美國兒科葡萄膜炎照護可及性的區域差異 Regional Disparities in Pediatric Uveitis Care Availability in the United States

Ophthalmology Volume 130, Number 10, October 2023

美國兒科葡萄膜炎照護可及性的區域差異

中文摘要

這篇文章探討了美國兒童視網膜炎治療可及性的區域差異。兒童視網膜炎的治療十分複雜而繁重，往往需要一個由兒童眼科專家、眼科炎症專家和風濕病專家組成的多學科團隊。雖然兒童視網膜炎的治療可及性可能存在不平等，但目前尚未得到足夠的研究。患者前往醫療服務提供者所需的時間是衡量醫療公平性的一個可靠指標。研究中將60分鐘的車程定義為每個提供者地址周圍的服務區域。本研究使用美國人口普查局的提供者分佈地圖，計算提供者Specialty Care Areas（SCA, 專科提供者區域）內外的人口特徵，並使用卡方檢定來分析是否存在顯著差異。此外，研究還評估了特定地理區域的專科醫生和其SCA之間的差異，這些地理區域參考了聯邦機構的劃分。為了理解形塑提供者決策的因素，將每個地區的專科醫生人數與該地區年齡在1至19歲之間的人口相對比，以區域的特殊職業比例/年齡人口比例計算為定位指數（location quotient, LQ）。LQ < 1表示該地區的專科醫生數量與年齡在1至19歲之間的人口相比，不成比例地較低。為了總結各地區LQ的整體效果，計算了區域分布的不平均程度的指數，該指數衡量了2個分佈在一組地區中的平均程度。此值表示為了使專科醫生的地區分佈與年齡在1至19歲之間的人口的地區分佈相匹配，需要將多少百分比的專科醫生調動到其他地區。該指數可用來評估提供者的地理分佈是否均勻。本研究計算(D)作為兩者比例之間的絕對差異的一半，分別為專科人員(ai)和0至19歲人口比例(bi)的區域計算。研究對1040位小兒眼科醫師、562位葡萄膜炎專科醫師和1409位風濕病學家進行了分析，並對17種葡萄膜炎進行了地圖繪製。小於19歲的人口中，91.3%居住在任何專科的範圍內，而有8.7%居住在這些範圍之外。居住在範圍之外的兒童更有可能屬於白種人種（χ-square [1，n = 78408275] = 297396.8，P < 0.001），生活在聯邦貧窮線以下（χ-square [1，n = 72860312] = 193168.3，P < 0.001），缺乏醫療保險（χ-square [1，n = 78408275] = 18804.9，P < 0.001）。南部和非大陸美國地區的提供者和兒童比例最高和最低。中大西洋和新英格蘭地區的各專業和所有專業的LQs最高。這兩個地區相對於1至19歲的人口而言，專科醫生的比例較高，這是由於從波士頓到華盛頓特區的城市走廊上有大量診所，儘管這兩個地區分別只有全美國小兒人口的15％和5％。近一半的葡萄膜炎研究生計劃也在中大西洋地區。這份研究主要探討美國不同地區兒童眼科醫生、著眼於著眼於眼睛中的發炎疾病的專科醫生（uveitis specialists）以及風濕病科醫生（rheumatologists）的數量分佈情況。結果顯示，大西洋和新英格蘭地區擁有最高的相對指數locat（LQs），而大平原地區和西南地區的LQs最低。另外，研究還發現一些大城市缺乏相關專科醫生。在沒有提供相關專科服務的前十大城市中，人口總數在9萬至26萬之間。有些城市靠近毗鄰大都市地區，那裡有能提供全部三個專科服務的醫生；但有些城市距離最近的專科醫生足足有兩個小時車程之遠。這篇文章探討了由於受限的兒童葡萄膜炎盛行率資料，導致一些地區成為服務沙漠的風險。該研究發現，在美國的鄉村和小型都會地區，兒童葡萄膜炎的醫療不平等存在地理上的障礙，並呼籲進一步研究以克服這些地理和衛生障礙，改善眼科的綜合照護不平等問題。此外，研究還提到了兒童眼科訓練人數下降以及不是所有兒童眼科醫師都會治療葡萄膜炎的現實，因此需要更加謹慎的對待這些地理性障礙。

English Abstract

This content discusses the regional disparities in the availability of pediatric uveitis care in the United States. Pediatric uveitis care is complex and often requires a team of specialists, including a pediatric ophthalmologist, uveitis specialist, and rheumatologist. However, access to this specialized care is likely unequal but has not been extensively studied. The study aimed to analyze the geographic distribution of these specialties and quantify the disparities between their availability and the pediatric population. Provider office addresses were obtained from various professional societies, and their locations were analyzed using geographic mapping software. The study used data from the American Community Survey to measure travel time to providers as an indicator of healthcare equity.The content discusses a study that aimed to analyze population characteristics and the distribution of specialists in different regions. The study used data from the U.S. Bureau and performed chi-square tests to identify significant differences. They also looked at the number of specialists in each region compared to the population and calculated a location quotient to determine if the number of specialists was proportionate. Additionally, the study analyzed the distribution of specialists across regions using the index of dissimilarity. The study took into account uveitis fellowship training programs and assumed that all providers are capable of evaluating and managing children.The content describes the calculation of a metric called “D” which represents the difference between the percentage of specialists in a region and the percentage of the population aged 0-19 in that region. The study analyzed the distribution of pediatric ophthalmologists, uveitis specialists, and rheumatologists in the US and mapped the prevalence of uveitis. It was found that the intersection of Specialty Care Areas (SCAs) generally corresponds to the overall pediatric population density. Most children in the US live within the SCAs, but a small percentage live outside of them, with characteristics such as being of White race, living below the poverty level, and lacking health insurance. The South and non-Continental US regions have the highest percentages of providers and children, while the Mid-Atlantic and New England regions have the highest concentration of specialists relative to the pediatric population. The region between Boston and Washington DC has a high number of practices and uveitis fellowship programs despite its small percentage of the overall pediatric population.The Atlantic and New England regions had higher LQs overall compared to the Great Plains and Southwest regions. The Great Plains and Southwest regions had the lowest LQs overall and for specific specialties, and were the only regions without a medical institution offering a uveitis fellowship. To achieve regional equity with the pediatric population, around 10.8% of pediatric ophthalmologists, 11.4% of uveitis specialists, and 12.1% of rheumatologists (or 11.1% of all specialists combined) would need to be redistributed to these regions. Some large urban areas had no providers, with populations ranging from 90,000 to 260,000. Some of these cities were near larger regions with providers, while others were at least a 2-hour drive away from the nearest specialists. The study is limited by the use of online society directories for provider addresses, which may not include certain practitioners or updates. The study also does not account for allied eye professionals and could not estimate the population need. The study highlights disparities in pediatric uveitis care in rural and small metropolitan areas of the United States, where service availability near ophthalmology training centers is disproportionately high. The geographic barriers in accessing care exacerbate socioeconomic challenges in timely diagnosis and management. The article suggests future studies focused on overcoming telehealth and geographic barriers, as well as exploring referral patterns through clinician surveys, to mitigate care disparities in ophthalmology.