Purpose
To determine if there are variations in regional practice patterns for retinal detachment repair in the United States.
Design
Retrospective, noninterventional, cross-sectional study.
Methods
Year 2009 Medicare fee-for-service claims for retinal detachment repair were aggregated in 4 geographic regions and evaluated. The relative preference for retinal detachment repair by pars plana vitrectomy, scleral buckling, and pneumatic retinopexy was analyzed.
Results
The Midwest demonstrated a greater preference for scleral buckling compared to all other regions ( P < .01) and lower preference for pars plana vitrectomy relative to the South and West ( P ≤ .02). The Northeast demonstrated a greater preference for pneumatic retinopexy when compared to all other regions ( P < .01). The Northeast also revealed a trend toward a lower preference for pars plana vitrectomy compared to the West and South ( P ≤ .08).
Conclusion
There are statistically significant variations in regional practice patterns for retinal detachment repair. The West, despite its historical association with pneumatic retinopexy, did not demonstrate a greater preference for the surgical technique.
In the United States, national practice patterns for retinal detachment repair are well described in the literature. Numerous studies have demonstrated steep declines in stand-alone scleral buckling accompanied by a significant rise in pars plana vitrectomy procedures. Employment of other techniques for retinal detachment repair, including pneumatic retinopexy, cryotherapy, and endolaser, appear relatively stable.
Regional differences in practice patterns for retinal detachment repair in the United States are unclear. A survey of Vitreous Society members in 1990, conducted 4 years after the introduction of pneumatic retinopexy, demonstrated no geographic trends when evaluating surgeon preference between scleral buckling and pneumatic retinopexy. A survey of Vitreous Society and Retina Society members in 1991 identified increased use of pneumatic retinopexy in California and Florida. A follow-up survey of Vitreous Society and Retina Society members in 1997 corroborated a west coast preference (California, Oregon, Washington, Hawaii) for pneumatic retinopexy. The survey also identified lower use of pneumatic retinopexy in north central states (Illinois, Idaho, Michigan, Minnesota, Wisconsin, Iowa, Kansas, Missouri, and Nebraska). Regional variation with other surgical techniques such as scleral buckling and pars plana vitrectomy are poorly described in the literature.
The purpose of this study was to identify any differences in regional practice patterns for retinal detachment repair in the United States.
Methods
The 2009 Medicare Part B Carrier Summary Data File and Part B National Summary Data File were downloaded from the Centers for Medicare and Medicaid Services websites ( http://www.cms.gov/NonIdentifiableDataFiles/04_5_PartBCarrierSummaryDataFile.asp#TopOfPage and http://www.cms.gov/NonIdentifiableDataFiles/03_PartBNationalSummaryDataFile.asp#TopOfPage ; accessed March 31, 2011). These data files are in the public domain and the most recent available data was for 2009. These files are also limited to Medicare Fee-For-Service (FFS) Part B Physician/Supplier data and do not include data from Medicare managed care or non-Medicare plans.
The number of allowed services, allowed charges, and payment amounts was determined for each Medicare carrier (Medicare Part B Carrier Summary Data File) and on a national level (Part B National Summary Data File) for Current Procedural Terminology (CPT) codes 67110 (pneumatic retinopexy), 67107 (scleral buckling), and 67108 (pars plana vitrectomy). Other CPT codes for repair of retinal detachment were excluded since the purpose of the study was to examine practice patterns for retinal detachments that were not repairable by simple application of cryotherapy or laser (CPT 67101 and 67105), were not reoperations (CPT 67112), and were not complex (CPT 67113).
For privacy purposes, Medicare carriers do not report the number of procedures performed in their region for a specific CPT code if fewer than 11 procedures were performed. However, Medicare carriers do report the corresponding charges and payments for such services. To estimate the number of unreported procedures performed in such cases, the total payment for services provided was divided by the average payment per service. The average payment per service was determined by dividing the total payment for known procedures by the total number of known procedures by Medicare carriers.
Data from each Medicare carrier were pooled into 4 geographic groups for regional analysis, as defined by the National Census Bureau website ( http://www.census.gov/geo/www/us_regdiv.pdf , accessed March 31, 2011). The groups consisted of the Northeast (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont, New Jersey, New York, and Pennsylvania), Midwest (Illinois, Indiana, Michigan, Ohio, Wisconsin, Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and South Dakota), South (Delaware, District of Columbia, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, West Virginia, Alabama, Kentucky, Mississippi, Tennessee, Arkansas, Louisiana, Oklahoma, and Texas), and West (Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming, Alaska, California, Hawaii, Oregon, and Washington). Statistical analysis was performed on 2 datasets: 1) procedures directly reported by Medicare carriers (Part B Carrier Summary Data, which excludes procedures done in carrier regions reporting fewer than 11 procedures for a specific CPT code); and 2) estimated number of procedures using extrapolated data to account for unreported procedures (Part B Carrier Summary Data and calculated number of unreported cases). Subgroup analysis was performed for the Pacific region of the West (defined by the National Census Bureau as Alaska, California, Hawaii, Oregon, and Washington).
Numerical computations were performed using a spreadsheet package (Excel 2003; Microsoft, Redmond, Washington, USA). Statistical comparison of categorical findings was performed using χ 2 analysis.
Results
The number of retinal detachment procedures for Medicare beneficiaries in each region is summarized in Table 1 . To protect the privacy of beneficiaries, Medicare carriers do not report the number of procedures performed for a specific CPT code in their region if fewer than 11 procedures were performed. The results in Table 1 include only procedures directly reported by Medicare carriers. χ 2 analysis was conducted to identify any difference in regional preference for retinal detachment repair. The Northeast demonstrated a greater preference for pneumatic retinopexy compared to all other regions (17% of cases in the Northeast compared to 14% of cases in all other regions; P < .01). The Midwest had a greater preference for scleral buckling compared to all other regions (15% of cases in the Midwest compared to 10% of cases in the Northeast, 9% of cases in the South, and 10% of cases in the West; P < .01) and also demonstrated a preference against pars plana vitrectomy relative to the South and West (71% of cases in the Midwest compared to 76% of cases in the South and 77% of cases in the West; P ≤ .01). The Pacific region did not demonstrate any procedural preference for retinal detachment repair compared to the aggregate national preference ( P = .39).
| Number of Procedures (%) | |||
|---|---|---|---|
| Pneumatic Retinopexy | Scleral Buckling | Pars Plana Vitrectomy | |
| Region | (CPT 67110) | (CPT 67107) | (CPT 67108) |
| Northeast | 648 (17) b | 371 (10) | 2701 (73) |
| Midwest | 655 (14) | 672 (15) c | 3192 (71) d |
| South | 1303 (14) | 857 (9) | 6889 (76) |
| West | 593 (14) | 413 (10) | 3319 (77) |
| Total | 3199 (15) | 2313 (11) | 16 101 (74) |
a Includes all Medicare Fee-For-Service procedures with the exception of procedures from carrier regions with fewer than 11 procedures for a specific CPT code.
b Higher proportion of retinal detachments repaired by pneumatic retinopexy compared to all other regions ( P < .01).
c Higher proportion of retinal detachments repaired by scleral buckle compared to all other regions ( P < .01).
d Lower proportion of retinal detachments repaired by pars plana vitrectomy compared to the South and West ( P ≤ .01).
Table 2 reports on the total number of retinal detachment procedures for Medicare beneficiaries in each region using: 1) data reported directly from Medicare carriers ( Table 1 ); and 2) extrapolated data to account for unreported cases by Medicare carriers with fewer than 11 procedures for a specific CPT code (see Methods). Statistical analysis on the extrapolated data ( Table 2 ) demonstrated similar findings to the analysis on data reported directly by Medicare carriers ( Table 1 ). The Northeast demonstrated a preference for pneumatic retinopexy compared to all other regions (17% of cases in the Northeast compared to 14% of cases in all other regions; P < .01) and a trend toward lower use of pars plana vitrectomy compared to the South and West (72% of cases in the Northeast compared to 76% of cases in the South and West; P ≤ .08). The Midwest demonstrated a greater preference for scleral buckling compared to all other regions (15% of cases in the Midwest compared to 11% of cases in the Northeast and 10% of cases in the South and West; P < .01) and a lower preference for pars plana vitrectomy compared to the South and West (71% of cases in the Midwest compared to 76% of cases in the South and West; P ≤ .02).
| Number of Procedures (%) | |||
|---|---|---|---|
| Pneumatic Retinopexy | Scleral Buckling | Pars Plana Vitrectomy | |
| Region | (CPT 67110) | (CPT 67107) | (CPT 67108) |
| Northeast | 662 (17) a | 411 (11) | 2712 (72) b |
| Midwest | 655 (14) | 673 (15) c | 3192 (71) d |
| South | 1304 (14) | 897 (10) | 6889 (76) |
| West | 610 (14) | 435 (10) | 3319 (76) |
| Total | 3233 (15) | 2417 (11) | 16 112 (74) |
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