoung, with a mean age of 44.5 years for those fromthe European Union, but around 30 years for thosefrom South America, Africa, and East Europe.

Obviously, the estimates for demand and need aredetermined by changes in the population and sodepend on the quality of the predictions of populationgrowth. The hypothesized changes in the population inour model correspond to those made by the NationalInstitute of Statistics but, given that the extent ofimmigration is uncertain, an alternative scenario has


Rev Esp Cardiol. 2006;59(7):703-17 711

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Figure 2. Age pyramid of Spanishcardiologists up to 65 years. A: 2004.B: prediction for 2020.


been drawn up in which immigrants arrive in Spain insimilar numbers to the last 5 years.

For indicators such as mortality, natality,emigration, etc, we opted to maintain the overallstructure of the population so as to err on the side ofcaution, although a subsequent sensitivity analysiscould be performed to see how the results change onvarying these values.

Simulation Model: Results of the Basic ModelThrough to 2020

Supply. The age distribution of the cardiologists willundergo substantial changes in the coming 15 years(Figure 2A and B). The current top-heavy age pyramidwill give way to one with a wider base correspondingto more young cardiologists. This will be due to 2

factors: a) the resident training program willincorporate new young cardiologists at a rate of morethan 100 per year, which is higher than the retirementrate, and b) through to 2020, 1119 professionals willretire, that is, 58% of the current cardiologist, becausethey will have passed the mandatory retirement age of65 years.

The estimated number of cardiologists in 2020 is2348, 22% more than in 2004. Of these, 1092 will bewomen (46.5%) compared to the current percentage ofwomen of 19.1%. Female cardiologists will have ayounger age profile than male ones. In some agegroups, there will be more female cardiologists thanmale ones (Figure 3A and B).

Demand/need. The first catalyst factor in thedemand and need for cardiologists is demographic.

712 Rev Esp Cardiol. 2006;59(7):703-17


120

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Figure 3. Age pyramid of Spanishcardiologists up to 65 years,according to sex. A: 2004. B:prediction for 2020.


According to the population model, whichextrapolates demographic trends from the past andtakes into account the large numbers of youngimmigrants arriving in Spain, in 2020 the Spanishpopulation will be 51 364 417.3 The currentcomposition of the Spanish population and that in2020 by broad age groups is shown in Table 5. Eachage group will of course have its own correspondingneeds for cardiologists.

This demographic pattern that determines the needfor cardiologists, according to the benchmarksdiscussed earlier, is essentially subject to growth in thebirth rate and the arrival of immigrants under 44 yearsof age.

In the next 15 years, and in accordance with thebenchmarks established for the basic model (1/100 000inhabitants for subjects under 14 years of age,4 /100 000 inhabitants for subjects between 15 and 44years of age, 7/100 000 inhabitants for those agedbetween 45 and 64 years, and 9/100 000 inhabitants forthose aged over 65 years), the need for cardiologistswill increase by 512 professionals (from 2179 thatwould be required in 2004 to 2691 that would beenneeded in 2020, an increase in need of 23%).

The Deficit of Cardiologists in Spain, 2004-20

The deficit in professionals, which was 253cardiologists in 2004, will widen each year until

reaching 343 in 2020. Expressed as a percentage, thecurrent deficit is 13% and will increase to 14.5% in2020.

The supply of professionals will increase by 422over the period covered by the model, correspondingto a growth in supply of 22%, whereas the growth indemand will be 512 professionals, an increase of 23%.The current deficit will increase by 35% (from 253 to343 professionals) (Figure 4). The annual cumulativeincrease in the number of resident training positionsoffered will need to be 4% (in order to offer 215training positions in 2020, that is, almost twice thecurrent training capacity) to reach an equilibrium in2020. But if immigration increases in the coming 15years at the same rate as it has done in the 5 precedingyears, the current deficit in cardiologists will double inthe same period from 253 to 502. And if the training


Rev Esp Cardiol. 2006;59(7):703-17 713

2500

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02005 2010 2015

Year2020

Demand for Cardiologists Total Number of Cardiologists

Figure 4. Supply and demand ofcardiologists in Spain, 2004-20.

TABLE 5. Spanish Population in 2004 and 2020, by Age

2004 2020

Number Percentage Number Percentage

0-14 6 043 479 14 7 947 193 1515-44 19 792 999 46 20 285 032 3945-64 9 603 966 22 14 098 865 27>65 7 276 620 17 9 033 325 18

42 717 064 100 51 364 415 100


period is increased by 1 year, the deficit in 2020,which was 14% in the basic model, will be as high as19.5%. In terms of absolute numbers, 439 morecardiologists will be required in 2020.

Synthesis, Discussion,and Recommendations

In 2004, there were 1926 potentially activecardiologists in Spain whereas, according to ourestimates based on the benchmarks discussed earlier,2185 would be needed. Spain has 253 fewercardiologists than needed, that is, the number ofpracticing cardiologists would need to increase by13.4%. In 2020, the deficit will be 14.5%. The needfor cardiologists will increase by 512 professionals(from the 2179 that would be needed in 2004 to 2691that would be required in 2020, an increase of 23% inthe need).

In order to balance the number of cardiologistsneeded in 2020 with the expected demand, the annualcumulative increase in the number of resident trainingpositions offered for cardiology would need to be 4%(so that 215 positions are awarded in 2020, that is,almost double the current training capacity).

POSSIBLE LINES OF ACTION IN THE FUTURE

Although all such prospective analyses have theirlimitations, particularly when the predictions aresubject to many influences-some of which cannot evenbe conceived at present-it seems clear that the presentdeficit in cardiologists will tend to worsen in theimmediate future. The following sections summarizesome of the possible actions that can be taken toaddress this situation.

Reduction in the Demand

A decrease in the demand for cardiologists in thenear future in order to better align demand with currentavailability would require a decrease in the incidenceand prevalence of cardiovascular diseases. As hasalready been discussed earlier, a simple decrease inmortality among patients with cardiovascular diseasedoes not reduce the need for visits to the cardiologist.In fact, such a need may even increase because patientswhose life has been saved become chronic patients whorequire continued specialist care. It would therefore benecessary to prevent cardiovascular disease in the firstplace, which is essentially the goal of preventativemedicine. Although advances in this field have beenimpressive, it is hard to be optimistic. Prevention withinthe population should not depend on greater intake ofmedication but rather on extensive changes in lifestyle.However, many of the habits inherent in our westernlifestyle that need to be modified are closely linked to

the current model of western society-stress, haste, lackof exercise, and poor eating habits are not going todisappear overnight. And like Jason’s battle with the 7-headed hydra, the threat from cardiovascular diseasereacts to improvement in one risk factor (smokinghabits) with new challenges such as obesity anddiabetes. In any case, even in the best case scenario,partial success in cardiovascular prevention will notlead to eradication of the disease but only delay itspresentation. In a society with an ever increasing lifeexpectancy, the demand for cardiologists is not likely todecrease.

Increase in the Supply of Cardiologists

To bolster the supply of cardiologists, the first andmost immediate option would be to increase thenumber trained by the current resident trainingprogram. In some countries, such as the United Statesof America, physicians in training, particularly thosethat belong to certain groups such as women andforeigners, are less interested in becomingcardiologists. This is not the case in Spain, wheredemand for cardiology among those who enter theresident training program is high, and so the capacityto meet demand is derived from the limitations of thesystem itself. The availability of training positions inthe system was 118 in 2004, according to a survey ofthe centers recognized for specialist training in thisfield and the number of positions that each canaccept. Of these positions, 114 were advertisednationally in the round of applications. The NationalCardiology Commission of the Spanish NationalBoard of Medical Specialties under the auspices ofthe Ministry of Health, when consulted, hadrecommended-as it does every year-that all positionsavailable were advertised.39 But even if this requesthad been met, this increase would have beeninsufficient to cover not only future needs but alsocurrent ones. According to the simulation model used,more than 200 positions would need to be offered in2020, which represents an annual cumulative increaseof 4% from the present time. This would require thenumber of recognized hospitals and/or the number ofresidents per hospitals to be increased. The legislationfor recognition of teaching hospitals is very strict40

and requires a series of conditions that the hospitaland the cardiology service itself have to meet. It istherefore unlikely that hospitals, apart from thosealready recognized, will easily obtain recognition.This same legislation covers the requirements forextending the number of residents per hospital inorder to guarantee full training with sufficientpractical experience in techniques and procedures.With this legislation, it is also unlikely that thenumber of positions in most of the hospitals can beincreased. Clearly, a move towards more resident

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cardiologists in training would require a change in thecurrent legislation.

If this alternative were insufficient to improvesupply, some of the other alternatives presented belowwould need to be considered.

Increase in the Number of Cardiologists byTraining Systems Other Than the Current One

This option includes the establishment of therequirements for the training of general clinicalcardiologists. Working Group no. 8 of the 35thBethesda Conference41 started by defining the differenttypes of cardiologist, in accordance with thesubspecialties that we are familiar with at present andwith others that will appear in the near future (forexample, the cardiologist who concentrates onmagnetic resonance imaging/computed tomography).The general clinical cardiologist is, according to thisworking group, someone who is dedicated to thediagnosis, treatment, and prevention of cardiovasculardiseases. He or she is essentially responsible forhospitalized patients and outpatients and is in contactwith the physicians who refer the patients to aspecialist. This person should be able to interpret andperform electrocardiograms, exercise tests, Holtermonitoring, and transthoracic echocardiography. Sucha cardiologist can undergo short track training, whichwould reduce the length of training in the Americansystem from 6 years (3 years of internal medicine plus3 years of cardiology) to 5 years (2 years of internalmedicine, one transition year, and 2 years ofcardiology). In the Spanish system, training couldconsist of one year of internal medicine plus 2 years ofmainly clinical cardiology, which of course wouldneed to be spent in recognized cardiology services.This same common program of 2 years of clinicalcardiology could also be considered as part of thetraining of family physicians. The Spanish healthsystem has sufficient capacity to absorb the training ofthis type of specialist, given that the number ofcardiology residents that can be trained at present islimited by the need to have a minimum experience interms of number of invasive tests and other testsperformed. This type of cardiology could provide aplatform for subspecialization through optional andadditional training periods that would have to bedefined. The foreseeable problem with this approach isthat clinical cardiology has to be seen as an attractiveoption for physicians in training. This problem goesbeyond the scenarios considered in this analysisalthough it represents a real problem for cardiology.Young physicians in training are fascinated by theattractive options offered by technically complexmedicine such as electrophysiology andcatheterization in the case of cardiology. On the otherhand, the practice of cardiology in the public system is


Rev Esp Cardiol. 2006;59(7):703-17 715

burdened with overcrowding and physicians havelimited amounts of time to deal with the patients,whether in hospital or an outpatient clinic. Because ofthese factors, many young cardiologists do not think ofclinical cardiology as their first option. To try andovercome this perception, it is necessary to remindphysicians in training that patient considerationsshould be at the heart of the medical professional. Theclinic, which integrates much of what cardiovascularmedicine has to offer the patients, plays a central rolein attending to patient needs.

Importation of Cardiologists Trained OutsideSpain

Any cardiologist who wishes to practice in Spain, atleast within the Spanish National Health System,requires official recognition of the cardiologyqualification obtained outside Spain. The legislationfor this recognition requires the duration and contentof the respective programs to be equivalent to theSpanish ones. When the programs are not fullyequivalent but there are no large discrepancies, it ispossible to take an examination. In 2004, the NationalCardiology Commission examined the applications of23 cardiologists from Argentina (n=10), Germany(n=4), Cuba (n=3), Romania (n=2), Venezuela (n=2),Mexico (n=1), and Uruguay (n=1). Of these, 6received a favorable decision. At present, there are 36applicants waiting to take the theoretical and practicalexamination foreseen for those cases in which thereare no substantial differences between the content andduration of the training followed in the country oforigin and the current program in Spain. The currentlegislation that regulates the recognition ofqualifications of specialist physicians from memberstates of the European Union, presented in Act1171/2003, dated September 12, 2003, that modifiesarticle 12bis of Act 1691/1989, dated December 29,1989, foresees automatic equivalence of cardiologyqualifications in the 15 member states. But a glance at

TABLE 6. Comparison of Salaries of Physicians in Different Countries of the European Union*

CountryMean Gross Annual Salary*,

RangeEuro

Spain 37 500 (+20% retainer) 35 000-45 000Portugal 55 000 40 000-70 000United Kingdom 122 500 95 000-150 000Germany 65 000 NAFrance 70 000 NAItaly 55 000 NA*NA indicates not available.*Equivalent to an associate physician in the Spanish National Health Systemwith 5 years experience in the position.Taken from the Diario Médico42 and Pay scales.43


the origin of the applications received last yearsuggests that future immigration is unlikely to comefrom the European Union. The reason for this is theworking conditions. The mean salary of an associatecardiologist in the Spanish health system is arounds37 500 (plus 20% retainer fee), which is below thatof other European countries with similarsocioeconomic conditions such as the UnitedKingdom and Portugal42,43 (Table 6). Both the UnitedKingdom and Portugal are net importers of qualifiedmedical manpower, and at present, there are 1688Spanish members in Portugal and 1084 in the UnitedKingdom, according to data from the General Councilof the Association of Spanish Professional MedicalBodies (through to February 2005).

Modification of the Structure of CardiologyServices by Incorporating Noncardiologists

Cardiology, like other current fields of medicine, isan exercise in teamwork, and the importance ofteamwork is evident in clinical services, such ascardiology. From the point of view of healthprofessionals, the team is currently made up ofcardiologists and nurses, each with their own welldefined duties. University hospitals also have atemporary contribution from the personnel in training,including cardiology residents and residents from otherspecialties who spend time learning about cardiology.The present lack of cardiologists on the one hand andthe integrated approach to patients with multipleillnesses on the other may stimulate a search for moreimaginative alternatives. Under the supervision ofcardiologists, internists and family physicians couldform part of the team. After a period of adaptation, theycould carry out some of the mainly clinical functionswhich are currently the reserve of cardiologists in thecardiology services but which are no different to thoseconducted by internists or general practitioners incardiovascular patients in other services. Such anapproach contrasts with what happens whencardiovascular patients are attended in noncardiologyservices. Questions of divisions of professional dutiesaside, polyvalent services (internal medicine orintensive medicine) undeniably see a wide range ofpatients, so each physician spends little time withcardiovascular patients. In the proposed alternative,however, noncardiologists who form part of thecardiology services would dedicate themselves almostexclusively to attending patients with heart disease,with close support from cardiologists. The proposalwould be complemented with the incorporation ofnonmedical technicians for specific tasks. A clearexample of this is echocardiography. In countries suchas the United States of America, scans are recorded bytechnicians and interpreted by physicians, and so theperformance of the physicians, measured in terms of

716 Rev Esp Cardiol. 2006;59(7):703-17


the number of scans, is very high. Such an approach isalready the norm in some hospitals in Spain, wherenurses are responsible for recording the scans. If suchan approach were to become more widespread, the typeof training, qualification, and duties of the differenttypes of technician would need to be regulated. Finally,such an integrated team approach should not be limitedto the clinical services of large hospitals. Theintegration of the cardiology resources of smallhospitals could also be pooled into one large regionalcardiology service, so facilitating rotation of personneland coordination of referrals.

If these alternatives, or indeed other alternatives yetto be considered, are not taken up, the outlook forcardiovascular patients could be bleak. If there are toofew cardiologists, they would be restricted toperforming certain techniques which, because of theirtechnical nature, need to be performed by a specialist.Care of the patients would then fall onnoncardiologists. This is not in the best interests of thepatients, and it would also be negative for cardiologyas such, because cardiologists should be providingsupport for the clinicians who attend the patients. Theother possibility would be to select a limited thenumber of patients to be attended by a cardiologist.Once again, this would not be in the best interests ofthe patients because it would create 2 different levelsin the quality of care.

SUMMARY

The current situation in Spain shows an imbalancebetween the number of practicing cardiologists andthose that would be necessary. This imbalance isapproximately 14%. The age pyramid reflects anageing population of mainly male cardiologists.Predictions for the future indicate that the situationwill get worse through to the year 2020. Correction ofthis imbalance requires other sources of training to bedeveloped and/or reorganization of the health careservices. Some of these alternatives are presented inthe final part of this document, in the form ofproposals to stimulate debate.

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Imbalance Between the Supply and Demand for Cardiologists in Spain. Analysis of the Current...

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