Eye Care Availability and Access Among Individuals With Diabetes, Diabetic Retinopathy, or Age-Related Macular Degeneration

Abstract

IMPORTANCE Understanding whether differences in the local availability of eye care professionals are related to differences in realized access to eye care is important for assessing whether and where public health efforts are needed to increase access to eye care professionals.OBJECTIVE To examine whether the county-level availability of ophthalmologists and optometrists is associated with measures of realized access to eye care for individuals with diabetes mellitus, diabetic retinopathy, or age-related macular degeneration (ARMD). DESIGN, SETTING, AND PARTICIPANTS We studied a cross-sectional sample of US adults 40 years and older (1098 individuals with diabetes, 345 with diabetic retinopathy, and 498 with ARMD) from the 2005-2008 National Health and Nutrition Examination Survey.MAIN OUTCOMES AND MEASURES Outcomes were whether diabetic individuals reported undergoing a dilated eye examination in the past year, whether individuals were unaware they had diabetic retinopathy, whether diabetic individuals had vision-threatening diabetic retinopathy, and whether individuals were unaware they had ARMD. RESULTSIn logistic regression models that also included individual characteristics, individuals who lived in a county in the highest ophthalmologist availability quartile were less likely to be unaware they had diabetic retinopathy (predictive margin [PM], 66.1%; 90% CI, 48.8%-83.4%; vs PM, 84.1%; 90% CI, 78.7%-89.6%) and were less likely to have vision-threatening diabetic retinopathy (PM, 1.4%; 90% CI, 0.9%-1.9%; vs PM, 2.6%; 90% CI, 1.8%-3.4%) than individuals who lived in a county in the lower 3 ophthalmologist availability quartiles. Individuals who lived in a county in the lowest ophthalmologist availability quartile were more likely to be unaware they had ARMD (PM, 93.8%; 90% CI, 90.6%-97.0%; vs PM, 88.3%; 90% CI, 84.7%-91.9%) than individuals who lived a county in the higher 3 ophthalmologist availability quartiles. Optometrist availability quartiles were not significantly related to any of the outcomes. CONCLUSIONS AND RELEVANCEThe results suggest that efforts to increase access to ophthalmologists to improve outcomes related to diabetic retinopathy or to increase awareness of ARMD should focus on improving access for diabetic individuals who live in counties in the lowest 3 quartiles of ophthalmologist availability and on individuals at risk of ARMD who live in counties in the lowest quartile of ophthalmologist availability.

Screening for Diabetic Retinopathy

“…This is consistent with national data showing that minorities tend to have lower rates of screening [10]. Screening rates also vary by geographic location, with rural populations having lower rates of screening, likely due to issues with access to care [11]. Diabetes patients with retinopathy who have access to reti- nopathy screening at or near the office of their primary care provider may more likely be screened out of convenience compared with those who are referred to an eye care specialist [12].…”

The geographic distribution of eye care providers in the United States: Implications for a national strategy to improve vision health

“…Previous research on the US found that greater county-level availability of ophthalmologists, with availability measured using population-weighted quartiles of the county-level number of ophthalmologists per capita, was associated with increased use of eye care services and better visual health outcomes (Gibson, 2014). These findings motivate the decision to describe eye care provider availability in a similar fashion in this paper.…”

“…On average, counties with lower eye care provider availability per capita had fewer physicians per capita, lower population density, and a poorer, less urban, and older population than counties with greater eye care provider availability per capita. These characteristics may exacerbate or moderate the challenges for public health interventions in counties with limited eye care provider availability, although most of these characteristics increase the expected challenge (Gohdes et al, 2005;Layde et al, 2012;Prevent Blindness America and National Association of Chronic Disease Directors, 2005;Prevent Blindness America, 2004;Saadine et al, 2003;US Centers for Disease Control, 2009;Zhang et al, 2007). For example, older individuals are both more likely to need eye care services and to use eye care services (US Centers for Disease Control, 2009;Lee et al, 2009).…”

“…Among Americans aged 40 years and older, 25.4 million have cataracts, 7.7 million have diabetic retinopathy, 2.7 million have glaucoma, and 1.8 million have age-related macular degeneration (Eye Diseases Prevalence Research Group, 2004;Prevent Blindness America, 2012). On the basis of these numbers, projected demographic trends in the US, the availability of effective treatments for many eye conditions, and the large financial and quality of life burden of vision loss, it has been argued widely that vision loss in the US is a public health problem (Gohdes et al, 2005;Lee et al, 2012;Prevent Blindness America and National Association of Chronic Disease Directors, 2005;Saadine et al, 2003;US Centers for Disease Control, 2009;Zhang et al, 2008). The Vision Health Initiative (VHI) of the US Centers for Disease Control and Prevention has developed a national public health strategy for improving vision health in the US.…”

“…The Vision Health Initiative (VHI) of the US Centers for Disease Control and Prevention has developed a national public health strategy for improving vision health in the US. Since community characteristics such as the local availability of health care providers influence the use of health care services and the effectiveness of public health interventions, one of the recommendations in the VHI strategy is to determine the patterns of local eye care provider availability in the US in order to develop and disseminate public health interventions that are effective in these contexts (Gohdes et al, 2005;Layde et al, 2012;Prevent Blindness America and National Association of Chronic Disease Directors, 2005;Prevent Blindness America, 2004;US Centers for Disease Control, 2009;Zhang et al, 2007Zhang et al, , 2008.…”