Trends Over Time and Regional Variations in the Rate of Laser Trabeculoplasty in the Medicare Population

Jampel, Henry D.; Cassard, Sandra D.; Friedman, David S.; Shekhawat, Nakul; Vos, Julia Whiteside-de; Quigley, Harry A.; Gower, Emily W.

doi:10.1001/jamaophthalmol.2014.369

Cited by 22 publications

(9 citation statements)

References 21 publications

(32 reference statements)

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“…Such geographic variability in surgical habit has been observed across many surgical procedures, including cataract surgery. 6,8–10 One may expect to see less variation at the state level than at smaller units, such as 2 cities, because states have a greater number of opinion leaders and clinical practice offices, such that the wide variation in practice patterns would be averaged across the state. However, our findings suggest nearly a 3-fold variation in vitrectomy use across states.…”

Section: Discussionmentioning

confidence: 99%

Characteristics of Endophthalmitis after Cataract Surgery in the United States Medicare Population

et al. 2015

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Purpose Endophthalmitis is a rare but sight-threatening infection after cataract surgery. Roughly one third of eyes remain blind after treatment. We report United States population-based data on microbiological investigations and treatment patterns plus risk factors for poor outcomes. Design Retrospective cohort study. Participants Medicare beneficiaries from 5 states in whom endophthalmitis developed within 6 weeks after cataract surgery in 2003 and 2004. Methods We identified endophthalmitis cases occurring after cataract surgery using Medicare billing claims. We contacted treating physicians and requested they complete a questionnaire on clinical and microbiological data and submit relevant medical records. Two independent observers reviewed materials to confirm that cases met a standardized definition. Main Outcome Measures Positive culture results, vitrectomy status, microbiology spectrum, and final visual acuity. Results In total, 615 cases met our case definition. Initial visual acuity was counting fingers or worse for 72%. Among 502 cases with known culture results, 291 (58%) had culture positive results. Twelve percent had positive results for streptococci. More than 99% of cases were treated with intravitreal vancomycin. Vitrectomy was performed in 279 cases (45%), including 201 cases with initial acuity better than light perception. Rates of vitrectomy varied across states, with California having the highest rate and Michigan having the lowest (56% and 19% of cases, respectively). Overall, 43% of individuals achieved visual acuity of 20/40 or better. Poor initial acuity (adjusted odds ratio [OR], 1.08; 95% confidence interval [CI], 1.04–1.12 per 0.10 logarithm of the minimum angle of resolution units), older age at diagnosis (OR, 1.22; 95% CI, 1.03–1.45 per 5-year increase), and more virulent organisms were important predictors of poor final visual acuity. Cases with streptococci infection were 10 times more likely to have poor final acuity than coagulase-negative staphylococci cases (adjusted OR, 11.28; 95% CI, 3.63–35.03). Vitrectomy was not predictive of final visual acuity (adjusted OR, 1.26; 95% CI, 0.78–2.04). Conclusions Population-based data on the microbiology of acute postoperative endophthalmitis in the United States after cataract surgery are consistent with prior reports. Vitrectomy usage is higher than that recommended from the Endophthalmitis Vitrectomy Study, with no evidence of increased benefit.

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Section: Discussionmentioning

confidence: 99%

Characteristics of Endophthalmitis after Cataract Surgery in the United States Medicare Population

et al. 2015

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“…Introduction of selective laser trabeculoplasty (SLT) in the late 1990s 5 has resulted in a significant increase in the number of trabeculoplasties performed in the past decade. 6–8 The IOP-lowering effect of argon laser trabeculoplasty (ALT) is mediated through an increase in conventional outflow facility, 9 which in turn may be mechanically or biologically mediated after the delivery of laser to the anterior chamber angle structures. 10–12 As SLT delivers approximately 1% of total energy used by a typical ALT and does not have any thermal coagulative effects like ALT, 13 it purportedly can have a mechanism of action different from ALT.…”

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confidence: 99%

Mechanism of Action of Selective Laser Trabeculoplasty and Predictors of Response

Gulati

Fan

Gardner

et al. 2017

Invest. Ophthalmol. Vis. Sci.

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PurposeThis study was designed to evaluate the changes in aqueous humor dynamics (AHD) produced by selective laser trabeculoplasty (SLT) and to explore if baseline AHD parameters are predictive of IOP response to SLT.MethodsThirty-one consecutive subjects diagnosed with ocular hypertension or primary open-angle glaucoma scheduled to undergo SLT as their primary IOP-lowering therapy were enrolled in this prospective observational study. Subjects underwent baseline assessment of AHD in both eyes. Variables assessed were IOPs at 9 AM and noon, aqueous humor flow rate (fluorophotometry), episcleral venous pressure (EVP, venomanometry), outflow facility (pneumatonography and fluorophotometry) and uveoscleral outflow (calculated using modified Goldmann equation). All subjects underwent 360 degrees SLT and AHD measurements were repeated 3 months later.ResultsCompared with baseline, IOPs after SLT were significantly lower at 9 AM (22.9 ± 5.1 vs. 19.7 ± 3.0 mm Hg; P = 0.001) and noon (23.4 ± 4.6 vs. 20.0 ± 3.5 mm Hg; P < 0.001). Outflow facility by fluorophotometry was significantly increased from 0.17 ± 0.11 μL/min/mm Hg at baseline to 0.24 ± 0.14 μL/min/mm Hg at 3 months (P = 0.008). Outflow facility by tonography (baseline: 0.16 ± 0.07 μL/min/mm Hg vs. 3 months: 0.22 ± 0.16 μL/min/mm Hg; P = 0.046) was similarly increased. No change in aqueous flow or EVP was observed. There were no changes in IOP or AHD in the contralateral untreated eye. Using multiple linear regression models, higher baseline aqueous flow, lower baseline outflow facility, and possibly lower uvescleral outflow were associated with more IOP lowering with SLT.ConclusionsThe IOP-lowering effect of SLT is mediated through an increase in outflow facility. There is no contralateral effect. Higher aqueous flow and lower outflow facility may be predictive of better response to SLT.

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“…1,2 The advent of selective LTP contributed to a 46% increase in this procedure among Medicare beneficiaries from January 1, 2002, through December 31, 2009. 3 Ophthalmologists have been performing LTP since 1979 when the procedure was first developed by Wise and Witter. 4 Recently, optometrists have been lobbying state legislatures for expanded privileges so they may perform LTP.…”

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confidence: 99%

Comparison of Outcomes of Laser Trabeculoplasty Performed by Optometrists vs Ophthalmologists in Oklahoma

et al. 2016

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IMPORTANCE Oklahoma is one of the few states where optometrists have surgical privileges to perform laser trabeculoplasty (LTP). Optometrists in other states are lobbying to obtain privileges to perform LTP and other laser procedures. Little is known whether outcomes of patients undergoing this procedure by optometrists are similar to those undergoing LTP by ophthalmologists. OBJECTIVE To compare outcomes of LTPs performed by ophthalmologists with those performed by optometrists to determine whether differences exist in the need for additional LTPs. DESIGN, SETTING, AND PARTICIPANTS This retrospective longitudinal cohort study used a health care claims database containing more than 1000 eyes of Medicare enrollees with glaucoma who underwent LTP in Oklahoma from January 1, 2008, through December 31, 2013. For each procedure, the data specify the type of eye care professional who performed the LTP. The rate of LTPs performed by ophthalmologists that required 1 or more additional LTPs in the same eye was compared with the rate of LTPs performed by optometrists. Regression models determined factors affecting risk of undergoing more than 1 LTP in the same eye. MAIN OUTCOMES AND MEASURES Proportion of enrollees requiring additional LTPs, hazard ratio with 95% CIs of undergoing additional LTPs.

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Trends Over Time and Regional Variations in the Rate of Laser Trabeculoplasty in the Medicare Population

Cited by 22 publications

References 21 publications

Characteristics of Endophthalmitis after Cataract Surgery in the United States Medicare Population

Characteristics of Endophthalmitis after Cataract Surgery in the United States Medicare Population

Mechanism of Action of Selective Laser Trabeculoplasty and Predictors of Response

Comparison of Outcomes of Laser Trabeculoplasty Performed by Optometrists vs Ophthalmologists in Oklahoma

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