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Glaucoma Dialogue IGR 14-3

Response

Comment by Cambell on:

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

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We thank the editors for their interest in our work and the reviewers for their thought-provoking and insightful comments. Subspecialization is a growing phenomenon within all areas of medicine and our work helps to quantify the extent of this process in glaucoma surgery. As highlighted by a number of the reviewers, we used a population- based approach ‐ capturing data on all physicians and all patients in a well-defined, large population. The progressive concentration of glaucoma surgery in the hands of fewer ophthalmologists raises a number of issues, which are highlighted in both our report and the reviews. In particular, while higher volumes of some surgical procedures lead to better outcomes, the volume level beyond which improved performance plateaus is not precisely known for glaucoma surgery.^1-4 Indeed, while the limited available evidence suggests that a fairly small number of surgeries may be needed to provide good outcomes, larger studies are needed.^5,6 However, improvements in outcomes need to be balanced against the impact of declining numbers of glaucoma surgeons on access to care, especially in large geographic regions with widely dispersed populations. Further research is also needed to assess the impact of subspecialization on the provision of the non-surgical elements of glaucoma care, an aspect of care equal in importance to surgical management.

The generalizability of our findings are an important consideration. While we agree that it is possible that Ontario's universal healthcare system may have contributed to the developments we observed, we feel that our findings stem primarily from surgical developments applicable to most high-income nations, and that the increasing concentration of glaucoma surgery is likely an important development worldwide.

Our colleagues also noted that the rates of glaucoma surgery in our study were relatively stable over the time period, whereas trabeculectomy rates have been reported to have decreased in studies from other jurisdictions.^7,8 A number of reasons likely underpin this finding. Firstly, because our study focused on the distribution of surgical cases and not surgical rates, we did not express our data on a population basis. Taking into account the 20% growth in the population of Ontario over the study period, glaucoma surgical rates have indeed fallen in Ontario on a population basis. Secondly, we included all types of glaucoma surgery in our study, and consequently, the decrease in trabeculectomy surgery was partially offset by increases in other types of glaucoma surgery. Finally, a major strength of our study was our ability to incorporate data from an entire well-defined population. Previous studies from the UK and US have studied population subsets which may vary over time, hindering the interpretation of rates.^7,8

 Subspecialization is the focus of debate in many areas of medicine and is an issue with which accreditation and credentialing bodies continue to grapple. To date, there has been resistance to official recognition of ophthalmology subspecialties.⁹ This has lead instead to the voluntary segmentation of ophthalmologists. In the future, we may see the implementation of governance structures around ophthalmology subspecialties in many jurisdictions. We believe our study adds to the foundation of evidence upon which such a process may be built.

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