Geographic Distribution of Access to Diabetic Retinopathy Care in the United States: An American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight) Analysis.

Abstract

To evaluate access to diabetic retinopathy (DR) care by quantifying the geographic distribution of therapeutic and diagnostic procedures for DR across the United States. Retrospective cohort study. Using the IRIS® Registry (Intelligent Research in Sight), we identified patients with ≥2 International Classification of Disease(ICD) codes for DR between January 1, 2013, and December 31, 2024. We excluded those with concurrent ocular conditions that independently require similar treatments. Care was classified as therapeutic (intravitreal injections(IVI), panretinal photocoagulation(PRP), focal laser photocoagulation(FLP), and pars plana vitrectomy(PPV), or diagnostic (optical coherence tomography(OCT), fundus photography(FP), and fluorescein angiography(FA) by Current Procedural Terminology(CPT) codes. Urban versus non-urban practice locations were defined using the U.S. Department of Agriculture Rural-Urban Commuting Area codes. Procedure volume, population-adjusted and disease-adjusted rates, physician and practice-level utilization, and physician subspecialty distributions were compared across settings. A sub-analysis examined disease burden, DR care adherence, and DME management among non-urban residents stratified by treating practice urbanization and sociodemographic factors. Likelihood of each diagnostic and therapeutic procedure occurring in urban areas. We identified 11,254,015 therapeutic and 35,892,574 diagnostic procedures from 1,142,505 patients with DR. Urban practices performed 95-99% of all procedures, 67-80% after adjusting for population differences, and 65-90% after adjusting for disease burden, with non-urban sites contributing only 1-35% across categories. In non-urban practices, comprehensive ophthalmologists performed more than 35% of IVI and PRP, whereas in urban practices, they performed roughly 5-7% of these procedures. More than 93% of non-urban residents and over 97% of urban residents received therapeutic procedures in urban practices. We found higher odds of all available procedures occurring in urban practice locations. Non-urban residents had a higher PDR prevalence (18.21%vs16.02%) and higher rates of all therapeutic procedures. Of those receiving care at urban practices, 47.7% had a >1-year OCT gap versus 44.1% at non-urban practices; this increase in discontinuity was disproportionately larger among older, Black patients, and those with lower household incomes. DR-related diagnostic and therapeutic services were concentrated predominantly in urban practice locations, even after adjustment for population differences and disease burden, and support the need for strategies to improve access in non-urban communities.