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Editors Selection IGR 14-2

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Comment by Keith Barton on:

51038 Subspecialization in glaucoma surgery, Campbell RJ; Bell CM; Gill SS et al., Ophthalmology, 2012; 119: 2270-2273

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The article by Campbell et al. provides an interesting insight into the changing trends in glaucoma surgery in one reimbursement environment. The data are particularly interesting as they appear to represent glaucoma surgical activity for the whole population of Ontario, rather than a selected sample. At first glance, the most puzzling aspect of this report, unless I misunderstand Figure 2, is one that is not related directly to the focus of the report, i.e., that during the first part of the period in question ‐ 1995-2000 ‐ that encompasses the introduction of most of the new drugs, the total number of incisional glaucoma procedures did not decline at all in Ontario. This is in contrast to the findings of Ramulu (Ophthalmology 2007; 114: 2265-2270) who reported a marked drop in the number of glaucoma procedures reimbursed by Medicare in the US between 1995 and 2004 and Whittaker (Eye 2001; 15: 449-452) who reported the same effect in Department of Health Hospital Episode Statistics in England at the same time period.

Although the focus of the article is clearly the increasing tendency for procedures to be performed by higher volume surgeons, it is somewhat surprising that there was no observable decline in the total number of procedures performed after the introduction of Trusopt in 1995 and Xalatan in 1996. This begs the question as to whether a real decline in trabeculectomy numbers was masked by an increase in some other type of incisional procedure, in which case one might wonder if increasing subspecialization was responsible for the whole trend towards more glaucoma surgery performed by higher volume surgeons. It would be interesting to examine the overall breakdown of the surgical mix that the higher volume surgeons were performing. Where these also higher volume cataract and refractive surgeons, or did glaucoma take up an increasing proportion of their surgical workload?

It is frightening that 50% of surgeons perform less than five glaucoma procedures a year

An alternative explanation might be that the at-risk population in Ontario grew more than that in the United States or England, so that there was no observable decline. Perhaps a great proportion of the Ontario population are elderly.

Other possible explanations might be a change in statistical methods during the study time, e.g. recoding, that might result in missing a decline or a peculiarity of the reimbursement environment in Ontario that favored trabeculectomy over new medications.

Irrespective of the reason for the lack of decline, it is frightening that 50% of surgeons perform less than five glaucoma procedures a year. Although the decline in the number of such low volume surgeons does provide some grounds for optimism, I agree with the authors' conclusion that this statistic, as well as the others presented, will have important implications for stakeholders from policy makers and hospitals to academic departments and residency education programs.

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