Access to Pediatric Ophthalmological Care by Geographic Distribution and US Population Demographic Characteristics in 2022 (2024)

Associated Data

Supplementary Materials

This cross-sectional study analyzes the geographic distribution of pediatric ophthalmologists in 2022 and compares the distribution to population demographic characteristics in the US.

Key Points

Abstract

Introduction

The national shortage of pediatric ophthalmologists in relation to the expanding population of the US has become increasingly apparent over the past few years. This shortage is compounded by an overall lack of trainee interest in pediatric ophthalmology, as nearly half of pediatric ophthalmology and strabismus fellowship positions go unfilled each year.¹ Reasons for this shortage are multifactorial and include lower reimbursem*nt rates, the difficulty of performing eye examinations in children, and lack of mentorship.² Furthermore, the pediatric ophthalmologist shortage is complicated by a lack of geographic distribution among the existing practitioners.² Prior investigations by the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) workforce reported on nationwide pediatric ophthalmologist service coverage analysis with the introduction of an interactive map display; however, service coverage was last reported in 2007.³ In the past 15 years, the demographic landscape of the US has changed considerably, especially in regard to increased population diversity and geographic distribution.⁴ These differences need to be evaluated appropriately to address how the needs of important services, such as health care, have changed. Moreover, to our knowledge, no previous reports have addressed demographic and socioeconomic differences between areas served by pediatric ophthalmologists and those without access to pediatric ophthalmologists. The goal of this study was to assess the number and location (ie, geographic distribution) of pediatric ophthalmologists in the US in relation to US population demographic characteristics.

Methods

In this cross-sectional study, pediatric ophthalmologists were identified in March 2022 using 2 online public databases: the “Find an Ophthalmologist” tool on the American Academy of Ophthalmology (AAO) website and the “Find a Doctor” tool on the AAPOS website. We used all addresses listed on these websites to ascertain location. Office address, state, zip code, sex, degree, and specialty listed online were all collected for each pediatric ophthalmologist. The University of Miami Institutional Review Board deemed the study exempt from review and waived the requirement for informed consent because all data were publicly available. We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

Addresses were geocoded using ArcGIS Pro, version 2.9 (Esri). For the 14 addresses that showed a post office box address instead of an office address, the address was found using a Google search (Alphabet Inc).

Results

A total of 1056 pediatric ophthalmologists (611 [57.9%] men and 445 [42.1%] women) in the US were identified. Of these, 981 physicians (92.9%) were identified using the AAO “Find an Ophthalmologist” tool, and 75 physicians (7.1%) were identified using the AAPOS “Find a Doctor” tool. A total of 968 (91.7%) held a doctor of medicine degree, 63 (6.0%) held a doctor of medicine dual degree, 21 (2.0%) held a doctor of osteopathic medicine degree, and 4 (0.4%) held a bachelor of medicine, bachelor of surgery degree. Men outnumbered women in each degree category except for the doctor of osteopathic medicine category, in which there were 10 men (0.9%) and 11 women (1.0%).

The geographic distribution of pediatric ophthalmologists by county in the US is illustrated in the Figure. The distribution of pediatric ophthalmologists by state, state population, and pediatric ophthalmologists per person are summarized in Table 1. The states with the most pediatric ophthalmologists were California (n = 116 [11.0%]), New York (n = 97 [9.2%]), Florida (n = 69 [6.5%]), and Texas (n = 62 [5.9%]), the 4 most populous states according to the 2020 US Census.⁵ There were 314 of 3142 counties (10.0%) with 1 or more pediatric ophthalmologists, and 140 of 314 counties (44.6%) had only 1 pediatric ophthalmologist. Counties with the most pediatric ophthalmologists were Los Angeles County, California (n = 38 [3.6%]), New York County, New York (n = 26 [2.5%]), Cook County, Illinois (n = 20 [1.9%]), Suffolk County, Massachusetts (n = 19 [1.8%]), and Harris County, Texas (n = 17 [1.6%]). Four states (New Mexico, North Dakota, South Dakota, and Vermont; 8.0%) and 2828 counties (90.0%) had 0 pediatric ophthalmologists. Totals for the 30 most populous US counties stratified by the number of pediatric ophthalmologists, by total population, and by total population younger than 19 years are shown in Table 2. Nineteen of the 30 counties (63.3%) with the greatest number of pediatric ophthalmologists are also among the 30 most populated counties. Additionally, 19 of the 30 counties (63.3%) with the most pediatric ophthalmologist coverage were among the top 30 counties by population younger than 19 years. The 20 most populous Metropolitan Statistical Areas from 2007 are listed in Table 3 as a comparison over time.

The 2020 US Census estimated 331 893 745 persons living in the US by July 1, 2021, with 83 267 556 of those persons younger than 19 years.⁵ Overall, there were 3.2 pediatric ophthalmologists per million persons in the US. For the younger US population, there were 12.7 pediatric ophthalmologists per million persons younger than 19 years. In counties with 1 or more pediatric ophthalmologists, there was a mean (range) of 7.7 (0.4-185.5) pediatric ophthalmologists per million persons and a mean (range) of 32.2 (1.6-217.5) pediatric ophthalmologists per million persons younger than 19 years. The 20 most populous US counties are listed in Table 3.

There was a greater percentage of households with no persons younger than 18 years in the 314 counties with 1 or more pediatric ophthalmologists compared with the 2828 counties with 0 pediatric ophthalmologists (71.2% vs 69.3%; difference, −1.9%; 95% CI, −2.8% to −0.1%; P < .001) (Table 4). In the counties with 1 or more pediatric ophthalmologists, there was a mean (range) of 1 pediatric ophthalmologist per 57 707 (1 per 1339 to 1 per 59 158) people younger than 19 years. There were higher densities of pediatric ophthalmologists in coastal metropolitan areas, such as Los Angeles, California; Miami, Florida; and New York, New York, and lower densities of pediatric ophthalmologists in central northern states, such as the Dakotas, Montana, and Nebraska. While there was no difference in mean (SD) family size (3.0 [0.2] vs 3.1 [0.2]; difference, 0.1; 95% CI, −1.4 to −0.1; P = .34), counties with 0 pediatric ophthalmologists had a higher median (SD) age than counties with 1 or more pediatric ophthalmologists (39.5 [5.1] years vs 37.2 [3.9] years; difference, 2.2; 95% CI, 1.7-2.9 years; P < .001).

Socioeconomic data also differed between the 2 groups, as described in Table 4. The 2021 median (SD) family income was greater in counties with 1 or more pediatric ophthalmologists compared with counties with 0 pediatric ophthalmologists ($70 230.59 [$18 945.05] vs $53 263.62 [$12 786.07]; difference, −$16 966.97; 95% CI, −$18 544.57 to −$14 389.37; P < .001). The proportion of families in each county without internet service (8.0% vs 4.7%; difference, 3.4%; 95% CI, 3.0%-3.7%; P < .001) and the proportion of persons younger than 19 years without health insurance (5.7% vs 4.1%; difference, 1.6%; 95% CI, 1.1%-2.2%; P < .001) were greater in counties with 0 pediatric ophthalmologists compared with counties with 1 or more pediatric ophthalmologists. There was a greater proportion of persons aged 25 or older who held bachelor’s degrees in counties with 1 or more pediatric ophthalmologists compared with counties with 0 pediatric ophthalmologists (25.2% vs 15.3%; difference, −9.9%; 95% CI, −10.1% to −9.2%; P < .001). Finally, more households in counties with 0 pediatric ophthalmologists reported not having access to vehicles at home compared with counties with 1 or more pediatric ophthalmologists (2.1% vs 1.8%; difference, 0.3%; 95% CI, 0.6%-5.2%; P = .001).

Consumer spending habits for vision care also differed between the 2 groups and are displayed in the eTable in Supplement 1. On average, households in counties with 1 or more pediatric ophthalmologists spent more on Blue Cross Blue Shield vision care insurance (mean [SD], $3.41 [$0.83] vs $2.46 [$0.78]; difference, $0.95; 95% CI, $1.04-$0.86; P < .001), more on vision care insurance excluding Blue Cross Blue Shield (mean [SD], $38.82 [$10.32] vs $31.07 [$8.33]; difference, $7.74; 95% CI, $6.75-$8.74; P < .001), and more on eyeglasses and contact lenses (mean [SD], $106.54 [$28.89] vs $89.41 [$23.64]; difference, $17.13; 95% CI, $14.31-$19.96; P < .001) per month compared with households in counties with 0 pediatric ophthalmologists.

Discussion

In this cross-sectional study, we identified geographic and socioeconomic disparities in pediatric ophthalmological care. The Association of American Medical Colleges has vocalized concern for physician shortages in the US.⁶ These shortages are prevalent across many specialties, which suggests that a large proportion of the US population is unable to access health care in a timely, convenient manner.⁷ To complicate this issue further, some studies have reported that the rural-urban gap in the distribution of physicians has not only persisted but has increased in recent years.⁸ The extent to which this applies to all ophthalmology subspecialties is unknown, but physician shortages in rural areas have been well documented as a concern in oculofacial plastic surgery,⁹ cataract surgery,¹⁰ and pediatric glaucoma.^11,12 Of the 1056 pediatric ophthalmologists who were identified through public databases, most had practices located in metropolitan areas in coastal states and around academic institutions. Considering the metropolitan location preference of practicing pediatric ophthalmologists in conjunction with shortages of pediatric ophthalmologists overall, we can conclude that rural populations disproportionately lack access to such care, which can impact the time to diagnosis, treatment, and management of complications of serious ophthalmological diagnoses in children.

About one-third (11 of 30) of the top 30 counties by the total number of pediatric ophthalmologists were not accounted for in the top 30 counties by total population or in the top 30 counties by population younger than 19 years, suggesting a difference between pediatric ophthalmologist practice location and counties with large pediatric populations. While these populated counties may be adjacent to a county with pediatric ophthalmologist access, driving time is widely acknowledged to decrease the use of health care services and lead to worse health outcomes.¹³ By cross-referencing publicly available demographic data with pediatric ophthalmologist addresses, we found that lower median family income, lower household educational level, increased uninsured status, decreased access to vehicles, and decreased home internet service were all more prevalent in counties served by 0 pediatric ophthalmologists than those in counties with 1 or more pediatric ophthalmologists. The aforementioned factors all can have marked implications for patients’ ability to seek and consistently access both virtual and in-person pediatric ophthalmological care, which may be exacerbated by the lack of available local practitioners evidenced in this study.

Using the 2020 US Census population estimates, there was 1 pediatric ophthalmologist per 3.2 million persons in the US. However, 90.0% of counties were not served by any pediatric ophthalmologists. Even in the 314 counties with at least 1 pediatric ophthalmologist, there was a median of 1 pediatric ophthalmologist per 7.7 million persons, with a range of 1 pediatric ophthalmologist per 0.4 million persons to 185.5 million persons. In the 314 counties with access to a practitioner, there was a median of 1 pediatric ophthalmologist per 32.8 million persons younger than 19 years, with a range of 1 pediatric ophthalmologist per 1.6 million persons younger than 19 years to 217.5 million persons younger than 19 years. In the 2007 AAPOS workforce distribution project that analyzed service coverage of pediatric ophthalmologists on a national level,³ the member-to-million-persons ratio varied from 1.3 to 27 (for 2.8 million persons; average unknown). While the total number of practicing pediatric ophthalmologists with publicly available addresses has increased by more than 300 over the past 15 years, so has the range of practitioner to million persons, suggesting a divergent gap in access to care. Although the different geographic units (metropolitan statistical area vs US counties) used in each report preclude a direct comparison, an adjustment to practitioner to million persons aims to account for this discrepancy and provides insight into generic patterns in pediatric ophthalmologist density over time. These results support the need to improve incentive structures to redistribute pediatric ophthalmologist resources to match the unequal health burden in underserved counties. Additionally, these results support the need to incentivize ophthalmology trainees to pursue careers in pediatric ophthalmology. Studies have reported that students exposed to niche specialties early on are more invested in the long term.¹⁴ While current efforts focus on recruiting ophthalmology residents to pursue pediatric ophthalmology, it may be more effective to introduce the field to interested individuals before they enter an ophthalmology residency or even before they choose a career in medicine (eg, high school and college students).

We found that counties served by pediatric ophthalmologists had higher rates of health insurance, higher median family incomes, more internet and vehicle access, higher rates of advanced educational attainment, and higher mean household spending on vision care items and vision care insurance, all of which can facilitate improved and sustainable access to pediatric ophthalmological care. Such populations were found in the counties with increased proportions of pediatric ophthalmologists, which suggests that the geographic distribution of pediatric ophthalmologists in the US may exacerbate existing socioeconomic inequities in pediatric ophthalmological care. Furthermore, the present analysis found that there are more households on average with children younger than 19 years in underserved counties, suggesting a large need for pediatric ophthalmologists in these areas. It is important that disadvantaged regions be targeted for recruitment of pediatric ophthalmologists, especially areas with high pediatric populations with low socioeconomic status, fewer health care resources, and less access to care. This finding on underserved counties highlights the potential need for more granular research describing the needs of counties meeting these criteria, which could then be used for creative initiatives incentivizing pediatric ophthalmologists to reach these areas.

Providing accurate, up-to-date contact information for pediatric ophthalmologists in each region may be an important first step in reaching underserved areas. As online resources and telemedicine potentially improve access to health care, pediatric ophthalmologists may be able to extend the reach of their care by providing updated contact information on websites, such as AAPOS.org and AAO.org.^15,16 While our updated service coverage analysis may aid in identifying optimal locations for new pediatric ophthalmologist services, our demographic analysis identified differences in internet access as a substantial and compounding barrier that underserved counties face. Efforts to expand access to pediatric ophthalmological care should consider this factor by implementing alternate strategies, including collaboration with local pediatricians and schools alongside updated online sources to augment awareness of pediatric ophthalmologist services and locations. Furthermore, the lower rates of health insurance in counties without pediatric ophthalmologist coverage may prevent communities in need from accessing telemedicine resources. These and other social determinants of health should prompt evidence-based approaches to increase access to pediatric ophthalmologists in underserved communities. The extent to which these factors alter the use of ophthalmologic services and ultimately impact patient outcomes are pertinent future directions for research.

Conclusions

Findings of this cross-sectional study suggest that disparities in access to pediatric ophthalmologists are not only persistent but have increased over time. Key demographic and socioeconomic differences exist between populations in areas with vs without access to pediatric ophthalmological care, with disparities in access to such care associated with lower socioeconomic status. Further studies are needed to examine whether these differences affect the use of pediatric ophthalmological services and ultimately patient outcomes.

Notes

References