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

PURPOSE: To evaluate access to diabetic retinopathy (DR) care by quantifying the geographic distribution of therapeutic and diagnostic procedures for DR across the United States.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Using the IRIS® Registry (Intelligent Research in Sight), we identified patients with 2 or more International Classification of Diseases codes for DR between January 1, 2013, and December 31, 2024.

METHODS

Care was classified as therapeutic (intravitreal injections [IVIs], panretinal photocoagulation [PRP], focal laser photocoagulation, and pars plana vitrectomy) or diagnostic (OCT, fundus photography, and fluorescein angiography) by Current Procedural Terminology codes. Urban versus nonurban practice locations were defined using the United States Department of Agriculture Rural-Urban Commuting Area codes. Procedure volume, population-adjusted and disease-adjusted rates, and physician subspecialty distributions were compared across settings. A subanalysis examined disease burden, DR care adherence, and diabetic macular edema management among nonurban residents stratified by treating practice urbanization and sociodemographic factors.

MAIN OUTCOME MEASURES: Likelihood of each diagnostic and therapeutic procedure occurring in urban areas.

RESULTS

We identified 11 254 015 therapeutic and 35 892 574 diagnostic procedures undergone by 1 142 505 patients with DR. Urban practices performed 67% to 80% of all procedures after adjusting for population differences, and 65% to 90% after adjusting for disease burden, with nonurban sites contributing only 1% to 35% across categories. In nonurban practices, comprehensive ophthalmologists performed more than 35% of IVI and PRP procedures, whereas in urban practices, they performed roughly 5% to 7% of these procedures. More than 93% of nonurban residents and more than 97% of urban residents received therapeutic procedures in urban practices. Nonurban residents showed a higher PDR prevalence (18.21% vs. 16.02%) and higher rates of all therapeutic procedures. Of those receiving care at urban practices, 47.7% had a more than 1-year OCT gap versus 44.1% at nonurban practices; this increase in discontinuity was disproportionately larger among older patients, Black patients, and those with lower household incomes.

CONCLUSIONS

Diabetic retinopathy-related diagnostic and therapeutic services were concentrated in urban practice locations, even after adjustment for population differences and disease burden. This finding supports the need for strategies to improve access in nonurban communities.

FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.