Self-Reported Visual Disability and Unemployment: Findings from the National Health Interview Survey.

PURPOSE: To investigate the association between visual impairment and employment status due to disability, utilizing data from the 2022 National Health Interview Survey (NHIS). METHODS: Adults 18 years of age and older were extracted from the 2022 NHIS dataset. A multivariable logistic regression model was created to evaluate the odds of unemployment ("laid off" and "looking for work"). Persons over the age of 65, as well as persons retired, going to school, self-employed, seasonal, or contract workers were excluded. Independent variables for the model included gender, race, Hispanic ethnicity, urban residency, level of education, citizenship, and self-reported vision. The latter variable was categorized as seeing with "some" difficulty, with "severe" difficulty, "can't see at all," and "a lot of difficulty." Outcomes were reported as odds ratios (OR) with 95% confidence intervals (CI). RESULTS: Associations with unemployment included education less than high school (OR 6.05, 95% CI: 3.98-9.18) and high school (OR 3.80, 95% CI 2.78-5.21); severe vision difficulty (OR 3.68 95% CI 1.73-7.86); Asian race (OR 2.53, 95% CI 1.64-3.89); and Black race (OR 1.78, 95% CI 1.31-2.41). The odds of unemployment were marginally elevated for those living in large metropolitan areas, while being born in the United States had a modest protective effect (OR 0.53, 95% CI 0.42-0.66). CONCLUSION: The degree of visual impairment in this post-COVID-19 pandemic survey substantially affects employment, which is consistent with historical studies. Education among those with impaired vision is an important and modifiable variable that can positively influence the chances of employment.

Association of the Robert Wood Johnson Foundations' Social Determinants of Health and Medicare Ocular Hospitalizations: A Cross Sectional Data Analysis.

INTRODUCTION: Social determinants of health (SDH) may influence inpatient utilization rates and outcomes but have yet to be associated with ocular diagnoses. The purpose of this paper was to determine whether the SDH are associated with ocular hospitalizations. METHODS: Patients from the national Medicare 100% Inpatient Limited Dataset were examined and linked to SDH measures from the Robert Wood Johnson Foundation (RWJF) County Health Rankings. Patients were included in the study group with either an admitting or primary diagnosis of an ophthalmic condition. All other hospitalized Medicare patients served in the comparison group. Nested logistic regression of these Medicare patients was conducted in their respective communities at the county level. SDH measures were benchmarked above or below the national median. RESULTS: Positively associated SDH factors included communities with air pollution exceeding 11.62 micro grams per cubic meter (OR 1.05; 95% CI 1.01-1.08), communities where severe housing problems exceeding 14.38% (OR 1.13; 95% CI 1.09-1.18), children in single parent households exceeding 32.13% (OR 1.06; 95% CI 1.02-1.11), violent crime rate exceeding 250.54 per 100,000 (OR 1.07; 95% CI 1.03-1.12), diabetes exceeding 10.95% (OR 1.09: 95% CI 1.04-1.14), and drug poisoning deaths including opioids exceeding 14.17 per 100,000 (OR 1.04; 95% CI 1.01-1.08). CONCLUSION: When compared to an all-condition, hospitalized population, ocular hospitalizations tended to have small, yet statistically significant associations with health behaviors, socioeconomic, and physical environment factors. Further research will be needed on how the physical environment, social, and community variables affect ocular health relative to all-cause hospitalizations.

Payment Reform Needed to Address Health Disparities of Undiagnosed Diabetic Retinopathy in the City of Chicago.

INTRODUCTION: The Affordable Care Act (ACA) has expanded health coverage for thousands of Illinois residents. Expanded coverage, however, does not guarantee appropriate health care. Diabetes and its ocular complications serve as an example of how providers in underserved urban areas may not be able to keep up with new demand for labor- and technology-intensive health care unless changes in reimbursement policies are instituted. METHODS: A retrospective cohort study was conducted using medical encounter information from the Chicago HealthLNK Data Repository (HDR), an assembly of non-duplicated and de-identified patient medical records. We used a method of estimating the geographic distribution of undiagnosed diabetic retinopathy in the city of Chicago to illustrate the magnitude of potentially preventable eye disease. All rates were calculated for all ZIP Codes within Chicago (Cook County), and statistical differences between observed and geographically adjusted expected rates (p < 0.10, p < 0.05, p < 0.01) were highlighted as underserved areas. RESULTS: This analysis included 150,661 patients with diabetes identified from a total of nearly two million patients in Chicago. High rates of undetected diabetic retinopathy were found in low-income and minority areas. Within these areas, 37% of the identified diabetics were uninsured, with rates ranging widely from 20% to 68.6%. Among those with insurance, 32.8% were covered by Medicare and only 10% by Medicaid. Most patients with untreated diabetic retinopathy were found to reside in areas where primary health care is provided through Federally Qualified Health Centers. CONCLUSIONS: With 150,661 diabetics identified in the city of Chicago, and this number continuing to rise each year, a manpower approach with ophthalmologist screening for diabetic retinopathy is not realistic. The ability to identify the growing number of diabetic patients with retinopathy in low-income areas will likely require the adoption of cost-effective screening technologies that are currently not funded by Medicare and Medicaid.

Volume of Cataract Surgery and Surgeon Gender: The Florida Ambulatory Surgery Center Experience 2005 Through 2012.

Cataract is the most common surgically reversible cause of vision loss and the most common major surgical procedure performed in the United States. To understand how gender composition might affect differences in health services, we examined the surgeon gender-specific rates of routine cataract surgery performed in ambulatory surgical centers in Florida. Routine cataract surgeries were identified through the Florida Agency for Health Care Administration (AHCA) ambulatory surgery center dataset. The background of individual surgeons was determined by linking license numbers in the dataset to physician profiles publicly available from AHCA. From 2005 through 2012, women ophthalmologists in Florida performed roughly half the annual rate of cataract surgery as their male counterparts. This difference is not explained by greater time in clinical practice for men. Further investigation into the causes of this gender-volume disparity is warranted to determine what roles choice and barriers may play.

Demographic patterns of ED patients diagnosed as having corneal ulcer.

PURPOSE: This work aimed to study the demographic features of patients with emergency department (ED) visits for ulcerative keratitis, including information on insurance coverage and on-site consultant support. METHODS: Demographic features of corneal ulcers diagnosed in the ED were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes in Florida Agency of Health Care data sets for 2010. Patterns of patient encounters, including type of insurance coverage and consultant ED visits, were analyzed foremost descriptively. RESULT: In 2010, 2124 patients were evaluated in EDs in Florida with the primary diagnosis of corneal ulcer. Of these patients, 190 required hospital admission for further care. Thirty percent of patients discharged from the ED were seen on the weekend. About one-third of patients had no insurance (34.7%). Compared with outpatients, those hospitalized were older (54 years vs 39 years [P < .001]) and more often had insurance coverage (90.5% vs 65.3% [P < .001]). Ophthalmologists were associated with as many as 70.9% of outpatient encounters. The ratio of outpatients to those requiring hospitalization in urban areas ranged from 2.3 to 1 in counties on the west coast of Florida to 28.1 to 1 among counties in the southeast coast. CONCLUSION: Emergency department participation by ophthalmologist for ulcerative keratitis was relatively high. Whether the lack of health insurance affects the decision to hospitalize patients with corneal ulcers is a question that deserves further study. What influence the high proportion of uninsured ED patients will have on ophthalmologists coverage in the future may need to be addressed.

Factors associated with the utilization of cataract surgery for veterans dually enrolled in Medicare.

BACKGROUND: Cataract is the most common age-related disorder amenable to surgical correction in persons 65 years or older in the United States. Persons who are eligible for benefits through both the Veterans Health Administration (VHA) and Medicare have a choice in which system to receive medical care. METHODS: We examined factors that might influence the choice of having cataract surgery through the VHA and fee-for-service Medicare using a national database from the VHA Information Resource Center. RESULTS: In 2007, 159,094 dually eligible veterans had cataract surgery, with 137,726 (86.6%) having surgery in the private sector. Strong associations with the use of VHA for surgery were living within 20 miles of a facility, severity of service-connected disability, and low income or Medicaid eligibility. CONCLUSION: The VHA remains an important safety net for many veterans who are dually enrolled in Medicare. Dependency on the VHA for quality of life surgery needs to be kept in mind if budgetary pressures lead to restrictions of VHA services for veterans with Medicare.

Short-term mortality following cataract surgery: comparison of Veterans Health Administration and Medicare outcomes.

PURPOSE: To compare short-term risk of death following cataract surgery in veterans having surgery in the Veterans Health Administration (VHA) and through Medicare. METHODS: Medicare and VHA databases were merged to identify a cohort of veterans (N = 149,023) that had outpatient cataract surgery during 2007. National mortality sources were used to ascertain vital statistics. A Cox regression model estimated hazard ratios for routine and complex cataract extractions. RESULTS: Ninety days after cataract surgery the rates of death were 0.80% for patients in Medicare and 0.70% for beneficiaries in the VHA (P > 0.05). There was no difference in death hazard 6 months following surgery, after adjusting for age, race, gender, and medical comorbidities. Significant Medicare hazard ratio (HR) was seen at one year with routine cataract extraction (HR 1.17, 95% confidence interval, CI, 1.09-1.27), and with complex cataract extraction (HR 1.17, 95% CI 1.08-1.27). CONCLUSIONS: The 6-month risk of death after cataract surgery is low, and does not differ among veterans whose surgery was performed in the VHA or through Medicare. If confirmed, excess postoperative mortality at one year in Medicare needs to be studied through more direct methodologies.

Comparison of complication rates in veterans receiving cataract surgery through the Veterans Health Administration and Medicare.

BACKGROUND: To compare the 90-day rates of select secondary procedures after cataract extraction in patients having fee-for-service surgery under Medicare to surgeries provided through the Veterans Health Administration (VHA) during the same calendar year. METHODS: Medicare, VHA, and VHA Fee Basis Program data for calendar year 2007 were merged to identify a cohort of veterans that had outpatient cataract surgery. Secondary surgeries were tracked using selected Current Procedural Terminology (CPT) codes as surrogate markers for complications. Primary surgery and corrective surgeries were linked through right and left eye CPT modifier codes. Risks of complications were adjusted for race, age, sex, and ocular and medical comorbidities. RESULTS: A total of 223,873 cataract extractions were performed on veterans during calendar year 2007, 88.4% of which were provided through Medicare. The 90-day overall rate of CPT-coded secondary procedures was greater for patients having cataract surgery through the VHA (37.2 per 1000 surgeries) than Medicare (18.2 per 1000 surgeries). The overall rate was influenced primarily by higher rates of vitrectomy and related procedures, after both routine and complex cataract extractions. The adjusted odds ratio of vitrectomy within 90 days of routine cataract surgery in the VHA with reference to Medicare was 3.77 (95% confidence interval, 3.44-4.14). CONCLUSIONS: In 2007, the pattern and rates of secondary surgeries after cataract extraction varied between the Medicare and the VHA programs. If these results are confirmed, further research to identify the sources of higher secondary procedure rates is warranted to enhance patient safety.

Emergency department eye care in Florida: a study of principal payer sources 2005 through 2009.

OBJECTIVE: To describe trends in health insurance coverage for emergency department (ED) eye care in Florida from January 1, 2005, through December 31, 2009. METHODS: The Florida Agency for Health Care Administration ED data sets for ED outpatient visits and ED admissions for eye care were analyzed for type of insurance coverage and stratified according to age younger than 18 years and 18 years or older. Negative binomial regression models were used to measure the percentage of change in payer distribution for each 1-year increase in calendar year. RESULTS: During the 5-year study period, commercial insurance was the most frequent payer of ED outpatient services (31.1%), followed by self-pay (26.2%) and Medicaid (22.0%). For persons younger than 18 years, Medicaid and self-payment made up 67.7% of principal payers. For outpatient ED visits, the percentage of change in Medicaid increased 5.9% for each calendar year (P < .001) and commercial coverage declined 4.5% (P < .001 ). The proportion of Florida residents receiving Medicaid during the study period was less than the national average. CONCLUSIONS: A substantial proportion of ED eye care in Florida is reimbursed through Medicaid or is paid for out of pocket. How the Patient Protection and Affordable Care Act of 2010 and the national economic recovery will affect safety-net institutions such as EDs and hospital staff is speculative, but the effect could be substantial.

Analysis of ophthalmology workforce and delivery of emergency department eye care in Florida.

OBJECTIVE: To measure annual population-based volume of emergency department (ED) eye care and concurrent ophthalmology on-call coverage. METHODS: Analysis and correlation of the 2006 Florida Agency of Health Care Administration ED and inpatient data sets with the 2007 Florida Physician Workforce Survey. RESULTS: The Florida Physician Workforce Survey showed 46.3% of ophthalmologists surveyed took ED call in Florida in 2006. Based on estimates derived from the survey, 462 to 532 ophthalmologists participated in ED coverage that year. The level of workload varied considerably depending on International Classification of Diseases code diagnosis. Annual workload for open wounds to the eye, on average, ranged from 2.7 to 3.1 per ophthalmologist taking ED call. CONCLUSIONS: Strategic planning for the delivery of ED eye care needs to consider both the number and types of cases presenting to the ED and the availability of ophthalmologists to provide care that other specialists cannot. This preliminary study explores the use of a workload statistic that may help to gauge manpower needs in the future.

Hospitalization for nontraumatic disorders of the eye and ocular adnexa: analysis of the Florida agency for health care administration data set.

OBJECTIVE: To study the demographic features and patterns of hospital admission in Florida for nontraumatic disorders of the eye and ocular adnexa. METHODS: The public data set from the Florida Agency for Health Care Administration for 2001 was used to identify persons hospitalized for 24 hours or longer for nontraumatic disorders of the eye and ocular adnexa by using International Classification of Diseases, Ninth Revision, Clinical Modification codes. RESULTS: In 2001, there were 2137 hospital admissions for nontraumatic disorders of the eye and ocular adnexa, most of which were for infections or neuro-ophthalmologic disorders. The median length of stay was 3.0 days (mean +/- SD, 3.4 +/- 3.8 days). On average, 1 patient was admitted per month to 180 Florida hospitals. Eighty-three patients (3.9% of eye admissions) were hospitalized for 10 days or longer and accounted for 18.1% of total hospital-patient days. Prolonged hospital stay was positively associated with hospital transfer (P <.001) and facial cellulitis (P =.04). A trend for positive association with Medicaid coverage was also observed (P =.07). CONCLUSIONS: Nontraumatic eye care composes a small proportion of all inpatient care (< 0.1%) in Florida. Few of these patients require prolonged hospitalization but use a large proportion of inpatient care on the basis of the percentage of gross charges. An opportunity exists to improve hospital efficiency and improve eye care by targeting the patients at highest risk for prolonged hospital stay.