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Broadband Access and Ophthalmologist Density in the United States: Cross-Sectional Questionnaire Study
Patrick Akarapimand1, John C Lin1, Ingrid U Scott2,3
1Department of Ophthalmology, Scheie Eye Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.
Background:
Rural US communities experience disproportionately high rates of visual disability yet have limited access to ophthalmologists. Teleophthalmology may help address these gaps, but its effectiveness depends on broadband connectivity. The relationship between broadband access and ophthalmologist density has not been well characterized.
Objective:
The aim of this study is to quantify the association between household broadband access-defined as subscription rates or connection prevalence-and county-level ophthalmologist density and to identify sociodemographic predictors of access.
Methods:
We conducted an ecological study of all 3141 US counties using 2019 data from the American Community Survey, Area Health Resources File, and National Center for Health Statistics (NCHS). Broadband access was the primary exposure; ophthalmologist count with county population as an offset was the outcome. The primary analysis used negative binomial regression, adjusting for urbanicity, income, education, age, sex, race/ethnicity, unemployment, and insurance status. Sensitivity analyses included population-weighted linear regression and state fixed effects models. County-level heatmaps illustrated geographic patterns.
Results:
Median household broadband access was 56.6%, ranging from 72.2% in the most urban counties (NCHS category 1) to 49.1% in the most rural (NCHS category 6). In unadjusted negative binomial regression, each 10-percentage-point increase in broadband access was associated with a 68% higher ophthalmologist rate (incidence rate ratio=1.68, 95% CI 1.61-1.76; P<.001). After adjustment, each 10-percentage-point increase was associated with a 46% higher rate (incidence rate ratio=1.46, 95% CI 1.37-1.56; P<.001). Sensitivity analyses were consistent with primary analysis. Regions with both low broadband access and zero ophthalmologist density were concentrated in the South, Mountain West region, and Alaska.
Conclusions:
Broadband access is strongly associated with ophthalmologist availability across US counties, independent of sociodemographic factors. Areas lacking ophthalmologists also tend to lack broadband adoption, creating compounded barriers to both in-person and teleophthalmic care. Efforts to expand broadband may support more equitable access to vision services in underserved regions.
