U.S. Suffers Significant Geographic Disparities in Access to Neurologists and Multiple Sclerosis Care

A new study published in Neurology highlights concerning gaps in access to neurological care across different regions and demographic groups in the United States. The Cleveland Clinic-led cross-sectional analysis examined geographic access to both general neurologists and subspecialty multiple sclerosis (MS) centers using national physician data.

“We found that rural and micropolitan areas had far lower availability of neurological care, with 80% and 60% less access, respectively, compared with metropolitan regions,” says the study’s lead and corresponding author, Marisa McGinley, DO, a neurologist with Cleveland Clinic’s Mellen Center for Multiple Sclerosis. “Access to MS subspecialty care was further limited. Especially large barriers to access were faced by communities with larger Hispanic populations and higher rates of disabled individuals and uninsured individuals.”

Study rationale and design

The researchers undertook the study to better understand disparities in geographic access to neurological care in the context of rising numbers of Americans with neurological disorders and a growing shortage of neurologists. “Geographic proximity isn’t the only factor determining healthcare access, but it’s an important one that requires better characterization,” Dr. McGinley explains.

She and her colleagues analyzed locations of neurologist practices from the 2022 Care Compare database of the Centers for Medicare & Medicaid Services and locations of MS centers as defined by the Consortium of Multiple Sclerosis Centers. Their objective was to compute spatial access to these locations for all U.S. census tracts and identify community characteristics associated with relative levels of proximity to neurological care. Community characteristics were determined at the census tract level using 2020 American Community Survey five-year estimates. The researchers used logistic and linear regression models to evaluate access to a neurologist or an MS center within 60 miles as well as 60-mile spatial access ratios.

Findings in brief

Of 70,858 census tracts analyzed, 388 had no neurologists within 60 miles while 17,937 had no MS centers within 60 miles. The latter finding reveals that vast swaths of the U.S. lack easy geographic access to the specialty care needed for a complex condition like MS. “Managing MS requires a multidisciplinary approach, but the location of centers makes this highly difficult for many patients,” Dr. McGinley notes.

Compared with metropolitan areas, geographic access to neurologists was 80.5% lower for rural areas and 60.5% lower for micropolitan areas (i.e., cities of 10,000 to 50,000 residents). Lower spatial access to neurologists was also seen in census tracts with higher percentages of Hispanic individuals and uninsured individuals — and particularly in tracts with greater percentages of residents with hearing, vision or ambulatory difficulties.

The latter group is disproportionately represented among the populations that neurologists serve. “It can become a troubling cycle where care is out of reach for those who need it most,” Dr. McGinley observes.

Census tracts with higher percentages of Black individuals, holders of college degrees, computer owners, nonowners of automobiles, individuals with cognitive difficulty, individuals with limited English and older individuals (median age difference of at least 10 years) tended to have higher spatial access to neurologists.

Covariates for spatial access to MS centers followed similar patterns to those for access to neurologists.

Race and income data told a complex story. Metropolitan areas with larger Black and low-income populations had better spatial access to neurological care, but this finding was inversed in micropolitan and rural areas. This finding suggests that proximity to a neurologist is the not the main barrier to accessing neurological care for urban Black communities but may be a more significant barrier for Black individuals in rural and micropolitan areas, Dr. McGinley notes. “This highlights the need to develop access interventions that target the unique needs of individual communities,” she says.

A call to rethink delivery models

Overall, the authors conclude that while physician shortages play a role, deeper geographic disparities in access to neurologists may remain even if shortages would ease. They warn that as the U.S. population ages and rates of neurological disease rise, the need for equitable access will only grow.

“This research spotlights where we’re falling short,” Dr. McGinley says. “We have shortages, absolutely, but compounding factors such as geography and disability-related barriers are major drivers of unequal access.”

The study’s findings indicate how far the U.S. needs to go to meet national goals of improving care access and reducing health disparities. “It will take enormous effort, from expanding the neurology workforce to telemedicine innovations to tackling broader systemic inequities related to disability, race and ethnicity,” Dr. McGinley concludes. “We hope these findings on geographic access disparities can help policymakers and other develop more equitable healthcare delivery models.”