Ophthalmic drop waste due to self-imposed use cessation dates.

Self-imposed use cessation dates for multi-use eye drop bottles lead to significant drug waste and increased costs. We quantified the residual medication in eye drop bottles across three clinics in an academic ambulatory setting.

Outcomes and variables that impact pneumatic retinopexies.

AIM: To evaluate the efficacy of pneumatic retinopexy (PR) in patients undergoing PR as primary treatment for rhegmatogenous retinal detachment (RRD) and analyze the factors associated with success and failure in the studied population. METHODS: A retrospective chart review was done of patients with RRD treated with PR as primary management method treated at New York Eye and Ear Infirmary of Mount Sinai between January 2017 and December 2021. Primary outcome measured success or failure of PR. Secondary outcome measured best corrected visual acuity (BCVA) after PR. A separate risk analysis was done to identify and stratify risks associated with success and failure of PR. RESULTS: A total of 179 eyes from 179 patients were included for final analysis. The 83 patients (46.37%) achieved anatomical reattachment of the retina after primary PR with no need for additional surgery. The 96 patients (53.63%) had a failed primary PR and required a PPV and 6 of them required pars plana vitrectomy (PPV) with scleral buckle (SB). In total, 19 cases (10.61%) were done as temporizing pneumatics, 18 (94.74%) underwent PPV, and 1 (5.26%) did not require further intervention. The visual acuities at postoperative month 1 (POM1) for patients who underwent primary PR successfully and for those that underwent PPV after, were 0.58 (20/80) and 1.03 (20/200) respectively. Patients who met Pneumatic Retinopexy Versus Vitrectomy for the Management of Primary Rhegmatogenous Retinal Detachment Outcomes Randomized Trial (PIVOT) criteria had a statistically significant decreased risk of primary PR failing (hazard ratio 0.29, P=0.00). Majority of missed or new breaks were found superotemporally. CONCLUSION: PR is a good treatment option for treating RRDs in patients that meet PIVOT criteria and can be conducted as a temporizing measure. PIVOT criteria and fovea on status decrease the risk of PR failure.

Genomic Surveillance of SARS-CoV-2 Sequence Variants at Universities in Southwest Idaho.

Although the impact of the SARS-CoV-2 pandemic on major metropolitan areas is broadly reported and readily available, regions with lower populations and more remote areas in the United States are understudied. The objective of this study is to determine the progression of SARS-CoV-2 sequence variants in a frontier and remote intermountain west state among university-associated communities. This study was conducted at two intermountain west universities from 2020 to 2022. Positive SARS-CoV-2 samples were confirmed by quantitative real-time reverse transcription-polymerase chain reaction and variants were identified by the next-generation sequencing of viral genomes. Positive results were obtained for 5355 samples, representing a positivity rate of 3.5% overall. The median age was 22 years. Viral genomic sequence data were analyzed for 1717 samples and phylogeny was presented. Associations between viral variants, age, sex, and reported symptoms among 1522 samples indicated a significant association between age and the Delta variant (B 1.167.2), consistent with the findings for other regions. An outbreak event of AY122 was detected August-October 2021. A 2-month delay was observed with respect to the timing of the first documented viral infection within this region compared to major metropolitan regions of the US.

Gentrification as a Factor in the Incidence of Firearm Injuries.

Importance: Firearm injuries are an epidemic in the US; more than 45 000 fatal injuries were recorded in 2020 alone. Gaining a deeper understanding of socioeconomic factors that may contribute to increasing firearm injury rates is critical to prevent future injuries. Objective: To explore whether neighborhood gentrification is associated with firearm injury incidence rates over time. Design, Setting, and Participants: This cross-sectional study used nationwide, urban US Census tract-level data on gentrification between 2010 and 2019 and firearm injuries data collected between 2014 and 2019. All urban Census tracts, as defined by Rural Urban Commuting Area codes 1 to 3, were included in the analysis, for a total of 59 379 tracts examined from 2014 through 2019. Data were analyzed from January 2022 through April 2023. Exposure: Gentrification, defined to be an area in a central city neighborhood with median housing prices appreciating over the median regional value and a median household income at or below the 40th percentile of the median regional household income and continuing for at least 2 consecutive years. Main Outcomes and Measures: The number of firearm injuries, controlling for Census tract population characteristics. Results: A total of 59 379 urban Census tracts were evaluated for gentrification; of these tracts, 14 125 (23.8%) were identified as gentrifying, involving approximately 57 million residents annually. The firearm injury incidence rate for gentrifying neighborhoods was 62% higher than the incidence rate in nongentrifying neighborhoods with similar sociodemographic characteristics (incidence rate ratio [IRR], 1.62; 95% CI, 1.56-1.69). In a multivariable analysis, firearm injury incidence rates increased by 57% per year for low-income Census tracts that did not gentrify (IRR, 1.57; 95% CI, 1.56-1.58), 42% per year for high-income tracts that did not gentrify (IRR, 1.42; 95% CI, 1.41-1.43), and 49% per year for gentrifying tracts (IRR, 1.49; 95% CI, 1.48-1.50). Neighborhoods undergoing the gentrification process experienced an additional 26% increase in firearm injury incidence above baseline increase experienced in neighborhoods not undergoing gentrification (IRR, 1.26; 95% CI, 1.23-1.30). Conclusions and Relevance: Results of this study suggest that gentrification is associated with an increase in the incidence of firearm injuries within gentrifying neighborhoods. Social disruption and residential displacement associated with gentrification may help explain this finding, although future research is needed to evaluate the underlying mechanisms. These findings support use of targeted firearm prevention interventions in communities experiencing gentrification.

Financial Health of Private Equity-Backed Groups: Perspectives From Eye Care.

BACKGROUND: In private equity (PE) buyouts of medical practices, it is common for the PE firm to raise significant levels of debt in order to finance the purchase. This debt is subsequently shouldered by the acquired practice(s). There remains a scarcity of literature quantifying the effect of PE acquisition on the subsequent financial performance of eye care practices. We aim to identify and characterize debt valuations of ophthalmology and optometry private equity-backed group (OPEG) practices, which serve as an indicator of practice financial performance. METHODS: A cross-sectional study from March 2017 to March 2022 was conducted using business development company (BDC) quarterly/annual filings to the Securities and Exchange Commission (SEC). The 2021 BDC Report was used to identify all BDCs actively filing annual reports (Form 10-Ks) and quarterly reports (Form 10-Qs) in the United States in 2021. The public filings of BDCs lending to OPEGs were searched from the inception of the OPEG's debt instrument in a BDC's portfolio and the amortized cost and fair value of each debt instrument were tabulated. A panel linear regression was used to evaluate temporal changes in OPEG valuations. RESULTS:  A total of 2,997 practice locations affiliated with 14 unique OPEGs and 17 BDCs were identified over the study period. Debt valuations of OPEGs decreased by 0.46% per quarter over the study period (95% CI: -0.88 to -0.03, P = 0.036). In the COVID-19 pre-vaccine period (March 2020 to December 2020), there was an excess (additional) 4.93% decrease in debt valuations (95% CI: -8.63 to -1.24, P = 0.010) when compared to pre-pandemic debt valuations (March 2017 to December 2019). Effects of COVID-19 on valuations stabilized during the pandemic post-vaccine period (February 2021 to March 2022), with no change in excess debt valuation compared to pre-pandemic baseline (0.60, 95% CI: -4.59 to 5.78, P = 0.822). There was an increase in practices that reported average discounted debt valuations from 20 practices (1.6%) associated with one OPEG to 1,213 practices (40.5%) associated with nine OPEGs (including 100% of newly acquired practices), despite the stabilization of COVID-19-related excess (additional) debt. CONCLUSIONS: Debt valuations of eye care practices have declined significantly post-PE investment from March 2017 to March 2022, suggesting that the financial health of these groups is volatile and vulnerable to economic contractions such as the COVID-19 pandemic. Eye care practice owners must consider long-term financial risks and impacts of subsequent patient care when selling their practice to a private equity group. Future research should assess the impact of secondary transactions of OPEGs on the financial health of practices, practitioner lifestyle, and patient outcomes.

Epidemiology of rhegmatogenous retinal detachment in commercially insured myopes in the United States.

Myopia is a known risk factor for rhegmatogenous retinal detachment (RRD). Given global trends of increasing myopia, we aimed to determine the absolute risk (incidence rate) of RRD in non-myopes, myopes and high myopes in the United States over ten years. We performed a retrospective cohort study of 85,476,781 commercially insured patients enrolled in the Merative™ Marketscan® Research Database. The incidence rate of RRD in phakic patients in the United States was 39-fold higher in high myopes than non-myopes (868.83 per 100,000 person-years versus 22.44 per 100,000 person-years) and three-fold higher in myopes than non-myopes (67.51 per 100,000 person-years versus 22.44 per 100,000 person-years). The incidence rate was significantly higher in males in each category (P < 0.01). Combined, the incidence rate of RRD in phakic patients in the United States from 2007 to 2016 was 25.27 RRDs per 100,000 person-years, a rate higher than those in prior published studies in North America, South America, Europe, Asia, and Australia. The absolute risk of myopia and high myopia increased from 2007 to 2016. The risk of RRD in phakic high myopes rose with increasing age. Notably, the magnitude of increased risk of RRD in myopes varied substantially according to the minimum follow-up period in our models and should be accounted for when interpreting data analyses.

The Impact of Redlining on Modern-Day Firearm Injuries: A Nationwide Study of Federal Policy.

OBJECTIVES: To evaluate whether exposure to the United States discriminatory housing practice of redlining, which occurred in over 200 cities in the 1930s, is associated with modern-day, community-level incidence of firearm injury. BACKGROUND: Firearm violence is a public health epidemic within the United States. Federal policies are crucial in both shaping and reducing the risk of firearm violence; identifying policies that might have contributed to risks also offers potential solutions. We analyzed whether 1930s exposure to the discriminatory housing practices that occurred in over 200 US cities was associated with the modern-day, community-level incidence of firearm injury. METHODS: We performed a nationwide retrospective cohort study between 2014 and 2018. Urban Zip Code Tabulation Areas (ZCTAs) historically exposed to detrimental redlining (grades C and D) were matched to unexposed ZCTAs based on modern-day population-level demographic characteristics (ie, age, Gini index, median income, percentage Black population, and education level). Incidence of firearm injury was derived from the Gun Violence Archive and aggregated to ZCTA level counts. Our primary outcome was the incidence of firearm injury, modeled using zero-inflated negative binomial regression. RESULTS: When controlling for urban firearm risk factors, neighborhoods with detrimental redlining were associated with 2.6 additional firearm incidents annually compared with nonredlined areas with similar modern-day risk factors. Over our study period, this accounts for an additional 23,000 firearm injuries. CONCLUSIONS: Historic, discriminatory Federal policies continue to impact modern-day firearm violence. Policies aimed at reversing detrimental redlining may offer an economic means to reduce firearm violence.

Private equity in ophthalmology and optometry: a time series analysis from 2012 to 2021.

Purpose: To identify temporal and geographic trends in private equity (PE)-backed acquisitions of ophthalmology and optometry practices in the United States from 2012 to 2021. Methods: In this cross-sectional time series, acquisition data from 10/21/2019 to 9/1/2021 and previously published data from 1/1/2012 to 10/20/2019 were analyzed. Acquisition data were compiled from 6 financial databases, 5 industry news outlets, and publicly available press releases. Linear regression models were used to compare rates of acquisition. Outcomes included number of total acquisitions, practice type, locations, provider details, and geographic footprint. Results: A total of 245 practices associated with 614 clinical locations and 948 ophthalmologists or optometrists were acquired by 30 PE-backed platform companies between 10/21/2019 and 9/1/2021. Of 30 platform companies, 18 were new vis-à-vis our prior study. Of these acquisitions, 127 were comprehensive practices, 29 were retina practices, and 89 were optometry practices. From 2012 to 2021, monthly acquisitions increased by 0.947 acquisitions per year (P < 0.001*). Texas, Florida, Michigan, and New Jersey were the states with the greatest number of PE acquisitions, with 55, 48, 29, and 28 clinic acquisitions, respectively. Average monthly PE acquisitions were 5.71 per month from 1/1/2019 to 2/29/2020 (pre-COVID), 5.30 per month from 3/1/2020 to 12/31/2020 (COVID pre-vaccine [P = 0.81]), and 8.78 per month from 1/1/2021 to 9/1/2021 (COVID post-vaccine [P = 0.20]). Conclusions: PE acquisitions increased during the period 2012-2021 as companies continue to utilize regionally focused strategies for acquisitions.

Fall risk in patients with pseudophakic monovision.

OBJECTIVE: Vision changes can precipitate falls in the elderly resulting in significant morbidity and mortality. We hypothesized that pseudophakic monovision and ensuing anisometropia and aniseikonia impact elderly fall risk. This study assessed fall risk in patients with pseudophakic monovision, pseudophakic single vision distance (classic cataract surgery), and cataracts with no surgery. DESIGN: Retrospective single-institution cohort study PARTICIPANTS: Patients with bilateral cataracts diagnosed at 60 years of age or older who underwent bilateral cataract surgery (monovision or single vision distance) or did not undergo any cataract surgery (n = 13 385). Patients with unilateral surgery or a fall prior to cataract diagnosis were excluded. METHODS: Data were obtained from the Stanford Research Repository. Time-to-fall analysis was performed across all 3 groups. Primary outcome was hazard ratio (HR) for fall after second eye cataract surgery or after bilateral cataract diagnosis. RESULTS: Of 13 385 patients (241 pseudophakic monovision, 2809 pseudophakic single vision, 10 335 no surgery), 850 fell after cataract diagnosis. Pseudophakic monovision was not associated with fall risk after controlling for age, sex, and myopia. Pseudophakic single-vision patients had a decreased time to fall compared with no-surgery patients (log rank, p < 0.001). Older age at cataract diagnosis (HR =1.05, 95% confidence interval [CI] 1.04-1.06, p < 0.001) or at time of surgery (HR = 1.05, 95% CI 1.03-1.07, p < 0.001) increased fall risk, as did female sex (HR = 1.29, 95% CI 1.10-1.51, p = 0.002) and preexisting myopia (HR = 1.31, 95% CI 1.01-1.71, p = 0.046) among nonsurgical patients. CONCLUSIONS: Pseudophakic monovision did not impact fall risk, but pseudophakic single vision may increase falls compared with patients without cataract surgery.

Time to Treatment of Pediatric Retinal Detachments: A US Claims-based Analysis.

PURPOSE: To characterize delays in diagnosis and treatment of retinal detachments (RDs) in a pediatric population. DESIGN: Retrospective cohort study using insurance claims data. SUBJECTS: Pediatric patients with RD who underwent repair in the outpatient setting. METHODS: A retrospective analysis of commercially insured patients from a national cohort (IBM MarketScan Research Databases) aged ≤ 18 years with an incident diagnosis of RD between 2007 and 2016. Patients with preceding eye-related visits, time to diagnosis, and time to repair were calculated and compared between patients with pre-existing ocular diagnosis and those without. MAIN OUTCOME MEASURES: The time from diagnosis to specialist consultation, time from diagnosis to repair, time from specialist consultation to repair, number of preceding visits, and presence of previous eye-related diagnosis. RESULTS: Our sample consisted of 826 patients, the majority (77%) of whom were diagnosed with rhegmatogenous RD. Only 40% of patients had at least 1 preceding eye-related visit, and 33% had at least 2 visits before RD diagnosis, with a median time from the last eye-related visit of 32 days (4-197 days) and median time from the second to last visit of 118 days (24-437 days). The median time from RD diagnosis to repair was 2 days (0-9 days). The 323 (37.9%) patients with pre-existing ocular diagnoses more frequently had at least 1 (44% vs. 37%; P = 0.079) or 2 preceding eye-related visits (40% vs. 29%; P = 0.002) compared with those without and also had a shorter time to RD diagnosis (median, 14.5 days vs. 44.5 days; P = 0.011) and repair (1 day vs. 3 days; P = 0.003). CONCLUSIONS: Retinal detachment is an important cause of morbidity in children. This work highlighted how pediatric patients without previous ocular diagnoses and visits with eye care professional may have a delayed diagnosis and repair of their RD. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Utilization of Crowdfunding for Cataract and LASIK Procedures.

PURPOSE: To study the nature of crowdfunding campaigns for common ophthalmologic procedures. METHODS: Cross sectional, retrospective study of campaigns on GoFundMe.com from January 1st, 2021 to July 31st, 2021. All domestic and international campaigns referring to cataract and intraocular lens placement or LASIK procedures, excluding those with non-ophthalmologic conditions or campaigns for multiple conditions. Descriptive analysis of campaigns including condition, country of origin of patient, total and median value raised, total and median value sought, age of the patient, funding goal met, insurance status when possible. Total and median funds raised and sought, international versus domestic campaigns, success rate for campaigns, percent of campaigns involving children, percent of campaigns mentioning insurance. RESULTS: 137 campaigns were identified, 67.9% (93/137) were for cataract and 32.1% (44/137) were for LASIK. 13.1% (18/137) of campaigns were international. 7.3% (10/137) campaigns were successful at reaching fing goals. Of successful campaigns, 70.0% (7/10) were for cataract and 30.0% (3/10) were for LASIK. Total value raised (in USD) was $131,763, where $106,593 was for cataract and $25,170 was for LASIK. The median value sought overall was $5,000, where the median sought for cataract procedures was $5,000 and the median for LASIK was $4,000. The median value raised was $395. 5.8% (8/137) of campaigns mentioned minors. 12.5% (1/8) of campaigns for children or minors successfully met funding goals compared to 7.0% (9/129) adult campaigns. The total funds raised for children or minors was $9,224 with a goal of $41,050. The total funds raised for adults was $122,539 out of a goal of $775,617. 14.6% (20/137) campaigns mentioned insurance coverage, of which 85% (17/20) were for cataract and 15.0% (3/20) were for LASIK. Premium lenses (toric, multifocal, etc.) were mentioned in 1.1% of cataract campaigns (1/93) as being cost prohibitive. CONCLUSIONS: Crowdfunding is ineffective as a means for patients to raise funds for ophthalmic procedures. The broad range of financial requests within campaigns indicates a large patient knowledge gap in cost for procedures.

A new solid target design for the production of 89Zr and radiosynthesis of high molar activity [89Zr]Zr-DBN.

Due to the advent of various biologics like antibodies, proteins, cells, viruses, and extracellular vesicles as biomarkers for disease diagnosis, progression, and as therapeutics, there exists a need to have a simple and ready to use radiolabeling synthon to enable noninvasive imaging trafficking studies. Previously, we reported [89Zr]zirconium-p-isothiocyanatobenzyl-desferrioxamine ([89Zr]Zr-DBN) as a synthon for the radiolabeling of biologics to allow PET imaging of cell trafficking. In this study, we focused on improving the molar activity (Am) of [89Zr]Zr-DBN, by enhancing 89Zr production on a low-energy cyclotron and developing a new reverse phase HPLC method to purify [89Zr]Zr-DBN. To enhance 89Zr production, a new solid target was designed, and production yield was optimized by varying, thickness of yttrium foil, beam current, irradiation duration and proton beam energy. After optimization, 4.78±0.33 GBq (129.3±8.9 mCi) of 89Zr was produced at 40 µA for 180 min (3 h) proton irradiation decay corrected to the end of bombardment with a saturation yield of 4.56±0.31 MBq/µA. Additionally, after reverse phase HPLC purification the molar activity of [89Zr]Zr-DBN was found to be in 165-316 GBq/µmol range. The high molar activity of [89Zr]Zr-DBN also allowed radiolabeling of low concentration of proteins in relatively higher yield. The stability of [89Zr]Zr-DBN was measured over time with and without the presence of ascorbic acid. The newly designed solid target assembly and HPLC method of [89Zr]Zr-DBN purification can be adopted in the routine production of 89Zr and [89Zr]Zr-DBN, respectively.

Incidence of Retinal Artery and Vein Occlusions During the COVID-19 Pandemic.

BACKGROUND AND OBJECTIVE: To examine whether new cases of retinal artery occlusion (RAO) or retinal vein occlusion (RVO) increased during the coronavirus 209 (COVID-19) pandemic. PATIENTS AND METHODS: This was a retrospective cohort study of patients visiting retina clinics with a new diagnosis in two time periods: between January 1, 2019, and February 29, 2020 (the pre-COVID-19 period), and between March 1, 2020, and December 31, 2020 (the COVID-19 period). The key outcome was the percentage of newly diagnosed central RAO (CRAO), branch RAO (BRAO), central RVO (CRVO), and branch RVO (BRVO) seen in each period. RESULTS: The study population included 285,759 new patients in the pre-COVID-19 period and 156,427 new patients in the COVID-19 period. The overall number of new patients dropped dramatically during the first few months of the COVID-19 pandemic (24%, 66%, and 51% less new patients in March, April, and May 2020 than in the same months in 2019; P < .0001 for all 3 months). However, the decrease in the number of newly diagnosed patients with CRAO, CRVO, and BRAO during these months was less dramatic. As most states reopened in June and the number of patients in retina clinics started to increase, the newly diagnosed patients with these conditions as a percentage of all new diagnoses returned to similar trends as seen in the pre-COVID-19 period. CONCLUSIONS: The percentage of new cases of RAO and RVO with respect to all new diagnoses in retina clinics remained stable for the majority of the COVID-19 period. There was an increase in these percentages during the first few months of the COVID-19 pandemic, particularly for CRAO, CRVO, and BRAO, which may have led to the presumption that more patients presented with these conditions during the COVID-19 period evaluated in this study. [Ophthalmic Surg Lasers Imaging Retina. 2022;53:22-30.

Higher prevalence of fundus haemorrhages in early-screened (NEST Study) as compared to late-screened (SUNDROP Study) newborn populations.

BACKGROUND/AIMS: To determine whether timing of ophthalmic screening influences prevalence of neonatal fundus haemorrhages. We compared the prevalence of fundus haemorrhages in two populations: term newborns screened early (less than 72 hours) and preterm newborns screened late (4-11 weeks). Additionally, we reviewed the literature on timing and prevalence of newborn haemorrhages. METHODS: Retrospective observational cohort study. Infants who underwent wide-angle ophthalmic digital imaging over one overlapping year in the Newborn Eye Screen Testing (NEST) or Stanford University Network for Diagnosis of Retinopathy of Prematurity (SUNDROP) programme were included. The PubMed database was filtered to include English-language articles dating back to 1950. Nine articles were selected for review based on inclusion of the prevalence of newborn fundus haemorrhages at multiple time points. RESULTS: A total of 202 patients received early imaging in the NEST cohort and 73 patients received late imaging in the SUNDROP cohort. In the NEST cohort, 20.2% of newborns had haemorrhages. In contrast, we found haemorrhages in only one case or 1.4% of the SUNDROP cohort. Using prevalence data from nine additional studies, we developed a predicted probabilities model of newborn haemorrhages. Per this model, the probability of seeing a haemorrhage if you screen an infant at 1 hour is 18.8%, at 2 weeks is 2.9% and at 1 month is 0.28%. CONCLUSION: We found a significant difference in the prevalence of fundus haemorrhages between the early-screened NEST cohort and the late-screened, preterm SUNDROP cohort. Likely, this difference is due to the transient nature of most newborn haemorrhages.

Visual acuity and progression of macular atrophy in patients receiving intravitreal anti-VEGF for age-related macular degeneration.

PURPOSE: Whether intravitreal anti-vascular endothelial growth factors (VEGFs) cause retinal atrophy is still a subject of debate. We reported 13 eyes that received several injections of anti-VEGF for wet age-related macular degeneration (AMD) with good visual acuity despite geographic atrophy on imaging. METHODS: This is a case series study conducted at Byers Eye Institute at Stanford University. Patients of three retina specialists with wet AMD who received six or more intravitreal injection of anti-VEGFs with visual acuity of 20/60 or better and incomplete RPE and outer retina atrophy (iRORA) or complete RPE and outer retinal atrophy (cRORA) were enrolled in this case series. Different imaging modalities were reviewed by three retina specialists comparing the baseline with the most recent exam. RESULTS: About 13 eyes of 10 patients met the selection criteria. Eleven eyes were classified as iRORA and 2 as cRORA. Despite the development of macular atrophy on imaging after an average of 38.1 injections, eyes maintained stable visual acuity. CONCLUSION: The discrepancy between structural and functional findings in this cohort suggests that patients treated by anti-VEGF drugs exhibit divergent clinical outcomes for currently unknown reasons. The authors propose anti-VEGF may affect melanosomes within RPE without disrupting RPE and photoreceptors function completely. This requires further investigation.

Development of a Knee Arthroplasty Episode-Based Cost Measure for Evaluating Cost in the Merit-Based Incentive Payment System.

BACKGROUND: Under the Merit-based Incentive Payment System (MIPS), the U.S. Centers for Medicare and Medicaid Services (CMS) evaluate clinicians who manage Medicare patients on the basis of cost and quality outcomes. CMS contractor Acumen, LLC, convened an expert panel to develop a knee arthroplasty episode-based cost measure (EBCM) for use in the MIPS. METHODS: A Clinical Subcommittee of 28 clinician experts affiliated with 27 specialty societies provided guidance in developing the knee arthroplasty EBCM. The Clinical Subcommittee specified all aspects of the EBCM including triggering of the episode, services within the episode, risk adjustment, subgrouping, and exclusions. Services were counted only if the Clinical Subcommittee deemed them under the influence of the clinician assigned to the EBCM (selective service assignment; SSA). We assessed the reliability of the EBCM and compared it with an alternative population-based cost measure constructed without SSA. RESULTS: We identified 249,301 knee arthroplasty episodes from June 1, 2016, to May 31, 2017, with 10,681 clinicians having at least 10 attributed episodes. The mean episode cost was $19,321 with a standard deviation of $1,816. SSA increased the reliability score from 0.71 to 0.81 relative to an alternative measure that counted all patient costs. SSA also led to reclassification of 41.8% of clinicians into different quintiles of performance. CONCLUSIONS: We found that the use of SSA in the creation of the EBCM substantially reduces random noise (i.e., unrelated medical procedures or costs) and offers a tool for assessing clinicians' costs of management that is focused on care directly related to knee arthroplasty.

MicroRNA Regulation of Bone Marrow Mesenchymal Stem Cell Chondrogenesis: Toward Articular Cartilage.

The production of a clinically useful engineered cartilage is an outstanding and unmet clinical need. High-throughput RNA sequencing provides a means of characterizing the molecular phenotype of populations of cells and can be leveraged to better understand differences among source cells, derivative engineered tissues, and target phenotypes. In this study, small RNA sequencing is utilized to comprehensively characterize the microRNA transcriptomes (miRNomes) of native human neonatal articular cartilage and human bone marrow-derived mesenchymal stem cells (hBM-MSCs) differentiating into cartilage organoids, contrasting the microRNA regulation of engineered cartilage with that of a promising target phenotype. Five dominant microRNAs are upregulated during cartilage organoid differentiation and disproportionately regulate transcription factors: miR-148a-3p, miR-140-3p, miR-27b-3p, miR-140-5p, and miR-181a-5p. Two microRNAs that dominate the miRNomes of hBM-MSCs, miR-21-5p and miR-143-3p, persist throughout the differentiation process and may limit the ability of these cells to differentiate into an engineered cartilage resembling target native articular cartilage. By using predictive bioinformatics tools and antagomir inhibition, these persistent microRNAs are shown to destabilize the mRNA of genes with known or potential roles in cartilage biology including FGF18, TGFBR2, TET1, STOX2, ARAP2, N4BP2L1, LHX9, NFIA, and RPS6KA5. These results shed light on the extent to which only a few microRNAs contribute to the complex regulatory environment of hBM-MSCs for engineered tissues. Impact statement MicroRNAs are emerging as important controlling elements in the differentiation of human bone marrow-derived mesenchymal stem cells (hBM-MSCs). By using a robust bioinformatic approach and further validation in vitro, here we provide a comprehensive characterization of the microRNA transcriptomes (miRNomes) of a commonly studied and clinically promising source of multipotent cells (hBM-MSCs), a gold standard model of in vitro chondrogenesis (hBM-MSC-derived cartilage organoids), and an attractive in vivo target phenotype for clinically useful engineered cartilage (neonatal articular cartilage). These analyses highlighted a specific set of microRNAs involved in the chondrogenic program that could be manipulated to acquire a more robust articular cartilage-like phenotype. This characterization provides researchers in the cartilage tissue engineering field a useful atlas with which to contextualize microRNA involvement in complex differentiation pathways.

The Utility of Universal Newborn Eye Screening: A Review.

Universal newborn eye screening can identify ocular abnormalities early and help mitigate long-term visual impairment. Traditional neonatal and infant eye screening is administered by neonatologists and pediatricians using the red reflex test. If this test identifies an ocular abnormality, then the patient is examined by an ophthalmologist. Notably, the red reflex test may be unable to detect amblyogenic posterior segment pathology. Recent studies using fundus imaging and telemedicine show reduced cost of human resources and increased sensitivity compared with traditional approaches. In this review, the authors discuss universal newborn eye screening pilot programs with regard to disease prevalence, referral-warranted disease, and cost-effectiveness. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:S6-S16.].

Utilization of Generic Cardiovascular Drugs in Medicare's Part D Program.

BACKGROUND: Generic medications cost less than brand-name medications and are similarly effective, but brand-name medications are still prescribed. We evaluated patterns in generic cardiovascular medication fills and estimated the potential cost savings with increased substitution of generic for brand-name medications. METHODS: This was a cross-sectional study of cardiovascular therapies using the Medicare Part D database of prescription medications in 2017. We evaluated drug fill patterns for therapies with available brand-name and generic options. We determined the generic substitution ratio and estimated the potential savings with increased generic substitution at the national, state, and clinician level. We compared states with laws related to mandatory pharmacist generic substitution and patient consent for substitution. RESULTS: Of ≈$22.9 billion spent on cardiovascular drugs in Medicare Part D prescription programs in 2017, ≈$11.0 billion was spent on medications with both brand-name and generic options. Although only 2.4% of medication fills were for the brand-name choice, they made up 21.2% of total spending. Accounting for estimated brand-name rebates, generic substitution for these medications would save $641 million, including $135 million in costs shouldered by patients. Furthermore, the minority of clinicians with the lowest generic utilization was responsible for a large proportion of the potential cost savings. CONCLUSIONS: There are substantial potential cost savings from substituting brand-name medications with generic medications. These savings would be primarily driven by lower use of brand-name therapies by the minority of clinicians who prescribe them at increased rates.