Trends in Glaucoma Surgeries Performed by Glaucoma Subspecialists versus Nonsubspecialists on Medicare Beneficiaries from 2008 through 2016

Siddarth Rathi, Chris A Andrews, David S Greenfield, Joshua D Stein, Siddarth Rathi, Chris A Andrews, David S Greenfield, Joshua D Stein

Abstract

Purpose: To characterize the use of laser and incisional glaucoma surgeries among Medicare beneficiaries from 2008 through 2016 and to compare the use of these surgeries by glaucoma subspecialists versus nonsubspecialists.

Design: Retrospective, observational analysis.

Participants: Medicare beneficiaries (n = 1 468 035) undergoing ≥1 laser or incisional glaucoma surgery procedure during 2008 through 2016.

Methods: Claims data from a 20% sample of enrollees in fee-for-service Medicare throughout the United States were analyzed to identify all laser and incisional glaucoma surgeries performed from 2008 through 2016. We assessed use of traditional incisional glaucoma surgery techniques (trabeculectomy and glaucoma drainage implant [GDI] procedure) and microinvasive glaucoma surgery (MIGS). Enrollee and procedure counts were multiplied by 5 to estimate use throughout all of Medicare. Linear regression was used to compare trends in use of glaucoma surgeries between ophthalmologists who could be characterized as glaucoma subspecialists versus nonsubspecialists.

Main outcome measures: Numbers of laser and incisional glaucoma surgeries performed overall and stratified by glaucoma subspecialist status.

Results: The number of Medicare beneficiaries undergoing any glaucoma therapeutic procedure increased by 10.6%, from 218 375 in 2008 to 241 565 in 2016. The total number of traditional incisional glaucoma surgeries decreased by 11.7%, from 37 225 to 32 885 (P = 0.02). The total number of MIGS procedures increased by 426% from 13 705 in 2012 (the first year MIGS codes were available) to 58 345 in 2016 (P = 0.001). Throughout the study period, glaucoma subspecialists performed most of the trabeculectomies (76.7% in 2008, 83.1% in 2016) and GDI procedures (77.7% in 2008, 80.6% in 2016). Many MIGS procedures were performed by nonsubspecialists. The proportions of endocyclophotocoagulations, iStent (Glaukos; San Clemente, CA) insertions, goniotomies, and canaloplasties performed by glaucoma subspecialists in 2016 were 22.0%, 25.2%, 56.9%, and 62.8%, respectively.

Conclusions: From 2008 through 2016, a large shift in practice from traditional incisional glaucoma surgeries to MIGS procedures was observed. Although glaucoma subspecialists continue to perform most traditional incisional glaucoma surgeries, many MIGS procedures are performed by nonsubspecialists. These results highlight the importance of training residents in performing MIGS procedures and managing these patients perioperatively. Future studies should explore the impact of this shift in care on outcomes and costs.

Copyright © 2020 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.

Figures

Figure 1.
Figure 1.
Overall Trends in Utilization of All Laser and Incisional Glaucoma Surgeries Among Medicare Enrollees from 2008 to 2016 *A given enrollee may be in Medicare for multiple years and may undergo surgeries in more than 1 year. Red bar indicates the number of beneficiaries receiving ≥ 1 therapeutic glaucoma procedure. Blue bar captures the percentage of all beneficiaries in fee-for-service Medicare who received ≥ 1 therapeutic glaucoma procedure
Figure 2.
Figure 2.
Glaucoma Drainage Device Implantation and Trabeculectomy Volumes From 2008–2016 Among Glaucoma Subspecialists and Nonspecialists Trabeculectomy volumes include those performed with or without Ex-PRESS shunts. Red bar indicates the number of beneficiaries receiving ≥ 1 of the surgery of interest in a given year. Blue bar captures the percentage of the surgery of interest that were performed by glaucoma subspecialists each year.
Figure 3.
Figure 3.
Transcleral Diode Cyclophotocoagulation Procedure Volume From 2008–2016 Among Glaucoma Subspecialists and Nonspecialists Red bar indicates the number of beneficiaries receiving ≥ 1 of the surgery of interest in a given year. Blue bar captures the percentage of the surgery of interest that were performed by glaucoma subspecialists each year.
Figure 4.
Figure 4.
Goniotomy and Canaloplasty Procedure Volumes From 2008–2016 Among Glaucoma Subspecialists and Nonspecialists Red bar indicates the number of beneficiaries receiving ≥ 1 of the surgery of interest in a given year. Blue bar captures the percentage of the surgery of interest that were performed by glaucoma subspecialists each year.

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Source: PubMed

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