S989 Gastrointestinal Physician Density (GIPD) in the USA: The Critical Shortage of Gastroenterologists and the Impact on Upper Gastrointestinal Bleeding Mortality Across All 50 States

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Introduction: Upper gastrointestinal bleeding (UGIB) continues to be a significant burden on the national healthcare system. Despite the availability of innovative treatments, trends in UGIB have been on the rise. Few studies exist that examine the mortality of UGIB in the United States over a prolonged period. Additionally, geographical patterns of disease-associated mortality for UGIB have never been explored in-depth. Therefore, we studied the trends of UGIB mortality in the United States (US) and examined the impact of primary care provider density (PCPD) and gastrointestinal physician density (GIPD) at state and county levels. Methods: The ICD-10 codes were selected first on the Center for Disease Control and Prevention - Wide-ranging Online Data for Epidemiologic Research (CDC-WONDER) database for UGIB mortality and all patients were included without any age restrictions. Crude and Age-Adjusted Mortality Rates (AAMRs) were abstracted from multiple cause of death files from 1999-2023 using the 2000 US Census as the standard population. Correlation and linear regression analyses were then performed to determine area health resource files (AHRF) study variables including PCPD and GIPD. Results: The overall crude mortality rate (CMR) over the study period (1999-2023) for UGIB was 12.1 per 100,000 and the AAMR was 11.0 per 100,000 among the US population. Overall, mortality trends increased during the period 2018-2021 (Annual Percent Change [APC]: +9.05) and decreased from 2021-2023 (APC: -7.93). CMR was highest in older age groups, American Indians, Native Alaskans, and in rural communities. Males have higher AAMR than females. States in the top (90th) percentile for CMR overall from 1999-2023 included: West Virginia, Rhode Island, Vermont, South Dakota, New Mexico, and Wyoming. According to Area Health Resource Files (AHRF), GIPD in most of the 50 states is significantly correlated with CMR (rho= -0.214, P< 0.001), with lower quartiles of GIPD being associated with the highest UGIB mortality. Conclusion: GIPD rather than PCPD was significantly associated with high mortality for UGIB in most United States counties. Addressing the rising mortality trends of UGIB will require increasing the number of gastroenterologists in the US by creating additional new fellowship programs in gastrointestinal diseases and by expanding the size of existing fellowship programs in graduate medical education. Additionally, enhancing resources like endoscopy suites will be crucial in effectively combating this condition (see Figure 1, Table 1).Figure 1.: Age-Adjusted Mortality Rates (AAMRs) of Upper gastrointestinal bleeding (UGIB) for gender (A), Crude Mortality Rate of UGIB for age-groups (B), AAMRs of UGIB for Race (C), AAMRs of UGIB for urbanization (D), AAMRs of UGIB for US Census Region (E), and AAMRs of UGIB among States with varying trends (F). Table 1. - State-wide characteristics of area health resource files (AHRF) datasets with CDC crude mortality data US State No. of Counties included in the crude analysis Total population (census 2020 from AHRF) Total deaths (1999-2023) Crude mortality rate per 100,000 population (1999-2023) Total Physician workforce (AHRF) Primary care physicians (AHRF) GI physicians (AHRF) AL Alabama 67 4997675 17345 12.98 11961 3208 186 AK Alaska 17 735951 1984 9.89 2114 709 11 AZ Arizona 15 7079203 18279 9.92 17347 4835 303 AR Arkansas 75 3006310 11825 14.34 6491 2047 98 CA California 57 39455353 107225 10.15 110826 31820 1754 CO Colorado 57 5723176 17960 12.01 18322 4816 222 CT Connecticut 8 3605330 14574 14.61 14058 2983 294 DE Delaware 3 981892 3441 13.31 3262 740 39 DC District of Columbia 1 683154 2594 15.05 6976 863 77 FL Florida 67 21339762 65468 11.83 61273 15903 1109 GA Georgia 153 10625615 26065 9.41 27117 7121 411 HI Hawaii 4 1453498 5302 13.91 4999 1285 55 ID Idaho 41 1811617 5465 11.88 3251 1174 47 IL Illinois 102 12821813 38195 10.74 40556 10026 596 IN Indiana 92 6751340 24277 12.93 15649 4465 233 IA Iowa 99 3179090 13113 14.97 7981 2305 82 KS Kansas 100 2932099 10471 12.92 6220 2284 99 KY Kentucky 119 4494141 18170 14.56 10006 2816 182 LA Louisiana 63 4657305 12493 9.70 11800 3210 240 ME Maine 16 1357046 5271 14.39 4104 1473 49 MD Maryland 24 6148545 21763 13.26 22851 5227 366 MA Massachusetts 13 6991854 24742 13.24 33125 7053 596 MI Michigan 83 10062512 36160 12.86 33879 7875 370 MN Minnesota 86 5670472 18118 11.75 16413 5033 296 MS Mississippi 81 2967023 11622 13.94 5900 1573 113 MO Missouri 114 6141534 20550 12.15 17871 4342 275 MT Montana 43 1077978 4195 14.53 3043 920 36 NE Nebraska 73 1951480 6621 12.54 4955 1462 73 NV Nevada 14 3059238 8569 11.13 6201 1745 87 NH New Hampshire 10 1372174 4998 13.29 4841 1209 73 NJ New Jersey 21 9234024 32375 12.98 29402 7245 591 NM New Mexico 31 2109366 9346 16.23 5333 1574 67 NY New York 62 20114745 59804 10.95 87943 15938 1535 NC North Carolina 100 10367011 32793 12.15 28305 7469 525 ND North Dakota 46 773344 3067 15.38 1700 599 15 OH Ohio 88 11769923 45745 14.15 37504 8868 529 OK Oklahoma 76 3948136 15095 13.94 9477 2354 113 OR Oregon 33 4207177 15184 13.75 14242 3989 181 PA Pennsylvania 67 12970650 56093 15.79 46623 10252 761 RI Rhode Island 5 1091949 5048 16.82 4443 1060 83 SC South Carolina 46 5078914 19997 14.77 14699 3495 191 SD South Dakota 54 881785 3959 16.71 2650 715 26 TN Tennessee 95 6859497 25550 13.89 19410 4854 299 TX Texas 233 28862581 76149 10.32 71063 17818 1097 UT Utah 25 3231370 6203 7.64 8072 1870 107 VT Vermont 14 641637 2973 16.77 2213 718 33 VA Virginia 132 8582479 23827 10.48 23222 6443 387 WA Washington 38 7617364 26911 13.70 23538 6440 340 WV West Virginia 55 1801049 9493 18.60 5001 1352 68 WI Wisconsin 72 5871661 21668 13.27 16071 4713 218 WY Wyoming 23 576641 2592 16.11 1248 402 13 All United States combined 3012 329725483 1070727 12.13 985575 248730 15551 Counties were excluded if they weren’t reported crude mortality rates (suppressed or unreliable If less than 10 in number according to CDC WONDER guidelines).

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