The Relative Impact of Patient, Physician, and Geographic Factors on Variation in Primary Rhegmatogenous Retinal Detachment Management.
The Relative Impact of Patient, Physician, and Geographic Factors on Variation in Primary Rhegmatogenous Retinal Detachment Management.
复制标题
患者、医生和地理因素对原发性孔源性视网膜脱离治疗变化的相对影响。
DOI：
10.1016/j.ophtha.2019.04.019
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发表时间：
2020
期刊：
影响因子：
13.7
通讯作者：
Afshar,ArminR
中科院分区：
文献类型：
--
作者：
Vail,Daniel;Pershing,Suzann;Reeves,Mary-Grace;Afshar,ArminR
目的评估原发孔源性视网膜脱离(RRD)治疗中患者特征、医生实践和地理区域对差异的相对贡献。设计基于回顾索赔的分析。参与者2008-2016年间诊断为RRD的商业保险患者(12779例)。方法我们确定患者是否在确诊后60天内进行了RRD修复，并确定了修复类型。我们使用医生标识变量来描述医生，并通过组合统计区域或基于核心的统计区域来描述地理位置。我们使用多水平混合效应Logistic回归模型来评估患者、医生和地理水平在患者是否接受RRD修复方面的差异，并使用多水平混合效应多项式模型来表征修复类型的差异。对于每个模型，我们评估了嵌套在地理随机效应中的患者固定效应和医生随机效应。我们分别估计了组内相关系数和方差分配系数，以比较患者、医生和地理位置对总体差异的相对贡献。主要结果衡量RRD修复的ODDS比率和患者、医生和地理位置的差异估计。结果大多数RRD患者在确诊后60天内接受了治疗。最常见的是玻璃体切除(49%)，其次是激光屏障(23%)、巩膜扣带术和气动视网膜固定术(均为11%)和冷凝(5%)。医生水平的差异比地理水平的差异对接受任何治疗的影响更大(估计的差异系数分别为1.09和0.32)。患者水平的特征约占接受任何修复的总变异的82%，而医生水平的特征为16%，地理水平的因素为2%。在接受修复的RRD患者中，地理因素的估计变异系数为0.07，医生因素的估计变异系数为3.37。医生层面的因素约占修复类型总变异的50%，其次是患者层面(49%)和地理层面(1%)。结论孔源性视网膜脱离修复决策受患者层面和医生层面因素的影响较小，受地理变异的影响较小。患者的特征是接受修复的差异的主要原因，而医生的实践是选择手术的差异的主要原因。这些发现表明，需要进行更多的研究，以了解护理和临床结果差异背后的驱动因素，并确定获得护理的障碍。
PurposeTo evaluate geographic variation and characterize the relative contributions of patient characteristics, physician practice, and geographic region on variation in primary rhegmatogenous retinal detachment (RRD) management.DesignRetrospective claims-based analysis.ParticipantsCommercially insured patients with incident RRD diagnosed between 2008 and 2016 (12 779 patients).MethodsWe determined whether patients underwent primary RRD repair within 60 days of diagnosis and identified repair type. We characterized physicians using physician identifier variables and characterized geography by Combined Statistical Areas or Core-Based Statistical Area. We used multilevel mixed effects logistic regression models to evaluate patient-, physician-, and geographic-level variation in whether patients underwent RRD repair and used multilevel mixed effects multinomial models to characterize variation in repair type. For each model, we evaluated patient fixed effects and physician random effects nested within geographic random effects. We estimated intraclass correlation coefficients and variance partition coefficients, respectively, to compare relative contributions of patient, physician, and geography to overall variation.Main Outcome MeasuresOdds ratios for RRD repair and variation estimates for patient, physician, and geography.ResultsMost incident RRD patients received treatment within 60 days post-diagnosis. Pars plana vitrectomy was most common (49%), followed by laser barricade (23%), scleral buckle and pneumatic retinopexy (both 11%), and cryotherapy (5%). Physician-level variation showed greater impact on receipt of any treatment than geographic-level variation (estimated variance coefficients of 1.09 and 0.32, respectively). Patient-level characteristics represented approximately 82% of overall variation in receipt of any repair, versus 16% from physician-level and 2% from geographic-level factors. Among RRD patients who underwent repair, estimated variance coefficients were 0.07 for geography and 3.37 for physician. Physician-level factors represented approximately 50% of total variation in repair type, followed by patient-level (49%), and geographic-level (1%) factors.ConclusionsRhegmatogenous retinal detachment repair decisions are influenced by patient-level and physician-level factors, less so by geographic variation. Patient characteristics account for most of the variation in receipt of repair, and physician practice accounts for most of the variation in choice of procedure. These findings indicate a need for additional studies to understand drivers behind differences in care and clinical outcomes and to identify barriers in access to care.