Study: Pediatric eye care deserts are a growing issue

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When it comes to pediatric vision care, patients and their families may be left to wander across eye care “deserts” to find an ophthalmologist.

Regions of the country where the health care needs of a population are not being addressed because of inadequate access to facilities or physicians are frequently identified as medical deserts, and they are proving to be a growing problem as the disproportionate geographical distribution of the health care workforce and services caring for patients comes into focus.

A cross-sectional study, published recently in JAMA Ophthalmology, included pediatric ophthalmologists and pediatric optometrists and had results that found the geographic distribution of pediatric ophthalmologists and pediatric optometrists had a large amount of overlap. The study results also found that regions of the country lacking access to pediatric ophthalmologists or pediatric optometrists were in a lower-income demographic.¹

In the study, researchers set out to characterize the geographic distribution of pediatric eye care practitioners and analyze possible links with population demographics.

The study used public databases on the websites of the American Academy of Ophthalmology, the American Association for Pediatric Ophthalmology and Strabismus, the American Optometric Association, and the American Academy of Optometry to identify the addresses of pediatric ophthalmologists and pediatric optometrists nationwide in April 2023. According to the study, the addresses were geocoded and data of the population demographic were collected. Pediatric ophthalmologists and pediatric optometrists listed in the public databases as well as respondents to the 2020 US census were included in this study. Data were analyzed from April to July 2023.¹

The authors include Kara M. Cavuoto, MD, with the Bascom Palmer Eye Institute at the University of Miami Miller School of Medicine in Florida, and Nora E. Siegler, BA, and Hannah L. Walsh, BS, both with the University of Miami Miller School of Medicine.

The study further set out to examine disparities in service coverage of pediatric ophthalmologists and pediatric optometrists in relation to patient demographics to cast a light on at-risk populations and provide data for future decisions.

In the study, 1060 pediatric ophthalmologists (590 male, 55.7%) and 586 pediatric optometrists (302 female, 51.5%) were identified. Among US counties, 308 (9.7%) had at least 1 pediatric ophthalmologist and 203 (6.5%) had at least 1 pediatric optometrist, demonstrating substantial geographic overlap (OR, 12.7; 95% CI, 9.4-17.4; P < .001).

Moreover, the researchers found that in the 2834 counties without pediatric ophthalmologists, 2731 (96.4%) also lacked pediatric optometrists. They also noted there were more pediatric ophthalmologists per 1 million people (3.3) compared with pediatric optometrists per 1 million people (2.5) across all states (difference, 0.8; 95% CI, 0-1.9; P = .047).

Ophthalmology Times® discussed the study with members of its editorial advisory board, and Stacy L. Pineles, MD, pediatric ophthalmologist at UCLA Health in Los Angeles, California, noted that eye care deserts can present a problem because pediatric eye diseases are often serious and treatable only inside a certain window of time.

“For example, if a patient has a congenital cataract or strabismus, these conditions can lead to permanent vision loss from amblyopia if not addressed in a timely fashion,” Pineles, who is not affiliated with the study, said. “Also, even for refractive error, which can usually be easily treated with spectacles, if children don’t have access to eye care, they can fall behind in school and lag behind peers in many other areas of life.”

According to a separate study, the states with the most pediatric ophthalmologists include California (116), New York (97), Florida (69), Texas (62), and Illinois (49). Four states had no pediatric ophthalmologists, including New Mexico, North Dakota, South Dakota and Vermont.²

The study findings noted that in the US counties with practitioners, researchers found the median number of pediatric optometrists per 1 million people was 7.8 (range, 0.4-245.0), surpassing the median number of pediatric ophthalmologists per 1 million people, 5.5 (range, 1.0-117.0).

The study findings also detailed that the counties with pediatric ophthalmologists had greater average household incomes than counties with pediatric optometrists ($76,126.87 vs $68,681.77) and a higher mean average population with bachelor’s degrees than counties with pediatric optometrists (79,016 [SD, 82,503] vs 23,076 [SD, 44,025]. Counties with neither specialist type had the lowest mean household income ($57,714.03 [SD, $2731] vs $78,388.67 [SD, $18,499.21].¹

The top counties by number of pediatric ophthalmologists were Los Angeles County, California; New York, New York; Cook County, Illinois; Suffolk County, Massachusetts; and Harris County in Texas.²

Pineles said she would surmise that desirability to live in an area could be one issue behind the demographic differences and insurance coverage of patients in a region could be another factor.

Solutions to the issue can prove to be elusive. Pineles said she doesn’t see a quick solution.

“It may help to train more pediatric ophthalmologists and maybe have programs to improve conditions for practicing physicians in these areas,” she said, adding that this could include improving government insurance reimbursement and loan repayment for physicians committed to these areas.

In a separate commentary, Alejandra G. de Alba Campomanes, MD, MPH, and Olivia Bass, OD, both researchers from the University of California San Francisco (UCSF), cautioned that the study methods may have undercounted providers in some regions.³

Bass and de Alba Campomanes pointed out that colleagues at UCSF aren’t listed in any manner that would be captured by the methods of the study, which could pass over large groups of professionals. They also aren’t registered with the professional society site used in the study.²

However, the researchers pointed out that by highlighting the differences in access to pediatric eye care were linked with socioeconomic status. These results back up pursuing evidence-based efforts to increase practitioner reimbursement and recruitment in underserved areas, which ultimately could boost access to pediatric eye care on those regions.¹

Michael X. Repka, MD, MBA, spokesperson and medical director for government affairs at the American Academy of Ophthalmology, in a statement to Ophthalmology Times, noted that it is a worthwhile effort to gain insight into how various medical physician specialties are distributed across the country, but it is difficult to determine what the true need is on a population level.

“This information could help inform public health initiatives,” he explained. “However, the limitations of this study are significant, as noted by the study authors.”

Repka noted that because the data were derived only from the professional membership organizations, the information does not include nonmembers or members who opted out of database inclusion.

“The data also excludes information on comprehensive and other non-pediatric ophthalmologists who care for children,” he said.

Moreover, Repka noted the AAO supports more research to understand gaps in access to pediatric eye and vision care.

“The Academy also acknowledges that rural areas, in general, need more medical physicians,” he added. “That’s why, amongst other efforts, the Academy has urged Congress to increase funding for the Pediatric Specialty Loan Repayment program to $30 million in fiscal year 2025. This program will increase access to pediatric MD subspecialists who provide care in underserved and rural areas. It provides up to $100,000 in loan repayment annually in exchange for practicing in an underserved area for at least three years.”

Kyle Klute, OD, FAAO, the founder of Good Life Eyecare in Omaha, Nebraska, and Glenwood, Iowa, and a consultant for Eyecode Education, pointed out that while he does not doubt there are underserved pediatric populations across the country, the study’s results highlight a major flaw within the study and some problems that need to be addressed.

“The study methodology is flawed in how they gathered data on optometrists managing pediatric patients,” said Klute, who was not involvd in the study or the summary. “The authors searched databases where optometrists would likely self-report as pediatric optometrists. This is a huge underestimation of optometrists caring for pediatric patients.”

Klute pointed out that while not every optometrist performs pediatric eye care, a re-analysis of the data should include "family practice" optometrists, which would likely include nearly 30,000 locations alone. He also questioned why the researchers elected to only search pediatric optometrists in the database.

“I admit I'm speculating here, but I believe it is because of the perception in eye care and medicine that only specialists can manage pediatric patients,” he explained. “Yes, some children need specialists but the vast majority do not and can be well taken care of in the primary care setting.”

Moreover, in the previous study on geographic distribution of ophthalmologists, researchers noted the study’s limitations, noting the AAO and AAPOS websites may list pediatric ophthalmologists who are no longer in practice or list incorrect or outdated practice addresses, which may over- represent the populations served in those areas.²

References

1. Siegler NE, Walsh HL, Cavuoto KM. Access to Pediatric Eye Care by Practitioner Type, Geographic Distribution, and US Population Demographics. JAMA Ophthalmol. Published online April 11, 2024. doi:10.1001/jamaophthalmol.2024.0612

2. Hannah L. Walsh, BS; Abraham Parrish, MA, MILS; Lauren Hucko, BA; Jayanth Sridhar, MD; Kara M. Cavuoto, MD. Access to Pediatric Ophthalmological Care by Geographic Distribution and US Population Demographic Characteristics in 2022. JAMA Ophthal. Published online January 26, 2023. Accessed April 11, 2024. 

3. Bass O, de Alba Campomanes AG. Mapping the Pediatric Eye Care Deserts in the US—A Call for Action. JAMA Ophthalmol. Published online April 11, 2024. doi:10.1001/jamaophthalmol.2024.0798