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  • Differences in Tertiary Glaucoma Care Among VA Health System Models

    By Lynda Seminara
    Selected and Reviewed By: Neil M. Bressler, MD, and Deputy Editors
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    Journal Highlights

    JAMA Ophthalmology, November 2018

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    In a retrospective review, Lee et al. compared rates of tertiary glaucoma management among the 4 care deliv­ery models of the Veterans Affair (VA) health system. They noted substantial disparity in the use of glaucoma sur­gery: Rates of laser and filtering surgery were much lower in optometry-only clinics than in those with an ophthal­mology component or specialty.

    The eye care models in the health system are 1) ophthalmology-only clinics, 2) optometry-only clinics, 3) centers with optometry and ophthal­mology functioning as an integrated unit with ophthalmology at the helm, and 4) centers with optometry and ophthalmology functioning separately. Data were extracted from a large VA database, which included the medical records of 490,926 veterans with a glau­coma-related diagnosis who received care at a VA medical center in 2016.

    Documented data included demographics, baseline clinical factors, ICD-10 and CPT codes, and rates of glaucoma surgery procedures. Also noted was the organizational structure of each facility. Univariate and multi­variate regression analyses were applied to discern log percent associations with laser peripheral iridotomy (LPI), laser trabeculoplasty (LTP), and filtering sur­gery. The main outcomes were rates of LPI, LTP, and filtering surgery. (Treat­ment outcomes were not addressed.)

    Most patients were male (95%); more than half were white (63%); and 41% were 65 to 74 years of age. The rates of LPI were 0.30%, 0.28%, 0.67%, and 0.69% for optometry-only clinics, ophthalmology-only clinics, integrated centers, and nonintegrated centers, re­spectively (p < .001). The correspond­ing rates of LTP were 0.31%, 1.06%, 0.93%, and 0.92% (p < .001). The rates of filtering surgery were 0.32%, 0.51%, 0.69%, and 0.60%, respectively (p < .001). In multivariate regression analy­ses, these differences remained signifi­cant even with adjustment for potential confounders.

    Overall, rates of laser and filtering surgery were 3.39-fold to 19.11-fold higher in care delivery models that included ophthalmologists. Further research is needed to identify factors responsible for this disparity and to determine whether the discrepancy in rates is associated with differences in clinical outcomes. (Also see related commentary by Alan L. Robin, MD, in the same issue.)

    The original article can be found here.