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  • Retina/Vitreous

    A study of surgeries performed at either academic centers or community-based facilities associated with Massachusetts Eye and Ear Infirmary (MEEI) found that while primary rhegmatogenous retinal detachment (RRD) repairs appear to take significantly longer when teaching of fellows is involved, Medicare reimbursements may cover only some of the additional associated costs, even when a surgical modifier is applied.

    Study Design

    This was a 3-year, observational, retrospective study comparing surgical time and reimbursement associated with 300 primary RRD repairs performed at either academic or community-based vitreoretinal centers associated with MEEI. The study included 20 randomly selected attending surgeons who had been practicing for ≥1 year and had each performed ≥20 surgeries, 10 surgeons from each practice setting. Included patients had primary RRD repair with pars plana vitrectomy (PPV) or combined scleral buckle (SB)/PPV and no prior surgery in the affected eye.


    Macula-off RRDs and combined SB/PPV surgeries were more common among academic cases than community cases. All academic surgeon–based repairs had fellows present vs only 50% of community surgeon–based repairs. A sub-analysis of repairs using PPV only (representing 92% of all surgeries) found that operating times were 31.4% (16.6 minutes) longer when fellows were involved. However, a cost analysis revealed that Medicare's teaching modifier added only 16% of additional reimbursement for fellow-assisted surgeries, accounting for about half of the estimated costs associated with the extra time spent on these surgeries.


    Although this study attempted to minimize some variables, case duration is inherently multifactorial. Factors such as the involvement of trainees from other specialties, variability in surgical staffing, differences in case complexity, and comorbidities can affect surgery duration. Also, differences may exist in the operating frequency for each surgeon, which could have affected their familiarity with the surgical setup and their efficiency.

    Clinical Significance

    This study sheds important light on factors that may increase surgical time, such as fellow involvement, combination PPV/SB vs PPV alone, and membrane peeling. Additionally, the increased surgical time seems to have detrimental implications for surgeons receiving appropriate reimbursement, even when using the teaching modifier intended to offset these costs. This gap in reimbursement likely places an additional burden on academic centers.

    Financial Disclosures: Dr. Jessica Randolph discloses financial relationships with Apellis Pharmaceuticals (Lecture Fees/Speakers Bureau); Astellas, Genentech (Consultant/Advisor).