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Patterns and Disparities in Recorded Gonioscopy During Initial Glaucoma Evaluations in the US
TAKE-HOME MESSAGE
- An analysis of a large database of healthcare claims revealed that only 20.4% of patients who were initially diagnosed with glaucoma received gonioscopy on the same day of diagnosis, with only 29.5% of patients receiving gonioscopy within the first 6 months after diagnosis. Patients with narrow angles were more likely to have had gonioscopy. This finding is surprising in light of the clear recommendations by both the American Academy of Ophthalmology and the World Glaucoma Association.
- This report highlights the significantly low rate of gonioscopy as part of the diagnostic workup for glaucoma.
abstract
This abstract is available on the publisher's site.
Access this abstract now Full Text Available for ClinicalKey SubscribersPURPOSE
To assess patterns in gonioscopy during initial glaucoma evaluations in the United States.
DESIGN
Retrospective, case-control study.
METHODS
Patients undergoing initial glaucoma evaluation between 2009-2020 were identified in the Optum Clinformatics® DataMart. Initial evaluation was defined as: 1) glaucoma suspect, anatomical narrow angle (ANA), or primary/secondary glaucoma diagnosed by an ophthalmologist; 2) continuously observable during a 36-month lookback period; 3) no history of glaucoma medications, laser, or surgical procedures; 4) OCT or visual field performed within 6 months of initial diagnosis. Logistic regression models were developed to identify factors associated with no record of gonioscopy based on Current Procedural Terminology (CPT) codes.
RESULTS
Among 198,995 patients, 20.4% and 29.5% had recorded gonioscopy on the day of diagnosis or within 6 months, respectively. On multivariable analysis, odds of recorded gonioscopy within 6 months of initial evaluation was lower (p<0.001) among non-Hispanic Whites (OR=0.84) but similar for Blacks (OR=1.02) and Hispanics (OR=0.96) compared to Asians. Age over 60 years (OR<0.82), pseudophakia/aphakia (OR=0.58), or residence outside of the Northeast region (OR=0.66-0.84) conferred lower odds of recorded gonioscopy (p<0.001). Angle closure glaucoma (OR=0.85), secondary glaucoma (OR=0.31), or open angle glaucoma/suspect (OR=0.12/0.24, respectively) patients were less likely to have recorded gonioscopy compared to ANA patients (p<0.01).
CONCLUSIONS
Over 70% patients undergoing initial glaucoma evaluation in the United States do not have record of gonioscopy, especially elderly, non-Hispanic White, and pseudophakic patients in non-Northeast regions. This pattern does not conform to current practice guidelines and could contribute to misdiagnosed disease and suboptimal outcomes.
Additional Info
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Patterns and Disparities in Recorded Gonioscopy During Initial Glaucoma Evaluations in the United States
Am J Ophthalmol 2024 Feb 27;[EPub Ahead of Print], LJ Hui, Y Kristy, I Khristina, A Galo, T Brian, S Carina, X BenjaminFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
The authors used the Optum® Clinformatics® DataMart to evaluate the use of gonioscopy in 198,995 patients who underwent initial glaucoma evaluation between 2009 and 2020. Gonioscopy was performed in 20.4% of patients at initial presentation, increasing to 29.5% within 6 months of initial presentation.
Multivariable and univariable analyses showed that patients aged 60 years and older had a statistically significant lower rate of recorded gonioscopy within 6 months of initial glaucoma diagnosis than those younger than 60 years of age (P < .001). Similarly, non-Hispanic Whites demonstrated a statistically significant lower likelihood of receiving gonioscopy compared with Asian Americans (P < .001). Patients who resided outside the Northeast region also showed a statistically significant lower rate of documented gonioscopy when compared with patients who lived in the Northeast (P < .001).
Hui et al noted that, instead of relying on gonioscopy, clinicians might have relied on the Van Herick test findings or the hyperopic refractive error. They hypothesized that this was a "cognitive bias — a shortcut taken by the brain to expedite medical decisions." This, combined with the longer time at the slit lamp, resulted in reduced use of the procedure.
The study by Hui et al showed that the rate of use of gonioscopy within 6 months of glaucoma diagnosis was comparable in Asian Americans (35.3%), Hispanics (32.7%), and Blacks (32.6%) but lower in non-Hispanic Whites (27.9%). The difference in gonioscopy rates between Asian Americans and non-Hispanic Whites was statistically significant (OR, 0.84; P < .001). Hui et al noted that "recent studies reported a higher risk of blindness and need for glaucoma surgery among Blacks and Hispanics with primary angle-closure glaucoma than among non-Hispanic White" patients. They postulated that this discrepancy was owing to "suboptimal access to care — well-documented in many facets of medical care for racial minorities — rather than the quality of care received"; I disagree with their viewpoint. My hypothesis is that, although Asian Americans, Hispanics, and Blacks had comparable rates of gonioscopy, the higher rates of blindness and need for glaucoma surgery in these two groups were probably owing to a lack of education and low income. Patients might be diagnosed with a condition; however, if there is a poor understanding on the patient's part, the probability of the patient returning for care may be low. The authors had financial and educational data on all patients; however, there was no mention of whether these variables influenced patient follow-up.
Hui et al should have also plotted the use of anterior segment optical coherence tomography over the same time period. It is quite possible that clinicians might be foregoing gonioscopy in lieu of anterior segment optical coherence tomography; however, this has not been well-documented. Still, it does not change the authors' conclusion that more than 70% of patients who present for an initial glaucoma evaluation do not undergo gonioscopy.