PURPOSE To evaluate geographic variation and characterize the relative contributions of patient characteristics, physician practice, and geographic region on variation in primary rhegmatogenous retinal detachment (RRD) management. DESIGN Retrospective claims-based analysis. PARTICIPANTS Commercially insured patients with incident RRD diagnosed between 2008 and 2016 (12 779 patients). METHODS We determined whether patients underwent primary RRD repair within 60 days of diagnosis and identified repair type. We characterized physicians using physician identifier variables and characterized geography by Combined Statistical Areas or Core-Based Statistical Area. We used multilevel mixed effects logistic regression models to evaluate patient-, physician-, and geographic-level variation in whether patients underwent RRD repair and used multilevel mixed effects multinomial models to characterize variation in repair type. For each model, we evaluated patient fixed effects and physician random effects nested within geographic random effects. We estimated intraclass correlation coefficients and variance partition coefficients, respectively, to compare relative contributions of patient, physician, and geography to overall variation. MAIN OUTCOME MEASURES Odds ratios for RRD repair and variation estimates for patient, physician, and geography. RESULTS Most incident RRD patients received treatment within 60 days post-diagnosis. Pars plana vitrectomy was most common (49%), followed by laser barricade (23%), scleral buckle and pneumatic retinopexy (both 11%), and cryotherapy (5%). Physician-level variation showed greater impact on receipt of any treatment than geographic-level variation (estimated variance coefficients of 1.09 and 0.32, respectively). Patient-level characteristics represented approximately 82% of overall variation in receipt of any repair, versus 16% from physician-level and 2% from geographic-level factors. Among RRD patients who underwent repair, estimated variance coefficients were 0.07 for geography and 3.37 for physician. Physician-level factors represented approximately 50% of total variation in repair type, followed by patient-level (49%), and geographic-level (1%) factors. CONCLUSIONS Rhegmatogenous retinal detachment repair decisions are influenced by patient-level and physician-level factors, less so by geographic variation. Patient characteristics account for most of the variation in receipt of repair, and physician practice accounts for most of the variation in choice of procedure. These findings indicate a need for additional studies to understand drivers behind differences in care and clinical outcomes and to identify barriers in access to care.

中文翻译：

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患者，医师和地理因素对原发性血源性视网膜脱离管理变化的相对影响。

目的评估地理变异并描述患者特征，医师实践和地理区域对原发性视网膜源性视网膜脱离（RRD）管理变异的相对贡献。设计回顾性基于索赔的分析。参与者2008年至2016年间诊断为RRD事件的商业保险患者（12 779名患者）。方法我们确定患者在诊断后60天内是否进行了RRD初次修复，并确定了修复类型。我们使用医师标识符变量对医生进行了特征描述，并通过组合统计区域或基于核心的统计区域对地理特征进行了描述。我们使用了多级混合效应Logistic回归模型来评估患者，医师，患者是否接受RRD修复以及使用多级混合效应多项式模型来表征修复类型的差异以及地理级别的差异。对于每个模型，我们评估了患者固定效应和嵌套在地理随机效应内的医生随机效应。我们分别估计了类内相关系数和方差分配系数，以比较患者，医师和地理位置对总体变化的相对贡献。主要观察指标RRD修复，患者，医师和地理区域估计值的比值比。结果大多数事件RRD患者在诊断后60天内接受了治疗。平面pars玻璃体切除术最为常见（49％），其次是激光路障（23％），巩膜扣和气压性视网膜手术（均为11％）和冷冻疗法（5％）。与地理水平的变化相比，医师水平的变化对接受任何治疗的影响更大（估计方差系数分别为1.09和0.32）。患者水平的特征约占任何修receipt总变化的82％，而医师水平的占16％，地理水平的因素占2％。在接受修复的RRD患者中，地理估计变异系数为0.07，医生估计变异系数为3.37。医师级别的因素占修复类型总变化的大约50％，其次是患者级别的因素（49％）和地理级别的因素（1％）。结论血源性视网膜脱离的修复决定受患者水平和医师水平因素的影响，而不受地理差异的影响较小。病人特征是导致修receipt情况变化的主要因素，而医生的执业则是造成手术选择变化的主要因素。这些发现表明需要进行更多的研究，以了解造成护理和临床结果差异的驱动因素，并确定获得护理的障碍。