Clinical Decisionmaking

Managed care patients with glaucoma are receiving recommended care, but care could be improved in a few areas

Chronic (open-angle) glaucoma, caused by an increase in intraocular pressure (IOP), may produce no symptoms except for gradual loss of peripheral vision over a period of years. For the most part, managed care patients with primary open-angle glaucoma (POAG) are receiving care that is consistent with recommendations of the American Academy of Ophthalmology's Preferred Practice Pattern. However, care is falling short in several key areas. For example, IOP still is not controlled in a significant number of patient visits, according to a study supported by a cooperative agreement between the Agency for Healthcare Research and Quality (HS09942) and the American Association of Health Plans Foundation.

Researchers obtained data from administrative, survey, and eye care records on 395 working-age patients with POAG who were enrolled in six managed care plans across the United States between 1997 and 1999. They assessed processes of care at the initial and followup visits, control of IOP, intervals between visits and visual field tests, and adjustments in therapy. Results revealed that most recommended care processes—visual acuity, IOP, and slitlamp examinations; optic disc and nerve fiber layer evaluation; and fundus evaluation—were performed during 88 to 99 percent of initial evaluations. However, only 53 percent of patients received an optic nerve head photograph or drawing, and only 1 percent had a target IOP level documented.

Recommended care processes were performed at 80 to 97 percent of followup visits. Using loose criteria for IOP control (21 mm Hg or less), IOP was controlled in 66 percent of followup visits for patients with mild glaucoma and 52 percent of visits for patients with moderate to severe glaucoma. Adjustments in therapy were more likely with worse control of IOP, although adjustments occurred in only half of visits where the IOP was 33 mm Hg or higher.

More details are in "Patterns of care for open-angle glaucoma in managed care," by Allen M. Fremont, M.D., Ph.D., Paul P. Lee, M.D., J.D., Carol M. Mangione, M.D., M.S.P.H., and others, in the June 2003 Archives of Ophthalmology 121, pp. 777-783.

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