Findings from a recent study published in JAMA Ophthalmology assessed the geographic distribution of the ophthalmic subspecialist surgeon workforce and evaluated factors associated with practicing in rural areas.
Give me some background.
Even though 20% of the U.S. population resides in rural areas, less than 10% of U.S. physicians practice in rural areas.
Further: Rural residents are more likely than urban residents to be 65+ years, below the federal poverty level, and uninsured.
- As such: A potential workforce discrepancy may impact the burden of care faced by rural ophthalmic surgeons.
Now get into this study.
In this cross-sectional population-based study, investigators analyzed Medicare Fee-For-Service (FFS) claims on subspecialized ophthalmic procedures for patients 65+ that used Current Procedural Terminology (CPT) codes and took place from 2012-2022 (n = 1,619,043).
Surgeons (n = 13,526) were defined as subspecialists based on CPT codes and required the performance of at least one subspecialty procedure from the following subspecialties:
- Cornea
- Glaucoma
- Oculoplastic
- Retina
- Strabismus
Main outcome measure: The population density of practice for subspecialist surgeons and residence for patients (rural or urban).
- Secondary outcomes: Characteristics associated with rural practice.
Findings?
Of the included 13,526 ophthalmic surgical subspecialists, 9,823 were male (72.6%), 3,235 were female (26.8%), and 4,484 (33.2%) practiced in the South.
The breakdown of ophthalmic subspecialties was as follows:
- Cornea: 2,540 subspecialists (18.5%)
- Glaucoma: 3,676 subspecialists (26.8%)
- Oculoplastic: 1,951 subspecialists (14.2%)
- Retina: 4,123 subspecialists (30.0%)
- Strabismus: 1,236 subspecialists (9.0%)
Across subspecialties: A higher proportion of patients (17.4%, 95% confidence interval [CI] 16.9-17.9%) resided in rural areas relative to surgeons (5.6%, 95% CI 5.3-5.9%), with differences ranging from 6.2-14.8%.
Anything else?
The percentage of subspecialist surgeons in rural settings declined as follows:
- Cornea: 1.3%
- Glaucoma: 3.3%
- Oculoplastic: 2.1%
- Retina: 0.4%
Characteristics of surgeons who were less likely to practice rurally included:
- Female surgeons (adjusted odds ratio [aOR] 0.63, 95% CI 0.51-0.79, P<0.001)
- Surgeons in the Northeast (aOR 0.62, 95% CI 0.48-0.78, P<0.001)
- Surgeons in the West (aOR 0.63, 95% CI 0.50-0.79, P<0.001)
- Recent graduates
- Those who graduated 11-20 years ago (aOR 1.66, 95% CI 1.25-2.21, P<0.001)
- Those who graduated 21-30 years ago (aOR 1.83, 95% CI 1.38-2.42, P<0.001)
- Those who graduated 31 years ago or longer (aOR 1.43, 95% CI 1.08-1.90, P=0.13)
What was the geographic distribution of ophthalmic subspecialist surgeons?
Per 100k patients, the geographic distribution of ophthalmic subspecialist surgeons was as follows:
- The West had the highest number of surgeons for cornea (158), oculoplastics (300), and glaucoma (156)
- The Midwest and South had the lowest number of cornea (102) and glaucoma (110) surgeons
- The South had the fewest number of oculoplastic surgeons (196)
In a similar calculation per 10k patients:
- The Northeast had the highest number of retina surgeons (54), while the South had the lowest (33)
- The Northeast had the most strabismus surgeons (332), and the South had the least (208)
Expert opinion?
These findings suggested that 18.2% of patients undergoing cornea transplants are rurally located; though, previous research has indicated that only 3.5% of transplants occur in a rural area—suggesting that many rural patients do not receive care locally, the study authors noted.
As such: These findings may be concerning for older rural patients, who may face impairments hindering their ability to drive to a subspecialist surgeon.
- Further: Alternative transportation modes, such as buses or shuttles, also may not be readily available in rural settings.
Take home.
These findings indicate that rural patients disproportionately outnumber rural surgeons.
Additionally: The percentage of rural surgeons declined over time, with female surgeons and recent medical school graduates being less likely to practice rurally.
Meaning: There is a growing disparity in the number of rural subspecialist surgeons available to care for rural patients.