Differences in Tertiary Glaucoma Care in the Veterans Affairs Health Care System

Abstract

IMPORTANCE Glaucoma is a common cause of visual impairment in the Veterans Affairs (VA) health care system, but to our knowledge, no data exist concerning tertiary glaucoma care (ie, laser and filtering surgery). OBJECTIVE To determine whether the rate of tertiary glaucoma care differs among veterans cared for through the 4 different eye care delivery models that are present in the VA: optometry-only clinics, ophthalmology-only clinics, clinics with optometry and ophthalmology functioning as a single integrated clinic with ophthalmology as the lead, and clinics with optometry and ophthalmology functioning as separate clinics. DESIGN, SETTING, AND PARTICIPANTS In this retrospective review of the Veterans Health Administration Support Service Center database, 490 926 veterans with a glaucoma-related diagnosis received care from 136 VA medical centers during fiscal year 2016. Demographic and baseline clinical factors, International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, and Current Procedural Terminology codes, and the rates of glaucoma surgery procedures were extracted from the database. The organizational structure of each VA eye clinic was obtained. Univariate and multivariate regression analyses were performed for log percent for laser peripheral iridotomy (LPI), laser trabeculoplasty (LTP), and filtering surgery. MAIN OUTCOMES AND MEASURES Rates of LPI, LTP, and filtering surgery. RESULTS Of the 490 926 veterans with a glaucoma-related diagnosis, 465 842 (94.9%) were male, 309 677 (63.1%) were white, and 203 243 (41.4%) were aged 65 to 74 years. The rate of LPI was 0.30%, 0.28%, 0.67%, and 0.69% in optometry-only clinics, ophthalmology-only clinics, integrated clinics, and separated clinics, respectively (P < .001). The rate of LTP was 0.31%, 1.06%, 0.93%, and 0.92% in care delivery models that included optometry-only clinics, ophthalmology-only clinics, integrated clinics, and separated clinics, respectively (P < .001). The rate of filtering surgery was 0.32%, 0.51%, 0.69%, and 0.60% in optometry-only clinics, ophthalmology-only clinics, integrated clinics, and separated clinics, respectively (P < .001). Multivariate regression analyses showed that these differences remained significantly different even after adjusting for potential confounders. CONCLUSIONS AND RELEVANCE Disparities exist in the use of tertiary glaucoma services within the VA, and different care delivery models may play a role. Outcomes of glaucoma care for the different models of eye care delivery were not analyzed in this study.

Collaboration Is Needed to Improve the Quality of Eye Care and Eliminate Inequities

“…The article by Lee et al in this issue of JAMA Ophthalmology analyzes the glaucoma surgical referral rates within the VHA system, including trabeculectomies, trabeculoplasties, and iridotomies. Their demographic data correlate with what we know: African American individuals make up a disproportionate number of veterans with glaucoma.…”

“…Importantly, finances did not seem to be a factor in surgical uptake, as even a small difference in payments can make a large difference in adherence within the VHA . Because of the way Lee et al used big data, we do not know the level of disease, the number of medications or prior surgical interventions, the appropriateness of procedures performed, or the patients’ outcomes.…”

“…The article also describes a relatively unique method of patient care. Rather than collaboration between optometry and ophthalmology in most cases, Lee et al describe a specific situation in which optometry and ophthalmology apparently can work in silos rather than in close collaboration. There is a potentially disturbing and significant difference in patients treated in optometry-only clinics.…”

“…Optometrists can serve a vital role in the health care algorithm. The study by Lee et al suggests that optometric care must be improved. This article and those by Shekhawat et al and Stein et al strongly suggest that changes in optometric education are needed to help optometrists practicing without direct ophthalmologic supervision better manage patients.…”

Disparities in Vision Health and Eye Care

“…143 Recent studies of minimally invasive glaucoma surgeries in non-Hispanic and Hispanic Black patients have shown good outcomes with certain minimally invasive glaucoma surgeries procedures. 144e146 Aside from race and ethnicity, potential disparities in rates of procedural glaucoma treatment and follow-up have been identified by age, 147 region, 148 provider type, 148 and distance from provider, 149 among other factors.…”