Glaucoma
June 2022
by Liz Hillman
Editorial Co-Director
Having a growth mindset throughout one’s career is important, according to Nathan Radcliffe, MD. But there is discernment and a process that affects when to learn new techniques and adopt new technologies.
Dr. Radcliffe said when he finished his glaucoma fellowship, he hadn’t performed MIGS at all. Now, he’s adopted all of the newer MIGS options.
“The focus of my career surgically is something that I wasn’t trained to do in fellowship. This highlights the value of taking a perpetual look at your career, and I think that if 3 months have gone by and I’m in the operating room and haven’t found something new to incorporate, changed a technique, talked to a colleague about a better way to do things, I’m slipping behind,” Dr. Radcliffe said. “We’re fortunate to have change and evolution in our treatments. That’s going to help our field and our patients in the long run. I think having a growth mindset approach to adopting new glaucoma procedures is incredibly valuable.”
Dr. Radcliffe and Constance Okeke, MD, spoke with EyeWorld about their process and considerations when it comes to bringing in new options that could enhance patient care in their glaucoma practices.
EyeWorld: How do you know when to adopt a new technology or technique? What is the onboarding process like?
Dr. Radcliffe: I think a lot of the decisions in when to adopt new technology vary from doctor to doctor, and it’s a disposition that may relate more to our personality characteristics. Some are early adopters and have an itch that needs to be scratched in making sure they’ve tried all the available options, and there are some who vary only a little from their residency training throughout their career. It has to do with your attitude toward rocking the boat and trying new things.
In glaucoma, I think there is a general feeling that we need innovation because we are so keenly aware that our current treatment options are never quite sufficient. They get better every year, they get safer every year, but we know we haven’t cured the disease yet, so we want to keep trying new things. For some doctors, the recommendation of a colleague will be very important. … Relationships can go a long way here as well. I think there is a true value that device representatives from the companies provide because they aren’t just there to push products, they help with education, they have training labs, there are tangible benefits that these representatives bring. The other thing is they get to spend time in the operating room with surgeons and they often have a lot of experience to share. So talking with representatives about complications, how to handle problems, even in some cases how to handle billing and coding, all of these conversations are beneficial.
Dr. Okeke: When it comes to adopting a new glaucoma treatment, sometimes I may be involved with clinical trials and have the ability to get some experience with it, which can make it easier to adopt when it comes out commercially. There are instances where I may want to adopt a new technology earlier, but I might be stalled due to poor insurance coverage or limitations for various reasons in my current practice. There are also times when I’m not yet sold on where I can see the new technology fitting in my practice. The easier I can see a new glaucoma treatment fitting in my practice, the earlier I am to adopt it.
If I have interest in adopting a device, there are a series of steps in the onboarding process. Before even getting the chance to learn the technique and master it over time, the device will need to be vetted for insurance coverage. There will be a short trial of a few patients to confirm coverage with everyone on board from the clinic staff to the surgical staff to the medical/surgical device representative all set on a specific start date. If [a device is] something that I think will be great for my patient population, the sooner I get access to it the better, but sometimes there is a device that I might have had access to through clinical trials/research, so I might be ready to adopt it right away. Insurance coverage can be a limiting factor for early adoption as well.
Source (all): Constance Okeke, MD
EyeWorld: How does training/learning curve affect bringing in a new treatment option?
Dr. Radcliffe: The procedures that are more straightforward and have a shorter learning curve will be adopted more quickly. Some of the treatments that require more patients and nuance can be valuable for doctors and can often pay off when newer procedures come around. I think when it comes to MIGS, learning all the different approaches makes it easier when newer approaches come out because they all share certain characteristics. As we all know with MIGS, the most important skill you can acquire is to have excellent visualization, so if you’ve been doing some sort of complicated MIGS, it’s likely you’ve gotten good at gonioscopy. Having learned that skill will shorten every other learning curve you have in your career.
Dr. Okeke: If I’m eager about the device, the training process will not be a deterrent. I welcome a well thought out training program with video instruction, wet labs, and live surgical trainer instruction. It always helps to make the process smoother for me.
EyeWorld: Is staffing a consideration?
Dr. Radcliffe: For the most part, MIGS today require very little help from our technical staff. But there have been some in the past where staff have to play a more active role, and I do think having more than one person in the OR who needs to be knowledgeable does limit this technology.
Dr. Okeke: If more staff training is required in order to bring in a new technology, that can be a rate limiting step. Given staff shortages recently, we need to make sure the practice is running well and patients are being taken care of, so heavy staff training requirements may delay the start date of new technology.
EyeWorld: Does patient preference ever drive adopting a new treatment option?
Dr. Radcliffe: In terms of patient preferences on these treatments, there are a few things patients tend to hone in on. They do notice if a stent is left behind. I would say patients are 50/50 on whether they would prefer to have a stent because of their positive affiliation with heart disease, or if they would prefer to not have something left behind in their eye, and ultimately I think most patients will look to the doctor for their advice. Laser is generally looked upon with favor by patients, but some are concerned. With all of these, I think most of the time, the patient is looking for a recommendation.
Dr. Okeke: Fortunately, through my practice, I’m able to stay up to date with current technologies as they come out, so it’s rare for a patient to come in requesting a technology that we don’t have access to. However, if it does come up that patients are requesting something that is within one’s reach to be able to provide, that can drive the desire to adopt new technology or get training for it.
EyeWorld: What are the reimbursement considerations that go into adopting new treatment options?
Dr. Radcliffe: Reimbursement considerations do matter in a variety of ways. Sometimes insurances simply won’t pay for certain procedures. That’s an issue I deal with quite a bit in New York City, and I have no choice but to adapt. It’s not reasonable to ask patients to pay out of pocket when the alternative options are so similar, so you simply have to do the best procedure that the insurance company is allowing you to do and in some cases explaining that to the patient, if you’ve had to make a change.
Dr. Okeke: If it’s an old code vs. a new code, old codes are more desirable because they’re more stable and reimbursement is less questionable. The newer codes can take some time to be adopted. … Reimbursement delays can sometimes slow down the onset of starting a device. It’s now routine for us to go through who will be best covered by this device and trial those limited insurances to make sure that with the particular procedure, the reimbursement will come back and be paid adequately. Once that happens, we can establish a level of experience with the device and reimbursement and go full speed ahead.
Case examples
Dr. Okeke shared a couple of examples of how she’s brought new treatment options into her practice. She said the XEN Gel Stent (Allergan), for example, came out with a new code, presenting a problem for reimbursement. She also said she was initially deterred from adopting the technology because of hearing about the high needling rate.
“Because of my busy practice, the idea of having to do a lot of needling was not something I was excited about,” she said.
But after learning from others’ experience, more research, more time on the market, and other pearls, she later adopted it, and it has become a useful tool in her practice. She said she’s become quite experienced with the device and has begun teaching about it with videos and at conferences.
“I’m now doing that procedure quite a bit and getting outcomes I’m happy with. This is a good example of a device that we had to pause on initially for about a year; after we knew the reimbursement was going to be acceptable and I had learned more about the surgical technique from others, I was ready to adopt it. Then once I did, I was comfortable mastering it and offering it to patients quite readily,” Dr. Okeke said.
Durysta (bimatoprost, Allergan) is another example. She said that surgeon interest is ultimately what drove its adoption in the practice. They had a trial for the practice but had some difficulty collecting patients, so it was smaller than anticipated. There was also confusion with billing, there were staffing and management changes in the process, and challenges due to COVID-19 didn’t help.
“We had to reinvent the wheel and start all over. The timeframe of being able to adopt it took more than a year, but it goes to the interest of the surgeons; we kept persisting in our interest to adopt it. That’s why it eventually came to the point where we were able to bring it on board,” she said.
About the physicians
Constance Okeke, MD
Assistant Professor of Ophthalmology
Eastern Virginia Medical School
Norfolk, Virginia
Nathan Radcliffe, MD
New York Ophthalmology
New York Eye Surgery Center
New York, New York
Relevant disclosures
Okeke: Alcon, Allergan, Glaukos, MST, Nova Eye Medical, New World Medical, Sight Sciences
Radcliffe: Alcon, Allergan, Glaukos, New World Medical, Sight Sciences
Contact
Okeke: iglaucoma@gmail.com
Radcliffe: drradcliffe@gmail.com
