Utility of Optical Coherence Tomography (OCT) in Centers For Medicare and Medicaid Services (CMS)-defined Severe Glaucoma Patients.

PRECIS: Patients with Centers For Medicare and Medicaid Services (CMS)-defined severe glaucoma often have clinically useful remaining retinal nerve fiber layer (RNFL), suggesting that structurally based rather than functionally based criteria would be more appropriate to use as guidelines for the utilization of optical coherence tomography (OCT) imaging. PURPOSE: RNFL OCT in glaucomatous eyes with advanced structural damage can reach a floor after which there is no further detectable thinning of RNFL. Insurers are considering limiting coverage for OCT in "severe stage glaucoma" defined by CMS. However, CMS definitions of severe glaucoma are based primarily on visual field criteria. Many of these patients may have preserved RNFL in other sectors. This study aims to assess the clinical utility of RNFL measurements by OCT in eyes with CMS-defined severe glaucoma. PATIENTS AND METHODS: Medical records of patients with CMS-defined severe glaucoma were consecutively reviewed. Data collected included average/sectoral RNFL thickness, and visual field mean deviation. Previous estimates of RNFL floor and test-retest variability for Cirrus OCT were used to establish 3 threshold values of RNFL. Data analysis included descriptive statistics, χ analysis, and analysis of variance. RESULTS: A total of 129 eyes qualified (age: 71±12 y; mean deviation: -13.5±4.3 dB; average RNFL: 60.9±7.9 µm), A majority (66%) of eyes met severe glaucoma criteria with defects in both hemifields; 34% met only paracentral defect criteria. The proportion of eyes that had significant remaining average, superior, or inferior RNFL, estimated by thresholds 1 to 3, was 21% to 54%, 29% to 51%, and 16% to 37%, respectively. At least 1 vertical quadrant had significant remaining RNFL in 35% to 66% of eyes, depending on the threshold used. CONCLUSIONS: Our data demonstrate a substantial portion of eyes with CMS-defined severe glaucoma have measurable RNFL above the floor in at least 1 vertical quadrant that may be longitudinally monitored for progression. The presence of CMS-defined severe glaucoma does not exclude the potential utility of OCT to monitor progression.

Area-level poverty, race/ethnicity & dialysis star ratings.

The Centers for Medicare and Medicaid Services recently released a five star rating system as part of 'Dialysis Facility Compare' to help patients identify and choose high performing clinics in the US. Eight dialysis-related measures determine ratings. Little is known about the association between surrounding community sociodemographic characteristics and star ratings. Using data from the U.S. Census and over 6000 dialysis clinics across the country, we examined the association between dialysis clinic star ratings and characteristics of the local population: 1) proportion of population below the federal poverty level (FPL); 2) proportion of black individuals; and 3) proportion of Hispanic individuals, by correlation and regression analyses. Secondary analyses with Quality Incentive Program (QIP) scores and population characteristics were also performed. We observed a negligible correlation between star ratings and the proportion of local individuals below FPL; Spearman coefficient, R = -0.09 (p<0.0001), and a stronger correlation between star ratings and the proportion of black individuals; R = -0.21 (p<0.0001). Ordered logistic regression analyses yielded adjusted odds ratio of 0.91 (95% confidence interval [0.80-1.30], p = 0.12) and 0.55 ([0.48-0.63], p<0.0001) for high vs. low level of proportion below FPL and proportion of black individuals, respectively. In contrast, a near-zero correlation was observed between star ratings and the proportion of Hispanic individuals. Correlations varied substantially by country region, clinic profit status and clinic size. Analyses using clinic QIP scores provided similar results. Sociodemographic characteristics of the surrounding community, factors typically outside of providers' direct control, have varying levels of association with clinic dialysis star ratings.