This large retrospective review of American patients with corneal endothelial disease (CED) found an increasing rate of endothelial keratoplasty (EK) from 2001 to 2009, a decrease in the number of visits for postoperative care, and no change in the rate of severe adverse events.
The authors reviewed the billing records of individuals with CED enrolled in a large, national, U.S. managed care network who were at least 40 years old and received eye care between 2001 and 2009.
Of the 38,648 enrollees who met the inclusion criteria, 2,187 underwent at least one keratoplasty. After adjustment for confounding factors, an individual with CED was approximately twice as likely to undergo keratoplasty in 2009 compared with 2001.
The authors note that rates of keratoplasty were relatively stable from 2002 to 2006 but increased substantially from 2007 to 2009. This increase corresponds to the widespread adoption of EK. Because the specific ICD-9-CM billing code for EK wasn’t introduced until 2009, it is not possible to distinguish those who underwent EK versus PK. But the authors suspect that the widespread adoption of EK since 2007 plays a large role in the increased rates of keratoplasty for CED.
Rates for postoperative visits during the year after surgery declined from a mean of 12.6 visits in 2002 through2006 to 10.5 in 2007 to 2008. Once again, the authors note, the reduction in postoperative visits may correspond, in part, to the introduction and widespread use of EK. Compared with PK, EK requires fewer sutures and produces less astigmatism, better refractive stability, and earlier visual recovery, all of which likely contribute to a reduced need for postoperative evaluations. Another factor could be the changing health care environment in the U.S., which encourages increased attention to efficiency and minimization of unnecessary medical visits.
Rates of severe, potentially sight-threatening, postoperative adverse events after keratoplasty were low and relatively stable from 2001 to 2009, which is consistent with previous studies.
Not surprisingly, older individuals (aged 60 to79 years) with CED had statistically significant increased odds of undergoing keratoplasty relative to younger individuals (aged 40 to 49 years). However, CED patients older than 79 years had lower odds of undergoing keratoplasty relative to those aged 40 to 49 years, suggesting that at older ages, surgeons and patients may decide that the potential risks of the surgery may outweigh the potential benefits.
The authors also found that those with CED who are less educated and more economically disadvantaged have higher odds of undergoing keratoplasty relative to those with higher levels of education and wealth. A possible explanation for this could be that economically disadvantaged individuals tend to seek medical care at a later point in their disease process because of barriers to routine health care.
Individuals with CED and ocular comorbidities, such as macular degeneration or open-angle glaucoma, were less likely to undergo keratoplasty, as were those with more systemic illnesses. These findings suggest that ocular comorbidities (which may limit visual potential) and overall health are factors that influence the decision to undergo keratoplasty.
With the creation of a unique billing code for EK in 2009, replicating this study in several years will likely reveal further trends in the use of keratoplasty for CED.