Effect of cataract surgery volume constraints on recently graduated ophthalmologists: a population-based cohort study

Background — Across Canada, graduates from several medical and surgical specialties have recently had difficulty securing practice opportunities, especially in specialties dependent upon limited resources. In most developed nations, cataract surgery is the most common operation performed, making practice opportunities sensitive to access to health system resources and making this procedure an exemplar of issues facing resource-intensive specialties.

Methods — We used population-based administrative data from Ontario for the period Jan. 1, 1994, to June 30, 2013, to compare health services provided by recent graduates and established ophthalmologists. The primary outcome was volume of cataract surgery, a resource-intensive service for which volume is controlled by the province.

Results — When cataract surgery volume in Ontario entered a period of government-mandated zero growth in 2007, the mean number of cataract operations performed by recent graduates dropped significantly (-46.37 operations/quarter, 95% confidence interval [CI] -62.73 to -30.00 operations/quarter), whereas the mean rate for established ophthalmologists remained stable (+5.89 operations/quarter, 95% CI 95% CI -1.47 to +13.24 operations/quarter). Decreases in service provision among recent graduates did not occur for services without volume control. The proportion of recent graduates providing exclusively cataract surgery increased over the study period, and recent graduates in this group were 5.24 times (95% CI 2.15 to 12.76 times) more likely to fall within the lowest quartile for cataract surgical volume during the period of zero growth in provincial cataract volume (2007-2013) than in the preceding period (1996-2006).

Interpretation — Recent ophthalmology graduates performed many fewer cataract surgery procedures after volume controls were implemented in Ontario. Integrated initiatives involving multiple stakeholders are needed to address the issues facing recently graduated physicians in Canada.