United States Population Disparities in Ophthalmic Care: Blindness and Visual Impairment in the IRIS® Registry (Intelligent Research in Sight).

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.

Cataract Surgery in the Medicare Merit-Based Incentive Payment System: Episode-Based Cost Measure Development and Evaluation.

Objective: To characterize the development and performance of a cataract surgery episode-based cost measure for the Medicare Quality Payment Program. Design: Claims-based analysis. Participants: Medicare clinicians with cataract surgery claims between June 1, 2016, and May 31, 2017. Methods: We limited the analysis to claims with procedure code 66984 (routine cataract surgery), excluding cases with relevant ocular comorbidities. We divided episodes into subgroups by surgery location (Ambulatory Surgery Center [ASC] or Hospital Outpatient Department [HOPD]) and laterality (bilateral when surgeries were within 30 days apart). For the episode-based cost measure, we calculated costs occurring between 60 days before surgery and 90 days after surgery, limited to services identified by an expert committee as related to cataract surgery and under the influence of the cataract surgeon. We attributed costs to the clinician submitting the cataract surgery claim, categorized costs into clinical themes, and calculated episode cost distribution, reliability in detecting clinician-dependent cost variation, and costs with versus without complications. We compared episode-based cost scores with hypothetical "nonselective" cost scores (total Medicare beneficiary costs between 60 days before surgery and 90 days after surgery). Main Outcome Measures: Episode costs with and without complications, clinician-dependent variation (proportion of total cost variance), and proportion of costs from cataract surgery-related clinical themes. Results: We identified 583 356 cataract surgery episodes attributed to 10 790 clinicians and 8189 with ≥ 10 episodes during the measurement period. Most surgeries were performed in an ASC (71%) and unilateral (66%). The mean episode cost was $2876. The HOPD surgeries had higher costs; geography and episodes per clinician did not substantially affect costs. The proportion of cost variation from clinician-dependent factors was higher in episode-based compared with nonselective cost measures (94% vs. 39%), and cataract surgery-related clinical themes represented a higher proportion of total costs for episode-based measures. Episodes with complications had higher costs than episodes without complications ($3738 vs. $2276). Conclusions: The cataract surgery episode-based cost measure performs better than a comparable nonselective measure based on cost distribution, clinician-dependent variance, association with cataract surgery-related clinical themes, and quality alignment (higher costs in episodes with complications). Cost measure maintenance and refinement will be important to maintain clinical validity and reliability. Financial Disclosures: Proprietary or commercial disclosure may be found after the references.

An evaluation of the content on pediatric ophthalmology fellowship program websites.

Fellowship program website content has been studied for some ophthalmological subspecialties; however, pediatric ophthalmology fellowship program websites have not been previously studied. Our cross-sectional analysis reveals that all US pediatric ophthalmology fellowship programs maintain an active website that is visible after Google search, which is not the case for all glaucoma, vitreoretinal surgery, or ophthalmic plastic and reconstructive surgery fellowship programs. Content on pediatric ophthalmology fellowship program websites varied widely, with program websites averaging only 12 ± 3.3 of 20 recruitment and education criteria evaluated (range, 3-18). Total number of fellows, number of clinical faculty, and geographic region did not affect fellowship program website content score. Fewer than half of fellowship program websites contained criteria often deemed important by applicants, including geographic placement of graduates, salary/benefits, and call schedule. Optimized recruitment and education content on fellowship programs websites may help applicants identify programs that best align with their career goals.

Accessibility and Content of Vitreoretinal Surgery Fellowship Program Websites.

Fellowship program websites represent an important information source for applicants. Our results demonstrate that vitreoretinal surgery fellowship websites are inconsistent and often incomplete. Incorporating additional recruitment and education criteria may improve website information potential.

An Analysis of the Diversity and Inclusion Content Featured on Ophthalmology Residency Program Web Sites.

Introduction Ophthalmology departments have been stated to be among the least diverse clinical departments at United States medical schools. Improvement requires recruiting a pipeline of diverse trainees. Residency program Web sites represent a potential diversity and inclusion recruitment tool. This study assesses how ophthalmology residency program Web sites demonstrate a commitment to diversity and inclusion. Methods We analyzed the diversity and inclusion content of 116 ophthalmology residency program Web sites in April 2021. Main outcome measures were the presence of 12 diversity and inclusion elements on program Web sites, based on prior work and Accreditation Council for Graduate Medical Education guidelines: nondiscrimination statement, diversity and inclusion message, community resources, extended faculty or resident biographies (including hobbies, etc.), faculty photos, resident photos, additional financial resources for trainees, wellness resources, mental health resources, health disparities/community engagement, and diversity council. We used Mann-Whitney U and Kruskal-Wallis tests to assess whether residency program characteristics such as rank, size, university affiliation, and geographic location were associated with commitment to diversity and inclusion on affiliated residency Web sites. Results Ophthalmology residency program Web sites included a mean of 4.4 ± 2.1 diversity elements. Sixteen percent of programs featured more than half (7 + ) of the evaluated diversity elements. The most featured common diversity elements included resident photos (85.3%), faculty photos (78.4%), and community resources (64.3%). Extended faculty biographies (2.6%), mental health resources (9.5%), and diversity council information (11.2%) were less commonly showcased. Top-ranked programs (7.6 ± 1.8, p < 0.0001) and university-based/-affiliated programs (4.7 ± 2.8, p = 0.0039) displayed more diversity elements than lower-ranked (4.1 ± 1.8) and community-based programs (2.8 ± 1.7). Conclusion Most ophthalmology residency program Web sites feature less than half of the 12 diversity and inclusion elements included in this study, suggesting room for improvement. By drawing attention to program diversity and inclusion efforts, Web sites offer a potential tool for residency programs to consider in their recruitment efforts for diverse trainees. Incorporating the diversity and inclusion elements analyzed in this study represents a low-burden way to signal a greater commitment to diversity that could help programs recruit diverse applicants.

Variability and Costs of Low-Value Preoperative Testing for Cataract Surgery Within the Veterans Health Administration.

Importance: The Choosing Wisely guidelines indicate that preoperative testing is often unnecessary and wasteful for patients undergoing cataract operations. However, little is known about the impact of these widely disseminated guidelines within the US Veterans Health Administration (VHA) system. Objective: To examine the extent, variability, associated factors, and costs of low-value tests (LVTs) prior to cataract operations in the VHA. Design, Setting, and Participants: This cohort study examined records of all patients receiving cataract operations within the VHA in fiscal year 2017 (October 1, 2016, to September 31, 2017). Records from 135 facilities nationwide supporting both ambulatory and inpatient surgery were included. Exposures: A laboratory test occurring within 30 days prior to cataract surgery and within 30 days after clinic evaluation. Main Outcomes and Measures: Overall national and facility-level rates and associated costs of receiving any of 8 common LVTs in the 30 days prior to cataract surgery. The patient characteristics, procedure type, and facility-level factors associated with receiving at least 1 test, the number of tests received, and receipt of a bundle of 4 tests (complete blood count, basic metabolic profile, chest radiograph, and electrocardiogram). Results: A total of 69 070 cataract procedures were identified among 50 106 patients (66 282 [96.0%] men; mean [SD] age, 71.7 [8.1] years; 53 837 [77.9%] White, 10 292 [14.9%] Black). Most of the patient population had either overweight (23 292 [33.7%] patients) or obesity (27 799 [40.2%] patients). Approximately 49% of surgical procedures (33 424 procedures) were preceded by 1 or more LVT with an overall LVT cost of $2 597 623. Among patients receiving LVTs, electrocardiography (7434 patients [29.9%]) was the most common, with some patients also receiving more costly tests, including chest radiographs (489 patients [8.2%]) and pulmonary function tests (127 patients [3.4%]). For receipt of any LVT, the intraclass correlation coefficient was 0.61 (P < .001) at the facility level and 0.06 (P < .001) at the surgeon level, indicating the substantial contribution of the facility to amount of tests given. Conclusions and Relevance: Despite existing guidelines, use of LVTs prior to cataract surgery is both common and costly within a large, national integrated health care system. Our results suggest that publishing evidence-based guidelines alone-such as the Choosing Wisely campaign-may not sufficiently influence individual physician behavior, and that system-level efforts to directly deimplement LVTs may therefore necessary to effect sustained change.

Development of the Elective Outpatient Percutaneous Coronary Intervention Episode-Based Cost Measure.

BACKGROUND: The Merit-Based Incentive Payment System adjusts clinician payments based on a performance score that includes cost measures. With the Centers for Medicare & Medicaid Services, we developed a novel cost measure that compared interventional cardiologists on a targeted set of costs related to elective percutaneous coronary intervention (PCI). We describe the measure and compare it to a hypothetical version including all expenditures post-PCI. METHODS: Measure development was guided by 39 clinician experts. They identified services within 30 days of PCI that could be potentially affected by the interventional cardiologist. Expenditures for these PCI-related services were included as measure costs in a process termed service assignment. We used 1 year of Medicare claims to calculate clinician scores using the final measure that included only PCI-related costs (with service assignment) and a hypothetical version that included all costs post-PCI (without service assignment). We calculated reliability for both measures. This marker of precision breaks measure variance into signal (difference between clinicians) versus noise (difference between PCI episodes for a clinician). We also determined the change in clinician performance quintile between measures. RESULTS: We identified 100 992 elective outpatient PCI episodes from May 2, 2016, to May 1, 2017. Total Medicare expenditures within 30 days of PCI averaged $13 234. After excluding costs unrelated to PCI, average cost was $10 966. For individual clinicians, mean reliability for the hypothetical measure without service assignment was 0.36. After service assignment, final measure reliability increased to 0.53. When evaluated as clinician groups, reliability increased from 0.43 to 0.73 following service assignment. Approximately 66% (2340 of 3527) of clinicians were reclassified into a different performance quintile after excluding unrelated costs. CONCLUSIONS: The elective outpatient PCI cost measure had increased precision and reclassified clinician performance relative to a hypothetical version that included total expenditures.

Bidirectional Association between Visual Impairment and Dementia Among Older Adults in the United States Over Time.

PURPOSE: Although visual impairment (VI) has been associated with worse cognitive performance among older adults, the temporal relationship between the 2 remains subject to debate. Our objective was to investigate the longitudinal impact of VI on cognitive function and vice versa. DESIGN: Retrospective, time-to-event study. PARTICIPANTS: National Health and Aging Trends Study (NHATS) participants from 2011 to 2018 cycles. METHODS: A total of 10 676 participants aged 65 years and older were included. Cox proportional hazards regression models evaluated the impact of baseline VI on subsequent dementia and impact of baseline dementia on subsequent VI. Models were adjusted for potential confounding variables, including demographics, clinical comorbidities, and hearing and physical function limitations. MAIN OUTCOME MEASURES: Hazard ratio (HR) for incident dementia among participants with baseline self-reported VI and HR for incident VI among participants with baseline dementia. RESULTS: Of the 10 676 participants included in the analysis, approximately 40% were aged 65-74 years, 40% were aged 75-84 years, and the remaining 20% were aged 85 years and older. The majority were female (59%), and 68% self-identified as non-Hispanic White. Among participants with normal cognitive status at baseline, subsequent dementia was observed in 1753 (16%), and among participants with normal self-reported vision at baseline, subsequent VI was reported in 2371 (22%). In adjusted regression models, participants with baseline VI had higher likelihood of developing dementia over subsequent follow-up (HR, 2.3; 95% confidence interval [CI], 2.0-2.6; P < 0.001). Likewise, participants with baseline dementia had a higher likelihood of developing self-reported VI over time (HR, 2.5; 95% CI, 2.2-2.8; P < 0.001). CONCLUSIONS: Self-reported VI in the US Medicare population is associated with greater dementia likelihood over time, and dementia is similarly associated with greater VI likelihood over time. Associations are likely multifactorial and bidirectional and could be explained by intervening variables in the path from VI to dementia, or vice versa, or by common risk factors for pathological processes in both eyes and brain. These findings suggest the need for early identification of older adults with visual compromise and consideration of visual disability in the cognitively impaired.

Cataract Surgery Complexity and Surgical Complication Rates Among Medicare Beneficiaries With and Without Dementia.

PURPOSE: To evaluate cataract surgery complexity and complications among US Medicare beneficiaries with and without dementia. DESIGN: Retrospective claims-based cohort study. PARTICIPANTS: A 20% representative sample of Medicare beneficiaries, 2006-2015. METHODS: Dementia was identified from diagnosis codes on or prior to each beneficiary's first-eye cataract surgery. For each surgery, we identified setting, routine vs complex coding, anesthesia provider type, duration, and any postoperative hospitalization. We evaluated 30- and 90-day complication rates-return to operating room, endophthalmitis, suprachoroidal hemorrhage, retinal detachment, retinal tear, macular edema, glaucoma, or choroidal detachment-and used adjusted regression models to evaluate likelihood of surgical characteristics and complications. Complication analyses were stratified by second-eye cataract surgery within 90 days postoperatively. RESULTS: We identified 457,128 beneficiaries undergoing first-eye cataract surgery, 23,332 (5.1%) with dementia. None of the evaluated surgical complications were more likely in dementia-diagnosed beneficiaries. There was also no difference in likelihood of nonambulatory surgery center setting, anesthesiologist provider, or postoperative hospitalization. Dementia-diagnosed beneficiaries were more likely to have surgeries coded as complex (15.6% of cases vs 8.8%, P < .0001), and surgeries exceeding 30 minutes (OR = 1.21, 95% CI = 1.17-1.25). CONCLUSIONS: Among US Medicare beneficiaries undergoing cataract surgery, those with dementia are more likely to have "complex" surgery" lasting more than 30 minutes. However, they do not have greater likelihood of surgical complications, higher-acuity setting, advanced anesthesia care, or postoperative hospitalization. This may be influenced by case selection and may suggest missed opportunities to improve vision. Future research is needed to identify dementia patients likely to benefit from cataract surgery.

Receipt of Eye Care Services among Medicare Beneficiaries with and without Dementia.

PURPOSE: To examine the relationship between dementia status and receipt of eye care among US Medicare beneficiaries. DESIGN: Retrospective, claims-based analysis. PARTICIPANTS: A 20% representative sample of Medicare beneficiaries who received care between January 1, 2006, and December 31, 2015. METHODS: Dementia was identified from diagnosis codes documented in a beneficiary's first 3 years of observed Medicare enrollment. Eye care visits were identified from provider specialty codes on each encounter claim. We used multivariable Cox proportional hazards regression models with time-varying covariates to compare the likelihood of receiving eye care between beneficiaries with and without dementia. All models were adjusted for potential confounders, including demographics, urban/rural residence, systemic health (Charlson Index), and ocular comorbidities. MAIN OUTCOME MEASURES: Hazard ratio (HR) and 95% confidence interval (CI) for (1) being seen by any eye care provider (ophthalmologist or optometrist); (2) being seen by an ophthalmologist specifically; and (3) receiving cataract surgery (among beneficiaries with ophthalmologist encounters). RESULTS: A total of 4 451 200 beneficiaries met inclusion criteria; 3 805 718 (85.5%) received eye care during the study period, and 391 556 (8.8%) had diagnosed dementia. Some 73.4% of beneficiaries diagnosed with dementia saw an eye care provider during the study period and 55.4% saw an ophthalmologist versus 86.7% and 74.0% of beneficiaries, respectively, without dementia diagnoses. Compared with those without dementia diagnoses, beneficiaries with diagnosed dementia had lower likelihood of seeing any eye care provider (adjusted HR, 0.69; 95% CI, 0.69-0.70) and were less likely to see an ophthalmologist (adjusted HR, 0.55; 95% CI, 0.55-0.55). Among the subset of beneficiaries who did see ophthalmologists, those with diagnosed dementia were also less likely to receive cataract surgery than beneficiaries without diagnosed dementia (HR, 0.62; 95% CI, 0.62-0.63) and less likely to receive a cataract diagnosis (18% vs. 82%). CONCLUSIONS: US Medicare beneficiaries diagnosed with dementia are less likely to receive eye care than those without diagnosed dementia. Depending on visual acuity and functional status, this may have implications for injury prevention, physical and cognitive function, and quality of life. Further work is needed to identify barriers to receiving eye care, determine eye care services and settings that provide greatest value to patients with dementia, and implement measures to improve access to appropriate eye care.

Characteristics of Ophthalmology Trials Registered in ClinicalTrials.gov, 2007-2018.

PURPOSE: To perform a comprehensive analysis of characteristics of ophthalmology trials registered in ClinicalTrials.gov. DESIGN: Cross-sectional study. METHODS: All 4,203 ophthalmologic clinical trials registered on ClinicalTrials.gov between October 1, 2007, and April 30, 2018, were identified by using medical subject headings (MeSH). Disease condition terms were verified by manual review. Trial characteristics were assessed through frequency calculations. Hazard ratios and 95% confidence intervals were determined for characteristics associated with early discontinuation. RESULTS: The majority of trials were multiarmed (73.6%), single-site (69.4%), randomized (64.8%), and had <100 enrollees (66.3%). A total of 33% used a data-monitoring committee (DMC), and 50.6% incorporated blinding. Other groups (51.6%) were funded by industry, whereas 2.6% were funded by the US National Institutes of Health (NIH). NIH trials were significantly more likely to address oncologic (NIH = 15.5%, Other = 3%, Industry = 1.5%; P < 0.001) or pediatric disease (NIH = 20.9%, Other = 5.9%, Industry = 1.4%; P < 0.001). Industry-sponsored trials (69.6% of phase 3 trials) were significantly more likely to be randomized (Industry = 68.7%, NIH = 58.9%, Other = 60.8%; P < 0.001) and blinded (Industry = 57.2%, NIH = 42.7%, Other = 43.5%; P < 0.001). A total of 359 trials (8.5%) were discontinued early, and 530 trials (12.6%) had unknown status. Trials were less likely to be discontinued if funded by sources other than industry (hazard ratio [HR], 0.72; 95% confidence interval [CI], 0.55-0.95; P = 0.021) and/or had a DMC (HR, 0.71; 95% CI, 0.55-0.92; P = 0.010). CONCLUSIONS: Ophthalmology trials in the past decade reveal heterogeneity across study funding sources. NIH trials were more likely to support historically underfunded subspecialties, whereas Industry trials were more likely to face early discontinuation. These trends emphasize the importance of carefully monitored and methodologically sound trials with deliberate funding allocation.

Development and validation of a predictive model for American Society of Anesthesiologists Physical Status.

BACKGROUND: The American Society of Anesthesiologists Physical Status (ASA-PS) classification system was developed to categorize the fitness of patients before surgery. Increasingly, the ASA-PS has been applied to other uses including justification of inpatient admission. Our objectives were to develop and cross-validate a statistical model for predicting ASA-PS; and 2) assess the concurrent and predictive validity of the model by assessing associations between model-derived ASA-PS, observed ASA-PS, and a diverse set of 30-day outcomes. METHODS: Using the 2014 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use Data File, we developed and internally cross-validated multinomial regression models to predict ASA-PS using preoperative NSQIP data. Accuracy was assessed with C-Statistics and calibration plots. We assessed both concurrent and predictive validity of model-derived ASA-PS relative to observed ASA-PS and 30-day outcomes. To aid further research and use of the ASA-PS model, we implemented it into an online calculator. RESULTS: Of the 566,797 elective procedures in the final analytic dataset, 8.9% were ASA-PS 1, 48.9% were ASA-PS 2, 39.1% were ASA-PS 3, and 3.2% were ASA-PS 4. The accuracy of the 21-variable model to predict ASA-PS was C = 0.77 +/- 0.0025. The model-derived ASA-PS had stronger association with key indicators of preoperative status including comorbidities and higher BMI (concurrent validity) compared to observed ASA-PS, but less strong associations with postoperative complications (predictive validity). The online ASA-PS calculator may be accessed at https://s-spire-clintools.shinyapps.io/ASA_PS_Estimator/ CONCLUSIONS: Model-derived ASA-PS better tracked key indicators of preoperative status compared to observed ASA-PS. The ability to have an electronically derived measure of ASA-PS can potentially be useful in research, quality measurement, and clinical applications.

Differences in Cataract Surgery Rates Based on Dementia Status.

BACKGROUND: Cataract surgery substantially improves patient quality of life. Despite the rising prevalence of dementia in the US, little is known about use of cataract surgery among this group. OBJECTIVE: To evaluate the relationship between dementia status and cataract surgery. METHODS: Using administrative insurance claims for a representative sample of 1,125,387 US Medicare beneficiaries who received eye care between 2006 and 2015, we compared cataract surgery rates between patients with and without dementia via multivariable regression models to adjust for patient characteristics. Main outcome measures were annual rates of cataract surgery and hazard ratio and 95% confidence interval (CI) for receiving cataract surgery. RESULTS: Cataract surgery was performed in 457,128 patients, 23,331 with a prior diagnosis of dementia. 16.7% of dementia patients underwent cataract surgery, compared to 43.8% of patients without dementia. 59 cataract surgeries were performed per 1000 dementia patients annually, versus 105 surgeries per 1000 nondementia patients. After adjusting for patient characteristics, dementia patients were approximately half as likely to receive cataract surgery compared to nondementia patients (adjusted HR = 0.53, 95% CI 0.53-0.54). Among the subset of patients who received a first cataract surgery, those with dementia were also less likely to receive second-eye cataract surgery (adjusted HR = 0.87, 95% CI 0.86-0.88). CONCLUSION: US Medicare patients with dementia are less likely to undergo cataract surgery than those without dementia. This finding has implications for quality of care and dementia progression. More information is necessary to understand why rates of cataract surgery are lower for these patients, and to identify conditions where benefits of surgery may outweigh risks.

Risk factors for incident central serous retinopathy: case-control analysis of a US national managed care population.

AIM: To evaluate clinical comorbidities and steroid use as risk factors for central serous retinopathy (CSR). METHODS: Using national insurance databases, we conducted a case-control study of beneficiaries with an incident diagnosis of CSR between 2007 and 2015 (n=35 492) and randomly selected controls matched on age-based and sex-based propensity scores (n=1 77 460). RESULTS: The mean age (SD) of cases was 49.1 (12.2) years, and the majority (69.2%) were male. Cases were more likely to have received steroids in the past year (OR 1.14, 95% CI 1.09 to 1.19, p<0.001) and to have comorbid Cushing's syndrome (OR 2.19, 95% CI 1.33 to 3.59, p=0.002), age-related macular degeneration (OR 5.24, 95% CI 5.00 to 5.49, p<0.001), diabetic macular oedema (OR 2.05, 95% CI 1.71 to 2.47, p<0.001) and diabetes mellitus (OR 1.44, 95% CI 1.33 to 1.56, p<0.001). Glaucoma was associated with lower odds of CSR (OR 0.54, 95% CI 0.51 to 0.56, p<0.001). Patients with other previously hypothesised risk factors (including essential hypertension, pregnancy, other autoimmune disease, sleep disorders, Helicobacter pylori infection and gastro-oesophageal reflux disease) had lower odds of CSR. CONCLUSIONS: Male middle-aged patients with recent steroid exposure were significantly more likely to develop CSR. Other risk factors include diabetes mellitus, diabetic macular oedema and age-related macular degeneration. Other previously hypothesised risk factors did not appear to confer increased risk. More research is needed to confirm and examine underlying pathophysiology.

Choice of Primary Rhegmatogenous Retinal Detachment Repair Method in US Commercially Insured and Medicare Advantage Patients, 2003-2016.

PURPOSE: To evaluate trends for rhegmatogenous retinal detachment (RRD) repair and the influence of patient characteristics on repair type in a large US population including children and adults, between 2003 and 2016. DESIGN: Retrospective cohort study. METHODS: Setting: Administrative claims for beneficiaries in a large nationwide managed-care network, including Medicare Advantage, employer-sponsored, and commercial insurance. POPULATION: Beneficiaries undergoing RRD primary repair procedures. MAIN OUTCOME MEASURE: RRD repair procedure type. RESULTS: We identified 31 995 beneficiaries with RRD over the study period, mean age 59.8 years. Ocular comorbidities, including pseudophakia (16.9%), vitreous hemorrhage (14.6%), myopia (2.9%), and lattice degeneration (11.0%), were more common among RRD than non-RRD patients. Pars plana vitrectomy (PPV) was consistently the most common repair procedure, increasing over time. Scleral buckle utilization declined and utilization of other procedures remained relatively constant. After adjustment for age, demographics, and geographic region, PPV was more likely among patients with pseudophakia (OR = 1.81, P < .001) and vitreous hemorrhage (OR = 1.38, P < .001). Lattice degeneration (OR = 1.42, P < .001) and younger age were associated with higher odds of scleral buckle. Pneumatic retinopexy was more likely among patients with better systemic health and less likely among patients with ocular comorbidities including vitreous hemorrhage or lattice degeneration. CONCLUSIONS: PPV is increasingly the most common RRD repair procedure across a broadly representative US population. However, other techniques are still preferred for some patients and, in aggregate, choice of repair procedure seems influenced by patient characteristics in a manner consistent with recommendations in the literature.

An Analysis of Medicare Reimbursement to Ophthalmologists: Years 2012 to 2013.

PURPOSE: To analyze trends in utilization and payment of ophthalmic services in the Medicare population for years 2012 and 2013. DESIGN: Retrospective, cross-sectional study. METHODS: A retrospective cross-sectional observational analysis was performed using publicly available Medicare Physician and Other Supplier aggregate file and the Physician and Other Supplier Public Use File. Variables analyzed included aggregate beneficiary demographics, Medicare payments to ophthalmologists, ophthalmic medical services provided, and the most common Medicare-reimbursed ophthalmic services. RESULTS: In 2013, total Medicare Part B reimbursement for ophthalmology was $5.8 billion, an increase of 3.6% from the previous year. From 2012 to 2013, the total number of ophthalmology services rendered increased by 2.2%, while average dollar amount reimbursed per ophthalmic service decreased by 5.4%. The top 5 highest reimbursed services accounted for 85% of total ophthalmic Medicare payments in 2013, an 11% increase from 2012. During 2013, drug reimbursement represented 32.8% of the total Medicare payments to ophthalmologists. Ranibizumab and aflibercept alone accounted for 95% of the entire $1.9 billion in drug reimbursements ophthalmologists in 2013. CONCLUSION: Medicare Part B reimbursement for ophthalmologists was primarily driven by use of anti-vascular endothelial growth factor (anti-VEGF) injections from 2012 to 2013. Of the total drug payments to ophthalmologists, biologic anti-VEGF agents ranibizumab and aflibercept accounted for 95% of all drug reimbursement. This is in contrast to other specialties, in which drug reimbursement represented only a small portion of Medicare reimbursement.

Self-reported Receipt of Dilated Fundus Examinations Among Patients With Diabetes: Medicare Expenditure Panel Survey, 2002-2013.

PURPOSE: To evaluate self-reported adherence to diabetic retinopathy screening examinations among diabetic subjects. DESIGN: Retrospective, population-based cross-sectional study. METHODS: Medical Expenditure Panel Survey (MEPS) consolidated full-year and prescribed drugs data from 2002-2013 were reviewed; multivariable logistic regression was used to identify patient characteristics as potential barriers to receiving examinations. RESULTS: Of 13 299 persons in the MEPS sample, only 39.62% (95% confidence interval [CI] 38.56%-40.67%) reported receiving annual dilated eye examinations, and 90.31% (CI 89.70%-90.91%) reported ever having received an eye examination. Significant factors related to ever receiving an eye examination included completed high school (odds ratio [OR] = 1.53; CI, 1.33-1.75), bachelor's degree or higher (OR = 1.94; CI, 1.56-2.41), private health insurance (OR = 2.07; CI, 1.70-2.52), public insurance (OR = 1.90; CI, 1.56-2.31), household income >400% of the poverty threshold (OR = 1.75; CI, 1.36-2.25), prescribed diabetes medication (OR = 1.45; CI, 1.27-1.65), diabetic kidney disease (OR = 1.31; CI, 1.08-1.59), prior foot examination (OR = 1.49; CI, 1.28-1.74), prior hemoglobin A1c test (OR = 1.45; CI, 1.28-1.64), and having a usual care provider (OR = 1.50; CI, 1.25-1.80). Self-reported Asian ethnicity (OR = 0.51; CI, 0.39-0.65), needing assistance for at least 3 months (OR = 0.79; CI, 0.62-1.00), and proxy needed to fill out the survey (OR = 0.72; CI, 0.61-0.85) were associated with lower odds of reporting ever having received a dilated eye examination. CONCLUSIONS: In this national-representative sample, 90.31% of patients with diabetes reported ever having a dilated eye examination; only 39.62% reported receiving one annually as recommended. These low rates appear associated with possibly modifiable factors, including having a regular care provider, increasing access to care, enrollment in health insurance, and higher education.

Physician Utilization Patterns for VEGF-Inhibitor Drugs in the 2012 United States Medicare Population: Bevacizumab, Ranibizumab, and Aflibercept.

BACKGROUND AND OBJECTIVE: To evaluate variation in physician use of vascular endothelial growth factor (VEGF) inhibitors. PATIENTS AND METHODS: Population-based analysis of comprehensive, publicly available 2012 Medicare claims, aggregated by physician specialty and service type - including intravitreal injections of bevacizumab (Avastin; Genentech, South San Francisco, CA), ranibizumab (Lucentis; Genetech, South San Francisco, CA), and aflibercept (Eylea; Regeneron, Tarrytown, NY). Physicians were characterized by total patients treated, proportion treated with each drug, total intravitreal injection payments, and proportion of total payments for each drug. RESULTS: The authors identified 2,869 ophthalmologists. On average, each treated 203 patients with VEGF-inhibitors, 75.9% of which were treated with bevacizumab. Using all three agents was the most common practice (1,121 physicians), closely followed by using bevacizumab only (1,061 physicians). Ranibizumab accounted for most payments, but bevacizumab was the largest payment source for a sizeable proportion of physicians who used only/mostly bevacizumab. CONCLUSION: Most ophthalmologists use multiple VEGF inhibitors, but vary in their relative use. A subset of ophthalmologists predominantly use ranibizumab, but ophthalmologists overall use more bevacizumab despite financial incentives favoring ranibizumab. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:555-562.].