Primary trabeculectomy for advanced glaucoma: pragmatic multicentre randomised controlled trial (TAGS).

OBJECTIVE: To determine whether primary trabeculectomy or primary medical treatment produces better outcomes in term of quality of life, clinical effectiveness, and safety in patients presenting with advanced glaucoma. DESIGN: Pragmatic multicentre randomised controlled trial. SETTING: 27 secondary care glaucoma departments in the UK. PARTICIPANTS: 453 adults presenting with newly diagnosed advanced open angle glaucoma in at least one eye (Hodapp classification) between 3 June 2014 and 31 May 2017. INTERVENTIONS: Mitomycin C augmented trabeculectomy (n=227) and escalating medical management with intraocular pressure reducing drops (n=226) MAIN OUTCOME MEASURES: Primary outcome: vision specific quality of life measured with Visual Function Questionnaire-25 (VFQ-25) at 24 months. SECONDARY OUTCOMES: general health status, glaucoma related quality of life, clinical effectiveness (intraocular pressure, visual field, visual acuity), and safety. RESULTS: At 24 months, the mean VFQ-25 scores in the trabeculectomy and medical arms were 85.4 (SD 13.8) and 84.5 (16.3), respectively (mean difference 1.06, 95% confidence interval -1.32 to 3.43; P=0.38). Mean intraocular pressure was 12.4 (SD 4.7) mm Hg for trabeculectomy and 15.1 (4.8) mm Hg for medical management (mean difference -2.8 (-3.8 to -1.7) mm Hg; P<0.001). Adverse events occurred in 88 (39%) patients in the trabeculectomy arm and 100 (44%) in the medical management arm (relative risk 0.88, 95% confidence interval 0.66 to 1.17; P=0.37). Serious side effects were rare. CONCLUSION: Primary trabeculectomy had similar quality of life and safety outcomes and achieved a lower intraocular pressure compared with primary medication. TRIAL REGISTRATION: Health Technology Assessment (NIHR-HTA) Programme (project number: 12/35/38). ISRCTN registry: ISRCTN56878850.

Use of Various Glaucoma Surgeries and Procedures in Medicare Beneficiaries from 1994 to 2012.

PURPOSE: Determine how procedural treatments for glaucoma have changed between 1994-2012. DESIGN: Retrospective, observational analysis. PARTICIPANTS: Medicare Part B beneficiaries. METHODS: We analyzed Medicare fee-for-service paid claims data between 1994-2012 to determine the number of surgical/laser procedures performed for glaucoma in the Medicare population each year. MAIN OUTCOME MEASURES: Number of glaucoma-related procedures performed. RESULTS: Trabeculectomies in eyes without previous scarring decreased 52% from 54 224 in 1994 to 25 758 in 2003, and a further 52% to 12 279 in 2012. Trabeculectomies in eyes with scarring ranged from 9054 to 13 604 between 1994-2003, but then decreased 48% from 11 018 to 5728 between 2003-2012. Mini-shunts done via an external approach (including ExPRESS [Alcon Inc, Fort Worth, TX]) increased 116% from 2718 in 2009 to 5870 in 2012. The number of aqueous shunts to the extraocular reservoir increased 231% from 2356 in 1994 to 7788 in 2003, and a further 54% to 12 021 in 2012. Total cyclophotocoagulation procedures increased 253% from 2582 in 1994 to 9106 in 2003, and a further 54% to 13 996 in 2012. Transscleral cyclophotocoagulations decreased 45% from 5978 to 3268 between 2005-2012; over the same period, the number of endoscopic cyclophotocoagulations (ECPs) increased 99% from 5383 to 10 728. From 2001 to 2005, the number of trabeculoplasties more than doubled from 75 647 in 2001 to 176 476 in 2005, but since 2005 the number of trabeculoplasties decreased 19% to 142 682 in 2012. The number of laser iridotomies was fairly consistent between 1994-2012, increasing 9% over this period and ranging from 63 773 to 85 426. Canaloplasties increased 1407% from 161 in 2007 to 2426 in 2012. Between 1994-2012, despite a 9% increase in beneficiaries, the total number of glaucoma procedures and the number of glaucoma procedures other than laser procedures decreased 16% and 31%, respectively. CONCLUSIONS: Despite the increase in beneficiaries, the number of glaucoma procedures performed decreased. Glaucoma procedures demonstrating a significant increase in use include canaloplasty, mini-shunts (external approach), aqueous shunt to extraocular reservoir, and ECP. Trabeculectomy use continued its long-term downward trend. The continued movement away from trabeculectomy and toward alternative intraocular pressure-lowering procedures highlights the need for well-designed clinical trials comparing these procedures.

A Quantitative Analysis of the Relationship between Medicare Payment and Service Volume for Glaucoma Procedures from 2005 through 2009.

PURPOSE: To calculate the association between Medicare payment and service volume for 6 commonly performed glaucoma procedures. DESIGN: Retrospective, longitudinal database study. SUBJECTS: A 100% dataset of all glaucoma procedures performed on Medicare Part B beneficiaries within the United States from 2005 to 2009. METHODS: Fixed-effects regression model using Medicare Part B carrier data for all 50 states and the District of Columbia, controlling for time-invariant carrier-specific characteristics, national trends in glaucoma service volume, Medicare beneficiary population, number of ophthalmologists, and income per capita. MAIN OUTCOME MEASURES: Payment-volume elasticities, defined as the percent change in service volume per 1% change in Medicare payment, for laser trabeculoplasty (Current Procedural Terminology [CPT] code 65855), trabeculectomy without previous surgery (CPT code 66170), trabeculectomy with previous surgery (CPT code 66172), aqueous shunt to reservoir (CPT code 66180), laser iridotomy (CPT code 66761), and scleral reinforcement with graft (CPT code 67255). RESULTS: The payment-volume elasticity was nonsignificant for 4 of 6 procedures studied: laser trabeculoplasty (elasticity, -0.27; 95% confidence interval [CI], -1.31 to 0.77; P = 0.61), trabeculectomy without previous surgery (elasticity, -0.42; 95% CI, -0.85 to 0.01; P = 0.053), trabeculectomy with previous surgery (elasticity, -0.28; 95% CI, -0.83 to 0.28; P = 0.32), and aqueous shunt to reservoir (elasticity, -0.47; 95% CI, -3.32 to 2.37; P = 0.74). Two procedures yielded significant associations between Medicare payment and service volume. For laser iridotomy, the payment-volume elasticity was -1.06 (95% CI, -1.39 to -0.72; P < 0.001): for every 1% decrease in CPT code 66761 payment, laser iridotomy service volume increased by 1.06%. For scleral reinforcement with graft, the payment-volume elasticity was -2.92 (95% CI, -5.72 to -0.12; P = 0.041): for every 1% decrease in CPT code 67255 payment, scleral reinforcement with graft service volume increased by 2.92%. CONCLUSIONS: This study calculated the association between Medicare payment and service volume for 6 commonly performed glaucoma procedures and found varying magnitudes of payment-volume elasticities, suggesting that the volume response to changes in Medicare payments, if present, is not uniform across all Medicare procedures.

Trends over time and regional variations in the rate of laser trabeculoplasty in the Medicare population.

IMPORTANCE: Laser trabeculoplasty (LTP) is routinely used to treat open-angle glaucoma; hence, understanding variations in its use over time and region is important. OBJECTIVE: To determine trends over time and the regional variation in the performance of LTP. DESIGN, SETTING, AND PARTICIPANTS: Database analysis of a 5% random sample of all Medicare beneficiaries 65 years or older with continuous Part B (medical insurance) coverage and no enrollment in a health maintenance organization for each year from 2002 through 2009. INTERVENTIONS: We counted unique claims with a Current Procedural Terminology code of 65855 (LTP) submitted by ophthalmologists, optometrists, ambulatory surgery centers, or outpatient hospitals by region for each year. We examined trends over time and regional variation in LTP rates in 9 large geographic regions. MAIN OUTCOMES AND MEASURES: Rate of LTP per 10,000 Medicare beneficiary person-years and per 10,000 diagnosed open-angle glaucoma (OAG) person-years. RESULTS: The LTP rates per 10,000 Medicare beneficiary person-years were 36.3, 60.1, and 53.5 for 2002, 2006, and 2009, respectively. The 65.6% increase between 2002 and 2006 and the 11.0% decrease between 2006 and 2009 were statistically significant (tests for linear trend, P = .009 and P < .001, respectively). Similarly, the LTP rate among Medicare beneficiaries with OAG increased from 507.9 per 10,000 person-years in 2002 to 824.3 per 10,000 person-years in 2006 (62.3% increase; P = .009) and then decreased to 741 per 10,000 person-years by 2009 (10.1% decrease; P = .004). The rates per 10,000 OAG person-years differed significantly by region, ranging from 314 in the East South-Central region to 607 in the East North-Central region in 2002 (93.2% higher; P < .001). A similar range of variation was observed in subsequent years. CONCLUSIONS AND RELEVANCE: The rate of LTP for Medicare patients with OAG peaked in 2006 and then decreased through 2009. Nearly twice as many LTP procedures per Medicare beneficiary were performed in some regions compared with others throughout the period.

Audit of ophthalmic surgical interventions in a resource-deficient tertiary eye care facility in Sub-Saharan Africa.

BACKGROUND: Ophthalmic surgical intervention is a critical component of therapeutic eye care services. Periodic audit of its output and outcome is needed to monitor service effectiveness and inform evidence-based eye health care reforms, in the spirit of VISION 2020-The Right to Sight. Objectives. To investigate the pattern and results of ophthalmic surgical interventions at the University of Nigeria Teaching Hospital (UNTH), Enugu, Nigeria. METHODS: The UNTH's eye theatre surgical logbook and patients' clinical charts were retrospectively reviewed, from August 2003-July 2008, to obtain patients' relevant demographic and clinical data. Personnel data were obtained from UNTH's human resources department. Descriptive and analytical statistics were performed. A p<.01 was considered statistically significant. RESULTS: Of the 881 eye operations on 676 patients, cataract extraction (45.1%), pterygium excision (18.4%) and trabeculectomy (7.5%) were the main surgeries performed. The yearly surgical output per surgeon was 23.2. The early outcome was satisfactory for trabeculectomy but sub-optimal for cataract surgery. Surgeries were performed mainly to restore or preserve vision (p<.01). CONCLUSIONS: The output and outcome of eye operations at UNTH, Enugu, are sub-optimal. Overcoming surgical uptake barriers, improved pre-operative evaluation, and provisions of micro-surgical consumables are instructive.

Effect of physician remuneration fees on glaucoma procedure rates in Canada.

PURPOSE: Earlier studies have reported wide regional variability in glaucoma procedure rates, suggesting nonclinical factors influencing procedure rates. This study was designed to investigate the possible influence of fees on procedure rates. METHODS: Databases were accessed to obtain yearly provincial population, procedure and ophthalmologist numbers, and physician fees for trabeculoplasties, trabeculectomies, and glaucoma drainage device (GDD) implantations from 1992 to 2007. Regression models using generalized estimating equation methods were used to evaluate the influence of fees on procedure rates after adjusting for temporal trends and the number of ophthalmologists per 1000 persons with glaucoma. RESULTS: Trends in glaucoma procedure rates and fees varied widely among provinces: decrease of 98% to an increase of 380% for trabeculoplasties, decrease of 72% to an increase of 42% for trabeculectomies, and decrease of 32% to an increase of 1292% for GDD. In 2007, provincial remuneration varied from $125 to $553 for trabeculoplasties, $370 to $748 for trabeculectomies, and $426 to $956 for GDD. The regression models found for every 1000 persons with glaucoma, a $100 increase in fee was associated with 0.68 more trabeculoplasties (P=0.94), 1.2 fewer trabeculectomies (P=0.17), and 0.18 more GDD implantations (P=0.18); and for every additional ophthalmologist per 1000 persons with glaucoma, 53.8 more trabeculoplasties (P=0.24), 0.34 more trabeculectomies (P=0.86), and 0.79 more GDD implantations (P=0.0004). A regression model examining procedure substitution effect did not find any association between relative remuneration and procedure rate. CONCLUSION: Our analysis did not show an influence of physician remuneration fee on procedure rates in Canada during the study period.

Glaucoma laser and surgical procedure rates in Canada: a long-term profile.

BACKGROUND: New laser and surgical techniques have had a significant effect on glaucoma therapy. A precise understanding of how these developments are affecting overall glaucoma management is fundamental to health services planning. The objective of this study was to synthesize Canadian national and provincial data regarding glaucoma laser and surgical procedure rates from 1992 to 2004. METHODS: Canadian provincial health insurance databases, which cover virtually all surgical procedures provided domestically to Canadians, were accessed to ascertain yearly total glaucoma procedure numbers. To estimate the number of individuals with glaucoma, an age-stratified glaucoma prevalence model was applied to population census data. RESULTS: Laser trabeculoplasty rates dramatically increased between 2001 and 2004 with the national Canadian rate more than doubling. However, this increase varied widely across regions, ranging from 0% to 530%. Trabeculectomy surgery rates slowly increased from 1992 to 1995, then declined by 29% nationally between 1995 and 2004. Implantation rates of glaucoma drainage devices increased 12-fold nationally between 1992 and 2004; by 2004 this procedure accounted for 10% of incisional glaucoma surgical procedures in Canada. INTERPRETATION: In Canada, laser trabeculoplasty rates have risen significantly over recent years. Trabeculectomy rates have recently declined, and implantation of glaucoma drainage devices is playing an increasingly important role in glaucoma management in this country.

A review of glaucoma treatment in Scotland 1994-2004.

OBJECTIVE: This study evaluated the changing trends in glaucoma management in Scotland between 1994 and 2004. METHODS: A retrospective analysis of national health statistics in Scotland from 1994 to 2004. The Scottish morbidity record was used to collect information on all episodes of trabeculectomy. Data on number of prescriptions were gathered for individual drugs and also for groups of active ingredient. The population likely to have glaucoma (PLG) was calculated from estimates of prevalence in individuals aged 40 years and older, based on published epidemiological studies. The outcome measures were trabeculectomy rates, corrected for population likely to be at risk of glaucoma (PLG), and prescribing volume and cost for glaucoma medications. RESULTS: Trabeculectomy rates have fallen by 67% from 46 per 1,000 PLG in 1994 to 15.4 per 1,000 PLG in 2004. Over the same time period, the population likely to be at risk of glaucoma (PLG) increased by 16.6%. The cost of prescribing has increased by 122% over 11 years compared with an increase in number of items per 1,000 PLG by 27.5%. In 1994, beta-blockers accounted for 65.2% of prescribed drugs but by 2004 this had dropped to 33%. Since their introduction, the prescribing of prostaglandin analogues has increased rapidly and in 2004, they accounted for 39.4% of prescribed drugs. CONCLUSION: The increasing use of prostaglandin analogues has led to an increase in prescribing rates and a rapid increase in cost. At the same time, prescribing of beta-blockers has declined and trabeculectomy rates have fallen.

Usage and cost of laser trabeculoplasty in the United States.

To determine annual usage and costs of laser trabeculoplasty (LTP) in the United States, we reviewed data from the Health Care Financing Administration from 1986 to 2000, using the Part B Extract and Summary System (BESS). The annual number of LTP procedures performed increased to a peak number of 176,670 in 1992 and has declined since that time, with a 57% reduction in the number of procedures performed in 2000 (75,838) compared with the peak number. The total allowed charges declined from a peak of $137,127,436 in 1991 to $27,622,073 in 2000 (80% reduction). The average allowed charge per procedure was highest in 1989 ($893), and by 2000 the average charge ($359) was reduced by 60% compared with the peak charge. The total number of LTP procedures performed in Medicare beneficiaries has decreased in recent years compared with the peak number in 1992. In recent years, there also has been a marked reduction in the total allowed charges and the average charge per procedure for LTP.

Trends in glaucoma surgery incidence and reimbursement for physician services in the Medicare population from 1995 to 1998.

OBJECTIVE: To better understand the relationship between glaucoma management and economic incentives, we examined the volume and the reimbursement of argon laser trabeculoplasty (ALT) and trabeculectomy in a 5% random sample of the Medicare population from 1995 to 1998. DESIGN: Retrospective cohort study. PARTICIPANTS: Subjects in a 5% random sample of the Medicare population who had ALT and trabeculectomy from 1995 to 1998. METHODS: Using the Health Care Financing Administration (HCFA) Physician/Supplier Part-B files for a 5% random sample of the Medicare population, we identified all subjects who had ALT and trabeculectomy from 1995 to 1998. Descriptive summaries (the number of surgeries and the mean and the standard deviation of reimbursement per surgery) were calculated for each year. Analysis of variance was used to test for differences in reimbursement per surgery across years. Chi-square tests were used to assess any associations between the changing numbers of ALTs and trabeculectomies over the study period and both age and race. MAIN OUTCOME MEASURES: We assessed the number of ALTs and trabeculectomies and the allowed charges for each surgery in the 5% random sample of the Medicare population from 1995 to 1998. RESULTS: The volume of both ALTs and trabeculectomies declined during the study period. Reimbursement per surgery for both ALT and trabeculectomy varied significantly across years (P < 0.001). Significant associations were found between the changing number of ALTs and both age and race. CONCLUSIONS: Changing numbers of ALT and trabeculectomy seem unrelated to reimbursement rates. Rather, these changes are more likely driven by new developments in the clinical management of glaucoma, among other factors.

Surgical undertreatment of glaucoma in black beneficiaries of medicare.

OBJECTIVE: To identify whether there was surgical undertreatment of glaucoma in black beneficiaries of Medicare from 1991 to 1994. METHODS: We performed a retrospective cohort analysis on all argon laser trabeculoplasty or trabeculectomy surgery claims to the Health Care Financing Administration between 1991 and 1994. There were 191 287 Medicare patients who were black or white, at least 65 years of age, and resided in the United States at the time of their glaucoma surgery. Age- and sex-adjusted rates were obtained and compared with surgery rates expected based on disease prevalence. RESULTS: The age-sex-adjusted rate ratio of glaucoma surgical procedures for blacks to whites was 2.14. Assuming that treatments should be done in proportion to age-race prevalence, blacks undergo glaucoma surgery at approximately 47% below the expected rate. CONCLUSIONS: Blacks underwent argon laser trabeculoplasties and trabeculectomies at half the rate of whites from 1991 to 1994. Although in 1993 and 1994 there was a slight trend toward higher surgery rates in blacks, the magnitude of this improvement was small compared with estimated differences in the surgery rates between blacks and whites.

Time parameters for glaucoma procedures.

Changes in physician reimbursement and the practice environment have emphasized the importance of determining physician time for procedures and services. Forty-five percent of the members of the American Glaucoma Society responded to a mail survey of estimates of the length of time and number of visits for the preoperative, operative, and 90-day postoperative care for six common glaucoma procedures. Results suggest a significant underestimation of time for trabeculectomies exists in the original and new resource-based relative value scale work values. Further, 47% to 53% of surgeons hospitalize patients on at least the first postoperative day. There were no apparent time efficiencies between "high-" and "low-volume" respondents. Thus, careful attention should be paid to the accuracy of certain time estimates and the resulting work values in the resource-based relative value scale. Additional work in this and other areas may prove illuminating.