Assessment of Changes in Rural and Urban Primary Care Workforce in the United States From 2009 to 2017

This cross-sectional study examines and compares the primary care workforce and its growth between urban and rural counties or county-equivalents from 2009 to 2017 in the US. Importance Access to primary care clinicians, including primary care physicians and nonphysician clinicians (nurse practitioners and physician assistants) is necessary to improving population health. However, rural-urban trends in primary care access in the US are not well studied. Objective To assess the rural-urban trends in the primary care workforce from 2009 to 2017 across all counties in the US. Design, Setting, and Participants In this cross-sectional study of US counties, county rural-urban status was defined according to the national rural-urban classification scheme for counties used by the National Center for Health Statistics at the Centers for Disease Control and Prevention. Trends in the county-level distribution of primary care clinicians from 2009 to 2017 were examined. Data were analyzed from November 12, 2019, to February 10, 2020. Main Outcomes and Measures Density of primary care clinicians measured as the number of primary care physicians, nurse practitioners, and physician assistants per 3500 population in each county. The average annual percentage change (APC) of the means of the density of primary care clinicians over time was calculated, and generalized estimating equations were used to adjust for county-level sociodemographic variables obtained from the American Community Survey. Results The study included data from 3143 US counties (1167 [37%] urban and 1976 [63%] rural). The number of primary care clinicians per 3500 people increased significantly in rural counties (2009 median density: 2.04; interquartile range [IQR], 1.43-2.76; and 2017 median density: 2.29; IQR, 1.57-3.23; P < .001) and urban counties (2009 median density: 2.26; IQR. 1.52-3.23; and 2017 median density: 2.66; IQR, 1.72-4.02; P < .001). The APC of the mean density of primary care physicians in rural counties was 1.70% (95% CI, 0.84%-2.57%), nurse practitioners was 8.37% (95% CI, 7.11%-9.63%), and physician assistants was 5.14% (95% CI, 3.91%-6.37%); the APC of the mean density of primary care physicians in urban counties was 2.40% (95% CI, 1.19%-3.61%), nurse practitioners was 8.64% (95% CI, 7.72%-9.55%), and physician assistants was 6.42% (95% CI, 5.34%-7.50%). Results from the generalized estimating equations model showed that the density of primary care clinicians in urban counties increased faster than in rural counties (beta = 0.04; 95% CI, 0.03 to 0.05; P < .001). Conclusions and Relevance Although the density of primary care clinicians increased in both rural and urban counties during the 2009-2017 period, the increase was more pronounced in urban than in rural counties. Closing rural-urban gaps in access to primary care clinicians may require increasingly intensive efforts targeting rural areas. Question What are the changes in the rural-urban distribution of the primary care workforce in the US from 2009 to 2017? Findings In this cross-sectional study of 3143 US counties (1167 urban and 1976 rural) using county-level data, the density of primary care clinicians increased significantly in both rural and urban counties from 2009 to 2017. The increase in primary care clinician density was more pronounced in urban counties compared with rural counties. Meaning In this study, the density of primary care clinicians increased overall, yet rural-urban disparities in the primary care workforce are increasing in the US.