Board Certification Is Associated With a Reduced Risk of Endophthalmitis After Intravitreal Injections

Abstract

Purpose: This work investigates associations between physician qualifications and the risk of postintravitreal injection endophthalmitis. Methods: This retrospective analysis of data from medical claims studied Medicare beneficiaries undergoing 1 or more intravitreal injections between January 1, 2013, and December 31, 2017. Logistic regression analysis was performed to assess whether board certification status or retina subspecialty training was associated with lower risk of postinjection endophthalmitis, controlling for patient's age, race, and sex, type of agent injected, diagnosis, and year of injection. The main outcome measure was odds ratio (OR) of receiving a diagnosis of endophthalmitis in the 14 days after intravitreal injection. Clinical outcome and quality of care were not evaluated in this study. Results: A total of 2 907 324 intravitreal injections were performed on 219 640 patients by 4315 ophthalmologists, 3196 (74%) of whom were retina specialists and 4021 (92%) of whom were certified by the American Board of Ophthalmology (ABO). Overall, there were 1088 (0.037%) cases of postinjection endophthalmitis, of which 1024 (0.037%) were injected by ABO-certified ophthalmologists and 64 (0.050%) by non–board-certified ophthalmologists. Injections by ABO-certified ophthalmologist had 28% reduced odds of endophthalmitis (OR = 0.72; 95% CI, 0.523-0.996, P = .05). Higher odds of endophthalmitis were observed for corticosteroid injections (OR = 3.91; 95% CI, 2.75-5.56, P < .001) and aflibercept injections (OR = 1.47; 95% CI, 1.19-1.80, P < .001). Patients' sex and race, the diagnosis associated with the injection, and providers' retina subspeciality training were not associated with the rate of endophthalmitis ( P < .20 for all comparisons). Conclusions: We found evidence that endophthalmitis may be reduced when ABO-certified physicians perform an intravitreal injection.

Role of physician extenders: more regulation is necessary before full integration into practice

“…Although some studies have demonstrated the benefits of utilizing physician extenders to perform some of the most common procedures in ophthalmology, another study demonstrated that there was a 28% reduced odds of endophthalmitis when American Board of Ophthalmology (ABO) board-certified providers administered intravitreal injections [11 ▪ ]. Despite the rates of endophthalmitis being low, this study should raise concern for allowing NPPs to administer intravitreal injections.…”

“…The involvement of physician extenders in this capacity may serve to undermine the boundary between ophthalmologists and nonophthalmologists and could ultimately lead to patient harm if less-trained providers begin to do procedures without adequate background and/or supervision. This is particularly dangerous for invasive procedures such as intravitreal injections where evidence suggests that noncertified proceduralists have worse outcomes [11 ▪ ].…”