Outlier ophthalmologists in the treatment of neovascular age-related macular degeneration with intravitreal therapy

Background To compare individual ophthalmologists grouped as outliers or non-outliers based on the mean 12-month visual acuity (VA) outcomes for their patients with neovascular age-related macular degeneration (nAMD). Methods This prospectively designed database study included treatment-naïve eyes with nAMD starting vascular endothelial growth factor inhibitors between July 2018 and April 2023 in Australia. Ophthalmologists were classified into high outliers, non-outliers and low outliers with a funnel plot of the adjusted mean 12-month VA change. The number of injections, last injection interval and proportion of visits where choroidal neovascularisation was active were compared between the groups. Results 38 ophthalmologists who treated a total of 1266 eyes (male, 35%; mean age, 81 years old) were classified into 1 high outlier, 34 non-outliers and 3 low outliers (mean VA change, 7.5, 5.1 and 2.5 letters, respectively). The high outlier gave significantly more injections than the non-outliers (mean, 8.6 vs 7.7; p<0.001), while the low outliers administered significantly fewer injections than the non-outliers (mean, 7.1 vs 7.7; p=0.009). The last injection interval was shortest in the high outlier’s eyes (9.4 weeks), followed by non-outliers’ (10.8 weeks; p=0.04 (vs high outlier’s)) and low outliers’ (11.8 weeks; p=0.22 (vs non-outliers’)). The low outliers’ patients had more visits with intraretinal fluid (59%) than non-outliers’ (29%; p<0.001) and high outlier’s patients (31%; p<0.001). Conclusion The low outliers’ eyes had fewer injections, a longer treatment interval and more visits with intraretinal fluid. Building a system through which low outliers are anonymously notified of their performance would help improve general quality of care.