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OBJECTIVE: Investigate disparities in retinal vein occlusion (RVO) presentation and initiation of anti-VEGF treatment. DESIGN: Retrospective cohort study. SUBJECTS: Patients in the American Academy of Ophthalmology IRIS® (Intelligent Research in Sight) Registry database (2015-2021) with branch or central RVO and macular edema (ME). METHODS: The association of demographic characteristics and presenting visual acuity (VA) with anti-VEGF treatment initiation were quantified using multivariable logistic regression. MAIN OUTCOME MEASURES: Treatment with ≥ 1 anti-VEGF injection within 12 months after RVO diagnosis. RESULTS: A total of 304 558 eligible patients with RVO and ME were identified. Age at presentation varied by race, ethnicity, sex, and RVO type (all P values < 0.001). Within the first year after RVO presentation, 192 602 (63.2%) patients received ≥ 1 anti-VEGF injection. In a multivariable regression model adjusting for relevant covariates, female (vs. male) patients had lower odds of receiving injections (odds ratio [OR], 0.95; 95% confidence interval [CI], 0.93-0.96; P < 0.0001) as did Black/African American (vs. White) patients (OR, 0.90; 95% CI, 0.88-0.92; P < 0.0001) and Asian (vs. White) patients (OR, 0.95; 95% CI, 0.91-0.99; P = 0.02), whereas older patients (vs. patients aged < 51 years) had higher odds (61-70 years: OR, 1.20; 95% CI, 1.16-1.24; 71-80 years: OR, 1.20; 95% CI, 1.16-1.24; > 80 years: OR, 1.15; 95% CI, 1.11-1.18; all P values < 0.0001). Hispanic (vs. non-Hispanic) patients had a small increased odds of treatment initiation (OR, 1.08; 95% CI, 1.04-1.11; P < 0.0001). Results were similar in the subset of 226 143 patients with VA data. In this subset, patients with presenting VA < 20/40 to 20/200 were most frequently treated in the first year after diagnosis (â¼ 70%) and patients with light perception/no light perception (LP-NLP) vision or VA of 20/20 or better were treated least frequently (36.9% and 41.9%, respectively). CONCLUSIONS: In this large national clinical registry, 37% of RVO patients with ME had no anti-VEGF treatment documented in the first year after diagnosis. Black/African American, Asian, and female patients and patients with VA of LP-NLP were least likely to receive treatment. Awareness of this undertreatment and these disparities highlight the need for initiatives to ensure all RVO patients receive timely anti-VEGF injections for optimized visual outcomes. FINANCIAL DISCLOSURES: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Inibidores da Angiogênese , Injeções Intravítreas , Sistema de Registros , Oclusão da Veia Retiniana , Fator A de Crescimento do Endotélio Vascular , Acuidade Visual , Humanos , Oclusão da Veia Retiniana/tratamento farmacológico , Oclusão da Veia Retiniana/diagnóstico , Feminino , Masculino , Estudos Retrospectivos , Inibidores da Angiogênese/administração & dosagem , Fator A de Crescimento do Endotélio Vascular/antagonistas & inibidores , Idoso , Pessoa de Meia-Idade , Bevacizumab/administração & dosagem , Academias e Institutos , Estados Unidos/epidemiologia , Tomografia de Coerência Óptica/métodos , Seguimentos , Ranibizumab/administração & dosagem , Receptores de Fatores de Crescimento do Endotélio Vascular/administração & dosagem , Receptores de Fatores de Crescimento do Endotélio Vascular/antagonistas & inibidores , Idoso de 80 Anos ou maisRESUMO
PURPOSE: To evaluate associations of patient characteristics with United States eye care use and likelihood of blindness. DESIGN: Retrospective observational study. PARTICIPANTS: Patients (19 546 016) with 2018 visual acuity (VA) records in the American Academy of Ophthalmology's IRIS® Registry (Intelligent Research in Sight). METHODS: Legal blindness (20/200 or worse) and visual impairment (VI; worse than 20/40) were identified from corrected distance acuity in the better-seeing eye and stratified by patient characteristics. Multivariable logistic regressions evaluated associations with blindness and VI. Blindness was mapped by state and compared with population characteristics. Eye care use was analyzed by comparing population demographics with United States Census estimates and proportional demographic representation among blind patients versus a nationally representative US population sample (National Health and Nutritional Examination Survey [NHANES]). MAIN OUTCOME MEASURES: Prevalence and odds ratios for VI and blindness; proportional representation in the IRIS® Registry, Census, and NHANES by patient demographics. RESULTS: Visual impairment was present in 6.98% (n = 1 364 935) and blindness in 0.98% (n = 190 817) of IRIS patients. Adjusted odds of blindness were highest among patients ≥ 85 years old (odds ratio [OR], 11.85; 95% confidence interval [CI], 10.33-13.59 vs. those 0-17 years old). Blindness also was associated positively with rural location and Medicaid, Medicare, or no insurance vs. commercial insurance. Hispanic (OR, 1.59; 95% CI, 1.46-1.74) and Black (OR, 1.73; 95% CI, 1.63-1.84) patients showed a higher odds of blindness versus White non-Hispanic patients. Proportional representation in IRIS Registry relative to the Census was higher for White than Hispanic (2- to 4-fold) or Black (11%-85%) patients (P < 0.001). Blindness overall was less prevalent in NHANES than IRIS Registry; however, prevalence in adults aged 60+ was lowest among Black participants in the NHANES (0.54%) and second highest among comparable Black adults in IRIS (1.57%). CONCLUSIONS: Legal blindness from low VA was present in 0.98% of IRIS patients and associated with rural location, public or no insurance, and older age. Compared with US Census estimates, minorities may be underrepresented among ophthalmology patients, and compared with NHANES population estimates, Black individuals may be overrepresented among blind IRIS Registry patients. These findings provide a snapshot of US ophthalmic care and highlight the need for initiatives to address disparities in use and blindness. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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BACKGROUND/OBJECTIVE: To identify geographic and socioeconomic variables associated with residential proximity to Phase 3 ophthalmology clinical trial sites. METHODS: The geographic location of clinical trial sites for Phase 3 clinical trials in ophthalmology was identified using ClinicalTrials.gov. Driving time from each United States (US) census tract centroid to nearest clinical trial site was calculated using real traffic patterns. Travel data were crosslinked to census-tract level public datasets from United States Census Bureau American Community Survey (ACS). Cross-sectional multivariable regression was used to identify associations between census-tract sociodemographic factors and driving time (>60 min) from each census tract centroid to the nearest clinical trial site. RESULTS: There were 2330 unique clinical trial sites and 71,897 census tracts. Shortest median time was to retina sites [33.7 min (18.7, 70.1 min)]. Longest median time was to neuro-ophthalmology sites [119.8 min (48.7, 240.4 min)]. Driving >60 min was associated with rural tracts [adjusted odds ratio (aOR) 7.60; 95% CI (5.66-10.20), p < 0.0001]; Midwest [aOR 1.84(1.15-2.96), p = 0.01], South [aOR 2.57 (1.38-4.79), p < 0.01], and West [aOR 2.52 (1.52-4.17), p < 0.001] v. Northeast; and tracts with higher visual impairment [aOR 1.07 (1.03-1.10), p < 0.001)]; higher poverty levels [4th v.1st Quartile of population below poverty, aOR 2.26 (1.72-2.98), p < 0.0001]; and lower education levels [high school v. Bachelor's degree or higher aOR 1.02 (1.00-1.03), p = 0.0072]. CONCLUSIONS: There are significant geographic and socioeconomic disparities in access to ophthalmology clinical trial sites for rural, non-Northeastern, poorer, and lower education level census tracts, and for census tracts with higher levels of self-reported visual impairment.
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Oftalmologia , Humanos , Censos , Estudos Transversais , Fatores Socioeconômicos , Estados Unidos , Transtornos da Visão , Ensaios Clínicos Fase III como Assunto , Características de Residência , Disparidades Socioeconômicas em SaúdeRESUMO
BACKGROUND: The number of patients with an immigration background in geriatric healthcare institutions in Germany is growing continuously. The number of medical staff with a migration background is also increasing because of the shortage of qualified employees in the healthcare sector. Therefore, the ability to act culturally sensitive is essential. A training course for employees caring for chronically ill elderly patients with a migration background was developed, tested and evaluated. METHODS: The training was developed on the basis of interviews with experts and research literature and took place over half a day. It was then tested in a pilot study in three hospitals (geriatric, orthopaedic, cardiologic clinics) and evaluated with respect to content and implementation using both guided interviews, which were subjected to content analysis, and a questionnaire. RESULTS: The training was feasible and well received by the participants, and a high demand for interventions on cultural sensitivity could be derived from the interviews. Improvements were achieved on the dimensions of self-reflection (recognizing one's own and others' cultural imprint), communication with patients and their relatives, and teamwork. DISCUSSION: The participants asked for a more extensive and broader training. A multiplier training should be considered in order to implement the contents nationwide and sustainably in clinics. A randomized controlled design is necessary to verify the assumed effects. CONCLUSION: Based on the results and the need for culture-sensitive training, the training should be carried out within a wider timeframe and in a bigger population.
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Assistência à Saúde Culturalmente Competente , Atenção à Saúde , Medicina , Idoso , Emigração e Imigração , Alemanha , Hospitais , Humanos , Projetos PilotoRESUMO
PURPOSE: To assess perceptions of occupational risk and changes to clinical practice of ophthalmology trainees in the United States during the coronavirus disease 2019 (COVID-19) pandemic. DESIGN: An anonymous, nonvalidated, cross-sectional survey was conducted online. Data were collected from April 7 through 16, 2020. PARTICIPANTS: Second-year U.S. vitreoretinal surgery fellows in two-year training programs were invited to participate. METHODS: Online survey. MAIN OUTCOME MEASURES: Survey questions assessed policies guiding COVID-19 response, exposure to severe acute respiratory syndrome coronavirus 2, changes in clinical duties, and methods to reduce occupational risk, including availability of personal protective equipment (PPE). RESULTS: Completed responses were obtained from 62 of 87 eligible recipients (71.2% response rate). Training settings included academic (58.1%), hybrid academic/private practice (35.5%), and private practice only settings (6.5%). Overall, 19.4% of respondents reported an exposure to a COVID-19-positive patient, 14.5% reported self-quarantining due to possible exposure, and 11.3% reported being tested for COVID-19. In regards to PPE, N95 masks were available in the emergency room (n = 40 [64.5%]), office (n = 35 [56.5%]), and operating room (n = 35 [56.5%]) settings. Perceived comfort level with PPE recommendations was significantly associated with availability of an N95 respirator mask in the clinic (P < 0.001), emergency room (P < 0.001), or operating room (P = 0.002) settings. Additional risk mitigation methods outside of PPE were: reduction in patient volume (n = 62 [100%]), limiting patient companions (n = 59 [95.2%]), use of a screening process (n = 59 [95.2%]), use of a slit-lamp face shield (n = 57 [91.9%]), temperature screening of all persons entering clinical space (n = 34 [54.84%]), and placement of face mask on patients (n = 33 [53.2%]). Overall, 16.1% reported additional clinical duties within the scope of ophthalmology, and 3.2% reported being re-deployed to nonophthalmology services. 98.4% of respondents, 98.4% expected a reduction in surgical case volume. No respondents reported loss of employment or reduction in pay or benefits due to COVID-19. CONCLUSIONS: Suspected or confirmed clinical exposure to COVID-19-positive patients occurred in approximately one fifth of trainee respondents. Perceived comfort level with PPE standards was significantly associated with N95 respirator mask availability. As surgical training programs grapple with the COVID-19 pandemic, analysis of trainees' concerns may inform development of mitigation strategies.
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COVID-19/epidemiologia , Bolsas de Estudo , Exposição Ocupacional , Oftalmologistas/psicologia , Padrões de Prática Médica/estatística & dados numéricos , SARS-CoV-2 , Cirurgia Vitreorretiniana/educação , Adulto , Atitude do Pessoal de Saúde , Estudos Transversais , Feminino , Inquéritos Epidemiológicos , Humanos , Transmissão de Doença Infecciosa do Paciente para o Profissional/prevenção & controle , Masculino , Pessoa de Meia-Idade , Oftalmologistas/educação , Percepção , Equipamento de Proteção Individual/estatística & dados numéricos , Quarentena , Inquéritos e Questionários , Estados Unidos/epidemiologiaRESUMO
Aim: Evaluate the cost-effectiveness of ocriplasmin in symptomatic vitreomacular adhesion (VMA) with or without full-thickness macular hole ≤400 µm versus standard of care. Methods: A state-transition model simulated a cohort through disease health states; assignment of utilities to health states reflected the distribution of visual acuity. Efficacy of ocriplasmin was derived from logistic regression models using Ocriplasmin for Treatment for Symptomatic Vitreomacular Adhesion Including Macular Hole trial data. Model inputs were extracted from Phase III trials and published literature. The analysis was conducted from a US Medicare perspective. Results: Lifetime incremental cost-effectiveness ratio was US$4887 per quality-adjusted life year gained in the total population, US$4255 and US$10,167 in VMA subgroups without and with full-thickness macular hole, respectively. Conclusion: Ocriplasmin was cost effective compared with standard of care in symptomatic VMA.
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Fibrinolisina/uso terapêutico , Fragmentos de Peptídeos/uso terapêutico , Perfurações Retinianas/tratamento farmacológico , Aderências Teciduais/tratamento farmacológico , Corpo Vítreo/patologia , Conduta Expectante , Idoso , Análise Custo-Benefício , Fibrinolisina/economia , Humanos , Injeções Intravítreas , Medicare , Modelos Teóricos , Fragmentos de Peptídeos/economia , Perfurações Retinianas/patologia , Aderências Teciduais/patologia , Estados Unidos , Acuidade VisualRESUMO
BACKGROUND: Vitreomacular traction (VMT) treatment options include watchful waiting, vitrectomy and intravitreal ocriplasmin injection (Jetrea®). This analysis used results from the recently completed OASIS randomized clinical trial to evaluate the 2-year budget impact of ocriplasmin injection availability for treatment of Stage I or II VMT without epiretinal membrane formation in a modeled US health plan. MATERIALS & METHODS: VMT prevalence, treatment patterns and disease resolution rates were from literature, a US retinal-specialist survey and the OASIS trial. Medicare payment rates were applied and a national scenario analysis was conducted. RESULTS: With ocriplasmin available, vitrectomy use and complications-related costs decreased. Budget impact of ocriplasmin to the health plan was US$143,599 over 2 years or US$0.0060 per-member per-month. CONCLUSION: Ocriplasmin was projected to be minimally cost-additive at US$0.0060 per-member per-month over 2 years.
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Fibrinolisina/economia , Fibrinolisina/uso terapêutico , Custos de Cuidados de Saúde/estatística & dados numéricos , Fragmentos de Peptídeos/economia , Fragmentos de Peptídeos/uso terapêutico , Descolamento do Vítreo/tratamento farmacológico , Descolamento do Vítreo/economia , Pesquisa Comparativa da Efetividade/métodos , Feminino , Humanos , Injeções Intravítreas , Masculino , Pessoa de Meia-Idade , Estados UnidosRESUMO
IMPORTANCE: The number of women in ophthalmology is rising. Little is known about their clinical activity and collections. OBJECTIVE: To examine whether charges, as reflected in reimbursements from the Centers for Medicare & Medicaid Services (CMS) to ophthalmologists, differ by sex and how disparity relates to differences in clinical activity. DESIGN, SETTING, AND PARTICIPANTS: Retrospective review of the CMS database for payments to ophthalmologists from January 1, 2012, through December 31, 2013. The dates of the analysis were February 1 through May 30, 2016. After exclusion of J and Q codes, the total payments to and the number of charges by individual ophthalmologists were analyzed. The mean values were compared using a single t test, and the medians were compared by the nonparametric Wilcoxon rank sum test. MAIN OUTCOMES AND MEASURES: Primary outcome measures were the mean and median CMS payments to male and female ophthalmologists in outpatient, non-facility-based settings. Secondary outcome measures included the number of charges submitted by men and women and the types of charges most commonly submitted by men and women. RESULTS: This study included 16â¯111 ophthalmologists (3078 women [19.1%] and 13â¯033 men [80.9%]) in 2012 and 16â¯179 ophthalmologists (3206 women [19.8%] and 12â¯973 men [80.2%]) in 2013. In 2012, the average female ophthalmologist collected $0.58 (95% CI, $0.54-$0.62; P < .001) for every dollar collected by a male ophthalmologist; comparing the medians, women collected $0.56 (95% CI, $0.50-$0.61; P < .001) for every dollar earned by men. Mean and median collections were similar when comparing female vs male ophthalmologists in 2013 (P < .001). The mean payment per charge was the same for men and women, $66 in 2012 and $64 in 2013. There was a strong association between collections and work product, with female ophthalmologists submitting fewer charges to Medicare in 2012 (median, 1120 charges; difference -935; 95% CI, -1024 to -846; P < .001) and in 2013 (median, 1141 charges; difference -937; 95% CI, -1026 to -848; P < .001) than male ophthalmologists. When corrected by comparing men and women with similar clinical activity, renumeration was still lower for women. In both years, women were underrepresented among ophthalmologists with the highest collections. CONCLUSIONS AND RELEVANCE: Remuneration from the CMS was disparate between male and female ophthalmologists in 2012 and 2013 because of the submission of fewer charges by women. Further studies are necessary to explore root causes for this difference, with equity in opportunity and parity in clinical activity standing to benefit the specialty.
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Gastos em Saúde/estatística & dados numéricos , Reembolso de Seguro de Saúde/economia , Medicare/economia , Oftalmologistas/economia , Oftalmologia , Honorários Médicos/estatística & dados numéricos , Feminino , Humanos , Reembolso de Seguro de Saúde/estatística & dados numéricos , Masculino , Medicare/estatística & dados numéricos , Oftalmologia/economia , Otolaringologia/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos , Recursos HumanosRESUMO
Lack of patient adherence with eye appointments can decrease ocular outcomes. This prospective, randomized, single-blinded controlled study assessed the effectiveness of multiple interventions in improving follow-up adherence to recommended eye appointments. Patients due for follow-up appointments were randomly assigned to usual care, automated intervention, or personal intervention. Automated-intervention patients and personal-intervention patients received a call one month prior to the recommended follow-up date, and a mailed appointment reminder letter. The call was automated for automated-intervention patients and personalized for personal-intervention patients. The primary outcome was adherence to the follow-up appointment. The secondary outcome was rate of appointment scheduling. Patients in the personal-intervention group had greater adherence to follow-up recommendations (38%) than patients in the usual care group (28%) and the automated-intervention group (30%). Personal intervention significantly increased appointment scheduling (51%) over usual care (32%) and automated intervention (36%). These results support systems-level changes to improve patient follow-up adherence in urban primary eye care settings.
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Agendamento de Consultas , Oftalmologia/estatística & dados numéricos , Cooperação do Paciente/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Sistemas de Alerta/estatística & dados numéricos , Fatores Etários , Idoso , Registros Eletrônicos de Saúde , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Oftalmologia/métodos , Atenção Primária à Saúde/métodos , Estudos Prospectivos , Fatores Sexuais , Método Simples-Cego , Fatores SocioeconômicosRESUMO
Although the importance of ophthalmologic screening in diabetic patients is widely recognized by clinicians, the cost-effectiveness of strategies aimed at improving eye care utilization in this population is not well established. A cost-effectiveness analysis was performed comparing behavior activation (BA) to supportive therapy (ST) in activating patients to receive a dilated fundus exam (DFE) and promoting healthy management of diabetes. Two hundred six subjects were randomized to receive either BA or ST between 2009 and 2013. Cost-effectiveness was calculated as incremental cost-effectiveness ratio (ICER) of BA versus ST. Total costs for BA and ST per participant were $259.02 and $216.12, respectively. At the 6-month follow-up, 87.91% of BA subjects received a DFE compared to 34.48% of ST subjects. The ICER for BA versus ST was $80.29/percent increase in DFE rate. In terms of improving DFE rates, BA was found to be more cost-effective than ST.
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Negro ou Afro-Americano , Diabetes Mellitus/psicologia , Técnicas de Diagnóstico Oftalmológico/economia , Técnicas de Diagnóstico Oftalmológico/estatística & dados numéricos , Cooperação do Paciente/etnologia , Idoso , Idoso de 80 Anos ou mais , Análise Custo-Benefício , Feminino , Hemoglobinas Glicadas , Humanos , Masculino , Anos de Vida Ajustados por Qualidade de VidaRESUMO
IMPORTANCE: Women in ophthalmology are growing in number and have made strides in traditional metrics of professional achievement. Professional ties to industry represent another potential means of career advancement, recognition, and income. OBJECTIVE: To report the representation of women among ophthalmologists receiving industry remuneration for research, consulting, honoraria, grants, royalties, and faculty/speaker roles. DESIGN, SETTING, AND PARTICIPANTS: In this observational, retrospective study, the Centers for Medicare and Medicaid Services Open Payments database for payments to ophthalmologists by biomedical companies was reviewed for representation, median payments, and mean payments by women and men for industry relationships in 2013 and 2014. The analysis was performed from July 2015 to November 2015. MAIN OUTCOMES AND MEASURES: The primary outcome measures were percentage representation of women vs men overall and in industry research, consulting, speaking roles, royalties and licenses, grants, services other than consulting, and honoraria. Secondary outcome measures included mean and median payments from industry to female vs male ophthalmologists. RESULTS: In 2013, 4164 of 21â¯380 (19.5%) ophthalmologists were women, and of 1204 ophthalmologists analyzed for industry payments, 176 (4.2%) women had industry ties compared with 1028 (6%) men (P < .001). Mean payments to women were $11â¯419 compared with $20â¯957 for men (P = .001), and median payments to women were $3000 compared with $4787 for men (P = .007). In 2013, women were underrepresented among ophthalmologists receiving industry payments for research (49 of 462 [10.6%]), consulting (96 of 610 [15.7%]), honoraria (3 of 47 [6.4%]), industry grants (1 of 7 [14.3%]), royalties and licenses (1 of 13 [7.7%]), and faculty/speaker roles (2 of 48 [4.2%]). In 2014, 4352 of 21â¯531 (20.2%) of ophthalmologists were women. Of 1518 ophthalmologists analyzed for industry payments, 255 (6%) women had industry ties compared with 1263 (7.4%) men (P < .001). Mean payments to women were $14â¯848 compared with $30â¯513 for men (P = .004), and median payments to women were $3750 compared with $5000 for men (P = .005). Women remained underrepresented among ophthalmologists receiving industry payments for research (25 of 241 [10.4%]), consulting (145 of 921 [15.7%]), honoraria (14 of 11 [12.6%]), industry grants (3 of 25 [12.0%]), royalties and licenses (1 of 22 [4.6%]), and faculty/speaker roles (21 of 189 [11.1%]) in 2014. CONCLUSIONS AND RELEVANCE: Women make up a minority of ophthalmologists with professional industry relationships, and the average woman partnering with industry earns less than her male colleagues. The reasons for differences are multifactorial and could not be determined by this study.
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Centers for Medicare and Medicaid Services, U.S./estatística & dados numéricos , Indústrias/economia , Oftalmologistas/economia , Oftalmologia/estatística & dados numéricos , Médicas/economia , Remuneração , Pesquisa Biomédica/economia , Pesquisa Biomédica/estatística & dados numéricos , Bases de Dados Factuais , Feminino , Humanos , Licenciamento/economia , Licenciamento/estatística & dados numéricos , Masculino , Patentes como Assunto/estatística & dados numéricos , Encaminhamento e Consulta/economia , Encaminhamento e Consulta/estatística & dados numéricos , Apoio à Pesquisa como Assunto/economia , Apoio à Pesquisa como Assunto/estatística & dados numéricos , Estudos Retrospectivos , Estados UnidosRESUMO
BACKGROUND: Glaucoma is the leadi ng cause of irreversible blindness in the USA. Glaucomatous vision loss is preventable with proper eye care, including appointment adherence. Therefore, interventions that improve appointment adherence can reduce the number of patients with more severe glaucoma. OBJECTIVES: The primary study aim was to determine the efficacy and cost-effectiveness of a multifaceted personal reminder intervention, which included a customized letter and personal telephone outreach, in improving appointment adherence of patients with glaucoma. A secondary study aim was to identify patient characteristics that were associated with non-adherence. METHODS: This prospective, randomized, controlled study included a cost-effectiveness analysis completed using a decision analytic model. The subjects included 256 patients with glaucoma. Study measures included appointment adherence and incremental cost effectiveness ratios. RESULTS: Patients in the intervention group were more likely to adhere to appointments (82.31 vs. 69.05 %; RR 1.23; 95 % CI 1.04-1.37, p < 0.012) than patients in the usual care group. Patients in the intervention group were 23 % more likely to adhere to appointments (RR 1.23; 95 % CI 1.08-1.41, p < 0.0021) than patients in the usual care group, when adjusting for age, secondary insurance, primary open angle glaucoma diagnosis, number of previous visits at Wills Eye Hospital, and follow-up recommendation using Poisson regression. Per-patient cost of the program was US$11.32, and cost per follow-up attended within the adherence window was US$73.56. CONCLUSIONS: A low cost reminder intervention consisting of a personalized letter and telephone outreach significantly improved appointment adherence of patients with glaucoma.
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Agendamento de Consultas , Glaucoma/economia , Glaucoma/terapia , Cooperação do Paciente , Sistemas de Alerta/economia , Telefone , Adulto , Idoso , Idoso de 80 Anos ou mais , Análise Custo-Benefício , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estados UnidosRESUMO
OBJECTIVE: Diabetic retinopathy is one of the leading causes of vision impairment among adults in the USA. While it is suggested that diabetics receive annual dilated fundus examinations (DFE), many patients do not adhere to these recommendations. This paper investigates the outcomes and costs of an educational and telephone intervention on DFE follow-up adherence in patients with diabetes. METHODS: In a prospective trial, 356 diabetic patients due for a DFE at an urban eye clinic were randomly assigned to usual care (UC; reference case), mailed intervention (MI), or telephone intervention (TI). UC patients (n = 119) received a standard form letter. MI patients (n = 117) received a personalized letter encouraging scheduling of an eye examination with an educational brochure about diabetic eye disease. TI patients (n = 120) received personal calls (up to three attempts) to schedule a follow-up with standard form letter. The primary outcome was obtaining a DFE within 90 days of suggested return. Costs (US$ 2013) included time costs for staff, phone charges, supplies, and postage. Since TI involved greater cost components compared to MI, univariate sensitivity analysis examined the impact of reducing phone costs. RESULTS: Patients were mostly female (66 %) and African American (70 %) with a mean age of 61 years. TI patients were more likely to schedule DFE [65 vs. 42 %; relative risk (RR) 1.54; CI 1.20-1.96; P < 0.001] versus UC patients. Obtaining a DFE within 90 days of suggested return was also significantly higher among TI patients compared to UC patients (51 vs. 36 %, RR 1.41; CI 1.05-1.89; P = 0.024). MI patients were slightly less likely to schedule DFE versus UC patients (38 vs. 42 %, RR 0.90; CI 0.66-1.22; P = NSS) and obtain a DFE (32 vs. 36 %; RR 0.90; CI 0.63-1.28; P = NSS). The total cost of TI was US$798.28 or US$6.65/patient and the cost/follow-up DFE was US$26.05. Sensitivity analyses revealed that the cost/follow-up can be greatly reduced but remains greater compared to UC (US$2.76 if US$0.25/call, US$11.13 if $1/call; US$22.29 if US$2/call). CONCLUSIONS: Personal phone assistance in scheduling DFE follow-up is more effective but also more costly. Follow-up research has been initiated to determine whether automated phone reminders can achieve similar effectiveness at a lower cost.
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Retinopatia Diabética/economia , Retinopatia Diabética/prevenção & controle , Cooperação do Paciente , Educação de Pacientes como Assunto/economia , Idoso , Custos e Análise de Custo , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Serviços Postais , Estudos Prospectivos , Sistemas de Alerta , TelefoneRESUMO
BACKGROUND: E-health tools have the potential to improve the quality of care for ophthalmic patients, many of whom have chronic conditions. However, little research has assessed ophthalmic patients' use or acceptance of technological devices and social media platforms for health-related purposes. The present study evaluated utilization of technological devices and social media platforms by eye clinic patients, as well as their willingness to receive health reminders through these technologies. SUBJECTS AND METHODS: A 31-item paper questionnaire was administered to eye clinic patients (n=843) at an urban, tertiary-care center. Questions focused on technology ownership, comfort levels, frequency of use, and preferences for receiving health reminders. Demographic data were also recorded. RESULTS: Eye clinic patients most commonly owned cellular phones (90%), landline phones (81%), and computers (80%). Overall, eye clinic patients preferred to receive health reminders through phone calls and e-mail and used these technologies frequently and with a high level of comfort. Less than 3% of patients preferred using social networking to receive health reminders. In addition, age was significantly associated with technology ownership, comfort level, and frequency of use (p<0.05). The majority of patients 18-45 years of age preferred to receive appointment reminders via text message (57%) and e-mail (53%). This age group also used these technologies more frequently and with a higher comfort level (p<0.001). CONCLUSIONS: These data support the proposal that e-mail and text-messaging e-health tools are likely to be immediately adopted by eye clinic patients and therefore have the greatest potential to improve health outcomes and increase quality of care. Eye clinic patients are interested in these technologies for appointment reminders, general eye and vision health information, asking urgent medical questions, and requesting prescription refills. Future controlled trials could further explore the efficacy of e-health tools for these purposes.
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Oftalmopatias/terapia , Microcomputadores/estatística & dados numéricos , Melhoria de Qualidade , Mídias Sociais/estatística & dados numéricos , Telefone/estatística & dados numéricos , Adolescente , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sistemas de Alerta , Inquéritos e Questionários , População UrbanaRESUMO
Scientific collaboration between academia and industry has a long history in the United States and abroad. Initially U.S. companies took responsibility for patenting and licensing discoveries made in collaborating universities. A publicly funded "middle man", The Research Corporation, was the next paradigm and had the advantages of neutrality and centralization, but proved ultimately unworkable. More recently, universities have negotiated their own patenting and licensing activities. The ethical pitfalls of scientists and physicians dealing directly with industry stimulated much public discussion in the past decade, with a resultant backlash discouraging collaboration. I discuss this evolution, and recent developments with models of possible productive collaboration and rules of engagement.
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Centros Médicos Acadêmicos/normas , Conflito de Interesses , Comportamento Cooperativo , Indústria Farmacêutica/normas , Oftalmologia/normas , Médicos/normas , HumanosRESUMO
TOPIC: To examine the outcomes of clinical trials and case studies that investigated the different dosing regimens used for the 3 intravitreal anti-vascular endothelial growth factor (VEGF) inhibitors that are available currently. The Comparisons of Age-Related Macular Degeneration (AMD) Treatments Trial (CATT) data are discussed briefly here and are reviewed in greater detail in a separate accompanying article. CLINICAL RELEVANCE: Sustained improvement with the 2 most widely used anti-VEGF drugs, bevacizumab and ranibizumab, requires monthly visits, posing a difficulty for patients. Thus, there is a need to evaluate whether individualized treatment regimens may reduce patient burden and improve patient outcomes. METHODS: Review of clinical trials and case studies presented at recent medical conferences and published in peer-reviewed literature. RESULTS: Numerous trials, including the Efficacy and Safety of Ranibizumab in Patients with Subfoveal Choroidal Neovascularization (CNV) Secondary to AMD, Prospective Optical Coherence Tomography Imaging of Patients with Neovascular AMD Treated with Intraocular Ranibizumab, Study of Ranibizumab in Patients with Subfoveal CNV Secondary to AMD, Extension Study to Evaluate the Safety and Tolerability of Ranibizumab in Subjects with CNV Secondary to AMD or Macular Edema Secondary to Retinal Vein Occlusion, Safety Assessment of Intravitreal Lucentis for AMD, and CATT, have evaluated alternatives to monthly dosing. Evidence suggests that either a treat-as-needed or, possibly, a treat-and-extend regimen provides a reasonable approach to monthly injections recommended for bevacizumab and ranibizumab, with the caveat that as yet, careful and ongoing surveillance remains a key feature of optical management. CONCLUSIONS: Individualization of antiangiogenic treatment using data from clinical trials evaluating various dosing regimens against the patient's disease, lifestyle, and economic restrictions continues to evolve.
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Inibidores da Angiogênese/administração & dosagem , Degeneração Macular/tratamento farmacológico , Fatores de Crescimento do Endotélio Vascular/antagonistas & inibidores , Anticorpos Monoclonais Humanizados/administração & dosagem , Bevacizumab , Ensaios Clínicos como Assunto , Efeitos Psicossociais da Doença , Esquema de Medicação , Humanos , RanibizumabRESUMO
PURPOSE: Inflammation may play an important role in the pathogenesis of diabetic macular edema, a major cause of vision loss in persons with diabetes. The purpose of this study was to evaluate combined antiinflammatory therapy and laser approaches for treating patients with diabetic macular edema. METHODS: In this prospective, factorial, randomized, multicenter trial, we compared cyclo-oxygenase-2 inhibitor (celecoxib) with placebo and diode grid laser with standard Early Treatment Diabetic Retinopathy Study focal laser treatment in 86 participants with diabetic macular edema. The primary outcome is change in visual acuity of > or = 15 letters from baseline, and the secondary outcomes include a 50% reduction in the retinal thickening of diabetic macular edema measured by optical coherence tomography and a 50% reduction in leakage severity on fluorescein angiography. RESULTS: Visual acuity and retinal thickening data from >2 years of follow-up did not show evidence of differences between the medical and laser treatments. However, participants assigned to the celecoxib group were more likely to have a reduction in fluorescein leakage when compared with the placebo group (odds ratio = 3.6; P < 0.01). CONCLUSION: This short-term study did not find large visual function benefits of treatment with celecoxib or diode laser compared with those of standard laser treatment. A suggestive effect of celecoxib in reducing fluorescein leakage was observed.
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Inibidores de Ciclo-Oxigenase 2/uso terapêutico , Retinopatia Diabética/terapia , Lasers de Estado Sólido/uso terapêutico , Edema Macular/terapia , Pirazóis/uso terapêutico , Sulfonamidas/uso terapêutico , Administração Oral , Permeabilidade Capilar , Celecoxib , Terapia Combinada , Inibidores de Ciclo-Oxigenase 2/administração & dosagem , Retinopatia Diabética/fisiopatologia , Feminino , Angiofluoresceinografia , Seguimentos , Humanos , Edema Macular/fisiopatologia , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Estudos Prospectivos , Pirazóis/administração & dosagem , Retina/patologia , Sulfonamidas/administração & dosagem , Tomografia de Coerência Óptica , Acuidade Visual/fisiologiaRESUMO
OBJECTIVE: To evaluate currently available data in the published literature to answer the question of whether laser scanning imaging is a sensitive and specific tool for detecting macular disease when compared with the current standard technique of slit-lamp biomicroscopy or stereoscopic fundus photography. METHODS: Literature searches conducted in December 2004 and in August 2006 retrieved 370 citations. The Retina Panel members selected 65 articles for the panel methodologist to review and rate according to the strength of the evidence. Of the 65 articles reviewed, 6 provided level I evidence, 9 provided level II evidence, and 50 provided level III evidence. A level I rating was assigned to studies that reported an independent masked comparison of an appropriate spectrum of consecutive patients, all of whom had undergone both the diagnostic test and the reference standard. A level II rating was assigned to an independent masked or objective comparison; a study performed in a set of nonconsecutive patients or confined to a narrow spectrum of study individuals (or both), all of whom had undergone both the diagnostic test and the reference standard; or an independent masked comparison of an appropriate spectrum, but the reference standard had not been applied to all study patients. A level III rating was assigned when the reference standard was unobjective, unmasked, or not independent; positive and negative tests were verified using separate reference standards; or the study was performed in an inappropriate spectrum of patients. RESULTS: There are high-level studies of the use of laser scanning imaging to quantify macular thickness and, thereby, macular edema in patients with diabetic retinopathy and to examine patients with a macular hole. There is lower-quality evidence on the use of laser scanning imaging for other diseases of the macula. There is insufficient evidence to compare the different instruments. CONCLUSIONS: There is level I evidence that laser scanning imaging can accurately and reliably quantify macular thickness in patients with diabetic retinopathy. There is level I evidence that optical coherence tomography provides additional information to clinical examination when used in patients with a macular hole. Laser scanning imaging provides important information that is helpful in patient management by allowing objective serial quantitative measurements. Although further studies are needed to develop an optimal testing strategy using these imaging modalities, laser scanning imaging is a sensitive, specific, reproducible tool for diagnosing macular edema and, therefore, is likely to be useful for managing diseases that result in macular edema.
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Diagnóstico por Imagem/métodos , Técnicas de Diagnóstico Oftalmológico , Doenças Retinianas/diagnóstico , Academias e Institutos , Humanos , Lasers , Oftalmologia , Sensibilidade e Especificidade , Avaliação da Tecnologia Biomédica , Estados UnidosRESUMO
OBJECTIVE: To evaluate whether single-field fundus photography can be used as a screening tool to identify diabetic retinopathy for referral for further ophthalmic care. METHODS: A MEDLINE search of the peer-reviewed literature was conducted in June 2001 for the years 1968 to 2001 and updated in September 2003, yielding 145 articles. The search was limited to articles published in English. The Cochrane Library of clinical trials was also investigated. The authors reviewed the abstracts of these articles and selected 63 of possible clinical relevance for review by the panel. Of these 63 articles, the panel selected 32 for the panel methodologist to review and rate according to the strength of evidence. RESULTS: Three of the 32 articles reviewed were classified as level I evidence, and 4 were classified as level II evidence. Evidence from level I studies demonstrates that as a tool to detect vision-threatening retinopathy, single-field fundus photography interpreted by trained readers has sensitivity ranging from 61% to 90% and specificity ranging from 85% to 97% when compared with the gold standard reference of stereophotographs of 7 standard fields. When compared with dilated ophthalmoscopy by an ophthalmologist, single-field fundus photography has sensitivity ranging from 38% to 100% and specificity ranging from 75% to 100%. CONCLUSIONS: Single-field fundus photography is not a substitute for a comprehensive ophthalmic examination, but there is level I evidence that it can serve as a screening tool for diabetic retinopathy to identify patients with retinopathy for referral for ophthalmic evaluation and management. The advantages of single-field fundus photography interpreted by trained readers are ease of use (only one photograph is required), convenience, and ability to detect retinopathy. Further studies will be required to assess the implementation of single-field photography-based programs to confirm the clinical and cost-effectiveness of these techniques in improving population visual outcomes. Future research also should include establishing standardized protocols and satisfactory performance standards for diabetic retinopathy screening programs.