Trends of Surgery, Patient, and Surgeon Characteristics for Corneal Transplants in the Medicare Population From 2011 to 2020.

PURPOSE: The aim of this study was to describe recent trends in corneal transplants and patient and surgeon characteristics for corneal transplants that occurred in the Medicare population. METHODS: This was a retrospective, cross-sectional study using Current Procedural Terminology codes. We identified Medicare Fee-For-Service (FFS) claims for different types of corneal transplant procedures performed on Medicare beneficiaries aged 65 years or older from 2011 to 2020. Number and types of corneal transplants performed each year and patient and surgeon demographics and characteristics were analyzed. RESULTS: We analyzed 148,981 corneal transplants performed by 2972 surgeons within the study period. Most corneal transplants performed were endothelial keratoplasties (70.1%). Most patients were women (60.3%) and White (85.8%). 18.2% of patients lived in a rural area, whereas only 3.5% of transplants occurred in a rural area and 5% of surgeons practiced in a rural area. Male surgeons represented 77.8% of all surgeons and performed 84.9% of all corneal transplants in the study period. The proportion of corneal transplants performed by female surgeons gradually increased over time, from 12.1% in 2011 to 19.0% in 2020. The proportion of female surgeons also increased from 16.2% in 2011 to 23.8% in 2020. Most surgeons (67%) performed <6 corneal transplants per year. CONCLUSIONS: Although the number of female corneal transplant surgeons has increased over time, women remain underrepresented in the surgical workforce. Further investigation should be conducted to identify the underlying reason and address the identified disparities within the landscape of corneal transplantation.

Endophthalmitis rates and risk factors following intraocular surgeries in the medicare population from 2016 to 2019.

AIMS: To determine endophthalmitis rates and risk factors following intraocular surgeries in the Medicare population. METHODS: Retrospective, cross-sectional study from 2016 to 2019 in Medicare fee-for-service and Medicare Advantage beneficiaries. 100% Medicare claims were used to identify eyes that underwent intraocular surgery. Exclusion criteria included eyes that had intraocular surgery 42 days before or after and eyes in patients with a history of endophthalmitis within 12 months. RESULTS: 9 744 400 intraocular surgeries were performed among Medicare beneficiaries from 2016 to 2019. A 42-day postoperative endophthalmitis rate was 0.09%. Endophthalmitis rate by surgery type was 0.43% for corneal transplant, 0.36% for secondary intraocular lens (IOL), 0.24% for retina, 0.16% for glaucoma, 0.11% for cataract combined with other procedures and 0.08% for cataract surgeries alone. On multivariable analysis, the risk of endophthalmitis was increased for all intraocular surgery types when compared with cataract surgeries; adjusted OR (aOR) 5.30 (p<0.01) for corneal transplant, aOR 4.50 (p<0.01) for secondary IOL, aOR 3.00 (p<0.01) for retina, aOR 1.93 (p<0.01) for glaucoma, aOR 1.45 (p<0.01) for combined cataract surgeries. Increased risk of developing endophthalmitis was associated with older age (≥85 vs 65-75 years: aOR 1.36; p<0.01), male sex (aOR 1.20; p<0.001) and greater Charlson Comorbidity Index (≥7 vs 0: aOR 1.79; p<0.01). CONCLUSIONS: Postoperative endophthalmitis rate after intraocular surgeries was 0.09% between 2016 and 2019 for Medicare beneficiaries. Endophthalmitis rates were highest for corneal transplant surgeries followed by secondary IOL surgeries and lowest for cataract surgeries. Older age, male gender and higher comorbidity index were associated with risk of endophthalmitis.

Early Endophthalmitis Incidence and Risk Factors after Glaucoma Surgery in the Medicare Population from 2016 to 2019.

PURPOSE: To determine early endophthalmitis incidence and risk factors after glaucoma surgeries in the Medicare population. DESIGN: Retrospective, longitudinal study. PARTICIPANTS: Medicare Fee-for-Service (FFS) and Medicare Advantage beneficiaries in the United States aged 65 years or older undergoing glaucoma surgery. METHODS: Medicare claims were used to identify all patients who underwent glaucoma, cataract, or combined cataract/glaucoma surgery from 2016 to 2019. Endophthalmitis cases within 42 days of the index surgery were identified using the diagnostic codes. Multivariable logistic regression models were used to evaluate factors associated with postoperative endophthalmitis. MAIN OUTCOME MEASURES: The 42-day postoperative endophthalmitis incidence and risk factors associated with endophthalmitis after glaucoma surgery. RESULTS: There were 466 928 glaucoma surgeries, of which 310 823 (66.6%) were combined with cataract surgery. Cataract surgeries alone (n = 8 460 360) served as a reference group. Microinvasive glaucoma surgeries constituted most glaucoma procedures performed (67.8%), followed by trabeculectomy (14.0%), tube shunt (10.9%), and other procedures (7.3%). There were 572 cases of endophthalmitis identified after all glaucoma surgeries. Endophthalmitis incidence after glaucoma, combined cataract/glaucoma, and cataract surgeries alone was 1.5 (95% confidence interval [CI], 1.3-1.7), 1.1 (95% CI, 1.0-1.2), and 0.8 (95% CI, 0.8-0.8) per 1000 procedures, respectively. The median day of diagnosis of endophthalmitis was later for glaucoma surgeries (16.5 days) compared with combined cataract/glaucoma or cataract surgeries alone (8 and 6 days, respectively). Compared with microinvasive glaucoma surgery (MIGS), tube shunts were the only surgery type to be a significant risk factor for endophthalmitis for both stand-alone (adjusted odds ratio [aOR], 1.8, P = 0.002) and combined surgery (aOR 1.8, P = 0.047). The other risk factor for both stand-alone (aOR 1.1, P = 0.001) and combined (aOR 1.06, P = 0.049) surgeries was the Charlson Comorbidity Index (CCI). Age (aOR 1.03, P = 0.004) and male gender (1.46, P = 0.001) were significant risk factors for combined cataract and glaucoma surgeries. CONCLUSIONS: Compared with cataract surgery, early endophthalmitis incidence was higher for both glaucoma and combined cataract/glaucoma surgeries, with the highest incidence among tube shunts. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Use and Cost of Sustained-Release Corticosteroids for Cataract Surgery Under the Medicare Pass-Through Program.

Importance: Sustained-release corticosteroids offer the potential of improved compliance and greater patient convenience for anti-inflammatory treatment after cataract surgery. However, they are substantially more expensive than postoperative corticosteroid eye drops, which have historically been standard care. Objective: To examine the use and cost of sustained-release corticosteroids in patients with Medicare who underwent cataract surgery in the US during the temporary pass-through reimbursement program period. Design, Setting, and Participants: This cross-sectional study examined Medicare fee-for-service (FFS) claims from beneficiaries with at least 12 continuous months of Medicare enrollment who underwent at least 1 cataract surgery from March 2019 through December 2021. Patients younger than 65 years, those with missing demographic information, those who had more than 1 cataract surgery on each eye, and those who received more than 1 corticosteroid on the day of surgery were excluded. Cataract surgeries with concurrent use of dexamethasone intraocular suspension 9% or dexamethasone ophthalmic insert were identified. Information on surgeon demographic characteristics and costs of surgery and drugs were extracted. Data were analyzed from June 15 to December 4, 2022. Exposure: Use of dexamethasone intraocular suspension 9% or dexamethasone ophthalmic insert during cataract surgery. Main Outcome Measures: Utilization rate and cost of dexamethasone intraocular suspension 9% and dexamethasone ophthalmic insert among Medicare FFS beneficiaries who underwent cataract surgery. Results: A total of 4 252 532 cataract surgeries in Medicare FFS beneficiaries (mean [SD] age, 74.8 [5.8] years; 1 730 811 male [40.7%] and 2 521 721 female [59.3%]) were performed by 12 284 ophthalmologists (8876 male [72.3%], 2877 female [23.4%], and 531 sex unknown [4.3%]). In all, 34 627 beneficiaries (0.8%) received dexamethasone intraocular suspension 9% and 73 430 (1.7%) received a dexamethasone ophthalmic insert; the use of both drugs increased over the study period. The mean (SD) Medicare allowed charges for dexamethasone intraocular suspension 9% and dexamethasone ophthalmic insert were $531.47 ($141.52) and $538.49 ($63.79), respectively. Conclusions and Relevance: Despite offering the potential of improved compliance and greater patient convenience, findings of this study suggest that sustained-release corticosteroid use during cataract surgery was low and associated with cost increases to the health care system vs conventional postoperative eye drops. As these new products must be priced high enough to qualify for the Medicare pass-through program, unreasonable cost may have been a deterrent to their use, suggesting that the current Medicare reimbursement rules may not be appropriate for sustained-release postoperative corticosteroids in cataract surgery.

Cost-effectiveness analysis of a low-cost bubble CPAP device in providing ventilatory support for neonates in Malawi - a preliminary report.

BACKGROUND: A low-cost bubble continuous positive airway pressure (bCPAP) device has been shown to be an excellent clinical alternative to nasal oxygen for the care of neonates with respiratory difficulty. However, the delivery of bCPAP requires more resources than the current routine care using nasal oxygen. We performed an economic evaluation to determine the cost-effectiveness of a low-cost bCPAP device in providing ventilatory support for neonates in Malawi. METHODS: We used patient-level clinical data from a previously published non-randomized controlled study. Economic data were based on the purchase price of supplies and equipment, adjusted for shelf life, as well as hospital cost data from the World Health Organization. Costs and benefits were discounted at 3%. The outcomes were measured in terms of cost, discounted life expectancy, cost/life year gained and net benefits of using bCPAP or nasal oxygen. The incremental cost-effectiveness ratio and incremental net benefits determined the value of one intervention compared to the other. Subgroup analysis on several parameters (birth weight categories, diagnosis of respiratory distress syndrome, and comorbidity of sepsis) was conducted to evaluate the effect of these parameters on the cost-effectiveness. RESULTS: Nasal oxygen therapy was less costly (US$29.29) than the low-cost bCPAP device ($57.78). Incremental effectiveness associated with bCPAP was 6.78 life years (LYs). In the base case analysis, the incremental cost-effectiveness ratio for bCPAP relative to nasal oxygen therapy was determined to be $4.20 (95% confidence interval, US$2.29-US$16.67) per LY gained. The results were highly sensitive for all tested subgroups, particularly for neonates with birth weight 1- < 1.5 kg, respiratory distress syndrome, or comorbidity of sepsis; these subgroups had a higher probability that bCPAP would be cost effective. CONCLUSION: The bCPAP is a highly cost-effective strategy in providing ventilatory support for neonates in Malawi.