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Editors Selection IGR 21-4

(Laser) Surgical treatment: Health care utilization in glaucoma

Comment by Louis Pasquale on:

20004 Utilization of various glaucoma surgeries and procedures in medicare beneficiaries from 1995 to 2004, Ramulu PY; Corcoran KJ; Corcoran SL et al., Ophthalmology, 2007; 114: 2265-2270

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Ramulu et al. (1475) present an observational study of Medicare beneficiaries to document trends in glaucoma laser and incisional surgery from 1994 through 2004. This time frame witnessed an expansion of the glaucoma medical armamentarium, the introduction of an endoscopic cyclodestructive procedure and the development of selective laser trabeculoplasty, as well as the publication of randomized clinical trials that have sought to guide glaucoma therapy. The authors utilized a database in the public domain consisting of procedures performed and not patients, so one cannot discern a sample size for this study. Caution is needed in interpreting the results as the data is not corrected for yearly variations in the number procedures performed, the number of people with an ICD9 code for the glaucomas, and the number of Medicare beneficiaries. If we assume the number of Medicare benefi ciaries actually increased in the decade under study, it is quite remarkable that the total number of glaucoma laser or incisional surgeries performed did not increase from 1995 to 2004. The data suggests that the expansion in medical therapy options contributed to curtailing the number of glaucoma procedures performed. There are two trends in the data that seem undeniable. Firstly, the number of trabeculectomies in previously un-operated eyes declined steadily from 51,690 in 1995 to 24,178 in 2004. Any further declines in trabeculectomy surgery could impact resident exposure to this procedure. Secondly, the number of laser trabeculoplasties decreased by more than 50% from the mid-to-late 1990s only to rebound to the baseline level from 2001-2004. It is tempting to attribute the upswing in trabeculoplasty utilization to the introduction the Q-switched Nd:YAG laser. Glaucoma healthcare utilization research can help prioritize areas where outcomes research is needed and such efforts are welcomed.

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