Review of the Disparities in Access to Pediatric Eye Care Among Low Socioeconomic Status and Underrepresented Racial Minority Groups Exacerbated by the Economic Downturn in Pediatric Ophthalmology

PURPOSE

To explore the association between race and socioeconomic status on health disparities in pediatric eye care, characterize the status of diversity within the pediatric ophthalmology workforce, and propose potential solutions to improve access to vision care, particularly for children from vulnerable populations.

METHODS

The major studies examining the socioeconomic and racial disparities in visual outcomes and the impact of diversity in the ophthalmology workforce were reviewed.

RESULTS

Currently, the pediatric ophthalmology workforce has limited racial diversity, and increasing the number of underrepresented in medicine providers has potential to improve access to pediatric eye care, particularly for underserved populations. Mobile eye clinics, school-based vision programs, and health literacy initiatives may engage communities to bring eye care directly to children and enhance follow-up.

CONCLUSIONS

Families with lower socioeconomic status may represent a vulnerable population facing significant access to pediatric eye care barriers, particularly for asymptomatic pediatric eye conditions. Emphasis on strategies that directly engage communities and bring free vision care to families should be given to improve disparities in visual health outcomes. Ophthalmologists and pediatric ophthalmologists should be aware of the current racial underrepresentation within the pediatric ophthalmology workforce, and the importance of workforce diversity in accelerating physician-patient concordance and access to eye care. [J Pediatr Ophthalmol Strabismus. 2024;61(3):172-178.].

What We Learned About the Economic and Workforce Issues in Pediatric Ophthalmology: Access to Eye Care and Possible Solutions

PURPOSE

To provide a blueprint reviewing the major economic and workforce issues in pediatric ophthalmology and its effect on access to pediatric eye care, as well as potential solutions.

METHODS

This was a systematic review of the landmark studies examining the economic and workforce issues in pediatric ophthalmology was performed.

RESULTS

The number of residents pursuing pediatric ophthalmology fellowship has steadily declined since the early 2000s. Increasing overhead costs, low Medicaid reimbursements, practice pattern changes, and workforce shortages have all contributed to a significant crisis in access to pediatric eye care.

CONCLUSIONS

Solutions to improve access to pediatric eye care involve pursuing more economical strategies within the confines of the pediatric ophthalmology practice, early exposure to the field during medical education, and enhancing residents' interest through faculty mentorship. Low reimbursements are a major driver contributing to extended appointment wait times for pediatric ophthalmology visits at major academic eye centers. Legislative changes at both the federal and state levels are needed to make appropriate increases in reimbursements, starting with states in the lowest quartile of Medicaid reimbursements. [J Pediatr Ophthalmol Strabismus. 2023;60(5):323-329.].

The Medicaid Dilemma and Its Profound Effect on the Economic and Workforce Issues in Pediatric Ophthalmology and Ultimately on Access to Pediatric Eye Care

PURPOSE

To identify new patient, follow-up, and surgery appointment wait times for children seeking care at academic eye centers/children's hospitals (AEC/CHs) in the setting of very low Medicaid reimbursements and workforce issues in pediatric ophthalmology.

METHODS

Each state in the United States with AEC/CHs was contacted by phone or email. Using a standardized script, the authors inquired about approximate wait times for non-emergency new patient, follow-up, and surgery appointment times, as well as percentage of patients insured by Medicaid seen at the AEC/CH. Medicaid reimbursements for new patient visits, follow-up visits, sensorimotor examinations, and one-muscle strabismus surgery were examined for each state.

RESULTS

The mean percentage of children enrolled in Medicaid across the United States was 38.0%. Appointment and Medicaid inquiry calls were conducted across 41 states. Mean wait times across the United States for new patient, follow-up, and surgery appointments were 3.9, 3.4, and 2.7 months, respectively. Mean percentage of patients insured by Medicaid at AEC/CHs was 57.1%. High Medicaid-insured states offered longer wait times for new patient appointments than low Medicaid-insured states (4.4 versus 3.5 months; P = .20). The lowest Medicaid reimbursements for new patient visit, follow-up visit, sensorimotor examination, and one-muscle strabismus surgery occurred in Illinois, California, Ohio, and Michigan, respectively.

CONCLUSIONS

Across the United States, states with higher percentages of patients insured by Medicaid exhibited longer new patient appointment wait times, suggesting that challenges related to Medicaid reimbursements directly contribute to disparities in access to pediatric eye care. [J Pediatr Ophthalmol Strabismus. 2023;60(3):170-177.].

Unanswered Questions Pertaining to the Economic and Workforce Issues in Pediatric Ophthalmology

PURPOSE

To create a survey that examines remaining unanswered questions related to the economic and workforce issues in pediatric ophthalmology.

METHODS

A 12-question survey was distributed to U.S.-based pediatric ophthalmologists on the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) discussion board and various other social media forums. Statistical analysis was performed on the basis of practice setting groups.

RESULTS

Two hundred eighty-seven pediatric ophthalmologists completed the survey. Of all respondents, 150 (52.3%) believed pediatric ophthalmology is a prestigious subspecialty, 137 (47.7%) thought that a hybrid fellowship combining pediatric ophthalmology and adult cataract surgery would increase the number of practicing pediatric ophthalmologists, 189 (65.9%) felt that early exposure during medical school would increase the number of residents who ultimately apply to pediatric ophthalmology fellowship, and 81 (28.2%) believed that the lobbyists hired by the AAPOS will be successful in preventing further Centers for Medicare and Medicaid Services reimbursement cuts. Medicaid patients comprised more than 25% of the total practice for 156 (54.4%) respondents. New patient, follow-up, and surgery wait times were greater than 2 months in 50.9%, 46.7%, and 38.7% of respondents, respectively.

CONCLUSIONS

As the economic crisis in pediatric ophthalmology continues to worsen, questions related to increasing interest in the field through early exposure, hybrid fellowship, prestige, appointment wait times, and belief in the success of AAPOS lobbyists remain. Exceptional measures are required to revitalize the field and improve access to care. [J Pediatr Ophthalmol Strabismus. 2023;60(3):163-169.].

In the Setting of Heightened Economic and Workforce Issues, What Are Third-Year (PGY-4) Ophthalmology Residents' Perspectives of Pediatric Ophthalmology?

PURPOSE

To investigate the factors influencing residents' choice to pursue a pediatric ophthalmology fellowship.

METHODS

A nine-question survey was distributed to third-year (PGY-4) ophthalmology residents of United States-based Accreditation Council for Graduate Medical Education residency training programs in ophthalmology.

RESULTS

One hundred two of 502 residents completed the survey. Fifty percent of all respondents had no debt and 14.7% had more than $300,000 in debt. Forty-four (43.1%) rated the quality of pediatric ophthalmology teaching in their residency program as "excellent," 37 (36.3%) did not enjoy performing clinical ophthalmologic examinations on children, 83 (81.4%) had a clinical role model in pediatric ophthalmology, 29 (28.4%) believed pediatric ophthalmology is a prestigious subspecialty, 47 (46.1%) reported that economic factors influenced their post-residency decisions, 60 (58.8%) believed a hybrid fellowship combining adult cataract surgery and pediatric ophthalmology would be a popular fellowship, and 58 (56.9%) had a first-year (PGY-2) residency rotation of at least 1 month in pediatric ophthalmology. Enjoying the ophthalmologic examination of children most strongly predicted whether a resident would pursue a pediatric ophthalmology fellowship (Phi = 0.482).

CONCLUSIONS

The desire to work with children overwhelmingly superseded other factors influencing a resident's decision to pursue a pediatric ophthalmology fellowship. Improving economic issues may be one of several factors that increase the attractiveness of the pediatric ophthalmology subspecialty. There is a dilemma in encouraging more residents to pursue pediatric ophthalmology in the setting of fewer technological advances consistent with lower perceived prestige. [J Pediatr Ophthalmol Strabismus. 2023;60(2):95-100.].

Is There a Path for an Economic Turnaround in Pediatric Ophthalmology?

PURPOSE

To create a survey that assesses potential solutions for an economic turnaround in pediatric ophthalmology and the frequency of their use.

METHODS

A 12-question survey was distributed to United States-based pediatric ophthalmologists on the American Association for Pediatric Ophthalmology and Strabismus discussion board and various social media fora. Demographic, economic, and workforce pattern data were collected and analyzed.

RESULTS

Three hundred one pediatric ophthalmologists completed the survey. Thirty-one (10.3%) respondents used optical coherence tomography in children with amblyopia, 81 (26.9%) were a partner in an ambulatory surgery center, 133 (44.2%) had a retinopathy of prematurity financial contract arrangement with a neonatal intensive care unit to examine premature children, and 95 (31.6%) had a financial contract arrangement with an optical shop in their office. Twenty-four (8.0%) respondents were currently in the process of being or had been bought out by a private equity investor, 52 (17.3%) owned a Spot Vision Screener (Welch Allyn) for refraction, 158 (52.5%) had hired a pediatric ophthalmology extender (pediatric optometrist, technician, or orthoptist), 87 (29.5%) had recently increased their marketing profile, and 90 (29.9%) owned the property that their practice occupied.

CONCLUSIONS

Potential for a revitalization and economic turnaround in pediatric ophthalmology depends on several income-generating suggestions that simultaneously improve workforce and manpower issues, thus increasing access to pediatric eye care. [J Pediatr Ophthalmol Strabismus. 2023;60(1):25-32.].

The Economic Downturn of Pediatric Ophthalmology and Its Impact on Access to Eye Care

PURPOSE

To discuss the economic downturn of pediatric ophthalmology in the setting of an alarming decline in the number of residents pursuing pediatric ophthalmology and its impact on limiting access to eye care.

METHODS

Survey studies and articles examining the recent economic impact of reimbursement cuts and practice pattern changes in pediatric ophthalmology were reviewed. Population data from the 2020 U.S. Census Bureau and the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) were analyzed to illustrate provider-to-population relationships by state.

RESULTS

Survey studies demonstrated a deteriorating economic situation marked by progression in reimbursement cuts, reductions in pediatric ophthalmologists accepting Medicaid patients, and dwindling numbers of residents pursuing pediatric ophthalmology fellowships. Provider-to-population relationships revealed that pediatric ophthalmologists are not evenly distributed to meet population demand, and that many states are suffering from a shortage of pediatric ophthalmologists. Furthermore, many states with high percentages of Medicaid coverage simultaneously have lower AAPOS members/million person ratios.

CONCLUSIONS

The simple economic principles of supply and demand reveal a crisis in access to pediatric eye and adult strabismus care. The economic downtown and change in practice patterns may produce rippling effects outside pediatric ophthalmology in fields such as pediatrics and comprehensive ophthalmology. An interdisciplinary effort among health care providers and governmental officials is needed to revive the field of pediatric ophthalmology and improve access to eye care. [J Pediatr Ophthalmol Strabismus. 2023;60(1):18-24.].

The Economic Factors Impacting the Viability of Pediatric Ophthalmology

PURPOSE

To create a survey that assesses the economic factors impacting the viability of pediatric ophthalmology between January 2021 and July 2022.

METHODS

A 12-question survey was distributed to United States-based pediatric ophthalmologists on the American Association for Pediatric Ophthalmology and Strabismus discussion board and various social media fora. Demographic, economic, and workforce pattern data were collected and analyzed.

RESULTS

A total of 243 pediatric ophthalmologists completed the survey. One hundred seven (44.0%) respondents reported a surgical revenue decrease between 10% and 25%, 117 (48.1%) a clinical revenue decrease of less than 10%, 111 (45.6%) an overall income decrease of less than 10%, and 127 (52.2%) an overhead cost increase between 10% and 25%. Seventy-two (29.6%) respondents reported subsidizing income with pursuits outside of pediatric ophthalmology, 27 (11.1%) stopped operating due to reimbursement cuts, 75 (30.8%) limited the number of Medicaid or other public funded patients, 16 (6.5%) retired in the past 3 years, and 92 (37.8%) would not recommend a resident pursue a pediatric ophthalmology fellowship.

CONCLUSIONS

There is a potential upheaval in the field of pediatric ophthalmology marked by increasing levels of disillusionment among current providers, a progressive decline in the number of trainees pursuing fellowship programs, and workforce issues suggestive of diversification of practice patterns outside of pediatric ophthalmology. The current economic crisis, in conjunction with these complex workforce issues, is and will continue to create a shortage of practicing pediatric ophthalmologists, seriously limiting access to pediatric and adult strabismus eye care. [J Pediatr Ophthalmol Strabismus. 2022;59(6):362-368.].

Economic Impact of the COVID-19 Pandemic Post-Mitigation on Pediatric Ophthalmologists

PURPOSE

To create a survey to assess the economic impact that the coronavirus disease 2019 (COVID-19) pandemic post-mitigation (post-shutdown) has had on pediatric ophthalmologists.

METHODS

A 14-question survey was disseminated to United States-based pediatric ophthalmologists on the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) discussion board and on social media. Demographic data and data on the economic effect of the COVID-19 pandemic post-mitigation were collected.

RESULTS

A total of 129 pediatric ophthalmologists completed the survey. Eighty-four (65.1%) respondents reported a clinical revenue decrease of greater than 10%, 83 (64.3%) a surgical decrease of greater than 10%, and 66 (51.2%) an income decrease of greater than 10%. Fifteen (11.6%) respondents reported limiting the number of Medicaid patients. This was more prevalent among those in private practice (P = .027). Twenty-seven (20.9%) pediatric ophthalmologists responded that they planned to retire earlier than anticipated because of the pandemic and 2 (1.6%) responded that they have retired since the start of the pandemic. Six (4.7%) respondents reported that they have sold their practice since the start of the COVID-19 pandemic.

CONCLUSIONS

Pediatric ophthalmologists continue to face economic challenges introduced by the COVID-19 pandemic. Reduced revenue may represent a new normal for the near future in pediatric ophthalmology. These unprecedented economic upheavals come at a time when the field of pediatric ophthalmology already faces difficulties with low reimbursement and attracting new trainees. This multitude of issues may escalate into a crisis in providing appropriate pediatric ophthalmic care. [J Pediatr Ophthalmol Strabismus. 2022;59(5):291-295.].

Indications and Outcomes for Extraocular Muscle Disinsertion in Strabismus Surgery

PURPOSE

To describe a case series of extraocular muscle (EOM) disinsertions, discuss the indications for muscle disinsertion, and examine deviation outcomes.

METHODS

All consecutive patients who underwent EOM disinsertion by one surgeon from 2013 to 2021 were included in the study. Age, sex, best corrected visual acuity, diagnosis, preoperative deviation, postoperative deviation, and follow-up interval were recorded.

RESULTS

Twelve patients (13 eyes) underwent EOM disinsertion. Ten were men and two were women. Eight eyes had an abducens nerve (cranial nerve 6) palsy, four had thyroid eye disease, and one had an oculomotor nerve palsy (cranial nerve 3). Preoperatively, the average age was 57.7 years, best corrected visual acuity was 0.24 logarithm of the minimum angle of resolution (logMAR) in the right eye and 0.35 logMAR in the left eye, and deviation was 56.4 prism diopters (PD). The average postoperative residual deviation was 5.3 PD with an average follow-up time of 290 days. Four patients underwent reoperation, one of whom underwent a third surgery.

CONCLUSIONS

EOM disinsertion is an effective treatment in certain specific strabismus conditions. Patients who may benefit are those with a severe cranial nerve 6 palsy who cannot abduct the eye even to the midline and those with thyroid eye disease whose EOMs are so tight intraoperatively that even a small hook cannot be easily passed under the operative muscle adequately to perform a large recession technique. [J Pediatr Ophthalmol Strabismus. 20XX;X(X):XX-XX.].

Practice Patterns of Pediatric Ophthalmologists During the COVID-19 Pandemic

PURPOSE

To report the use of protective personal equipment (PPE) during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

A 12-question multiple-choice survey was posted on a discussion board used by members of the American Association for Pediatric Ophthalmology and Strabismus (AAPOS). Respondents provided information about their experience, PPE use, office equipment, and approach to care during the COVID-19 pandemic.

RESULTS

One hundred twenty-eight pediatric ophthalmologists completed the survey. Eighty-seven (68.0%) identified as in private practice, whereas 41 (32.0%) identified as in an academic setting. Sixty-nine pediatric ophthalmologists (53.9%) reported routinely using N95 respirators, 72 (56.3%) reported wearing medical scrubs, 41 (32.0%) reported using disposable gloves, 33 (25.7%) reported wearing goggles, and 12 (9.4%) reported using face shields during office examinations. One hundred twenty-one pediatric ophthalmologists (94.5%) reported having slit lamps with plastic shields and 52 (40.6%) reported having phoropters with plastic shields. Ninety-nine (77.3%) responded that they would see a patient older than 2 years who refused to wear a mask for a nonemergency visit.

CONCLUSIONS

Practice patterns of pediatric ophthalmologists have varied during the COVID-19 pandemic. [J Pediatr Ophthalmol Strabismus. 2022;59(3):145-150.].

Anterior Segment Optical Coherence Tomography in Locating the Insertion of Horizontal Extraocular Muscles After Strabismus Surgery

PURPOSE

To evaluate the accuracy of anterior segment optical coherence tomography (AS-OCT) for locating horizontal extraocular muscle (EOM) insertion after strabismus surgery.

METHODS

The distance from the limbus to the postoperative muscle insertion was measured with calipers intraoperatively and by AS-OCT during the postoperative visit of adults undergoing strabismus surgery. Images were collected by masked technicians. Intraclass correlation coefficients (ICC) were used to evaluate the agreement between measurements.

RESULTS

Twenty-eight patients were recruited. Measurements were taken from 31 eyes, including 17 lateral and 14 medial rectus muscles. EOM insertion was successfully identified by AS-OCT for 14 (45%) cases. The ICC between intra-operative and AS-OCT measurement was 0.886 when the distance from the limbus to the insertion of EOM was less than 8 mm and 0.001 when the distance from the limbus was between 8 and 10 mm. EOM insertion was undetectable if distance to the limbus was greater than 10 mm.

CONCLUSIONS

AS-OCT can accurately identify post-surgical horizontal muscle insertion if the insertion is less than 8 mm from the limbus. [J Pediatr Ophthalmol Strabismus. 2021;58(1):62-65.].

Workforce Issues in Pediatric Ophthalmology

The fate of pediatric ophthalmology may be in jeopardy. For the past 20 years, there has been declining interest in the field compared to other subspecialties in ophthalmology, as fellowship positions and jobs remain unfilled. Of those fellows who do match in pediatric ophthalmology and strabismus, many are international medical graduates who often return to their native countries to practice, further diminishing the supply of pediatric ophthalmologists in the United States. In previous surveys, resident graduates have expressed disinterest in the field, reluctance to work with children, inadequate reimbursements, and insufficient interactions with faculty as reasons not to pursue this subspecialty. Millions of people throughout the United States do not have access to pediatric ophthalmologists, highlighting the issue of unequal distribution. As more pediatric ophthalmologists retire, there is concern that there will not be enough providers to meet the demands of this subspecialty. Although many of these factors deterring residents from entering this field have been resolved, the major issue of financial reimbursements has not been adequately addressed. [J Pediatr Ophthalmol Strabismus. 2020;57(1):9-11.].

Can the Red Reflex Test Detect Unequal Refractive Error?

OBJECTIVE

To determine the accuracy of the red reflex test in the detection of anisometropia.

STUDY DESIGN

This prospective, single-masked study enrolled new patients younger than the age of 18 years who had not undergone pharmacologic pupillary dilation. A fellow who was masked to all clinical information illuminated both eyes with a direct ophthalmoscope in a darkened room from a distance of 1 m, assessing whether the red reflex between the 2 eyes was symmetric or asymmetric. The patient was then dilated, and cylcoplegic refraction was performed by an attending pediatric ophthalmologist. Exclusion criteria included the presence of strabismus, anisocoria, previous intraocular surgery, media opacity, leukocoria, or nystagmus. Sensitivity was compared with a null hypothesized value of 50% using a 1-sided binomial test.

RESULTS

Ninety-two patients with a mean age of 7.3 years (range 3 months to 16 years) were enrolled. With spherical anisometropia greater than or equal to 0.125 diopters, the sensitivity of the red reflex test was 90.6% and the specificity was 58.3%. With cylindrical anisometropia greater than or equal to 0.25 diopters, the sensitivity of the red reflex test was 81.3% and the specificity was 70%. Anisometropia greater than 1.5 diopters in spherical equivalent (4 patients, range -10.625 to -2.625) or cylinder (3 patients, range 1.75-2.25) was accurately detected by red reflex testing in each case.

CONCLUSIONS

The red reflex test can be an accurate screening tool to detect anisometropia when performed by an ophthalmologist.

Strabismus Surgery Infection Prophylaxis and Timing of First Postoperative Visit

PURPOSE

To characterize the practice patterns of pediatric ophthalmologists regarding infection prophylaxis for strabismus surgery and timing of the first postoperative visit.

METHODS

A ten-question multiple-choice, close-ended questionnaire was e-mailed to members of the American Association for Pediatric Ophthalmology and Strabismus listserv. Survey responses were summarized using frequencies and percentages. Univariable tests of association between prophylactic measures and surgeons reporting a prior episode of postoperative cellulitis or endophthalmitis were performed.

RESULTS

Three hundred eighty pediatric ophthalmologists completed the survey. Most ophthalmologists instill 5% povidone-iodine solution during surgical preparation (88.4%), use topical antibiotics with or without steroids at the conclusion of surgery (90%), and prescribe oral or topical antibiotics postoperatively (85.5%). Eighty-five percent of strabismus surgeons routinely see patients for the first postoperative visit within the first week, although there is no consensus as to which day is preferred. Responders previously reporting experience with a postoperative infection were more likely to use intraoperative intravenous antibiotics (P = .002) and Tegaderm tape (3M, St. Paul, MN) or other adhesive drape to isolate the eyelids/eyelashes (P = .047).

CONCLUSIONS

A common practice pattern appears to exist regarding the use of 5% povidone-iodine solution in surgical preparation, application of topical antibiotics at the end of surgery, and a postoperative regimen of topical antibiotics/steroids. There is no prevailing practice pattern regarding the timing of the first postoperative visit. Previous experience with postoperative cellulitis or endophthalmitis may lead to the adoption of more formidable infection prophylaxis measures such as intravenous antibiotics prior to surgery. [J Pediatr Ophthalmol Strabismus. 2019;56(6):354-359.].

One-Muscle Strabismus Surgery: A Review

Proper management of a patient with small to moderate horizontal deviations continues to be challenging for the strabismus surgeon. The use of one-muscle surgery for comitant strabismus has been controversial because of concerns that it may result in a significant number of undercorrections and/or ocular incomitance. Recent literature on unilateral rectus muscle surgery has shown that this surgery is a safe and effective procedure for small and moderate angle horizontal deviations. It has the advantage of limiting surgery to one eye, reducing operative time and possible cost to the family, and leaving other muscles untouched in case repeat surgery is necessary. Larger studies need to be done in the future; however, this surgery should be considered as a primary approach in the treatment of small to moderate angle esotropia. [J Pediatr Ophthalmol Strabismus. 2018;55(5):288-292.].