Vail D, Pershing S, Reeves,M, et al. The Relative Impact of Patient, Physician, and Geographic Factors on Variation in Primary Rhegmatogenous Retinal Detachment Management. Ophthalmology 2020; 127: 97-106.
Rhegmatogenous Retinal Detachment (RRD) is one of the most common surgical diagnoses encountered by retina specialists. While there are many techniques available to successfully manage primary RRD including laser barricade, cryotherapy, pneumatic retinopexy, scleral buckle, and pars plana vitrectomy, there are several factors that help determine which procedure is selected. In this study, Veil et al evaluate variations in practice patterns for management of primary RRD across the country, specifically looking at patient characteristics, physician practice, and geographic region.
In this retrospective claims-based analysis from a Health MarketScan and Encounters database, 12,779 commercially insured patients across the United States with a new diagnosis of RRD between 2008 and 2016 were included. Patients were required to be followed for at least 1 year prior to the diagnosis of RRD and 60 days after the diagnosis. Multilevel mixed effects logistic regression and multinomial models were used to evaluate patient, physician, and geographic level variation in whether patients underwent RRD repair and the type of repair, respectively.
Most patients were treated within 60 days of diagnosis (62%) which increased to 92% when sample size was narrowed to 4,146 patients who were evaluated by an optometrist, ophthalmologist, or retina specialist and had diagnosis confirmed with a follow-up appointment. The most common procedures performed were PPV (49%), laser barricade (23%), SB and PR (both 11%), and cryotherapy (5%). Most common ocular comorbidities included lattice degeneration (19%) and vitreous hemorrhage (13%).
Patient level characteristics played a significant role in receipt of any repair (82%) compared to physician (16%) and geographic factors (2%). Interestingly, women were less likely than men to undergo any repair (odds ratio 0.62; 95% confidence interval, 0.48-0.8). When evaluating type of RRD repair, physician level factors accounted for 50% of total variation followed by patient factors (49%), and least by geography (1%). Patients who were pseudophakic or presented with vitreous hemorrhage were more likely to undergo PPV than any other procedure. Those with lattice degeneration were more likely to undergo PPV or laser barricade than PR or cryotherapy. Older patients were more likely to undergo PR than PPV, followed by PPV more than SB or laser barricade.
This study highlights that while there are variations in treatment across the country, patient characteristics and physician practice management played more significant roles in whether patients underwent RRD repair and in determining the type of procedure performed. The authors suggest that retina specialists consider evidence-based medicine and technological advancements when evaluating patients’ characteristics and selecting the procedure for RRD repair. For example, studies that have shown better outcomes with PPV for RRD with vitreous hemorrhage and for RRD in pseudophakic patients. Futhermore, wide-angle viewing systems have improved visualization of retinal breaks in both scenarios. Physician level variation is likely driven by surgical training, comfort level, access to operating room and anesthesia services, and consideration of patient transportation.
The authors speculate that women are less likely to undergo treatment due to taking on caregiving responsibilities with less time to devote to their own health care, lack of support – more likely to be widowed or live alone without a caregiver, and possible errors in coding.
The authors acknowledged the inherent limitation of claims databases, specifically with CPT codes and lack of specific data and notes. The study did not include uninsured patients and did not specify whether the RRD was macula involving – both factors that could potentially influence the variation in treatment.
Moving forward, the next steps would be to look at drivers behind physician and geographic level differences, and to identify possible gender-related disparities in RRD management and barriers in access to care.
Jaya B. Kumar, MD
The Florida Retina Institute