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Original Investigation |

Comparison of Outcomes of Laser Trabeculoplasty Performed by Optometrists vs Ophthalmologists in Oklahoma ONLINE FIRST

Joshua D. Stein, MD, MS1,2,3; Peter Y. Zhao, MD4; Chris Andrews, PhD1; Gregory L. Skuta, MD5
[+] Author Affiliations
1Department of Ophthalmology and Visual Sciences, University of Michigan, Medical School, WK Kellogg Eye Center, Ann Arbor
2Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor
3Department of Health Management and Policy, University of Michigan, School of Public Health, Ann Arbor
4Department of Internal Medicine, Lankenau Medical Center, Wynnewood, Pennsylvania
5Dean McGee Eye Institute, Department of Ophthalmology, University of Oklahoma College of Medicine, Oklahoma City
JAMA Ophthalmol. Published online July 28, 2016. doi:10.1001/jamaophthalmol.2016.2495
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Importance  Oklahoma is one of the few states where optometrists have surgical privileges to perform laser trabeculoplasty (LTP). Optometrists in other states are lobbying to obtain privileges to perform LTP and other laser procedures. Little is known whether outcomes of patients undergoing this procedure by optometrists are similar to those undergoing LTP by ophthalmologists.

Objective  To compare outcomes of LTPs performed by ophthalmologists with those performed by optometrists to determine whether differences exist in the need for additional LTPs.

Design, Setting, and Participants  This retrospective longitudinal cohort study used a health care claims database containing more than 1000 eyes of Medicare enrollees with glaucoma who underwent LTP in Oklahoma from January 1, 2008, through December 31, 2013. For each procedure, the data specify the type of eye care professional who performed the LTP. The rate of LTPs performed by ophthalmologists that required 1 or more additional LTPs in the same eye was compared with the rate of LTPs performed by optometrists. Regression models determined factors affecting risk of undergoing more than 1 LTP in the same eye.

Main Outcomes and Measures  Proportion of enrollees requiring additional LTPs, hazard ratio with 95% CIs of undergoing additional LTPs.

Results  A total of 1384 eyes of 891 eligible patients underwent LTP from January 1, 2008, through December 31, 2013. There were 1150 eyes that received LTP (83.1%) by an ophthalmologist and 234 eyes (16.9%) that had the procedure performed by an optometrist. The mean (SD) age at the initial LTP was 77.7 (7.5) years for enrollees with ophthalmologist-performed LTP and 77.6 (8.0) years for those with optometrist-performed LTP (P = .89). Among the 1384 eyes receiving LTP, 258 (18.6%) underwent more than 1 LTP in the same eye. The proportion of eyes undergoing LTP by an optometrist requiring 1 or more subsequent LTP session (35.9%) was more than double the proportion of eyes that received this procedure by an ophthalmologist (15.1%). Medicare beneficiaries undergoing LTP by optometrists had a 189% increased hazard of requiring additional LTPs in the same eye compared with those receiving LTP by ophthalmologists (hazard ratio, 2.89; 95% CI, 2.00-4.17; P < .001) after adjusting for potential confounders.

Conclusions and Relevance  Considerable differences exist among the proportions of patients requiring additional LTPs comparing those who were initially treated by ophthalmologists with those initially treated by optometrists. Health policy makers should be cautious about approving laser privileges for optometrists practicing in other states until the reasons for these differences are better understood.

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Figure 1.
STROBE Sample Selection Figure

Identification of beneficiaries eligible for current study from 20% Medicare claims database. ICD-9-CM indicates International Classification of Diseases, Ninth Revision, Clinical Modification; LTP, laser trabeculoplasty.

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Figure 2.
Time to Second Laser Trabeculoplasty in Same Eye for Beneficiaries Receiving Initial Treatment by Ophthalmologists and Optometrists

Kaplan-Meier estimates of cumulative incidence for each group. Data are clustered because of some beneficiaries having both eyes studied. The study lasted 72 months: follow-up began at the first laser trabeculoplasty. Therefore, there was none at risk at month 72. HCP indicates health care professional.

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