As liability costs increase and statutes of limitations for liability are extended, many ophthalmologists who could treat retinopathy of prematurity patients are abandoning the practice, a recent survey found.
The survey, conducted by the American Academy of Ophthalmology, showed that only half of all pediatric and retina subspecialists currently evaluate and treat retinopathy of prematurity (ROP). That number has dropped over the past 10 years, and one-fifth of those who still manage ROP said they plan to stop treating ROP in the future, according to the survey results.
“We can’t get people to do these exams,” Michael X. Repka, MD, of the Wilmer Eye Institute in Baltimore, told Ocular Surgery News. “At the hospitals around the city, neonatologists are scrambling to find somebody to do the exams.”
Robert S. Gold, MD, OSN Pediatrics/Strabismus Section Editor, said, “The treatment of retinopathy of prematurity has changed dramatically over the 20 years that I have been in practice. Due to the medicolegal climate surrounding ROP care, the responsibility of continuity of this care has been transferred from the parents to the doctors, including neonatologists, pediatric ophthalmologists and retina specialists.”
The AAO survey suggests that the transfer of responsibility referred to by Dr. Gold has led many ophthalmologists to stop practicing ROP care.
“It is driving many away from contributing to preserve the vision of our smallest patients,” Dr. Gold said.
Rare and difficult disease
Dr. Repka explained that ROP is not commonly treated in most hospital nurseries and, due to the premature age and size of the patients, is difficult to treat even with new technology.
“Babies who are born prematurely, less than 31 weeks, start getting examinations at 4 to 6 weeks of life,” he said. “There is a series of examinations for the premature baby, generally in the hospital, and on average they’re every 2 weeks starting at 4 to 5 weeks of life.”
The American Academy of Pediatrics has recently updated its guidelines for managing ROP, he added. The AAO said ROP threatens the vision of 80,000 premature infants annually, and about 600 are blinded by the disease.
“There are various types of premature retinal diseases,” Dr. Repka said. “Some of those occur and resolve nearly 100% of the time, but in a small proportion, the disease causes progressive neovascularization of the retina, which, because of hemorrhage or contraction of the scar, goes on to cause blindness.”
Today more infants are treated for ROP than were treated 10 years ago due to evolving treatment guidelines based on studies such as the Early Treatment of Retinopathy of Prematurity study, Dr. Gold explained.
“A little over a year ago, new criteria to treat progressing cases of ROP earlier than previous recommendations made it clear that we must be more aggressive and proactive to treat these cases to hope for a positive visual outcome or face possible consequences,” Dr. Gold said.
Even with improved treatment guidelines, around 12% of children end up with vision of 20/200 or worse, the legal definition of blindness in most states.
“The birth weight of the baby who gets the disease is smaller than it was 10 years ago,” Dr. Repka said. “There are more (ROP cases), but it’s mostly because there are more premature survivors at the lower end of the weight scale.”
Downturn in physicians
Due to liability concerns, the complex scheduling necessary for care of these young children and poor reimbursement levels, more than half of the pediatric ophthalmologists and retina subspecialists surveyed said they either have stopped performing ROP care already or will in the near future.
The AAO survey showed that half of the doctors who no longer take ROP cases made the decision to stop the practice within the past 10 years.
Of their reasons for doing so, 67% cited medical liability, including the high cost of insurance, 50% cited the complexity of scheduling care for children and 37% cited poor reimbursement.
“The problem has come about from two things: One, there have been large settlements against nurseries, universities, hospitals and ophthalmologists over poor outcomes,” Dr. Repka said. “In addition, in most nurseries the disease is fairly uncommon, so experience outside of the tertiary care centers is low.”
Dr. Repka said the acceptance of an effective treatment of ROP is no guarantee of success. “Even with the current treatments, we still have a failure rate,” he said.
In addition, blindness or poor vision can result because of missed examinations, failure to communicate between the neonatologist and the ophthalmologist who is doing the exam or failure to follow the published guidelines.
Dr. Repka said there have been a number of lawsuits regarding ROP care — with sums awarded in the multimillion dollar range, according to the AAO — that have had a stifling effect on the medical community.
The AAO plans to share the results of its survey with Congress in hopes of illustrating the need for medical malpractice reform, according to the press release.
Until then, Dr. Repka advised physicians still treating ROP to have an excellent communication system for monitoring ROP patients in conjunction with neonatologists and nursery staff, and to follow the published guidelines precisely.
Dr. Gold echoed this sentiment, noting that the recently updated guidelines “put a more exacting burden on all of us to follow these suggestions to the letter or face possible consequences.”
For more information:
- Michael X. Repka, MD, can be reached at 233 Wilmer Ophthalmological Institute, 600 N. Wolfe St, John Hopkins Hospital, Baltimore, MD 21287; 410-955-8314; fax: 410-955-0809;.
- Robert S. Gold, MD, can be reached at 225 W. State Road 434, Suite 111, Longwood, FL 32750; 407-767-6411; fax: 407- 767-8160.
- Katrina Altersitz is an OSN Staff Writer who covers all aspects of ophthalmology.
- Michael Piechocki is Managing Editor of OSNSuperSite.com. He writes daily updates on developments in all aspects of ophthalmology.