Procedures, Visits, and Procedure Costs in the Management of Microbial Keratitis.

PURPOSE: To investigate the burden of procedures, visits, and procedure costs in the management of microbial keratitis (MK). METHODS: Medical records of patients from an academic hospital outpatient facility between December 2013 and May 2018 were retrospectively reviewed. Patients were included if they were older than the age of 18 years, recruited for study of likely MK, and not concurrently undergoing treatment for other acute eye conditions. For procedural costs, Medicare data for billing were obtained using the Center for Medicare and Medicaid Services Physician Fee Lookup tool. RESULTS: A total of 68 patients were included for analysis. Patients were on average 51.3 years (SD = 19.5), 55.9% women (n = 38), and 89.7% White (n = 61). Per person, the average number of procedures was 2.9 (SD = 4.2). The average number of visits was 13.9 (SD = 9.2) over an average of 26.9 weeks (SD = 24.3). Age (P < 0.0001), positive Gram stain (P = 0.03), and mixed Gram stain (P = 0.002) were positively associated with the number of procedures. Age (P = 0.0003), fungal keratitis (P = 0.02), and mixed Gram stain (P = 0.01) were positively associated with the number of visits. Race was inversely associated with the number of procedures (P = 0.045) and visits (0.03). Patients with bacterial keratitis were more likely to have amniotic membrane grafts (P = 0.01) and tarsorrhaphies (P = 0.03) than fungal patients. Across all procedures performed for the management of MK, the mean cost per patient was $1788.7 (SD = $3324.62). CONCLUSIONS: Patients incur many procedural costs and attend many visits during the management of MK. These findings emphasize the importance of patient-provider communication for frequent follow-up care and the potential need to perform procedures for disease management.

Cost-Benefit and Cost-Utility Analysis of Amphotericin B Supplementation of Corneal Storage Media With Endothelial Keratoplasty-Prepared Tissue.

PURPOSE: To determine the cost-effectiveness of amphotericin B supplementation, we analyzed both current costs to treat postendothelial keratoplasty (EK) fungal infections and potential costs associated with amphotericin B supplementation. METHODS: We collected 19 US cases of post-EK fungal eye infections from the published literature and assessed the associated costs from the literature. A survey of surgeons was also conducted with questions regarding their experiences in managing these infections. RESULTS: We estimated that the costs to diagnose, manage, and treat post-EK fungal keratitis and post-EK fungal endophthalmitis are USD $21,113 and $34,850, respectively. The largest portion of the costs can be attributed to the need for additional surgical management, which is required in 79% of the cases. We estimated the total cost of amphotericin B supplementation to be $44.39 per graft with use of conventional amphotericin B and conservative assumptions regarding supplementation processes. Cost-effectiveness analysis demonstrated that amphotericin B supplementation is cost-effective at $100,000 per quality-adjusted life-year level only if amphotericin B supplementation can prevent more than 69.62% of post-EK fungal infections, assuming the incidence of post-EK fungal infection remains at the level it was between 2012 and 2017. CONCLUSIONS: We found that amphotericin B supplementation can be cost-effective under conservative assumptions if it is moderately effective in preventing post-EK fungal infections.

Delay Along the Care Seeking Journey of Patients with Microbial Keratitis in Uganda.

Purpose: To describe the care seeking journey and causes of delay among patients with Microbial Keratitis in Uganda. Methods: A prospective cohort of patients presenting with microbial keratitis at the two main eye units in Southern Uganda (2016-2018). We collected information on demographics, home address, clinical history, and presentation pathway including, order of facilities where patients went to seek care, treatment advice, cost of care, and use of Traditional Eye Medicine. Presentation time was noted. We compared "direct" presenters versus "indirect" presenters and analysed predictors of delay. Results: About 313 patients were enrolled. All were self-referred. Only 19% of the patients presented directly to the eye hospital. Majority (52%) visited one facility before presenting, 19% visited two facilities, 9% visited three facilities, and 2% visited four facilities. The cost of care increased with increase in the number of facilities visited. People in a large household, further distance from the eye hospital and those who used Traditional Eye Medicine were less likely to come directly to the eye hospital. Visiting another facility prior to the eye hospital and use of Traditional Eye Medicine aOR 1.58 (95%CI 1.03-2.43), p = .038 were associated with delayed presentation to the eye hospital. Conclusion: This study provided information on patient journeys to seek care. Delay was largely attributable to having visited another health facility: a referral mechanism for microbial keratitis was non-existent. There is need to explore how these health system gaps can be strengthened.

Fungal Keratitis: A Six-Year Review at a Tertiary Referral Centre.

Background This review reports the epidemiology, laboratory results, treatment regimens and costs of fungal keratitis at a tertiary referral center in Lucerne, Switzerland. Patients and Methods Culture-proven fungal infections between January 2010 and December 2015 were reviewed retrospectively. Results Seventeen patients with a mean age of 52 years were identified. Contact lens wear was the most important risk factor (n = 11) (65 % of all cases), with filamentous fungi being identified as the most common fungus type (n = 10) (91 % of all cases of contact lens-associated fungal keratitis). All non-contact lens-associated fungal infections (n = 6) (35 % of all cases) were related to Candida spp. Six patients (35 %) were treated on an outpatient basis; 11 cases (65 %) required hospitalisation. Systemic voriconazole was the treatment regimen prescribed most often (n = 12) (71 %), followed by topical natamycin 5 % (n = 11) (65 %). Corneal crosslinking and penetrating keratoplasty were required in 4 cases each (24 %). One case ended up in enucleation (6 %). Average costs per case were EUR 15 952 for hospitalised patients if surgical intervention was required, and EUR 7415 if no intervention was performed. Average costs for outpatients were EUR 7079. In a majority of cases, visual acuity could be improved (n = 9) (53 %) or preserved (n = 2) (12 %). Conclusion Despite the relatively low incidence of culture-proven keratitis (17 cases in 6 years), a clear pattern with regard to risk factors and fungus species was noted. In the absence of a gold standard for the treatment of fungal keratitis, the combination of systemic voriconazole and topical natamycin seems to be one of the most commonly used antifungal treatment regimens. The costs of outpatient versus inpatient non-surgical treatment were approximately the same.

Outcomes, impact on management, and costs of fungal eye disease consults in a tertiary care setting.

OBJECTIVE: To determine the frequency of clinical management changes resulting from inpatient ophthalmic consultations for fungemia and the associated costs. DESIGN: Retrospective case series. PARTICIPANTS: Three hundred forty-eight inpatients at a tertiary care center between 2008 and 2012 with positive fungal blood culture results, 238 of whom underwent an ophthalmologic consultation. METHODS: Inpatient charts of all fungemic patients were reviewed. Costs were standardized to the year 2014. The Student t test was used for all continuous variables and the Pearson chi-square test was used for categorical variables. MAIN OUTCOME MEASURES: Prevalence of ocular involvement, rate of change in clinical management, mortality rate of fungemic patients, and costs of ophthalmic consultation. RESULTS: Twenty-two (9.2%) of 238 consulted patients with fungemia had ocular involvement. Twenty patients had chorioretinitis and 2 had endophthalmitis. Only 9 patients (3.7%) had a change in management because of the ophthalmic consultation. One patient underwent bilateral intravitreal injections. Thirty percent of consulted patients died before discharge or were discharged to hospice. The total cost of new consults was $36 927.54 ($204.19/initial level 5 visit and $138.63/initial level 4). The cost of follow-up visits was $13 655.44 ($104.24/visit). On average, 26.4 patients were evaluated to find 1 patient needing change in management, with an average cost of $5620.33 per change in 1 patient's management. CONCLUSIONS: Clinical management changes resulting from ophthalmic consultation in fungemic patients were uncommon. Associated costs were high for these consults in a patient population with a high mortality rate. Together, these data suggest that the usefulness of routine ophthalmic consultations for all fungemic patients is likely to be low.

Economic analysis of corneal ulcers in South India.

PURPOSE: To estimate the costs of treating corneal ulcers at a tertiary eye care center in south India from a patient perspective. METHODS: A prospective cohort study design at a tertiary eye care center in south India. Each subject presenting with corneal ulcers to the center had a detailed clinical and laboratory workup including slit-lamp biomicroscopy, direct smear examination with appropriate stains, and cultures. Data on direct costs including costs of consultation, studies to confirm diagnosis, and treatment were collected at baseline and follow-up visits. We also collected indirect costs including travel, accommodation, food, and loss of wages of both the subject and accompanying persons. RESULTS: We recruited 498 consecutive cases for the study. The mean duration of onset of symptoms before presentation at the cornea service was 13.1 +/- 19.9 days. The mean follow-up duration was 34.8 +/- 28.2 days. The total overall cost for accessing and receiving care was 85.8 US dollars +/- 4.6 (95% confidence interval: 76.4 US dollars, 94.6). The mean total cost to diagnose and appropriately treat 1 case of keratitis such that the patient had vision better than 6/18 at final follow-up was 56.2 US dollars +/- 3.6 (95% confidence interval: 49.0 US dollars, 63.3). CONCLUSIONS: : The costs to the patient to receive appropriate care for corneal ulcers in this population are much higher than the average monthly wage for this population. There is an urgent need to devise strategies that may help reduce costs of care for corneal ulcers in this population.

Pharmacotherapy of fungal eye infections.

Fungal eye infections are rare. Trauma associated with contamination by vegetative material, contact lens wear and long term corticosteroid use are common risk factors. The aims of treatment are to preserve visual function, which depends on the rapid diagnosis and efficient administration of appropriate antifungal therapy. This necessitates a clinical suspicion of fungal aetiology and the taking of appropriate smears and cultures as early as possible to identify the fungal organism. Currently there are three main classes of drugs available for use in fungal eye infections: polyenes, azoles as derivatives of imidazoles, and 5-fluorocytosine. Of the polyenes, amphotericin B, natamycin and nystatin are of clinical ophthalmic use. Based on better pharmacokinetic profiles and spectra of antifungal activity, the triazoles are the agents of choice. Successful treatment of fungal keratitis depends on early initiation of specific therapy consisting of topically-applied antifungal agents since topical administration is most likely to provide the best opportunity for achieving therapeutic corneal levels. Hence, the molecular weight of the various antifungal agents is of importance since it influences their ability to penetrate the corneal epithelium. Systemic administration may be necessary for resistant fungal ulcers. For fungal endophthalmitis, to preserve visual function and eliminate the fungal pathogen, topical, systemic and possibly intraocular antifungal therapy is used, although some do not recommend use of systemic agents for exogenous endophthalmitis.

Incremental cost-effectiveness of laser therapy for choroidal neovascularization associated with histoplasmosis.

PURPOSE: Laser photocoagulation has been shown in a large clinical trial to be efficacious in reducing the degree of vision loss occurring secondary to choroidal neovascularization (CNV) associated with ocular histoplasmosis. Nevertheless, data are lacking concerning the impact of the therapy on quality of life and its value to stakeholders in health care. Recently, information concerning the utility value of visual states has become available. Accordingly, the authors undertook to ascertain the cost-effectiveness of laser photocoagulation for the treatment of extrafoveal CNV occurring in eyes with ocular histoplasmosis. METHODS: Design--A computer simulation, econometric model is presented to evaluate the incremental cost-effectiveness of laser photocoagulation therapy, as compared with the natural course of the disease, for the treatment of patients with extrafoveal CNV associated with ocular histoplasmosis. The model applies long-term visual data from previous clinical trials, utility analysis (which reflects patient perceptions of quality of life), decision analysis with Markov modeling, and present value analysis with discounting to account for the time value of money. Outcome measure--Cost per quality-adjusted life-year gained from treatment. RESULTS: Laser photocoagulation therapy for extrafoveal CNV associated with ocular histoplasmosis costs $4167 1999 US dollars (at a 3% discount rate) for each quality-adjusted life-year gained from treatment. Sensitivity analysis shows that changing the discount rate substantially alters the cost-effectiveness, with a value of $1339 at a 0% discount rate and $56,250 at a 10% discount rate. CONCLUSIONS: Compared with therapeutic modalities for other disease entities, laser therapy for the treatment of extrafoveal CNV associated with ocular histoplasmosis appears to be a cost-effective treatment from the patient preference-based point of view.