Specialist shortage leaves care of obese children to PCPs.

The distribution of children with diabetes and obesity does not parallel that of pediatric endocrinologists in the United States, largely because of geographic disparities in the supply of these specialists, according to Dr. Joyce M. Lee and colleagues at the University of Michigan, Ann Arbor.

This patient-specialist disparity is made especially acute by the growing epidemic of obesity, the authors report.

Data from the American Board of Pediatrics were used to estimate the number of board-certified pediatric endocrinologists by state, and national estimates of children with diabetes and obesity were derived from the National Survey of Children's Health, a representative cross-sectional random-digit-dial telephone survey of households with children younger than 18 years of age.

The investigators compared the observed ratios of obese children to pediatric endocrinologists under "index" conditions of greater supply and equitable distribution. They assumed that the ratio of the child population to specialists for each state was similar to that in the state with the largest supply, Massachusetts, where the ratio of obese children to endocrinologists was 5,132:1.

The highest ratio--99,984:1--was in Mississippi. Two states, Montana and Wyoming, had no endocrinologists.

Nationwide, there were 17,741 obese children for each board-certified pediatric endocrinologist. By region, the northeast had the lowest ratio (9,994:1) and the south had the highest (25,796:1).

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When the scientists examined the ratio of endocrinologists to children with diabetes, they found the best conditions in New England (113:1) and the worst in the east south-central region (594:1).

The nation as a whole had a ratio of 290:1 (Journal of pediatrics 2008; 152:331-6).

With an almost sixfold difference in ratios of children with diabetes to certified pediatric endocrinologists across census divisions, and no ideal benchmark ratio for children with chronic disease to pediatric sub-specialists, the authors believe it is unclear what effect this distribution has on access to the pediatric endocrinologists and health outcomes across geographic areas.

When observed ratios were compared with "index" ratios calculated under assumptions of equitable supply, the "index" ratios showed considerably less variation, the investigators explained.

The data suggest that geographic differences in endocrinologist supply, not geographic differences in diabetes and obesity prevalence, might be driving the variation.

The authors point out that childhood obesity clinics are receiving increasing attention as a possible solution to the treatment of pediatric obesity.

However, given the scope of the problem in the United States, "it is unclear whether childhood obesity clinics run by subspecialty providers represent a model of care that is either sustainable or effective in addressing the increasing burden," the investigators said.

Given this state of affairs, the role of the primary care pediatrician and the medical home in caring for the obese child becomes even more critical, Dr. Lee said in an interview.

"Our study may actually underestimate the ratios because most pediatric endocrinologists are affiliated with academic medical centers and spend a lot of time teaching and conducting research rather than seeing patients," said Dr. Lee of the division of pediatric endocrinology at the university.

The huge demand for obesity and diabetes treatment is expected to continue to out-pace the slow growth in new specialists, so emphasis should be placed on helping primary care pediatricians prevent and treat childhood obesity, she said.

"The American Diabetes Association states that, ideally, these children should be treated by pediatric endocrinologists, but they also can be treated by adult endocrinologists and even internists and family practitioners," Dr. Lee said in an interview.

"'The bottom line is these children need a medical home, and that home really resides with the primary care pediatrician," she concluded. BY BRUCE K. DIXON Chicago Bureau