Stein Joshua D, Zhao Peter Y, Andrews Chris, Skuta Gregory L
Department of Ophthalmology and Visual Sciences, University of Michigan, Medical School, WK Kellogg Eye Center, Ann Arbor2Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor3Department of Health Management and Policy, University of Michigan, School of Public Health, Ann Arbor.
Department of Internal Medicine, Lankenau Medical Center, Wynnewood, Pennsylvania.
JAMA Ophthalmol. 2016 Oct 1;134(10):1095-1101. doi: 10.1001/jamaophthalmol.2016.2495.
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.
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.
Proportion of enrollees requiring additional LTPs, hazard ratio with 95% CIs of undergoing additional LTPs.
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.
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.
俄克拉荷马州是少数几个验光师拥有进行激光小梁成形术（LTP）手术特权的州之一。其他州的验光师正在游说争取进行LTP和其他激光手术的特权。对于由验光师实施该手术的患者与由眼科医生实施LTP的患者的治疗效果是否相似，人们知之甚少。
比较眼科医生与验光师进行LTP的治疗效果，以确定在是否需要再次进行LTP方面是否存在差异。
设计、地点和参与者：这项回顾性纵向队列研究使用了一个医疗保健理赔数据库，该数据库包含2008年1月1日至2013年12月31日期间在俄克拉荷马州接受LTP的1000多只患有青光眼的医疗保险参保者的眼睛。对于每一例手术，数据都明确了实施LTP的眼科护理专业人员的类型。将同一只眼睛需要1次或更多次额外LTP的眼科医生实施LTP的比例与验光师实施LTP的比例进行比较。回归模型确定了影响同一只眼睛接受1次以上LTP风险的因素。
需要再次进行LTP的参保者比例，再次进行LTP的风险比及95%置信区间。
从2008年1月1日至2013年12月31日，共有891名符合条件的患者的1384只眼睛接受了LTP。其中1150只眼睛（83.1%）由眼科医生进行了LTP，234只眼睛（16.9%）由验光师进行了该手术。接受眼科医生实施LTP的参保者初次接受LTP时的平均（标准差）年龄为77.7（7.5）岁，接受验光师实施LTP的参保者为77.6（8.0）岁（P = 0.89）。在接受LTP的1384只眼睛中，258只（18.6%）在同一只眼睛接受了1次以上的LTP。由验光师进行LTP且需要1次或更多次后续LTP治疗的眼睛比例（35.9%）是由眼科医生进行该手术的眼睛比例（15.1%）的两倍多。在调整了潜在混杂因素后，与接受眼科医生LTP的医疗保险受益人相比，接受验光师LTP的受益人同一只眼睛需要再次进行LTP的风险增加了189%（风险比，2.89；95%置信区间，2.00 - 4.17；P < 0.001）。
在需要再次进行LTP的患者比例方面，最初由眼科医生治疗的患者与最初由验光师治疗的患者之间存在显著差异。在更好地理解这些差异的原因之前，卫生政策制定者在批准其他州验光师的激光手术特权时应谨慎行事。
