Beyond Pathology- Exploring Salutogenesis as a Novel Approach to Eye Inflammatory Disease Prevention and Management: A Perspective.

The aim of this perspective is to promote the theory of salutogenesis as a novel approach to addressing ophthalmologic inflammatory conditions, illustrating several concepts in which it is based upon and how they can be applied to medical practice. This theory can better contextualize why patients with similar demographics and exposures are not uniform in their clinical presentations. Stressors in daily life can contribute to a state of ill-health and there are various factors that help alleviate their negative impact. These alleviating factors are significantly impaired in people with poor vision, one of the most common presentations of ophthalmologic conditions. Salutogenic principles can guide the treatment of eye conditions to be more respectful of patient autonomy amidst shifting expectations of the doctor-patient relationship. Being able to take ownership of their health and feeling that their cultural beliefs were considered improves compliance and subsequently gives more optimal outcomes. Population-level policy interventions could also utilize salutogenic principles to identify previously overlooked domains that can be addressed. We identified several papers about salutogenesis in an ophthalmological context and acknowledged the relatively few studies on this topic at present and offer directions in which we can explore further in subsequent studies.

Artificial Intelligence and Diabetic Retinopathy: AI Framework, Prospective Studies, Head-to-head Validation, and Cost-effectiveness.

Current guidelines recommend that individuals with diabetes receive yearly eye exams for detection of referable diabetic retinopathy (DR), one of the leading causes of new-onset blindness. For addressing the immense screening burden, artificial intelligence (AI) algorithms have been developed to autonomously screen for DR from fundus photography without human input. Over the last 10 years, many AI algorithms have achieved good sensitivity and specificity (>85%) for detection of referable DR compared with human graders; however, many questions still remain. In this narrative review on AI in DR screening, we discuss key concepts in AI algorithm development as a background for understanding the algorithms. We present the AI algorithms that have been prospectively validated against human graders and demonstrate the variability of reference standards and cohort demographics. We review the limited head-to-head validation studies where investigators attempt to directly compare the available algorithms. Next, we discuss the literature regarding cost-effectiveness, equity and bias, and medicolegal considerations, all of which play a role in the implementation of these AI algorithms in clinical practice. Lastly, we highlight ongoing efforts to bridge gaps in AI model data sets to pursue equitable development and delivery.

Evaluating Access to Laser Eye Surgery by Driving Times Using Medicare Data and Geographical Mapping.

Importance: Recently, several states have granted optometrists privileges to perform select laser procedures (laser peripheral iridotomy, selective laser trabeculoplasty, and YAG laser capsulotomy) with the aim of increasing access. However, whether these changes are associated with increased access to these procedures among each state's Medicare population has not been evaluated. Objective: To compare patient access to laser surgery eye care by estimated travel time and 30-minute proximity to an optometrist or ophthalmologist. Design, Setting, and Participants: This retrospective cohort database study used Medicare Part B claims data from 2016 through 2020 for patients accessing new patient or laser eye care (laser peripheral iridotomy, selective laser trabeculoplasty, YAG) from optometrists or ophthalmologists in Oklahoma, Kentucky, Louisiana, Arkansas, and Missouri. Analysis took place between December 2021 and March 2023. Main Outcome and Measures: Percentage of each state's Medicare population within a 30-minute travel time (isochrone) of an optometrist or ophthalmologist based on US census block group population and estimated travel time from patient to health care professional. Results: The analytic cohort consisted of 1 564 307 individual claims. Isochrones show that optometrists performing laser eye surgery cover a geographic area similar to that covered by ophthalmologists. Less than 5% of the population had only optometrists (no ophthalmologists) within a 30-minute drive in every state except for Oklahoma for YAG (301 470 [7.6%]) and selective laser trabeculoplasty (371 097 [9.4%]). Patients had a longer travel time to receive all laser procedures from optometrists than ophthalmologists in Kentucky: the shortest median (IQR) drive time for an optometrist-performed procedure was 49.0 (18.4-71.7) minutes for YAG, and the the longest median (IQR) drive time for an ophthalmologist-performed procedure was 22.8 (12.1-41.4) minutes, also for YAG. The median (IQR) driving time for YAG in Oklahoma was 26.6 (12.2-56.9) for optometrists vs 22.0 (11.2-40.8) minutes for ophthalmologists, and in Arkansas it was 90.0 (16.2-93.2) for optometrists vs 26.5 (11.8-51.6) minutes for ophthalmologists. In Louisiana, the longest median (IQR) travel time to receive laser procedures from optometrists was for YAG at 18.5 (7.6-32.6) minutes and the shortest drive to receive procedures from ophthalmologists was for YAG at 20.5 (11.7-39.7) minutes. Conclusions and Relevance: Although this study did not assess impact on quality of care, expansion of laser eye surgery privileges to optometrists was not found to lead to shorter travel times to receive care or to a meaningful increase in the percentage of the population with nearby health care professionals.

United States Population Disparities in Ophthalmic Care: Blindness and Visual Impairment in the IRIS® Registry (Intelligent Research in Sight).

PURPOSE: To evaluate associations of patient characteristics with United States eye care use and likelihood of blindness. DESIGN: Retrospective observational study. PARTICIPANTS: Patients (19 546 016) with 2018 visual acuity (VA) records in the American Academy of Ophthalmology's IRIS® Registry (Intelligent Research in Sight). METHODS: Legal blindness (20/200 or worse) and visual impairment (VI; worse than 20/40) were identified from corrected distance acuity in the better-seeing eye and stratified by patient characteristics. Multivariable logistic regressions evaluated associations with blindness and VI. Blindness was mapped by state and compared with population characteristics. Eye care use was analyzed by comparing population demographics with United States Census estimates and proportional demographic representation among blind patients versus a nationally representative US population sample (National Health and Nutritional Examination Survey [NHANES]). MAIN OUTCOME MEASURES: Prevalence and odds ratios for VI and blindness; proportional representation in the IRIS® Registry, Census, and NHANES by patient demographics. RESULTS: Visual impairment was present in 6.98% (n = 1 364 935) and blindness in 0.98% (n = 190 817) of IRIS patients. Adjusted odds of blindness were highest among patients ≥ 85 years old (odds ratio [OR], 11.85; 95% confidence interval [CI], 10.33-13.59 vs. those 0-17 years old). Blindness also was associated positively with rural location and Medicaid, Medicare, or no insurance vs. commercial insurance. Hispanic (OR, 1.59; 95% CI, 1.46-1.74) and Black (OR, 1.73; 95% CI, 1.63-1.84) patients showed a higher odds of blindness versus White non-Hispanic patients. Proportional representation in IRIS Registry relative to the Census was higher for White than Hispanic (2- to 4-fold) or Black (11%-85%) patients (P < 0.001). Blindness overall was less prevalent in NHANES than IRIS Registry; however, prevalence in adults aged 60+ was lowest among Black participants in the NHANES (0.54%) and second highest among comparable Black adults in IRIS (1.57%). CONCLUSIONS: Legal blindness from low VA was present in 0.98% of IRIS patients and associated with rural location, public or no insurance, and older age. Compared with US Census estimates, minorities may be underrepresented among ophthalmology patients, and compared with NHANES population estimates, Black individuals may be overrepresented among blind IRIS Registry patients. These findings provide a snapshot of US ophthalmic care and highlight the need for initiatives to address disparities in use and blindness. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Race, Ethnicity, Insurance, and Population Density Associations with Pediatric Strabismus and Strabismic Amblyopia in the IRIS® Registry.

PURPOSE: To evaluate the associations of sociodemographic factors with pediatric strabismus diagnosis and outcomes. DESIGN: Retrospective cohort study. PARTICIPANTS: American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight) patients with strabismus diagnosed before the age of 10 years. METHODS: Multivariable regression models evaluated the associations of race and ethnicity, insurance, population density, and ophthalmologist ratio with age at strabismus diagnosis, diagnosis of amblyopia, residual amblyopia, and strabismus surgery. Survival analysis evaluated the same predictors of interest with the outcome of time to strabismus surgery. MAIN OUTCOME MEASURES: Age at strabismus diagnosis, rate of amblyopia and residual amblyopia, and rate of and time to strabismus surgery. RESULTS: The median age at diagnosis was 5 years (interquartile range, 3-7) for 106 723 children with esotropia (ET) and 54 454 children with exotropia (XT). Amblyopia diagnosis was more likely with Medicaid insurance than commercial insurance (odds ratio [OR], 1.05 for ET; 1.25 for XT; P < 0.01), as was residual amblyopia (OR, 1.70 for ET; 1.53 for XT; P < 0.01). For XT, Black children were more likely to develop residual amblyopia than White children (OR, 1.34; P < 0.01). Children with Medicaid were more likely to undergo surgery and did so sooner after diagnosis (hazard ratio [HR], 1.23 for ET; 1.21 for XT; P < 0.01) than those with commercial insurance. Compared with White children, Black, Hispanic, and Asian children were less likely to undergo ET surgery and received surgery later (all HRs < 0.87; P < 0.01), and Hispanic and Asian children were less likely to undergo XT surgery and received surgery later (all HRs < 0.85; P < 0.01). Increasing population density and clinician ratio were associated with lower HR for ET surgery (P < 0.01). CONCLUSIONS: Children with strabismus covered by Medicaid insurance had increased odds of amblyopia and underwent strabismus surgery sooner after diagnosis compared with children covered by commercial insurance. After adjusting for insurance status, Black, Hispanic, and Asian children were less likely to receive strabismus surgery with a longer delay between diagnosis and surgery compared with White children. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Prevalence of Diabetic Retinopathy in the US in 2021.

Importance: Diabetic retinopathy (DR) is a common microvascular complication of diabetes and a leading cause of blindness among working-age adults in the US. Objective: To update estimates of DR and vision-threatening diabetic retinopathy (VTDR) prevalence by demographic factors and US county and state. Data Sources: The study team included data from the National Health and Nutrition Examination Survey (2005 to 2008 and 2017 to March 2020), Medicare fee-for-service claims (2018), IBM MarketScan commercial insurance claims (2016), population-based studies of adult eye disease (2001 to 2016), 2 studies of diabetes in youth (2021 and 2023), and a previously published analysis of diabetes by county (2012). The study team used population estimates from the US Census Bureau. Study Selection: The study team included relevant data from the US Centers for Disease Control and Prevention's Vision and Eye Health Surveillance System. Data Extraction and Synthesis: Using bayesian meta-regression methods, the study team estimated the prevalence of DR and VTDR stratified by age, a nondifferentiated sex and gender measure, race, ethnicity, and US county and state. Main Outcomes and Measures: The study team defined individuals with diabetes as those who had a hemoglobin A1c level at 6.5% or more, took insulin, or reported ever having been told by a physician or health care professional that they have diabetes. The study team defined DR as any retinopathy in the presence of diabetes, including nonproliferative retinopathy (mild, moderate, or severe), proliferative retinopathy, or macular edema. The study team defined VTDR as having, in the presence of diabetes, severe nonproliferative retinopathy, proliferative retinopathy, panretinal photocoagulation scars, or macular edema. Results: This study used data from nationally representative and local population-based studies that represent the populations in which they were conducted. For 2021, the study team estimated 9.60 million people (95% uncertainty interval [UI], 7.90-11.55) living with DR, corresponding to a prevalence rate of 26.43% (95% UI, 21.95-31.60) among people with diabetes. The study team estimated 1.84 million people (95% UI, 1.41-2.40) living with VTDR, corresponding to a prevalence rate of 5.06% (95% UI, 3.90-6.57) among people with diabetes. Prevalence of DR and VTDR varied by demographic characteristics and geography. Conclusions and Relevance: US prevalence of diabetes-related eye disease remains high. These updated estimates on the burden and geographic distribution of diabetes-related eye disease can be used to inform the allocation of public health resources and interventions to communities and populations at highest risk.

Data Sources for Evaluating Health Disparities in Ophthalmology: Where We Are and Where We Need to Go.

Data provide an opportunity to discover disparities and inequities that may otherwise be unrecognized. Within the American Academy of Ophthalmology (AAO) Task Force on Disparities in Eye Care, the Leveraging Data Sub-task Force was charged with identifying data sources to study health disparities in eye care and to leverage data to advance health equity. We evaluated large data sources to determine their strengths, deficiencies, and relative accessibility in relation to the likelihood of identifying eye care disparities. We highlight the current challenges with these data sources and review key recommendations for improving future sources for studying health disparities in eye care.

Changes in Performance of Glaucoma Surgeries 1994 through 2017 Based on Claims and Payment Data for United States Medicare Beneficiaries.

PURPOSE: To evaluate trends in glaucoma procedures in the United States Medicare population and to evaluate which physicians are performing newer procedures. DESIGN: Analysis of publicly available claims and payment data. PARTICIPANTS: Surgeons and beneficiaries enrolled in United States Medicare between 1994 and 2017. METHODS: Data regarding payments to physicians by the Centers for Medicare and Medicaid Services (CMS) were downloaded for the years 2012 through 2017. Data regarding claims to CMS by physicians were requested and processed between 1994 and 2017. Procedure counts from both data sets then were normalized for changes in the Medicare population, with 1995 as the baseline. The normalized volumes of procedures over time were visualized, as were geographic distributions of surgeons and their volume of procedures. MAIN OUTCOME MEASURES: Trends in procedure counts over time, geographic distribution of surgeons, and their volume of procedures. RESULTS: The number of trabeculectomies continues to decline and now is similar to the number of tubes. Use of the relatively new trabecular bypass shunts has increased rapidly. Surgeons performing these procedures are less likely to be performing traditional glaucoma surgeries as well. The number of laser-based cyclodestruction procedures increased after introduction of the endoscopic technique and again with the introduction of so-called micropulse procedures. The procedure counts obtained with physician payment data consistently are lower than those from claims data given the limitations of the payment data. CONCLUSIONS: Glaucoma practice patterns change each time a new device or procedure is introduced. Collectively, the use of new microinvasive glaucoma surgery procedures has increased rapidly such that they now account for a significant majority of glaucoma surgeries. Given the almost complete lack of comparative data to inform surgeon choices regarding these procedures, it will be important that randomized studies are carried out to fill this gap.

Differences in characteristics of Medicare patients treated by ophthalmologists and optometrists.

PURPOSE: To quantify differences in the age, gender, race, and clinical complexity of Medicare beneficiaries treated by ophthalmologists and optometrists in each of the United States. DESIGN: Cross-sectional study based on publicly accessible Medicare payment and utilization data from 2012 through 2017. METHODS: For each ophthalmic and optometric provider, demographic information of treated Medicare beneficiaries was obtained from the Medicare Provider Utilization and Payment Data from the Centers for Medicare and Medicaid Services (CMS) for the years 2012 through 2017. Clinical complexity was defined using CMS Hierarchical Condition Category (HCC) coding. RESULTS: From 2012 through 2017, ophthalmologists in every state treated statistically significantly older beneficiaries, with the greatest difference (4.99 years in 2014) between provider groups seen in Rhode Island. In most states there was no gender difference among patients treated by the providers but in 46 states ophthalmologists saw a more racially diverse group of beneficiaries. HCC risk score analysis demonstrated that ophthalmologists in all 50 states saw more medically complex beneficiaries and the differences were statistically significant in 47 states throughout all six years. CONCLUSIONS: Although there are regional variations in the characteristics of patients treated by ophthalmologists and optometrists, ophthalmologists throughout the United States manage older, more racially diverse, and more medically complex Medicare beneficiaries.

Impact of traffic, poverty and facility ownership on travel time to emergency care in Nairobi, Kenya.

BACKGROUND: In many low and middle-income countries (LMICs), timely access to emergency healthcare services is limited. In urban settings, traffic can have a significant impact on travel time, leading to life-threatening delays for time-sensitive injuries and medical emergencies. In this study, we examined travel times to hospitals in Nairobi, Kenya, one of the largest and most congested cities in the developing world. METHODS: We used a network approach to estimate average minimum travel times to different types of hospitals (e.g. ownership and level of care) in Nairobi under both congested and uncongested traffic conditions. We also examined the correlation between travel time and socioeconomic status. RESULTS: We estimate the average minimum travel time during uncongested traffic conditions to any level 4 health facility (primary hospitals) or above in Nairobi to be 4.5 min (IQR 2.5-6.1). Traffic added an average of 9.0 min (a 200% increase). In uncongested conditions, we estimate an average travel time of 7.9 min (IQR 5.1-10.4) to level 5 facilities (secondary hospitals) and 11.6 min (IQR 8.5-14.2) to Kenyatta National Hospital, the only level 6 facility (tertiary hospital) in the country. Traffic congestion added an average of 13.1 and 16.0 min (166% and 138% increase) to travel times to level 5 and level 6 facilities, respectively. For individuals living below the poverty line, we estimate that preferential use of public or faith-based facilities could increase travel time by as much as 65%. CONCLUSION: Average travel times to health facilities capable of providing emergency care in Nairobi are quite low, but traffic congestion double or triple estimated travel times. Furthermore, we estimate significant disparities in timely access to care for those individuals living under the poverty line who preferentially seek care in public or faith-based facilities.

Medicare Incentive Payments to United States Ophthalmologists for Use of Electronic Health Records: 2011-2016.

PURPOSE: To investigate ophthalmologists' rate of attestation to meaningful use (MU) of their electronic health record (EHR) systems in the Medicare EHR Incentive Program and their continuity and success in receiving payments in comparison with other specialties. DESIGN: Administrative database study. PARTICIPANTS: Eligible professionals participating in the Medicare EHR Incentive Program. METHODS: Based on publicly available data sources, subsets of payment and attestation data were created for ophthalmologists and for other specialties. The number of eligible professionals attesting was determined using the attestation data for each year and stage of the program. The proportion of attestations by EHR vendor was calculated using all attestations for each vendor. MAIN OUTCOME MEASURES: Numbers of ophthalmologists attesting by year and stage of the Medicare EHR Incentive Program, incentive payments, and number of attestations by EHR vendor. RESULTS: In the peak year of participation, 51.6% of ophthalmologists successfully attested to MU, compared with 37.1% of optometrists, 50.2% of dermatologists, 54.5% of otolaryngologists, and 64.4% of urologists. Across the 6 years of the program, ophthalmologists received an average of $17 942 in incentive payments compared with $11 105 for optometrists, $16 617 for dermatologists, $20 203 for otolaryngologists, and $23 821 for urologists. Epic and Nextgen were the most frequently used EHRs for attestation by ophthalmologists. CONCLUSIONS: Ophthalmology as a specialty performed better than optometry and dermatology, but worse than otolaryngology and urology, in terms of the proportion of eligible professionals attesting to MU of EHRs. Ophthalmologists were more likely to remain in the program after their initial year of attestation compared with all eligible providers. The top 4 EHR vendors accounted for 50% of attestations by ophthalmologists.

Cost-effectiveness of age-related macular degeneration study supplements in the UK: combined trial and real-world outcomes data.

AIMS: To evaluate the cost-effectiveness of Age-Related Eye Disease Study (AREDS) 1 & 2 supplements in patients with either bilateral intermediate age-related macular degeneration, AREDS category 3, or unilateral neovascular age-related macular degeneration AMD (nAMD), AREDS category 4. METHODS: A patient-level health state transition model based on levels of visual acuity in the better-seeing eye was constructed to simulate the costs and consequences of patients taking AREDS vitamin supplements. SETTING: UK National Health Service (NHS). The model was populated with data from AREDS and real-world outcomes and resource use from a prospective multicentre national nAMD database study containing 92 976 ranibizumab treatment episodes. INTERVENTIONS: Two treatment approaches were compared: immediate intervention with AREDS supplements or no supplements. MAIN OUTCOME MEASURES: quality-adjusted life years (QALYs) and healthcare costs were accrued for each strategy, and incremental costs and QALYs were calculated for the lifetime of the patient. One-way and probabilistic sensitivity analyses were employed to test the uncertainty of the model. RESULTS: For AREDS category 3, the incremental cost-effectiveness ratio was £30 197. For AREDS category 4 compared with no intervention, AREDS supplements are more effective (10.59 vs 10.43 QALYs) and less costly (£52 074 vs 54 900) over the lifetime of the patient. CONCLUSIONS: The recommendation to publicly fund AREDS supplements to category 3 patients would depend on the healthcare system willingness to pay. In contrast, initiating AREDS supplements in AREDS category 4 patients is both cost saving and more effective than no supplement use and should therefore be considered in public health policy.

Disparities in delivery of ophthalmic care; An exploration of public Medicare data.

PURPOSE: Cataract is a major cause of age-related eye diseases in the United States, and cataract extraction is the most commonly performed surgery on Medicare beneficiaries. Analyzing the pattern in delivery of cataract care at the national level can highlight areas of disparities. We evaluated geographic disparities seen in cataract surgery delivery to Medicare beneficiaries in the United States. SETTING: Cataract extractions across the United States in 2012. DESIGN: Cross-sectional study examining distance to provider and observed versus expected number of cataract extractions. METHODS: Cataract extraction current procedural terminology codes were used to sum the total observed number of cataract extractions per cataract surgeon. Epidemiology data on expected number of cataract surgeries in one year by decade of life were extrapolated via a Gaussian Process model. A linear regression model was used to compare differences in delivery of care between US economic regions. RESULTS: 2.2 million patients underwent cataract surgery in the Medicare dataset in 2012. The average distance to the nearest provider was 9.846 miles (standard deviation: 11.410 miles). This distance was statistically significant (p < 2.0 x 10-22) in the New England (5.935 mi), Mideast (6.356 mi), Great Lakes (8.733 mi), Far West (9.038 mi), Southeast (9.793 mi), Southwest (12.711 mi), Plains (16.047 mi), and Rocky Mountain (17.934 mi) regions. The total number of expected cataract surgeries greater than 100 miles to the nearest cataract surgeon was 1,901, where Montana, South Dakota, and Texas each had over 200 of these expected distances. CONCLUSIONS: A large discrepancy exists in cataract delivery to the Medicare population based on geographic factors. Patients who live in rural areas travel farther on average to see ophthalmologists, resulting in a lower observed than expected rate of cataract surgery. Our results have implications in future allocation of resources and ophthalmologists.

UK AMD/DR EMR REPORT IX: comparative effectiveness of predominantly as needed (PRN) ranibizumab versus continuous aflibercept in UK clinical practice.

AIMS: To compare the effectiveness of continuous aflibercept versus pro re nata (PRN) ranibizumab therapy for neovascular age-related macular degeneration (nAMD). METHODS: Multicentre, national electronic medical record (EMR) study on treatment naive nAMD eyes undergoing PRN ranibizumab or continuous (fixed or treat and extend (F/TE)) aflibercept from 21 UK hospitals. Anonymised data were extracted, and eyes were matched on age, gender, starting visual acuity (VA) and year of starting treatment. Primary outcome was change in vision at 1 year. RESULTS: 1884 eyes (942 eyes in each group) were included. At year 1, patients on PRN ranibizumab gained 1.6 ETDRS (Early Treatment Diabetic Retinopathy Study) letters (95% CI 0.5 to 2.7, p=0.004), while patients on F/TE aflibercept gained 6.1 letters (95% CI 5.1 to 7.1, p=2.2e-16). Change in vision at 1 year of the F/TE aflibercept group was 4.1 letters higher (95% CI 2.5 to 5.8, p=1.3e-06) compared with the PRN ranibizumab group after adjusting for age, starting VA, gender and year of starting therapy. The F/TE aflibercept group had significantly more injections compared with the PRN ranibizumab group (7.0 vs 5.8, p<2.2e-16), but required less clinic visits than the PRN ranibizumab group (10.8 vs 9.0, p<2.2e-16). Cost-effectiveness analysis showed an incremental cost-effectiveness ratio of 58 047.14 GBP/quality-adjusted life year for continuous aflibercept over PRN ranibizumab. CONCLUSION: Aflibercept achieved greater VA gains at 1 year than ranibizumab. The observed VA differences are small and likely to be related to more frequent treatment with aflibercept, suggesting that ranibizumab should also be delivered by F/TE posology.

Evaluating Access to Eye Care in the Contiguous United States by Calculated Driving Time in the United States Medicare Population.

PURPOSE: To quantify the proximity to eye care in the contiguous United States by calculating driving routes and driving time using a census-based approach. DESIGN: Cross-sectional study based on United States (US) census data, Medicare payment data, and OpenStreetMap. PARTICIPANTS: 2010 US census survey respondents older than 65 years. METHODS: For each state in the United States, the addresses of all practicing ophthalmologists and optometrists were obtained from the 2012 Medicare Provider Utilization and Payment Data from the Centers for Medicare and Medicaid Services (CMS). The US census data from 2010 then were used to calculate the geolocation of the US population at the block group level and the number of people older than 65 years in each location. Geometries and driving speed limits of every road, street, and highway in the United States from the OpenStreetMap project were used to calculate the exact driving distance and driving time to the nearest eye care provider. MAIN OUTCOME MEASURES: Driving time and driving distance to the nearest optometrist and ophthalmologist per state. RESULTS: Driving times for 3.79×107 persons were calculated using a total of 3.88×107 available roads for the 25 508 optometrists and 17 071 ophthalmologists registered with the CMS. Nationally, the median driving times to the nearest optometrist and ophthalmologist were 2.91 and 4.52 minutes, respectively. Ninety percent of the population lives within a 13.66- and 25.21-minute drive, respectively, to the nearest optometrist and ophthalmologist. CONCLUSIONS: While there are regional variations, overall more than 90% of the US Medicare beneficiary population lives within a 30-minute drive of an ophthalmologist and within 15 minutes of an optometrist.

Patterns of Laboratory Testing Utilization Among Uveitis Specialists.

PURPOSE: To examine the range of practice in laboratory testing utilization among a subset of uveitis specialists using a scenario-based survey. DESIGN: Cross-sectional survey. METHODS: A web-based survey consisting of 13 patient scenarios was presented to the Executive Committee and Trustees of the American Uveitis Society. The participants were allowed to choose preferred testing in a free-form manner. The patterns of test utilization were studied and the cost of the testing was calculated based on Noridian Medicare reimbursal rates for Seattle, Washington. RESULTS: Nearly all providers recommended some testing for all scenarios. Forty-five different tests, including laboratory investigations and imaging and diagnostic procedures, were ordered. The mean number of tests ordered per scenario per provider was 5.47 ± 2.71. There was limited consensus among providers in test selection, with most tests in each scenario ordered by fewer than half of the providers. Average cost of testing per scenario per provider was $282.80, with 4 imaging tests (fluorescein angiography, magnetic resonance imaging, chest radiograph, and chest computed tomography) together contributing 59.9% of the total testing costs. CONCLUSIONS: Uveitis specialists have a high rate of laboratory testing utilization in their evaluation of new patients. There is substantial variability in the evaluations obtained between providers. Imaging tests account for the majority of evaluation cost. The low agreement on specific testing plans suggests need for evidence-based practice guidelines for the evaluation of uveitis patients.