Vail D, Pan C, Pershing S, Mruthyunjaya P. Association of Rhegmatogenous Retinal Detachment and Outcome With the Day of the Week That Patients Undergo a Repair or Receive a Diagnosis. JAMA Ophthalmol. 2019 Dec 19. doi: 10.1001/jamaophthalmol.2019.5300
Rhegmatogenous retinal detachment (RRD) is a sight threatening disease that requires urgent intervention. There are several techniques to treat RRD including barricade with laser or cryotherapy, pneumatic retinopexy (PR), primary scleral buckle (SB) and pars plana vitrectomy (PPV) with or without scleral buckle. The choice of intervention ideally should be made based upon surgeon experience and a number of clinical factors such as lens status, number and location of retinal breaks, distribution of subretinal fluid and the ability of the patient to position, among others. Although we always want the best possible outcomes for our patients, unfortunately, non-clinical factors like the timing of presentation relative to operating room availability and surgeon availability may influence treatment choice.
In this study, Vail et al used ICD-9 and ICD-10 codes within a large claims database of over 240,000,000 patients (MarketScan) between 2008 and 2016 to identify patients who underwent RRD repair. They used these data to determine whether the intervention choice and 30-day reoperation rates were associated with day of the week on which the patient was diagnosed with RRD.
The authors identified 265,616 patients who underwent RRD repair within this time period. After excluding those with complicating concurrent diagnoses, and those with insufficient, or non-continuous follow up, 38,144 patients were included. The most frequent modality used to treat RRD was PPV (57.0%) followed by laser photocoagulation (17.7%), PR (13.7%), SB (9.8%) and cryotherapy (1.3%). Patients were most likely to receive a diagnosis of RRD on Monday (21.9%) and least likely on Sunday (1.6%). Using multinomial logistic regression models, the authors determined that pneumatic retinopexy was more likely to be used to treat RRD if the patient was diagnosed on Friday (RRR, 1.73; 95% CI, 1.36-2.20), Saturday (RRR, 1.54; 95% CI, 1.08-2.17) or Sunday (RRR, 1.53; 95% CI, 1.33-1.80) in comparison to Wednesday. PR was also more likely to be used if intervention was performed on Friday (RRR, 1.55; 95% CI, 1.33-1.80), Saturday (RRR, 2.03; 95% CI, 1.61-2.56), Sunday (RRR, 2.28; 95% CI, 1.55-3.35), or Monday (RRR, 1.70; 95% CI, 1.46-1.98) as compared to Wednesday.
The authors determined the overall reoperation rate for PR within 30 days of the initial intervention to be 26%. Interestingly, those patients who underwent PR on Sundays were more likely to require a reoperation as compared to those undergoing the procedure on Wednesday (OR, 1.62; 95% CI, 1.07-2.45). This did not hold true for other weekend days. Furthermore, there were no associations found between the day of the week of the initial repair and reoperation rates for scleral buckle or pars plana vitrectomy.
This study brings up important questions regarding how non-clinical factors can influence treatment choice and patient outcomes. Perhaps the most worrisome conclusion to draw is that patients who present on Sundays are more likely to undergo pneumatic retinopexy, not because it is the best procedure for them, but because it is the only procedure available to them. The authors suggest that the inability to access an operating room with adequately trained staff and proper equipment over the weekend may prevent patients from undergoing vitrectomy or scleral buckle when this might otherwise be the treatment of choice. In my own experience, obtaining insurance authorization over the weekend can also delay care, and some patients do not want to take on the possibility of a large and potentially financially devastating bill later on, or a prolonged fight with their insurer.
However, this study suffers from the many limitations seen with all coding-based retrospective studies. Mainly, conclusions are drawn from data which lack clinical findings, and rely completely upon the accuracy of billing codes. We do not, for instance, know if patients presenting on the weekend tend to have detachments which are more amenable to pneumatic retinopexy. One possibility, for example, is that patients who seek a retina surgeon over the weekend are highly motivated to seek care and therefore present earlier in the disease course with a more limited detachment, which is more amenable to PR. If this is the case, the higher rate of PR on the weekends would be expected. Another possibility is that patients presenting with RRD on the weekend are more likely to undergo a temporizing pneumatic to prevent macular detachment with the intention of definitive repair later in the week. If this were the case, the higher re-operation rate seen in patients undergoing PR on Sundays might also be explained. Regardless of the cause, this study stimulates important questions which deserve further study.
Christian J. Sanfilippo, MD
The Retina Partners
Los Angeles, CA