For any medical speciality it is important to know the supply of available professionals in relation to the population served. The number of specialists available per 100,000 inhabitants is an indicator of health resources used for the organisation and evaluation of health systems.1,2

Different working groups in scientific societies in the Americas have studied the current situation and future projections for the speciality of rheumatology, taking into account possible scenarios of change in both supply and demand.2,3. In this sense, the European League Against Rheumatism promoted this type of analysis in Europe and established methodological recommendations for its correct performance4. In Spain, similar work has been carried out at a regional level.5,6

This study is an update of the one undertaken in 2017,7 and is based on data collected up to February 2020, so it can be considered an indicator of the situation of the speciality prior to the COVID-19 pandemic. The aim of this analysis was to determine the number of rheumatologists per 100,000 inhabitants in Spain and by autonomous community, active in public or private centres. The distribution of rheumatologists by age and sex in Spain and by autonomous community was also evaluated.

A cross-sectional study using the database of members of the Spanish Society of Rheumatology (SER for its initials in Spanish) as a source of information. Full members were selected (members with the title of specialist in rheumatology), active (non-retired members), with professional practice in public or private centres throughout Spain as of February 2020. As no information was available on time commitment, full time was assumed.

The selection of specialist doctors for this analysis started in April 2019. The initial data were corroborated by e-mail with the heads (service, section or unit chiefs) of the clinical services of each of the hospitals (public and private) available in the SER membership database. If no response was received, telephone contacts were made with those responsible to request that the available information be corroborated and updated in terms of the number, age and sex of rheumatologists at each centre. This work to review the number of specialists was completed in February 2020.

The rate of active rheumatologists per 100,000 inhabitants was calculated assuming that 95% of rheumatologists in Spain are members of the SER and using as a denominator the data from the National Institute of Statistics, corresponding to the information available in January 2020 for the population in Spain globally and by autonomous region.8

The rate of rheumatology specialists per 100,000 inhabitants in Spain is 2.17 (Table 1). The lowest ratios of specialists per 100,000 inhabitants are recorded in the Autonomous Community of Valencia (1.6), and the Basque Country, Andalusia and the Balearic Islands (1.7), and the highest in Cantabria (3.6) and La Rioja (3.2). The absolute number of practising professionals by Autonomous Community varies, ranging from 197 in the Community of Madrid to 10 in La Rioja (Table 1).

For Spain as a whole, the distribution by sex and age of rheumatology specialists is shown in Fig. 1. Percentage-wise, only in La Rioja (40%), Galicia (46.6%), Murcia (47.2%) and Extremadura (47.6%) do more male rheumatologists practice than female rheumatologists, while at the other extreme, in Navarre (71.4%) and the Balearic Islands (70%), more than 70% of rheumatologists are women. In terms of average age, Galicia (54.8 years) and Castilla-León (50.9 years) are the regions with the oldest specialists, while La Rioja (44.5 years), the Canary Islands (44.8 years) and Cantabria (44.9 years) have the youngest rheumatologists.

Fig. 1.

Gender and age distribution of rheumatology specialists in Spain in 2020. The data within the bars represent the absolute number of rheumatologists by sex and age stratum. M: men; W: women.

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The findings from this analysis show that, in contrast to previous decades, rheumatology is currently a speciality with a greater presence of women (59.7%) than men. However, over the age of 50, men still outnumber women. The progressive retirement of the more mature generations and the entry of new generations of residents with a preponderance of women has been changing the distribution by sex, with a predominance of women in all age strata in the rheumatology speciality in the 10-year future.

The main findings of this analysis are that: (1) the rate of rheumatologists in Spain remains above 2.0 per 100,000 inhabitants, with significant variations between autonomous communities; (2) among younger specialists, women predominate; and (3) the distribution of rheumatologists according to age and sex is uneven between autonomous communities.

Our results are in line with the predictions made by the Health Economics Research Group of the University of Las Palmas on the different medical specialities with data from 2006 and 2009.9,10 A paper by this group updated to January 2019 observed a proportion of women in rheumatology of 55.9%, a figure very similar to that presented in this analysis.11 This paper also estimated that 16.6% of rheumatologists were aged 60 years or older at the time of the analysis. Finally, this paper estimated a ratio of rheumatology specialists per 100,000 population of 2.0, a figure slightly lower than that found in this study.

In Catalonia, Dolors Grados Canovas et al. published an analysis of the situation of the speciality in Catalan public centres with data from 2017.6 In this study, they estimated a total of 141 rheumatologists working in public centres in this autonomous community. This figure is lower than that found in our analysis (189 rheumatologists), although in our case both public and private health centres were taken into account.

Internationally, the 2015 American College of Rheumatology Workforce Study found rates of rheumatology specialists per 100,000 population in the United States below 2.0 in virtually all states.2 This work identified significant variations between regions in the number of rheumatologists per 100,000 active population in 2015. A more recent analysis, with data from the Ontario region (Canada), shows significantly lower rates of rheumatologists (1.15 per 100,000 population) than those found in Spain.12 Precisely, researchers in Canada have found a female/male ratio of more than 1 among rheumatology specialists, a finding that coincides with the results obtained in our analysis.13 Fernández-Ávila et al. have carried out an analysis of the current situation and future projection of the speciality in different Latin American countries, finding a significant variability in the availability of rheumatologists per 100,000 inhabitants between countries, ranging from 3.6 in Uruguay to 0.16 in Nicaragua.3

No consensus has been established on the optimal ratio of rheumatologists per 100,000 population. In Europe, Austrian researchers evaluated the ratio of specialists per population needed to meet the demands derived from the care of health problems related to diseases treated in rheumatology services and established that 4.29 rheumatologists per 100,000 inhabitants were required,14 a figure much higher than the current figure in Spain.

This study has some limitations. A number of rheumatologists may not have been considered in the study as only rheumatologists who are members of the SER were included. The proportion of this group not included was estimated to be less than 5%. Centres in Melilla and Ceuta were not considered in the analysis for the calculation of the rate of specialists per 100,000 population. Furthermore, in this study no distinction was made between healthcare activity in public or private centres, nor the time of dedication, assuming a full-time activity, which may entail limitations when planning resources based on these characteristics. With respect to the work carried out in 2017, data collection and quality control have been improved, with the participation of heads of services, units and sections from centres throughout Spain. Finally, it should be borne in mind that this indicator is just one more to be considered for the evaluation of health services, but its interpretation is still subject to controversy.15

Our data show significant differences in the rates of rheumatologists per 100,000 inhabitants between the different autonomous communities in Spain, with a majority of women under the age of 54. These findings show a snapshot of the current situation of the speciality and provide a glimpse of how rheumatology is facing the healthcare challenges it is currently facing, as well as the imminent challenges that lie ahead in the coming years.

The authors have no conflict of interests to declare.