Estimating eye care workforce supply and requirements

Ophthalmology Workforce Projections in the United States, 2020 to 2035

PURPOSE

To analyze ophthalmology workforce supply and demand projections from 2020 to 2035.

DESIGN

Observational cohort study using data from the National Center for Health Workforce Analysis (NCHWA).

METHODS

Data accessed from the Department of Health and Human Services, Health Resources and Services Administration (HRSA) website were compiled to analyze the workforce supply and demand projections for ophthalmologists from 2020 to 2035.

MAIN OUTCOME MEASURES

Projected workforce adequacy over time.

RESULTS

From 2020 to 2035, the total ophthalmology supply is projected to decrease by 2650 full-time equivalent (FTE) ophthalmologists (12% decline) and total demand is projected to increase by 5150 FTE ophthalmologists (24% increase), representing a supply and demand mismatch of 30% workforce inadequacy. The level of projected adequacy was markedly different based on rurality by year 2035 with 77% workforce adequacy versus 29% workforce adequacy in metro and nonmetro geographies, respectively. By year 2035, ophthalmology is projected to have the second worst rate of workforce adequacy (70%) of 38 medical and surgical specialties studied.

CONCLUSIONS

The HRSA's Health Workforce Simulation Model forecasts a sizeable shortage of ophthalmology supply relative to demand by the year 2035, with substantial geographic disparities. Ophthalmology is one of the medical specialties with the lowest rate of projected workforce adequacy by 2035. Further dedicated workforce supply and demand research for ophthalmology and allied professionals is needed to validate these projections, which may have significant future implications for patients and providers.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

National trends in surgical subspecialisation in ophthalmology in the USA

BACKGROUND/AIMS

To assess surgical patterns in ophthalmology by subspecialty in the USA.

METHODS

Ophthalmic surgeons were categorised as comprehensive/subspecialist based on billed procedures in the 2017-2018 Medicare Provider Utilization and Payment Data. Poisson regression models assessed factors associated with physicians performing surgeries in the core domain (eg, cataract extractions) and subspecialty domain. Models were adjusted for provider gender, time since graduation, geographical region, practice setting and hospital affiliation.

RESULTS

There were 10 346 ophthalmic surgeons, 74.7% comprehensive and 25.3% subspecialists. Cataract extractions were performed by 6.0%, 9.9%, 21.0%, 88.1% and 95.3% of specialists in surgical retina, neuro-ophthalmology/paediatrics, oculoplastics, glaucoma and cornea, respectively. Retina specialists were more likely to perform cataract surgery if they were 20-30 or>30 years in practice (relative risk: 2.20 (95% CI: 1.17 to 4.12) and 3.74 (95% CI: 1.80 to 7.76), respectively) or in a non-metropolitan setting (3.78 (95% CI: 1.71 to 8.38)). Among oculoplastics specialists, male surgeons (2.71 (95% CI: 1.36 to 5.42)), those in practice 10-20 years or 20-30 years (1.93 (95% CI: 1.15 to 3.26) and 1.91 (95% CI: 1.11 to 3.27), respectively) and in non-metropolitan settings (3.07 (95% CI: 1.88 to 5.02)) were more likely to perform cataract surgery. Only 26 of the 2620 subspecialists performed surgeries in two or more subspecialty domains.

CONCLUSIONS

There is a trend towards surgical subspecialisation in ophthalmology in the USA whereby some surgeons focus their surgical practice on subspecialty procedures and rarely perform surgeries in the core domain.

Assessing needs-based supply of physicians: a criteria-led methodological review of international studies in high-resource settings

BACKGROUND

Many health systems embrace the normative principle that the supply of health services ought to be based on the need for healthcare. However, a theoretically grounded framework to operationalize needs-based supply of healthcare remains elusive. The aim of this paper is to critically assess current methodologies that quantify needs-based supply of physicians and identify potential gaps in approaches for physician planning. To this end, we propose a set of criteria for consideration when estimating needs-based supply.

METHODS

We conducted searches in three electronic bibliographic databases until March 2020 supplemented by targeted manual searches on national and international websites to identify studies in high-resource settings that quantify needs-based supply of physicians. Studies that exclusively focused on forecasting methods of physician supply, on inpatient care or on healthcare professionals other than physicians were excluded. Additionally, records that were not available in English or German were excluded to avoid translation errors. The results were synthesized using a framework of study characteristics in addition to the proposed criteria for estimating needs-based physician supply.

RESULTS

18 quantitative studies estimating population need for physicians were assessed against our criteria. No study met all criteria. Only six studies sought to examine the conceptual dependency between need, utilization and supply. Apart from extrapolations, simulation models were applied most frequently to estimate needs-based supply. 12 studies referred to the translation of need for services with respect to a physician's productivity, while the rest adapted existing population-provider-ratios. Prospective models for estimating future care needs were largely based on demographic predictions rather than estimated trends in morbidity and new forms of care delivery.

CONCLUSIONS

The methodological review shows distinct heterogeneity in the conceptual frameworks, validity of data basis and modeling approaches of current studies in high-resource settings on needs-based supply of physicians. To support future estimates of needs-based supply, this review provides a workable framework for policymakers in charge of health workforce capacity planning.

Using infodemiology metrics to assess patient demand for oculoplastic surgeons in the United States: insights from Google Search Trends

PURPOSE

The aim of this study was to compare state-by-state concentrations of oculoplastic surgeons against patient demand using Google Search Trends data, in order to identify potential areas of unmet need.

METHODS

Google Trends data from 2004 to 2019 was collected to determine relative search volumes for the keyword "blepharoplasty" in each US state and the District of Columbia. Oculoplastic surgeon density was calculated by dividing the number of active American Society of Plastic and Reconstructive Surgeons members in 2019 by the State Census Bureau population estimates. Relative search volume values were divided by the local concentration of surgeons, and results were normalized between 0 and 100 to obtain a relative demand index for each state.

RESULTS

Oculoplastic surgeon density varied widely across the country. The greatest concentrations of surgeons per 100,000 people were in D.C. (0.708) and Rhode Island (0.378), while the lowest were in Montana, New Mexico, North Dakota, South Dakota, and Wyoming (all 0). Relative search volumes were tightly distributed, ranging between 100 (Hawaii) and 45 (Vermont). The highest relative demand was found in low surgeon density states, such as Hawaii, Montana, New Mexico, North Dakota, South Dakota, and Wyoming. The lowest relative demand was found in DC (5), Rhode Island (12), and Utah (12).

CONCLUSIONS

Our results revealed vast disparities in surgical concentrations across the US and highlighted a number of areas with a relative undersupply of oculoplastic surgeons. Further investigation is necessary to examine the underlying factors impacting the supply and distribution of oculoplastic surgeons.

Association Between Geographic Distribution of Eye Care Clinicians and Visual Impairment in California

Importance

The association between availability of eye care clinicians and visual impairment, a condition presenting with increased morbidity and health care costs, has not been thoroughly studied.

Objective

To examine associations between the geographic distribution of eye care clinicians and visual impairment in California.

Design, Setting, and Participants

This survey-based cross-sectional study included ophthalmologists and optometrists licensed in California in 2018 and 2020 as well as respondents to the 2014 to 2018 American Community Survey (ACS) by California counties and Medical Service Study Areas (MSSAs). Data were analyzed from August 2020 to December 2021.

Main Outcomes and Measures

Prevalence of visual impairment by county and MSSA.

Exposures

The number of eye care clinicians was determined based on the number of member ophthalmologists of the American Academy of Ophthalmology in 2018 and optometrists listed in the 2020 Blue Book of Optometrists in California. The prevalence of visual impairment was determined using questionnaire data from the American Community Survey. Linear regression was used to assess multivariable associations between number of eye care clinicians and visual impairment by MSSA.

Results

A total of 30 068 581 California residents were included; 15 253 655 (50.7%) were female, and 5 314 389 (17.7%) were 65 years and older. The overall number of eye care clinicians was 22.18 clinicians per 100 000 residents. The overall prevalence of visual impairment was 2411.07 residents with visual impairment per 100 000 residents. San Francisco County had the highest number of eye care clinicians per 100 000 residents (39.24 clinicians per 100 000 residents). Four counties had no eye care clinicians (Alpine, Mariposa, Inyo, and Sierra counties). For every increase of 1 eye care clinician per 100 000 residents, there was a mean (SE) decrease of 3.90 (1.39) persons with visual impairment per 100 000 residents in adjusted analyses.

Conclusions and Relevance

In this cross-sectional study, a higher number of eye care clinicians was potentially associated with lower prevalence of visual impairment in California. Additional studies are needed to assess eye care clinician availability on a national and global scale and strategies to improve access to eye care.

Factors Influencing Career Decisions and Satisfaction Among Newly Practicing Ophthalmologists

PURPOSE

To describe the career choices of newly practicing ophthalmologists and explore factors influencing career decisions and satisfaction.

METHODS

A cross-sectional study was conducted using data from an electronic survey of ophthalmologists who completed training within the prior 5 years. The survey included questions about demographic information, medical education, current practice, factors affecting career choices, and career satisfaction. Statistical comparisons were made based on gender, type of practice, subspecialty training, and practice area.

RESULTS

Surveys were completed by 696 (32%) newly practicing ophthalmologists, including 276 (40%) women, 179 (29%) academicians, and 465 (67%) subspecialists. A higher proportion of female respondents entered academics than male respondents (36% vs 26%, P = .009). Female and male respondents pursued fellowship training with similar frequency (64% vs 68%, P = .32), but men were more likely to seek vitreoretinal fellowships (30% vs 11%, P < .001) and women were more likely to undertake fellowships in pediatric ophthalmology (21% vs 8%, P < .001), uveitis (10% vs 2%, P = .002), and neuro-ophthalmology (6% vs 2%, P = .042). A total of 514 (83%) respondents reported being happy with work life.

CONCLUSIONS

The career choices of newly practicing ophthalmologists differ based on gender, type of practice, subspecialty training, and practice area. Many factors affect career decisions, and they have varying influence on subgroups within ophthalmology. Ophthalmologists have high levels of career satisfaction. This information may prove useful when developing workforce strategies to meet future eye care needs. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

The health workforce demand: a systematic literature review

Understanding imbalances between the supply and demand of the human resour- ces for health (HRH) is essential for enhancing health outcomes. Addressing the HRH demand is particularly challenging, especially given the deficit of accurate data and surplus of unresolved methodological flaws. This study presents a systematic review of the literature surrounding HRH demand and answers the following key questions: How has HRH demand been addressed? What are the harms and barriers that accompany HRH demand modeling? This systematic review was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) statement. Relevant keywords were used in a thorough search of the PubMed/MEDLINE, SCOPUS, and Web of Science databases. A total of 2,599 papers were retrieved and evaluated according to their title and abstract. Of these, the full-text of 400 papers was analyzed, 53 of which successfully met the inclusion criteria in our study. While the topic's relevance is widespread, it still lacks a validated approach to model HRH demand adequately. The main characteristics of the applied methods are presented, such as their application complexity by health policymakers. Opportunities and orientations for further research are also highlighted.

Factors Influencing Postgraduate Career Decisions of Ophthalmology Residents

Objective This study aims to identify factors that influence ophthalmology residents' decision to pursue fellowship training or to practice comprehensive ophthalmology after residency.

Design This is a cross-sectional study.

Methods An anonymous survey was sent to ophthalmology residents in the United States from the graduating class of 2018. The main outcome measure was the decision to seek fellowship training or to practice comprehensive ophthalmology. Information on demographics, residency program characteristics, and factors influencing career choices were collected.

Results The overall response rate was 24.0% (112/467). Among the 112 respondents, 88 (78.6%) matched into subspecialty training. Compared with residents entering comprehensive ophthalmology, there was a greater proportion of Asians (37.5 vs. 8.3%) and a smaller proportion of non-Hispanic whites (47.7 vs. 70.8%, p = 0.029) among residents pursuing fellowship training. Residents pursuing fellowships had fewer children (0.4 vs. 0.8, p = 0.049), had less debt (median debt ≤ $100,000 vs. > $200,000, p = 0.008), had more first-author publications (4.3 vs. 1.2, p< 0.001), decided on their postgraduate career path earlier (median time postgraduate second year [PGY2] versus postgraduate third year [PGY3], p = 0.016), and were more likely to plan to practice in an academic setting (51.1 vs. 29.2%, p< 0.001) and in an urban location (44.3 vs. 12.5%, p = 0.004). In a multiple logistic regression model, factors predictive of fellowship training included a desire to acquire special skills (odds ratio [OR] =4.39; 95% confidence intervals [CI]: 1.70–16.37) and work with new technology (OR = 2.92; 95% CI: 1.16–10.02). Factors that predicted a career in comprehensive ophthalmology were higher levels of educational debt (OR = 0.35; 95% CI: 0.12–0.77), a later timing of postgraduate decision (OR = 0.17; 95% CI: 0.02–0.65), and lifestyle considerations (OR = 0.13; 95% CI: 0.03–0.36). Gender, prestige, or perceived favorable job market was not significant factors.

Conclusion The majority of U.S. ophthalmology residents matched into fellowships. A desire to gain special skills and a desire to work with new technology were major factors influencing residents to seek fellowship training. Lifestyle considerations and educational debt were more important in the decision to choose a comprehensive ophthalmology career. Future research that includes more trainees and programs may minimize the selection bias issues present in this study.

Ophthalmic Education and Ophthalmologists Growth Trends in Iran (1979-2016)

Purpose

To analyze the growth trends in ophthalmic education in Iran since 1979, and to discuss their implications on the profession.

Methods

This comprehensive national study was performed by the Academy of Medical Sciences of I.R. Iran. The data were gathered from the Specialty Training Council of the Ministry of Health and from the Medical Council of Iran.

Results

Our analysis revealed ten important current growth trends and seven future trends and implications. Between 1979-80 and 2015-16, the number of residents annually admitted to ophthalmology increased from 21 to 84 and related fellowships and from 0 to 34. The number of ophthalmologists graduating in the country increased from 21 (45%) in 1979 to 69 (98%) in 2015. The ratio of ophthalmologists per 100,000 people averaged 1.91 in 1979 and 3.00 in 2016. Considering migrant and retired ophthalmologists, there are approximately 2400 active ophthalmologists in Iran. In 1979, there was one active ophthalmologist per 52,112 people; in 2014, there was one per 33,333 people. This represents a per capita increase of 57%. Since 1979, the number of active ophthalmologists has increased by 234%. The number of active women ophthalmologists has increased by more than 600%, from 65 (9%) in 1979 to 470 (20%) in 2016.

Conclusion

Equitable geographic distribution and balanced combination of ophthalmologists (women/men and specialists/fellowships) are necessary to optimize community eye health. We propose further studies on the effects of fellowship training growth and work patterns of female and male ophthalmologists.

Differences in Wait Times for Cosmetic Blepharoplasty by ASOPRS Members

PURPOSE

Adequate access to subspecialty care is of concern to patients and physicians alike. One measure of availability is the wait time for cosmetic procedures. The authors investigated geographical differences in wait times for cosmetic upper eyelid blepharoplasty of American Society of Ophthalmic Plastic and Reconstructive Surgery members across the country.

METHODS

This study surveyed all 533 American Society of Ophthalmic Plastic and Reconstructive Surgery members' practices in the United States based on the publically available contact information (www.asoprs.org). Scripted telephone calls were made requesting self-referred cosmetic upper eyelid blepharoplasty. Wait times until the first available appointment and time until the first available surgery date were collected.

RESULTS

Of the membership, 387 (72.6% response rate) respondents offered appointments for cosmetic upper eyelid blepharoplasty. Overall, 84.2% of respondents were male. Practice breakdown was 83.4% in private practice and 16.5% in academic practice. Median wait time until the next available appointment was 14 days (mean 21.2 days, 0-205 days; p = 0.145). Private practice wait time was shorter than academic (median 14 vs. 18 days, mean 19.7 vs. 28.9 days; p =0.004). However, there was wide variability based on region.

CONCLUSIONS

Patients seeking cosmetic upper eyelid blepharoplasty have good access to care by American Society of Ophthalmic Plastic and Reconstructive Surgery members. There are variabilities based on academic versus private practice. Further study can evaluate whether similar findings exist for medically necessary functional procedures. This information may help assess the need for additional practitioners.

The landscape of ophthalmologists in Canada: present and future

OBJECTIVE

To describe the current national and regional population distribution of ophthalmologists in Canada and provide national predictions up to 2030.

DESIGN

Cross-sectional, study.

PARTICIPANTS

Ophthalmologists listed in the Canadian Medical Association (CMA) database and Canadian population.

METHODS

The CMA database was used to determine the number and location of currently licensed ophthalmologists in Canada. Using Statistics Canada population data, we determined the ratio of ophthalmologists to 100,000 population. Projections were also made for the supply of ophthalmologists up to 2030 using the CMA Physician Resource Evaluation Template and assuming a status quo scenario in terms of attrition and gain factors.

RESULTS

In Canada, there are currently 3.35 ophthalmologists per 100,000 population. There is, however, significant regional disparity; provincial ratios vary from 5.40 (Nova Scotia) to 1.96 (Saskatchewan) and 0.89 in the territories. If 3 ophthalmologists per 100,000 is the ideal ratio, then 4 provinces and the territories were below this ratio, and of the 104 regions with an ophthalmologist, 22 were below the ratio. The national projection to 2030 is a slight increase to 3.38; however, the full-time equivalent ratio is expected to decrease from 3.29 in 2012 to 3.06 in 2030. For the population ≥ 65 years old, with a projected growth 4 times greater than that of ophthalmologists, the ratio of ophthalmologists to population ≥ 65 years old is projected to decline by 34%.

CONCLUSIONS

Although national estimates appear stable, there is significant regional variation. The projected marked growth of the population ≥ 65 years old may compromise our future ability to provide care at the current standard.

The New York State optometry workforce study

This study presents an analysis of the current optometry workforce, both as a unique profession and more broadly within the context of all eye care providers (optometry and ophthalmology) in New York State. The supply and distribution of eye care practitioners provides useful information for policy makers while providing insights as to the impact of the one optometry school within the state. Several databases were employed and a web based survey was developed for completion by all optometrists. The questionnaire included demographic data, whether they were actively practicing in New York State or any other state, were they full time or part time, their primary mode of practice, or if they provided care within institutional settings. Access to care was gauged by the respondents' availability for appointments during evenings or weekends. Access to eye care services in New York State has improved significantly during the past 30 years as the supply of optometrists increased. Before this study was conducted it was generally believed that there were more optometrists than ophthalmologists in every state of the nation except New York, Maryland and the District of Columbia. Findings of this study demonstrate there are 37% more optometrists in New York State than ophthalmologists and more evenly distributed as optometrists are located in almost every county of the state. Sixteen counties have no ophthalmologists. This is attributed to the presence of the College of Optometry established in 1971. More than 60% of all optometrists in the state are SUNY College of Optometry graduates.

Factors Influencing Career Choices among Graduating Ophthalmology Residents

OBJECTIVE

To identify factors influencing graduating ophthalmology residents to pursue subspecialty training or a career in comprehensive ophthalmology.

DESIGN

Cross-sectional study.

PARTICIPANTS

Residents graduating from U.S. ophthalmology residency programs who participated in the ophthalmology match program.

METHODS

An anonymous survey was sent to each graduating ophthalmology resident in the United States between February 1, 2003, and February 28, 2003. Demographic data and information relating to medical school and residency training, career goals, and factors influencing career choices were collected from the surveys.

MAIN OUTCOME MEASURE

The decision to pursue or not to pursue fellowship training.

RESULTS

The individual response rate was 50.8% (222/437), and 74.1% (86/116) of residency training programs responded to the survey. After completion of residency training, 64% (142/222) were pursuing subspecialty training and 36% (80/222) planned to practice comprehensive ophthalmology. In a multivariate analysis, factors that predicted subspecialty training included a desire to acquire special skills (odds ratio [OR], 13.81) and a perceived more favorable job market (OR, 3.23) and prestige (OR, 3.20). Anticipated work hours (OR, 0.37) and preferred geographic location (OR, 0.47) were predictors of a career in comprehensive ophthalmology. Residents choosing comprehensive ophthalmology careers were more likely to plan to practice in a group private practice, and those seeking subspecialty training were more likely to intend to practice in a university setting or were undecided in their future practice type (OR, 2.04).

CONCLUSIONS

Several factors influenced career choices among graduating ophthalmology residents. A desire to acquire special skills and perceived prestige and job market were major factors influencing ophthalmology residents to seek subspecialty training. Lifestyle considerations were more important to residents choosing a comprehensive ophthalmology career. There were significant differences in practice preferences among residents pursuing or not pursuing subspecialty training.