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Utilization of Various Glaucoma Surgeries and Procedures in Medicare Beneficiaries from 1995 to 2004
Utilization of Various Glaucoma Surgeries and Procedures in Medicare Beneficiaries from 1995 to 2004 Pradeep Y. Ramulu, MD, PhD,1 Kevin J. Corcoran, COE, CPC,2 Suzanne L. Corcoran, COE,2 Alan L. Robin, MD1,3 Objective: To observe how the treatment of glaucoma has changed over the last decade. Design: Retrospective, observational, population-based analysis. Participants: Medicare beneficiaries between 1995 and 2004. Methods: Medicare fee-for-service data claims between 1995 and 2004 were analyzed to determine the number of penetrating surgeries and laser procedures performed for glaucoma in the decade spanning 1995 and 2004. Main Outcome Measure: Number of Medicare beneficiaries receiving glaucoma-related laser procedures or surgery. Results: Trabeculectomies in eyes without previous surgery or trauma decreased 53% over the study period, from 51 690 in 1995 to 24 178 in 2004, although trabeculectomy in eyes with scarring increased 9%. The number of aqueous shunting devices placed rose 184%, from 2728 in 1995 to 7744 in 2004. Cyclophotocoagulation procedures rose 248% over the study period, from 3264 procedures in 1995 to 11 356 procedures in 2004. Between 1995 and 2001, the number of laser trabeculoplasties decreased 57%, from a high of 151 244 in 1995 to a low of 75 647 in 2001. From 2001 to 2004, the number of trabeculoplasties more than doubled, with 157 490 performed in 2004. The number of laser iridotomies showed little fluctuation, increasing 18% over the study period and ranging from 63 773 to 85 286 every year. Over the study period, surgical iridectomies, including peripheral and sector iridectomies, decreased 66%, from a total of 4842 in 1995 to 1654 in 2004. Fistulization procedures other than trabeculectomy (including the Scheie and Holt procedures and iridencleisis) dropped 83% over the study period, decreasing from 2833 in 1995 to 478 in 2004. Conclusions: Medicare recipients with glaucoma are more likely to be treated with aqueous shunting procedures or cyclophotocoagulation and less likely to be treated with trabeculectomy, compared with past years. After a decline in use between 1995 and 2001, laser trabeculoplasty increased substantially from 2001 to 2004. Fistulization procedures other than trabeculectomy and surgical iridectomy have become very uncommon. Ophthalmology 2007;114:2265–2270 © 2007 by the American Academy of Ophthalmology.
Glaucoma is the second leading cause of blindness in Caucasians and leading cause of blindness in those of African and Latino descent.1,2 In all ethnic groups, the prevalence of glaucoma increases dramatically with age3—and the United States is aging. From 1950 to 2000, the number of Americans over 65 increased by 50%, and they are expected to Originally received: July 25, 2006. Final revision: February 2, 2007. Accepted: February 4, 2007. Available online: April 26, 2007. Manuscript no. 2006-820. 1 Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland. 2 Corcoran Consulting Group, San Bernardino, California. 3 Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland. Presented at: American Glaucoma Society meeting, March 2006, Charleston, South Carolina. Correspondence and reprint requests to Alan L. Robin, MD, 6115 Falls Road, Suite 333, Baltimore, MD 21209. E-mail: [email protected]. © 2007 by the American Academy of Ophthalmology Published by Elsevier Inc.
increase an additional 67% by 2050.4 As a result, the number of persons with glaucoma has risen and is expected to rise an additional 50% from 2000 to 2020.3 These demographic changes are expected to increase the demand for glaucoma treatments. The utilization of specific glaucoma treatments, however, will be driven not only by demographics, but also by the expansion of the therapeutic options for treating glaucoma. Indeed, all forms of glaucoma treatment—medical therapy, nonpenetrating procedures, and penetrating surgery— have experienced significant advances over the last several years (Fig 1). Medical therapy, which remains the primary method of therapy in most individuals, has seen a dramatic rise in the classes of medications useful for lowering intraocular pressure (IOP). Yet medicines still fail to control IOP for many patients. Forty percent of those receiving treatment of their ocular hypertension as part of the Ocular Hypertension Treatment Study required ⱖ2 medicines to achieve a 20% ISSN 0161-6420/07/$–see front matter doi:10.1016/j.ophtha.2007.02.005
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Ophthalmology Volume 114, Number 12, December 2007 procedure for glaucoma, though it has evolved with the introduction of adjunctive antimetabolite therapy in the early 1990s.18,19 Several surgical alternatives to trabeculectomy have also recently become available. Newer aqueous shunts, including the Baerveldt (1990) and the Ahmed (1993), have provided an option for difficult glaucomas for which trabeculectomy has had poor success rates.20 –22 Endoscopic cyclophotocoagulation has provided another option for reducing IOP, particularly as part of a combined procedure with cataract surgery.23–25 Here, we examine the trends in utilization of the most common glaucoma-related laser and surgical treatments for Medicare beneficiaries over the period 1995 to 2004.
Materials and Methods Figure 1. Timeline of new glaucoma therapeutics, 1990 to present. Nd: YAG ⫽ neodymium:yttrium–aluminum– garnet.
decrease in IOP,5 and 75% receiving treatment of their early to moderate glaucoma as part of the Collaborative Initial Glaucoma Treatment Study required ⬎2 medications to control their IOP adequately over a 5-year period.6 And although more classes of medicines are now available, adding a third or fourth medicine infrequently contributes to a substantial decrease in IOP.7 Thus, there are still a substantial number of people who may fail medical therapy and require other interventions. Laser trabeculoplasty, first introduced almost 30 years ago,8 remains the most frequent nonpenetrating procedure for glaucoma. Over the last 20 years, it has been well validated as both a primary treatment in newly diagnosed glaucoma9 –12 and an adjunct therapy to eyedrops in patients with advanced glaucoma.13 Additionally, a relatively nonthermal, Q-switched, neodymium-doped yttrium–aluminum–garnet (Nd:YAG) laser was recently introduced14 and also shown to be effective at lowering IOP when applied through a contact lens to the trabecular meshwork.15–17 Trabeculectomy remains the most common penetrating
Data points for this retrospective analysis were taken from the files developed by the Health Care Financing Administration, now known as the Centers for Medicare and Medicaid Services. Each file tabulates the number of paid claims to physicians by Current Procedural Terminology (CPT) code for part B services provided to Medicare beneficiaries in a single year. For this analysis, only those CPT codes used to report surgery of the anterior chamber, anterior sclera, iris, and ciliary body were tabulated (Table 1 [available at http://aaojournal.org]). Those CPT codes begin with 65800 and continue through 66770 in sequential order. Particular attention was paid to glaucoma surgery (Table 2). These data are in the public domain, although never more recent than 2 years ago. In 2006, the most recent data available were for 2004. Data for Medicare beneficiaries enrolled in part C, or managed care Medicare, are unavailable and were excluded from this analysis. Likewise, utilization data for non-Medicare beneficiaries are not public and not part of this analysis. Institutional review board approval was not required for this study.
Results The number of the glaucoma surgeries and lasers reimbursed by Medicare from 1995 to 2004 is shown in Table 2. The number of laser iridotomies showed little fluctuation, increasing 18% over the
Table 2. Number of Selected Glaucoma Procedures Paid for by Medicare, 1995 to 2004 CPT
Procedure
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
65855 Laser trabeculoplasty 151 244 148 816 104 579 91 737 84 511 76 968 75 647 108 202 144 866 157 490 66170 Trabeculectomy—no previous surgery 51 690 59 645 49 938 35 251 31 365 29 311 24 800 25 363 25 758 24 178 66172 Trabeculectomy—previous surgery or trauma 10 366 13 555 13 604 11 178 10 810 11 413 10 501 10 928 11 018 11 333 Other fistulization procedures 2833 2075 1368 901 631 577 518 504 452 478 Fistulization procedures, total 64 889 75 276 64 910 47 330 42 806 41 301 35 819 36 795 37 228 35 989 66180 Aqueous shunt to reservoir 2728 3923 4580 4149 4223 4726 4916 6307 7788 7744 66185 Revision of aqueous shunt 473 608 631 447 625 692 728 864 1087 1091 66710 Cyclophotocoagulation 3264 3963 4292 3680 4107 3705 4025 5795 9106 11 356 66761 Laser iridotomy 71 749 71 119 68 701 63 773 63 804 64 204 67 391 76 649 81 621 85 286 66825 Iridectomy, peripheral, for glaucoma 4292 4628 3401 2337 2049 1762 1804 1824 1760 1480 66630 Iridectomy, sector, for glaucoma 550 523 400 314 229 193 235 200 145 174 Iridotomy plus iridectomy, total 76 591 76 270 72 502 66 424 66 082 66 159 69 430 78 673 83 527 86 940 66762 Laser iridoplasty 6261 5914 4670 3274 3212 2897 2987 3428 3515 3338 Total of above procedures 305 450 314 769 256 164 217 041 205 566 195 448 193 552 240 064 287 117 303 948 CPT ⫽ Current Procedural Terminology.
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Ramulu et al 䡠 Utilization of Glaucoma Surgery
Figure 2. Number of laser trabeculoplasties and iridotomies/iridectomies paid for by Medicare, 1995 to 2004.
study period and ranging from 63 773 to 85 286 every year. Over the same period, surgical iridectomies, including peripheral and sector iridectomies, decreased 66%, from a total of 4842 in 1995 to 1654 in 2004. If laser iridotomies and surgical iridectomies are totaled, volume increased 13.5% over the study period (Fig 2). The number of laser trabeculoplasties performed increased 4% from 1995 to 2004, but demonstrated significant trends within the study period. From 1995 to 2001, the number of trabeculoplasties decreased 57%, from a high of 151 244 in 1995 to a low of 75 647 in 2001. From 2001 to 2004, however, the number more than doubled, to 157 490 (Fig 2). The most frequently performed glaucoma surgery between 1995 and 2004 remained trabeculectomy, although the volume of trabeculectomies in eyes without scarring from previous surgery or trauma decreased 53% over the study period, from 51 690 in 1995 to 24 178 in 2004, with most of the change occurring from 1996 to 2001 (Fig 3). The volume of trabeculectomies performed in eyes with scarring from previous surgery or trauma increased 9% over the study period and ranged from 9054 to 13 604 in every year (Fig 3). Fistulization procedures other than trabeculectomy (including the Scheie and Holt procedures and iridencleisis) dropped 83% over the study period, decreasing from 2833 in 1995 to 478 in 2004. The percentage of fistulization procedures not representing trabeculectomy decreased from 4.4% in 1995 to 1.3% in 2004. The volume of 2 other pressure-lowering therapies—aqueous
Figure 3. Number of Medicare-reimbursed trabeculectomies in eyes with and without previous surgery, 1995 to 2004.
Figure 4. Number of Medicare-reimbursed aqueous shunts and cyclophotocoagulations, 1995 to 2004.
shunting procedures and cyclophotocoagulation—increased substantially over the study period (Fig 4). The number of aqueous shunting devices placed rose 184%, from 2728 in 1995 to 7744 in 2004. The number of aqueous shunt revisions also rose a corresponding 130%, from 473 in 1995 to 1091 in 2004. Cyclophotocoagulation likewise rose a dramatic 248% over the study period, from 3264 procedures in 1995 to 11 356 procedures in 2004. The total number of glaucoma-related procedures, as listed in Table 2, decreased 0.5% from 1995 to 2004 (Fig 5). However, from 1995 to 2001 there was a 37% decrease in these glaucomarelated procedures, mostly resulting from decreased numbers of laser trabeculoplasty and primary trabeculectomies. From 2001 to 2005, there was a 57% increase in these glaucoma-related procedures, driven mainly by the increasing number of laser trabeculoplasties performed.
Discussion Several previous publications have looked at the utilization of glaucoma-related procedures in the 1990s.26 –30 None, however, examined any procedures other than laser trabeculoplasty and trabeculectomy. Additionally, limited data have been presented for the period 2001 to 2004, during which the number of laser trabeculoplasties rebounded significantly. Here, we present a detailed assessment of glaucoma-related procedures in Medicare beneficiaries for the decade between 1995 and 2004. We were particularly interested in looking at changes in the volume of laser iridotomy combined with surgical iridectomy, as there were essentially no changes in these procedures from after 1995, nor were there changes in the indications for their usage. Thus, we expected their combined volume to remain roughly proportional to the number of people insured by Medicare. Indeed, the total number of laser iridotomies combined with surgical iridectomies performed for glaucoma increased 13.5% from 1995 to 2004, nearly identical to the 13% increase in Americans over 65 from the closest corresponding census data between 1990 and 2000.4 As the total number of glaucoma procedures listed in Table 2 was basically unchanged over the study period, the actual per capita utilization of these procedures may have decreased.
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Figure 5. Total number of glaucoma-related procedures reimbursed by Medicare, 1995 to 2004. Totals reflect the sum of all glaucoma filtering procedures, aqueous shunting procedures, revisions of aqueous shunting procedures, surgical iridectomies, and the 4 most common laser procedures used in glaucoma (laser trabeculoplasty, laser iridotomy, laser iridoplasty, and cyclophotocoagulation).
Although laser trabeculoplasty and trabeculectomy remained the 2 most common glaucoma procedures during the study period, they both decreased substantially in volume in the late 1990s, driving the overall number of glaucomarelated procedures down by 37% between 1995 and 2001. This trend was previously noted within the U.S. and abroad by several groups.26 –30 The temporal relationship between the dip in trabeculectomy and laser trabeculoplasty numbers and introduction of new medical agents suggests that trabeculectomy and laser trabeculoplasty became less common because of increased utilization of the newly available medical therapy, obviating the need for glaucoma procedures. This idea is further supported by the substantial increase in spending for these newer glaucoma agents at the same time that trabeculectomy and laser trabeculoplasty numbers fell.27,30 Previous publications did not make a distinction between trabeculectomy in eyes without scarring (CPT 66170) and trabeculectomy in eyes with scarring (CPT 66172). Although the overall numbers of trabeculectomy fell from 1995 to 2004, the number of trabeculectomies performed in eyes with scarring increased 9% and showed no decrease from 1995 to 1999. This divergence in trends may reflect an increase in the amount of advanced disease requiring repeat trabeculectomies or a trend towards more aggressive pressurelowering in eyes with advanced disease. Alternately, it may represent a greater percentage of trabeculectomies performed in eyes with other previous ocular surgery, such as cataract removal, vitrectomy, or scleral buckling. More patients may indeed be getting trabeculectomy after previous cataract extraction as a result of (1) more time for cataract formation resulting from the increased efficacy of topical medicines, (2) a tendency away from combined procedures, or (3) delays in referrals to glaucoma specialists from an increasing proportion of primary ophthalmologists who are uncomfortable with glaucoma surgery. However, with most cataract surgery being performed through clear corneal incisions, no conjunctival scarring should be present, and trabeculectomy in such eyes should still fall under the 66170 CPT code (although it is unknown whether physicians code for this correctly). A growing number of patients with advanced glaucoma, more aggressive pressure-lowering treatment regimens, or
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an increasing tendency to treat such patients with procedures other than trabeculectomy could also explain the resurgence of laser trabeculoplasty after 2001, as well as the steady increase in cyclophotocoagulation and aqueous shunting procedures observed throughout the study period. However, technical advances in all these procedures occurred during or just before the study period, and these advances could also have driven their increased utilization. The 2 aqueous shunts most frequently used today—the Baerveldt and Ahmed—were introduced just before the study period (in 1990 and 1993, respectively). The increased number of aqueous shunting procedures observed during the study period might reflect improved efficacy of and/or increased surgeon comfort with these newer devices, particularly in the context of increased trabeculectomy complications noted after the introduction of antimetabolite therapy. Alternately, other surgical advances, such as shunt placement in the posterior subconjunctival space, may have led to a better, more frequently used procedure. It is also possible that the number of patients for which aqueous shunting is the most appropriate procedure increased (i.e., because of a surge in the amount of neovascular glaucoma from the recent epidemic of diabetes). Endoscopic cyclophotocoagulation, until 2005, was coded identically to transscleral cyclophotocoagulation. Thus, the increased number of cyclophotocoagulation procedures may represent an increased amount of external procedures performed in advanced disease or an increasingly popular way to lower eye pressure as part of cataract surgery. Given the large amount of cataract surgery done in patients with glaucoma or ocular hypertension, even a small number of surgeons performing endoscopic cyclophotocoagulation at the time of cataract surgery could result in a large number of these procedures being performed. Indeed, data from over 800 cyclophotocoagulations were recently reported by a single group of physicians [Berke SJ, Sturm RT, Caronia RM, et al. Phacoemulsification combined with endoscopic cyclophotocoagulation (ECP) in the management of cataract and medically controlled glaucoma: a large, long term study. Paper presented at: American Glaucoma Society 16th Annual Meeting, March 2006, Charleston, South Carolina].
Ramulu et al 䡠 Utilization of Glaucoma Surgery The increase in the utilization of laser trabeculoplasty coincides with the introduction and sales growth of a relatively nonthermal selective laser, strongly suggesting that the resurgence of laser trabeculoplasty results from increased use of these newer Q-switched Nd:YAG lasers. Recent data from outside the U.S. have also shown an increased use of laser trabeculoplasty after 2001,31 suggesting that this increase resulted from a new globally available technology rather than a change specific to the U.S. However, it is unknown whether more laser trabeculoplasties are being performed for additional pressure-lowering effect in patients already on topical therapy, as primary therapy in previously untreated patients, or as additional treatments in patients having received prior trabeculoplasty. Given that laser trabeculoplasty can be used in newly diagnosed or early glaucoma, methods for earlier detection and trends towards more aggressive lowering of IOP in early glaucoma may also contribute to its increased utilization. It should be noted that our data set has several limitations. As we are looking at only paid Medicare claims, we exclude most patients under 65, as well as those over 65 receiving their health care outside of Medicare. The exclusion of younger patients may mean that we are examining patients at mostly later stages of disease. Additionally, the percentage of people over 65 having their glaucoma surgery paid for by Medicare may have changed over the study period, creating false trends in the number of procedures performed. We would expect, however, that if this was true, all procedures examined would be affected similarly. Our analysis also assumes that physicians are coding correctly. For example, well over 100 iridencleises were paid for by Medicare over the study period, a number that almost certainly represents miscoding, given the extreme rarity of this procedure. Finally, there is ambiguity inherent in the CPT coding system, limiting the inferences that can be made. For example, laser trabeculoplasty may be performed with thermal (argon or diode) or nonthermal selective lasers, aqueous shunting devices may consist of setons or valveless drainage devices, and cyclophotocoagulation may be performed transsclerally or endoscopically. Our data also demonstrate changing standards in our treatment of glaucoma. Fistulization procedures other than trabeculectomy decreased from 4.1% of all fistulization procedures in 1995 to 1.3% of all fistulization procedures in 2004, suggesting that procedures such as sclerectomy, thermocauterization, and iridencleisis have become outside the standard of care and should be performed only with clear indications. Similarly, the ratio of laser iridotomy to surgical iridectomy increased from 15:1 in 1995 to 52:1 in 2004, suggesting that laser iridotomy has become the standard of care for treatment of or prophylaxis against angle closure. On the other hand, aqueous shunting and cyclophotocoagulation have become increasingly utilized alternatives to trabeculectomy. In 1995, 23 trabeculectomies were performed for every aqueous shunt, and 19 trabeculectomies were performed for every cyclophotocoagulation. By 2004, however, only 4.6 and 3.1 trabeculectomies were performed for every aqueous shunt and cyclophotocoagulation, respectively. Our data strongly suggest that patterns in utilization are shaped more by technological changes than demographic
changes or issues of reimbursement. For example, numbers of laser trabeculoplasties and trabeculectomies experienced very similar decreases in the late 1990s, even though laser trabeculoplasty reimbursement decreased and trabeculectomy reimbursement increased.28 The economic impact of these findings remains unclear. Prior studies have looked at the relative costs of trabeculectomy and medical treatment,32,33 although no study has compared different surgical procedures, and no studies have been performed since the introduction of latanoprost. It is preferable that our most utilized treatments have the strongest evidence justifying their usage. Given the recent increase in the number of laser trabeculoplasties, possibly from nonthermal trabeculoplasty, more evidence needs to be gathered on the efficacy of nonthermal trabeculoplasty and its efficacy relative to traditional laser trabeculoplasty and eyedrops. Similarly, given the increased numbers of aqueous shunting procedures and cyclophotocoagulations being performed, presumably at the expense of treatments such as trabeculectomy, more study needs to be devoted to the relative merits of these procedures. Indeed, some such work is already underway,34,35 and we eagerly await the results of these studies to validate, improve, and guide our practice of glaucoma.
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Ophthalmology Volume 114, Number 12, December 2007 11. Laser trabeculoplasty for primary open-angle glaucoma. Ophthalmology 1996;103:1706 –12. 12. Smith SD, Netland PA. The role of laser trabeculoplasty as primary therapy for open-angle glaucoma. Int Ophthalmol Clin 1994;34(3):149 – 61. 13. AGIS Investigators. The Advanced Glaucoma Intervention Study (AGIS). 4. Comparison of treatment outcomes within race: seven-year results. Ophthalmology 1998;105:1146 – 64. 14. Latina MA, Sibayan SA, Shin DH, et al. Q-switched 532-nm Nd:YAG laser trabeculoplasty (selective laser trabeculoplasty): a multicenter, pilot, clinical study. Ophthalmology 1998;105: 2082– 8, discussion 2089 –90. 15. Juzych MS, Chopra V, Banitt MR, et al. Comparison of long-term outcomes of selective laser trabeculoplasty versus argon laser trabeculoplasty in open-angle glaucoma. Ophthalmology 2004;111:1853–9. 16. Melamed S, Ben Simon GJ, Levkovitch-Verbin H. Selective laser trabeculoplasty as primary treatment for open-angle glaucoma: a prospective, nonrandomized pilot study. Arch Ophthalmol 2003;121:957– 60. 17. Nagar M, Ogunyomade A, O’Brart DP, et al. A randomised, prospective study comparing selective laser trabeculoplasty with latanoprost for the control of intraocular pressure in ocular hypertension and open angle glaucoma. Br J Ophthalmol 2005;89:1413–7. 18. Robin AL, Ramakrishnan R, Krishnadas R, et al. A long-term dose-response study of mitomycin in glaucoma filtration surgery. Arch Ophthalmol 1997;115:969 –74. 19. Khaw PT, Wilkins M. Antifibrotic agents in glaucoma surgery. In: Yanoff M, Duker JS, eds. Ophthalmology. London: Churchill Livingstone; 1999:12.31.1– 88. 20. Freedman J, Rubin B. Molteno implants as a treatment for refractory glaucoma in black patients. Arch Ophthalmol 1991; 109:1417–20. 21. Huang MC, Netland PA, Coleman AL, et al. Intermediateterm clinical experience with the Ahmed Glaucoma Valve implant. Am J Ophthalmol 1999;127:27–33. 22. Mills RP, Reynolds A, Emond MJ, et al. Long-term survival of Molteno glaucoma drainage devices. Ophthalmology 1996; 103:299 –305.
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23. Gayton JL, Van Der Karr M, Sanders V. Combined cataract and glaucoma surgery: trabeculectomy versus endoscopic laser cycloablation. J Cataract Refract Surg 1999;25:1214 –9. 24. Jacobi PC, Dietlein TS. Endoscopic surgery in glaucoma management. Curr Opin Ophthalmol 2000;11:127–32. 25. Lima FE, Magacho L, Carvalho DM, et al. A prospective, comparative study between endoscopic cyclophotocoagulation and the Ahmed drainage implant in refractory glaucoma. J Glaucoma 2004;13:233–7. 26. Albright CD, Schuman SG, Netland PA. Usage and cost of laser trabeculoplasty in the United States. Ophthalmic Surg Lasers 2002;33:334 – 6. 27. Bateman DN, Clark R, Azuara-Blanco A, et al. The effects of new topical treatments on management of glaucoma in Scotland: an examination of ophthalmological health care. Br J Ophthalmol 2002;86:551– 4. 28. Paikal D, Yu F, Coleman AL. Trends in glaucoma surgery incidence and reimbursement for physician services in the Medicare population from 1995 to 1998. Ophthalmology 2002;109:1372– 6. 29. Strutton DR, Walt JG. Trends in glaucoma surgery before and after the introduction of new topical glaucoma pharmacotherapies. J Glaucoma 2004;13:221– 6. 30. Walland MJ. Glaucoma treatment in Australia: changing patterns of therapy 1994-2003. Clin Experiment Ophthalmol 2004;32:590 – 6. 31. Rachmiel R, Trope GE, Chipman ML, et al. Laser trabeculoplasty trends with the introduction of new medical treatments and selective laser trabeculoplasty. J Glaucoma 2006;15: 306 –9. 32. Ainsworth JR, Jay JL. Cost analysis of early trabeculectomy versus conventional management in primary open angle glaucoma. Eye 1991;5:322– 8. 33. Calissendorff BM. Costs of medical and surgical treatment of glaucoma. Acta Ophthalmol Scand 2001;79:286 – 8. 34. Gedde SJ, Schiffman JC, Feuer WJ, et al. The Tube versus Trabeculectomy Study: design and baseline characteristics of study patients. Am J Ophthalmol 2005;140:275– 87. 35. Gedde SJ, Schiffman JC, Feuer WJ, et al. Treatment outcomes in the Tube versus Trabeculectomy Study after one year of follow-up. Am J Ophthalmol 2007;143:9 –22.
Ramulu et al 䡠 Utilization of Glaucoma Surgery Table 1. Number of Glaucoma and Anterior Segment Procedures Paid for by Medicare, 1995 to 2004 Code
Procedure
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
65800 65805 65810 65815 65820 65850 65855 65860 65865 65870 65875 65880 65900 65920 65930 66020 66030 66130 66150 66155 66160 66165 66170 66172 66180 66185 66220 66225 66250 66500 66505 66600 66605 66625 66630 66635 66680 66682 66700 66710 66720 66740 66761 66762 66770
Paracentesis, anterior chamber Paracentesis, release aqueous Paracentesis, remove vitreous Paracentesis, remove blood Goniotomy Trabeculotomy ab externo Trabeculoplasty Sever adhesions, laser Sever adhesions, incisional Sever anterior synechiae Sever posterior synechiae Sever corneovitreal adhesions Remove epithelial downgrowth Remove implanted material, anterior Remove blood clot, anterior segment Inject air or liquid, anterior chamber Inject medication, anterior chamber Remove lesion, sclera Fistulization of sclera, trephination with Fistulization of sclera Fistulization of sclera, sclerectomy with Fistulization of sclera, iridencleisis Trabeculectomy Trabeculectomy, scar tissue Implant aqueous shunt Revise aqueous shunt Repair eye lesion Repair eye lesion with graft Revision operative wound Iridotomy Iridotomy with transfixation Iridectomy, lesion removal Iridectomy, cyclectomy Iridectomy, peripheral Iridectomy, sector Iridectomy, optical Repair iris and ciliary body Suture iris and ciliary body Destruction, ciliary body, diathermy Destruction, ciliary body Destruction, ciliary body, cryotherapy Destruction, ciliary body, cyclodialysis Laser iridotomy Iridoplasty Destruction of iris or ciliary body lesion
1596 2683 1046 590 152 1492 151 244 1715 2122 1363 4234 161 111 2183 486 1892 854 234 694 455 1654 30 51 690 10 366 2728 473 14 285 12 094 399 42 680 46 4292 550 900 2139 1646 357 3264 2127 515 71 749 6261 361
1750 3490 1317 651 92 1896 148 816 1855 2757 2034 5911 214 188 2031 545 1825 1337 297 534 332 1165 44 59 645 13 555 3923 608 22 399 13 573 592 47 419 46 4628 523 832 1652 1864 303 3963 2054 699 71 119 5914 283
1915 3584 1244 713 219 1317 104 579 2121 2514 2379 5879 211 72 1813 505 1861 1037 282 344 224 778 22 49 938 13 604 4580 631 21 447 12 698 607 23 446 39 3401 400 850 1570 1718 274 4292 1837 895 68 701 4670 255
1444 3247 946 588 162 938 91 737 1770 598 1560 4588 138 52 1198 415 1243 721 168 171 185 534 11 35 251 11 178 4149 447 12 335 9060 91 17 198 30 2337 314 712 793 1197 192 3680 1262 452 63 773 3274 241
1317 3687 846 509 964 822 84 511 607 1698 1545 4991 156 51 1194 372 1092 695 178 103 115 401 12 31 365 10 810 4223 625 11 392 8636 128 24 101 20 2049 229 815 616 1122 136 4107 1012 284 63 804 3212 209
1236 4785 806 405 733 570 75 968 1625 1511 1317 4832 192 57 1087 351 1230 594 129 89 107 369 12 29 311 11 413 4726 692 18 450 8618 99 0 79 20 1762 193 751 614 1096 96 3705 865 259 64 204 2897 206
1195 4308 646 457 71 381 75 647 1690 1167 971 3401 154 55 985 368 902 728 125 97 114 307 0 24 800 10 501 4916 728 15 414 8842 114 0 80 20 1804 235 629 580 1025 81 4025 818 237 67 391 2987 285
1814 5612 538 543 86 335 108 202 1680 1001 1024 2364 164 101 986 463 903 862 124 125 81 298 0 25 363 10 928 6307 864 17 394 9881 124 0 87 24 1824 200 463 647 1182 71 5795 811 501 76 649 3428 297
2558 9861 370 638 64 288 144 866 1680 938 1176 2587 172 105 946 450 1042 707 140 119 42 276 15 25 758 11 018 7788 1087 22 499 10 204 136 12 104 24 1760 146 297 664 1139 89 9106 741 472 81 621 3515 263
2543 13,841 536 689 61 340 157 490 2052 869 1245 2713 175 97 976 506 989 806 117 151 49 265 11 24 178 11 333 7744 1091 19 453 10 492 121 10 77 11 1480 174 231 594 1194 89 11 356 681 397 85 286 3338 260
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Glaucoma is the second leading cause of blindness in Caucasians and leading cause of blindness in those of African and Latino descent.1,2 In all ethnic groups, the prevalence of glaucoma increases dramatically with age3—and the United States is aging. From 1950 to 2000, the number of Americans over 65 increased by 50%, and they are expected to Originally received: July 25, 2006. Final revision: February 2, 2007. Accepted: February 4, 2007. Available online: April 26, 2007. Manuscript no. 2006-820. 1 Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland. 2 Corcoran Consulting Group, San Bernardino, California. 3 Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland. Presented at: American Glaucoma Society meeting, March 2006, Charleston, South Carolina. Correspondence and reprint requests to Alan L. Robin, MD, 6115 Falls Road, Suite 333, Baltimore, MD 21209. E-mail: [email protected]. © 2007 by the American Academy of Ophthalmology Published by Elsevier Inc.
increase an additional 67% by 2050.4 As a result, the number of persons with glaucoma has risen and is expected to rise an additional 50% from 2000 to 2020.3 These demographic changes are expected to increase the demand for glaucoma treatments. The utilization of specific glaucoma treatments, however, will be driven not only by demographics, but also by the expansion of the therapeutic options for treating glaucoma. Indeed, all forms of glaucoma treatment—medical therapy, nonpenetrating procedures, and penetrating surgery— have experienced significant advances over the last several years (Fig 1). Medical therapy, which remains the primary method of therapy in most individuals, has seen a dramatic rise in the classes of medications useful for lowering intraocular pressure (IOP). Yet medicines still fail to control IOP for many patients. Forty percent of those receiving treatment of their ocular hypertension as part of the Ocular Hypertension Treatment Study required ⱖ2 medicines to achieve a 20% ISSN 0161-6420/07/$–see front matter doi:10.1016/j.ophtha.2007.02.005
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Ophthalmology Volume 114, Number 12, December 2007 procedure for glaucoma, though it has evolved with the introduction of adjunctive antimetabolite therapy in the early 1990s.18,19 Several surgical alternatives to trabeculectomy have also recently become available. Newer aqueous shunts, including the Baerveldt (1990) and the Ahmed (1993), have provided an option for difficult glaucomas for which trabeculectomy has had poor success rates.20 –22 Endoscopic cyclophotocoagulation has provided another option for reducing IOP, particularly as part of a combined procedure with cataract surgery.23–25 Here, we examine the trends in utilization of the most common glaucoma-related laser and surgical treatments for Medicare beneficiaries over the period 1995 to 2004.
Materials and Methods Figure 1. Timeline of new glaucoma therapeutics, 1990 to present. Nd: YAG ⫽ neodymium:yttrium–aluminum– garnet.
decrease in IOP,5 and 75% receiving treatment of their early to moderate glaucoma as part of the Collaborative Initial Glaucoma Treatment Study required ⬎2 medications to control their IOP adequately over a 5-year period.6 And although more classes of medicines are now available, adding a third or fourth medicine infrequently contributes to a substantial decrease in IOP.7 Thus, there are still a substantial number of people who may fail medical therapy and require other interventions. Laser trabeculoplasty, first introduced almost 30 years ago,8 remains the most frequent nonpenetrating procedure for glaucoma. Over the last 20 years, it has been well validated as both a primary treatment in newly diagnosed glaucoma9 –12 and an adjunct therapy to eyedrops in patients with advanced glaucoma.13 Additionally, a relatively nonthermal, Q-switched, neodymium-doped yttrium–aluminum–garnet (Nd:YAG) laser was recently introduced14 and also shown to be effective at lowering IOP when applied through a contact lens to the trabecular meshwork.15–17 Trabeculectomy remains the most common penetrating
Data points for this retrospective analysis were taken from the files developed by the Health Care Financing Administration, now known as the Centers for Medicare and Medicaid Services. Each file tabulates the number of paid claims to physicians by Current Procedural Terminology (CPT) code for part B services provided to Medicare beneficiaries in a single year. For this analysis, only those CPT codes used to report surgery of the anterior chamber, anterior sclera, iris, and ciliary body were tabulated (Table 1 [available at http://aaojournal.org]). Those CPT codes begin with 65800 and continue through 66770 in sequential order. Particular attention was paid to glaucoma surgery (Table 2). These data are in the public domain, although never more recent than 2 years ago. In 2006, the most recent data available were for 2004. Data for Medicare beneficiaries enrolled in part C, or managed care Medicare, are unavailable and were excluded from this analysis. Likewise, utilization data for non-Medicare beneficiaries are not public and not part of this analysis. Institutional review board approval was not required for this study.
Results The number of the glaucoma surgeries and lasers reimbursed by Medicare from 1995 to 2004 is shown in Table 2. The number of laser iridotomies showed little fluctuation, increasing 18% over the
Table 2. Number of Selected Glaucoma Procedures Paid for by Medicare, 1995 to 2004 CPT
Procedure
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
65855 Laser trabeculoplasty 151 244 148 816 104 579 91 737 84 511 76 968 75 647 108 202 144 866 157 490 66170 Trabeculectomy—no previous surgery 51 690 59 645 49 938 35 251 31 365 29 311 24 800 25 363 25 758 24 178 66172 Trabeculectomy—previous surgery or trauma 10 366 13 555 13 604 11 178 10 810 11 413 10 501 10 928 11 018 11 333 Other fistulization procedures 2833 2075 1368 901 631 577 518 504 452 478 Fistulization procedures, total 64 889 75 276 64 910 47 330 42 806 41 301 35 819 36 795 37 228 35 989 66180 Aqueous shunt to reservoir 2728 3923 4580 4149 4223 4726 4916 6307 7788 7744 66185 Revision of aqueous shunt 473 608 631 447 625 692 728 864 1087 1091 66710 Cyclophotocoagulation 3264 3963 4292 3680 4107 3705 4025 5795 9106 11 356 66761 Laser iridotomy 71 749 71 119 68 701 63 773 63 804 64 204 67 391 76 649 81 621 85 286 66825 Iridectomy, peripheral, for glaucoma 4292 4628 3401 2337 2049 1762 1804 1824 1760 1480 66630 Iridectomy, sector, for glaucoma 550 523 400 314 229 193 235 200 145 174 Iridotomy plus iridectomy, total 76 591 76 270 72 502 66 424 66 082 66 159 69 430 78 673 83 527 86 940 66762 Laser iridoplasty 6261 5914 4670 3274 3212 2897 2987 3428 3515 3338 Total of above procedures 305 450 314 769 256 164 217 041 205 566 195 448 193 552 240 064 287 117 303 948 CPT ⫽ Current Procedural Terminology.
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Ramulu et al 䡠 Utilization of Glaucoma Surgery
Figure 2. Number of laser trabeculoplasties and iridotomies/iridectomies paid for by Medicare, 1995 to 2004.
study period and ranging from 63 773 to 85 286 every year. Over the same period, surgical iridectomies, including peripheral and sector iridectomies, decreased 66%, from a total of 4842 in 1995 to 1654 in 2004. If laser iridotomies and surgical iridectomies are totaled, volume increased 13.5% over the study period (Fig 2). The number of laser trabeculoplasties performed increased 4% from 1995 to 2004, but demonstrated significant trends within the study period. From 1995 to 2001, the number of trabeculoplasties decreased 57%, from a high of 151 244 in 1995 to a low of 75 647 in 2001. From 2001 to 2004, however, the number more than doubled, to 157 490 (Fig 2). The most frequently performed glaucoma surgery between 1995 and 2004 remained trabeculectomy, although the volume of trabeculectomies in eyes without scarring from previous surgery or trauma decreased 53% over the study period, from 51 690 in 1995 to 24 178 in 2004, with most of the change occurring from 1996 to 2001 (Fig 3). The volume of trabeculectomies performed in eyes with scarring from previous surgery or trauma increased 9% over the study period and ranged from 9054 to 13 604 in every year (Fig 3). Fistulization procedures other than trabeculectomy (including the Scheie and Holt procedures and iridencleisis) dropped 83% over the study period, decreasing from 2833 in 1995 to 478 in 2004. The percentage of fistulization procedures not representing trabeculectomy decreased from 4.4% in 1995 to 1.3% in 2004. The volume of 2 other pressure-lowering therapies—aqueous
Figure 3. Number of Medicare-reimbursed trabeculectomies in eyes with and without previous surgery, 1995 to 2004.
Figure 4. Number of Medicare-reimbursed aqueous shunts and cyclophotocoagulations, 1995 to 2004.
shunting procedures and cyclophotocoagulation—increased substantially over the study period (Fig 4). The number of aqueous shunting devices placed rose 184%, from 2728 in 1995 to 7744 in 2004. The number of aqueous shunt revisions also rose a corresponding 130%, from 473 in 1995 to 1091 in 2004. Cyclophotocoagulation likewise rose a dramatic 248% over the study period, from 3264 procedures in 1995 to 11 356 procedures in 2004. The total number of glaucoma-related procedures, as listed in Table 2, decreased 0.5% from 1995 to 2004 (Fig 5). However, from 1995 to 2001 there was a 37% decrease in these glaucomarelated procedures, mostly resulting from decreased numbers of laser trabeculoplasty and primary trabeculectomies. From 2001 to 2005, there was a 57% increase in these glaucoma-related procedures, driven mainly by the increasing number of laser trabeculoplasties performed.
Discussion Several previous publications have looked at the utilization of glaucoma-related procedures in the 1990s.26 –30 None, however, examined any procedures other than laser trabeculoplasty and trabeculectomy. Additionally, limited data have been presented for the period 2001 to 2004, during which the number of laser trabeculoplasties rebounded significantly. Here, we present a detailed assessment of glaucoma-related procedures in Medicare beneficiaries for the decade between 1995 and 2004. We were particularly interested in looking at changes in the volume of laser iridotomy combined with surgical iridectomy, as there were essentially no changes in these procedures from after 1995, nor were there changes in the indications for their usage. Thus, we expected their combined volume to remain roughly proportional to the number of people insured by Medicare. Indeed, the total number of laser iridotomies combined with surgical iridectomies performed for glaucoma increased 13.5% from 1995 to 2004, nearly identical to the 13% increase in Americans over 65 from the closest corresponding census data between 1990 and 2000.4 As the total number of glaucoma procedures listed in Table 2 was basically unchanged over the study period, the actual per capita utilization of these procedures may have decreased.
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Figure 5. Total number of glaucoma-related procedures reimbursed by Medicare, 1995 to 2004. Totals reflect the sum of all glaucoma filtering procedures, aqueous shunting procedures, revisions of aqueous shunting procedures, surgical iridectomies, and the 4 most common laser procedures used in glaucoma (laser trabeculoplasty, laser iridotomy, laser iridoplasty, and cyclophotocoagulation).
Although laser trabeculoplasty and trabeculectomy remained the 2 most common glaucoma procedures during the study period, they both decreased substantially in volume in the late 1990s, driving the overall number of glaucomarelated procedures down by 37% between 1995 and 2001. This trend was previously noted within the U.S. and abroad by several groups.26 –30 The temporal relationship between the dip in trabeculectomy and laser trabeculoplasty numbers and introduction of new medical agents suggests that trabeculectomy and laser trabeculoplasty became less common because of increased utilization of the newly available medical therapy, obviating the need for glaucoma procedures. This idea is further supported by the substantial increase in spending for these newer glaucoma agents at the same time that trabeculectomy and laser trabeculoplasty numbers fell.27,30 Previous publications did not make a distinction between trabeculectomy in eyes without scarring (CPT 66170) and trabeculectomy in eyes with scarring (CPT 66172). Although the overall numbers of trabeculectomy fell from 1995 to 2004, the number of trabeculectomies performed in eyes with scarring increased 9% and showed no decrease from 1995 to 1999. This divergence in trends may reflect an increase in the amount of advanced disease requiring repeat trabeculectomies or a trend towards more aggressive pressurelowering in eyes with advanced disease. Alternately, it may represent a greater percentage of trabeculectomies performed in eyes with other previous ocular surgery, such as cataract removal, vitrectomy, or scleral buckling. More patients may indeed be getting trabeculectomy after previous cataract extraction as a result of (1) more time for cataract formation resulting from the increased efficacy of topical medicines, (2) a tendency away from combined procedures, or (3) delays in referrals to glaucoma specialists from an increasing proportion of primary ophthalmologists who are uncomfortable with glaucoma surgery. However, with most cataract surgery being performed through clear corneal incisions, no conjunctival scarring should be present, and trabeculectomy in such eyes should still fall under the 66170 CPT code (although it is unknown whether physicians code for this correctly). A growing number of patients with advanced glaucoma, more aggressive pressure-lowering treatment regimens, or
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an increasing tendency to treat such patients with procedures other than trabeculectomy could also explain the resurgence of laser trabeculoplasty after 2001, as well as the steady increase in cyclophotocoagulation and aqueous shunting procedures observed throughout the study period. However, technical advances in all these procedures occurred during or just before the study period, and these advances could also have driven their increased utilization. The 2 aqueous shunts most frequently used today—the Baerveldt and Ahmed—were introduced just before the study period (in 1990 and 1993, respectively). The increased number of aqueous shunting procedures observed during the study period might reflect improved efficacy of and/or increased surgeon comfort with these newer devices, particularly in the context of increased trabeculectomy complications noted after the introduction of antimetabolite therapy. Alternately, other surgical advances, such as shunt placement in the posterior subconjunctival space, may have led to a better, more frequently used procedure. It is also possible that the number of patients for which aqueous shunting is the most appropriate procedure increased (i.e., because of a surge in the amount of neovascular glaucoma from the recent epidemic of diabetes). Endoscopic cyclophotocoagulation, until 2005, was coded identically to transscleral cyclophotocoagulation. Thus, the increased number of cyclophotocoagulation procedures may represent an increased amount of external procedures performed in advanced disease or an increasingly popular way to lower eye pressure as part of cataract surgery. Given the large amount of cataract surgery done in patients with glaucoma or ocular hypertension, even a small number of surgeons performing endoscopic cyclophotocoagulation at the time of cataract surgery could result in a large number of these procedures being performed. Indeed, data from over 800 cyclophotocoagulations were recently reported by a single group of physicians [Berke SJ, Sturm RT, Caronia RM, et al. Phacoemulsification combined with endoscopic cyclophotocoagulation (ECP) in the management of cataract and medically controlled glaucoma: a large, long term study. Paper presented at: American Glaucoma Society 16th Annual Meeting, March 2006, Charleston, South Carolina].
Ramulu et al 䡠 Utilization of Glaucoma Surgery The increase in the utilization of laser trabeculoplasty coincides with the introduction and sales growth of a relatively nonthermal selective laser, strongly suggesting that the resurgence of laser trabeculoplasty results from increased use of these newer Q-switched Nd:YAG lasers. Recent data from outside the U.S. have also shown an increased use of laser trabeculoplasty after 2001,31 suggesting that this increase resulted from a new globally available technology rather than a change specific to the U.S. However, it is unknown whether more laser trabeculoplasties are being performed for additional pressure-lowering effect in patients already on topical therapy, as primary therapy in previously untreated patients, or as additional treatments in patients having received prior trabeculoplasty. Given that laser trabeculoplasty can be used in newly diagnosed or early glaucoma, methods for earlier detection and trends towards more aggressive lowering of IOP in early glaucoma may also contribute to its increased utilization. It should be noted that our data set has several limitations. As we are looking at only paid Medicare claims, we exclude most patients under 65, as well as those over 65 receiving their health care outside of Medicare. The exclusion of younger patients may mean that we are examining patients at mostly later stages of disease. Additionally, the percentage of people over 65 having their glaucoma surgery paid for by Medicare may have changed over the study period, creating false trends in the number of procedures performed. We would expect, however, that if this was true, all procedures examined would be affected similarly. Our analysis also assumes that physicians are coding correctly. For example, well over 100 iridencleises were paid for by Medicare over the study period, a number that almost certainly represents miscoding, given the extreme rarity of this procedure. Finally, there is ambiguity inherent in the CPT coding system, limiting the inferences that can be made. For example, laser trabeculoplasty may be performed with thermal (argon or diode) or nonthermal selective lasers, aqueous shunting devices may consist of setons or valveless drainage devices, and cyclophotocoagulation may be performed transsclerally or endoscopically. Our data also demonstrate changing standards in our treatment of glaucoma. Fistulization procedures other than trabeculectomy decreased from 4.1% of all fistulization procedures in 1995 to 1.3% of all fistulization procedures in 2004, suggesting that procedures such as sclerectomy, thermocauterization, and iridencleisis have become outside the standard of care and should be performed only with clear indications. Similarly, the ratio of laser iridotomy to surgical iridectomy increased from 15:1 in 1995 to 52:1 in 2004, suggesting that laser iridotomy has become the standard of care for treatment of or prophylaxis against angle closure. On the other hand, aqueous shunting and cyclophotocoagulation have become increasingly utilized alternatives to trabeculectomy. In 1995, 23 trabeculectomies were performed for every aqueous shunt, and 19 trabeculectomies were performed for every cyclophotocoagulation. By 2004, however, only 4.6 and 3.1 trabeculectomies were performed for every aqueous shunt and cyclophotocoagulation, respectively. Our data strongly suggest that patterns in utilization are shaped more by technological changes than demographic
changes or issues of reimbursement. For example, numbers of laser trabeculoplasties and trabeculectomies experienced very similar decreases in the late 1990s, even though laser trabeculoplasty reimbursement decreased and trabeculectomy reimbursement increased.28 The economic impact of these findings remains unclear. Prior studies have looked at the relative costs of trabeculectomy and medical treatment,32,33 although no study has compared different surgical procedures, and no studies have been performed since the introduction of latanoprost. It is preferable that our most utilized treatments have the strongest evidence justifying their usage. Given the recent increase in the number of laser trabeculoplasties, possibly from nonthermal trabeculoplasty, more evidence needs to be gathered on the efficacy of nonthermal trabeculoplasty and its efficacy relative to traditional laser trabeculoplasty and eyedrops. Similarly, given the increased numbers of aqueous shunting procedures and cyclophotocoagulations being performed, presumably at the expense of treatments such as trabeculectomy, more study needs to be devoted to the relative merits of these procedures. Indeed, some such work is already underway,34,35 and we eagerly await the results of these studies to validate, improve, and guide our practice of glaucoma.
References 1. Eye Diseases Prevalence Research Group. Causes and prevalence of visual impairment among adults in the United States. Arch Ophthalmol 2004;122:477– 85. 2. Rodriguez J, Sanchez R, Munoz B, et al. Causes of blindness and visual impairment in a population-based sample of U.S. Hispanics. Ophthalmology 2002;109:737– 43. 3. Eye Diseases Prevalence Research Group. Prevalence of open-angle glaucoma among adults in the United States. Arch Ophthalmol 2004;122:532– 8. 4. National Center for Health Statistics. Health, United States 2005; with chartbook on trends in the health of Americans. Special feature on adults 55– 64 years. Hyattsville, MD: NCHS; 2005:89. Available at: http://0-www.cdc.gov.mill1.sjlibrary.org/nchs/data/ hus/hus05.pdf. Accessed December 27, 2006. 5. Kass MA, Heuer DK, Higginbotham EJ, et al. The Ocular Hypertension Treatment Study: a randomized trial determines that topical ocular hypotensive medication delays or prevents the onset of primary open-angle glaucoma. Arch Ophthalmol 2002;120:701–13, discussion 829 –30. 6. Lichter PR, Musch DC, Gillespie BW, et al. Interim clinical outcomes in the Collaborative Initial Glaucoma Treatment Study comparing initial treatment randomized to medications or surgery. Ophthalmology 2001;108:1943–53. 7. Neelakantan A, Vaishnav HD, Iyer SA, Sherwood MB. Is addition of a third or fourth antiglaucoma medication effective? J Glaucoma 2004;13:130 – 6. 8. Wise JB, Witter SL. Argon laser therapy for open-angle glaucoma: a pilot study. Arch Ophthalmol 1979;97:319 –22. 9. Glaucoma Laser Trial Research Group. The Glaucoma Laser Trial (GLT). 2. Results of argon laser trabeculoplasty versus topical medicines. Ophthalmology 1990;97:1403–13. 10. Glaucoma Laser Trial Research Group. The Glaucoma Laser Trial (GLT) and Glaucoma Laser Trial follow-up study: 7. Results. Am J Ophthalmol 1995;120:718 –31.
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Ophthalmology Volume 114, Number 12, December 2007 11. Laser trabeculoplasty for primary open-angle glaucoma. Ophthalmology 1996;103:1706 –12. 12. Smith SD, Netland PA. The role of laser trabeculoplasty as primary therapy for open-angle glaucoma. Int Ophthalmol Clin 1994;34(3):149 – 61. 13. AGIS Investigators. The Advanced Glaucoma Intervention Study (AGIS). 4. Comparison of treatment outcomes within race: seven-year results. Ophthalmology 1998;105:1146 – 64. 14. Latina MA, Sibayan SA, Shin DH, et al. Q-switched 532-nm Nd:YAG laser trabeculoplasty (selective laser trabeculoplasty): a multicenter, pilot, clinical study. Ophthalmology 1998;105: 2082– 8, discussion 2089 –90. 15. Juzych MS, Chopra V, Banitt MR, et al. Comparison of long-term outcomes of selective laser trabeculoplasty versus argon laser trabeculoplasty in open-angle glaucoma. Ophthalmology 2004;111:1853–9. 16. Melamed S, Ben Simon GJ, Levkovitch-Verbin H. Selective laser trabeculoplasty as primary treatment for open-angle glaucoma: a prospective, nonrandomized pilot study. Arch Ophthalmol 2003;121:957– 60. 17. Nagar M, Ogunyomade A, O’Brart DP, et al. A randomised, prospective study comparing selective laser trabeculoplasty with latanoprost for the control of intraocular pressure in ocular hypertension and open angle glaucoma. Br J Ophthalmol 2005;89:1413–7. 18. Robin AL, Ramakrishnan R, Krishnadas R, et al. A long-term dose-response study of mitomycin in glaucoma filtration surgery. Arch Ophthalmol 1997;115:969 –74. 19. Khaw PT, Wilkins M. Antifibrotic agents in glaucoma surgery. In: Yanoff M, Duker JS, eds. Ophthalmology. London: Churchill Livingstone; 1999:12.31.1– 88. 20. Freedman J, Rubin B. Molteno implants as a treatment for refractory glaucoma in black patients. Arch Ophthalmol 1991; 109:1417–20. 21. Huang MC, Netland PA, Coleman AL, et al. Intermediateterm clinical experience with the Ahmed Glaucoma Valve implant. Am J Ophthalmol 1999;127:27–33. 22. Mills RP, Reynolds A, Emond MJ, et al. Long-term survival of Molteno glaucoma drainage devices. Ophthalmology 1996; 103:299 –305.
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23. Gayton JL, Van Der Karr M, Sanders V. Combined cataract and glaucoma surgery: trabeculectomy versus endoscopic laser cycloablation. J Cataract Refract Surg 1999;25:1214 –9. 24. Jacobi PC, Dietlein TS. Endoscopic surgery in glaucoma management. Curr Opin Ophthalmol 2000;11:127–32. 25. Lima FE, Magacho L, Carvalho DM, et al. A prospective, comparative study between endoscopic cyclophotocoagulation and the Ahmed drainage implant in refractory glaucoma. J Glaucoma 2004;13:233–7. 26. Albright CD, Schuman SG, Netland PA. Usage and cost of laser trabeculoplasty in the United States. Ophthalmic Surg Lasers 2002;33:334 – 6. 27. Bateman DN, Clark R, Azuara-Blanco A, et al. The effects of new topical treatments on management of glaucoma in Scotland: an examination of ophthalmological health care. Br J Ophthalmol 2002;86:551– 4. 28. Paikal D, Yu F, Coleman AL. Trends in glaucoma surgery incidence and reimbursement for physician services in the Medicare population from 1995 to 1998. Ophthalmology 2002;109:1372– 6. 29. Strutton DR, Walt JG. Trends in glaucoma surgery before and after the introduction of new topical glaucoma pharmacotherapies. J Glaucoma 2004;13:221– 6. 30. Walland MJ. Glaucoma treatment in Australia: changing patterns of therapy 1994-2003. Clin Experiment Ophthalmol 2004;32:590 – 6. 31. Rachmiel R, Trope GE, Chipman ML, et al. Laser trabeculoplasty trends with the introduction of new medical treatments and selective laser trabeculoplasty. J Glaucoma 2006;15: 306 –9. 32. Ainsworth JR, Jay JL. Cost analysis of early trabeculectomy versus conventional management in primary open angle glaucoma. Eye 1991;5:322– 8. 33. Calissendorff BM. Costs of medical and surgical treatment of glaucoma. Acta Ophthalmol Scand 2001;79:286 – 8. 34. Gedde SJ, Schiffman JC, Feuer WJ, et al. The Tube versus Trabeculectomy Study: design and baseline characteristics of study patients. Am J Ophthalmol 2005;140:275– 87. 35. Gedde SJ, Schiffman JC, Feuer WJ, et al. Treatment outcomes in the Tube versus Trabeculectomy Study after one year of follow-up. Am J Ophthalmol 2007;143:9 –22.
Ramulu et al 䡠 Utilization of Glaucoma Surgery Table 1. Number of Glaucoma and Anterior Segment Procedures Paid for by Medicare, 1995 to 2004 Code
Procedure
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
65800 65805 65810 65815 65820 65850 65855 65860 65865 65870 65875 65880 65900 65920 65930 66020 66030 66130 66150 66155 66160 66165 66170 66172 66180 66185 66220 66225 66250 66500 66505 66600 66605 66625 66630 66635 66680 66682 66700 66710 66720 66740 66761 66762 66770
Paracentesis, anterior chamber Paracentesis, release aqueous Paracentesis, remove vitreous Paracentesis, remove blood Goniotomy Trabeculotomy ab externo Trabeculoplasty Sever adhesions, laser Sever adhesions, incisional Sever anterior synechiae Sever posterior synechiae Sever corneovitreal adhesions Remove epithelial downgrowth Remove implanted material, anterior Remove blood clot, anterior segment Inject air or liquid, anterior chamber Inject medication, anterior chamber Remove lesion, sclera Fistulization of sclera, trephination with Fistulization of sclera Fistulization of sclera, sclerectomy with Fistulization of sclera, iridencleisis Trabeculectomy Trabeculectomy, scar tissue Implant aqueous shunt Revise aqueous shunt Repair eye lesion Repair eye lesion with graft Revision operative wound Iridotomy Iridotomy with transfixation Iridectomy, lesion removal Iridectomy, cyclectomy Iridectomy, peripheral Iridectomy, sector Iridectomy, optical Repair iris and ciliary body Suture iris and ciliary body Destruction, ciliary body, diathermy Destruction, ciliary body Destruction, ciliary body, cryotherapy Destruction, ciliary body, cyclodialysis Laser iridotomy Iridoplasty Destruction of iris or ciliary body lesion
1596 2683 1046 590 152 1492 151 244 1715 2122 1363 4234 161 111 2183 486 1892 854 234 694 455 1654 30 51 690 10 366 2728 473 14 285 12 094 399 42 680 46 4292 550 900 2139 1646 357 3264 2127 515 71 749 6261 361
1750 3490 1317 651 92 1896 148 816 1855 2757 2034 5911 214 188 2031 545 1825 1337 297 534 332 1165 44 59 645 13 555 3923 608 22 399 13 573 592 47 419 46 4628 523 832 1652 1864 303 3963 2054 699 71 119 5914 283
1915 3584 1244 713 219 1317 104 579 2121 2514 2379 5879 211 72 1813 505 1861 1037 282 344 224 778 22 49 938 13 604 4580 631 21 447 12 698 607 23 446 39 3401 400 850 1570 1718 274 4292 1837 895 68 701 4670 255
1444 3247 946 588 162 938 91 737 1770 598 1560 4588 138 52 1198 415 1243 721 168 171 185 534 11 35 251 11 178 4149 447 12 335 9060 91 17 198 30 2337 314 712 793 1197 192 3680 1262 452 63 773 3274 241
1317 3687 846 509 964 822 84 511 607 1698 1545 4991 156 51 1194 372 1092 695 178 103 115 401 12 31 365 10 810 4223 625 11 392 8636 128 24 101 20 2049 229 815 616 1122 136 4107 1012 284 63 804 3212 209
1236 4785 806 405 733 570 75 968 1625 1511 1317 4832 192 57 1087 351 1230 594 129 89 107 369 12 29 311 11 413 4726 692 18 450 8618 99 0 79 20 1762 193 751 614 1096 96 3705 865 259 64 204 2897 206
1195 4308 646 457 71 381 75 647 1690 1167 971 3401 154 55 985 368 902 728 125 97 114 307 0 24 800 10 501 4916 728 15 414 8842 114 0 80 20 1804 235 629 580 1025 81 4025 818 237 67 391 2987 285
1814 5612 538 543 86 335 108 202 1680 1001 1024 2364 164 101 986 463 903 862 124 125 81 298 0 25 363 10 928 6307 864 17 394 9881 124 0 87 24 1824 200 463 647 1182 71 5795 811 501 76 649 3428 297
2558 9861 370 638 64 288 144 866 1680 938 1176 2587 172 105 946 450 1042 707 140 119 42 276 15 25 758 11 018 7788 1087 22 499 10 204 136 12 104 24 1760 146 297 664 1139 89 9106 741 472 81 621 3515 263
2543 13,841 536 689 61 340 157 490 2052 869 1245 2713 175 97 976 506 989 806 117 151 49 265 11 24 178 11 333 7744 1091 19 453 10 492 121 10 77 11 1480 174 231 594 1194 89 11 356 681 397 85 286 3338 260
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