The American Academy of Ophthalmology recognizes that there is a shortage in uveitis specialists, and has recently written a letter to the US Senate Health, Education, Labor, and Pensions Committee to advocate for improved access to smaller subspecialities like uveitis.¹ As of 2023, there are 208 providers listed on the American Uveitis Society (AUS) directory.² Over the past 5 years, there have also been between 8 and 14 new uveitis fellowship graduates per year, far fewer than other subspecialties.³ The reasons for this modest number of uveitis specialists may include higher patient complexity, fewer surgeries, and lower reimbursement compared to other surgical subspecialties. In a recent survey of AUS members, 52% of respondents were dual-fellowship trained and 69% performed surgery.⁴ Other reasons for this workforce shortage may also include physician geographic preferences, which may skew toward urban areas and can have greater impact in smaller subspecialties.

CHALLENGES FOR ACCESS TO CARE

In a 2022 study that analyzed the geodemographic distribution of more than 220 uveitis specialists in the United States, 94% of providers’ offices were in urban communities.⁵ Moreover, there were 15 states without any office addresses listed on either the AUS or Ocular Immunology and Uveitis Foundation directories.⁵ In another study that examined the change in the ophthalmology workforce between 1995 and 2017, the growth rate of ophthalmologists was larger in urban areas compared to rural areas.⁶ This “urbanization” of ophthalmic care may have significant ramification on patient care outcomes, because patients living in rural areas and having longer travel distance to an ophthalmologist have been associated with more loss to follow-up and missed appointments.^7,8 Furthermore, problems with access to care for uveitis are often compounded by its multidisciplinary nature — several doctors from other specialties (eg, rheumatology) may be involved with care, each requiring separate visits. Together, these findings suggest increasing uveitis access barriers in rural areas compared to urban areas.

In a recent study, we explored pediatric uveitis care availability. Although uveitis is less prevalent in children compared to adults, pediatric uveitis is often more complex, requires multidisciplinary care, and has a potentially higher risk of poor visual outcomes. Service coverage analysis, which studies patient care access using travel time to provider locations and publicly available census data, is a useful tool to determine disparities in the geographic distribution of providers.^5,9-11 Although socioeconomic factors have been associated with disparities in health care access, a lack of providers within a 60-minute drive range means that every patient in a service area would be affected.

We geocoded office addresses for pediatric ophthalmologists, uveitis specialists, and rheumatologists using a geographic information system and compared the relative distribution of these providers with the pediatric population in the United States.⁹ The mid-Atlantic and New England regions had disproportionately more providers from the 3 specialties relative to the pediatric population compared to the rest of the United States. Conversely, the Southwest and Great Plains regions had the lowest proportion of providers relative to the pediatric population. We also found in our models that 11% of uveitis specialists, 11% of pediatric ophthalmologists, and 12% of rheumatologists (or 11% of all 3 specialties combined) would have to relocate their offices to match the regional distribution of the US pediatric population. However, the assumption made in these calculations is that all providers can care for pediatric uveitis. In a recent survey of the American Association of Pediatric Ophthalmology and Strabismus members, only 38% of pediatric ophthalmology respondents felt comfortable managing pediatric uveitis.¹²

POTENTIAL SOLUTIONS

Newer technologies may ease some travel burdens faced by patients without access to specialists, but they are unlikely to replace in-person visits completely. Telemedicine may be limited in uveitis care because routine video conferencing technology does not have sufficiently high image resolution to monitor inflammatory changes in the eye.¹³ However, telemedicine visits may be useful for relaying diagnostic results and management discussions with patients after a testing-only visit. During the height of the COVID-19 pandemic, some uveitis specialists were able to interpret optical coherence tomography, fluorescein angiography, and laser flare photometry results remotely and make management decisions over the phone with their patients.¹³ Some challenges may include lack of access to video conferencing technologies in underserved communities.

CONCLUSION

The uveitis specialist shortage disproportionally affects rural communities. Geographic preferences and scarcity in fellowship-trained specialists are likely contributing factors to these disparities. Public policies that provide financial incentives based on medical complexity rather than procedures may facilitate equitable access. Although newer technologies and virtual visits have helped doctors communicate with their patients and other specialists, further advancements are needed to make tele-ophthalmology more than an adjunct to in-person visits for complex specialties like uveitis. Lastly, a specialty-wide, coordinated effort to foster interest in uveitis through mentorship during medical training can help to supply the uveitis specialty applicant pool and ensure a robust workforce for the future. RP

REFERENCES

1. American Academy of Ophthalmology. Academy calls for solutions promoting access to some ophthalmology subspecialities. March 23, 2023. Accessed August 2, 2023. https://www.aao.org/advocacy/eye-on-advocacy-article/solutions-promote-access-some-subspecialties
2. American Uveitis Society. Uveitis specialist directory. Accessed August 2, 2023. https://uveitissociety.org/directory
3. Sfmatch. Ophthalmology fellowship match stats 2017-2022. Accessed August 2, 2023. https://sfmatch.org/specialty/ophthalmology-fellowship/Statistics
4. Tsui E, Crowell EL, Gangaputra S, et al. Current landscape of uveitis specialists in the United States. J Acad Ophthalmol (2017). 2022;14(2):e187-e192. doi:10.1055/s-0042-1755581
5. Mallem K, Xia T, Berkenstock MK. A geodemographic analysis of travel time to uveitis specialists in the United States. Ocul Immunol Inflamm. 2023;1-5. doi:10.1080/09273948.2023.2202249
6. Feng PW, Ahluwalia A, Feng H, Adelman RA. National trends in the United States eye care workforce from 1995 to 2017. Am J Ophthalmol. 2020;218:128-135. doi:10.1016/j.ajo.2020.05.018
7. Luo S, Lock LJ, Xing B, Wingelaar M, Channa R, Liu Y. Factors associated with follow-up adherence after teleophthalmology for diabetic eye screening before and during the COVID-19 pandemic. Telemed J E Health. 2022;10.1089/tmj.2022.0391. doi:10.1089/tmj.2022.0391
8. Funk IT, Strelow BA, Klifto MR, et al. The relationship of travel distance to postoperative follow-up care on glaucoma surgery outcomes. J Glaucoma. 2020;29(11):1056-1064. doi:10.1097/IJG.0000000000001609
9. Choudhury A, Stuart E, Stoler J, Vu DM, Chang TC. Regional disparities in pediatric uveitis care availability in the United States. Ophthalmology. 2023;S0161-6420(23)00369-X. doi:10.1016/j.ophtha.2023.05.025
10. Vu DM, Stoler J, Rothman AL, Chang TC. A service coverage analysis of primary congenital glaucoma care across the United States. Am J Ophthalmol. 2021;224:112-119. doi:10.1016/j.ajo.2020.12.009
11. Rothman AL, Stoler JB, Vu DM, Chang TC. A geodemographic service coverage analysis of travel time to glaucoma specialists in Florida. J Glaucoma. 2020;29(12):1147-1151. doi:10.1097/IJG.0000000000001648
12. Lueder G, Galli M, Cho JCC, Liegel K. Pediatric ophthalmology scope of practice. J Binocul Vis Ocul Motil. 2023;73(2):53-54.
13. Brill D, Papaliodis G. Uveitis specialists harnessing disruptive technology during the COVID-19 pandemic and beyond. Semin Ophthalmol. 2021;36(4):296-303. doi:10.1080/08820538.2021.1896753