Uveitis and health disparities: results from the National Inpatient Sample.

PURPOSE: Health disparities exist when the prevalence or outcome of the disease are influenced by age, race, sex or income. Health disparities are prevalent in autoimmune diseases. However, there is a lack of national US data regarding health disparities in uveitis. The primary aim of our study is to evaluate health disparities for uveitis in the USA. METHODS: We performed a retrospective, observational, cross-sectional study to ascertain health disparities for uveitis and its complications in the USA using the National Inpatient Sample (NIS) for the years 2002-2013. We used the International Classification of Disease, ninth revision, codes to identify uveitis cases and ocular complications. Uveitis was divided into total, infectious and non-infectious uveitis. We collected information on age, sex, race, income quartile and ocular complications. We preformed statistical analysis using SAS V.9.4. A logistic regression model was used to predict the odds of developing uveitis and its complications. RESULTS: There were a total of 94 143 978 discharges including 15 296 total uveitis, 4538 infectious and 10 758 non-infectious uveitis patients. Compared with the total NIS population, patients with uveitis were younger (mean age 45±18 vs 48±28 years, p value ≤0.0001, African-Americans (23% vs 10%, p value ≤0.0001), in the lowest income quartile (<$38 999; 29% vs 26%, p value ≤0.0001) and were insured by Medicaid (25% vs 20%, p value ≤0.0001). CONCLUSION: African-American patients have a higher prevalence of uveitis. Patients insured by Medicare and Medicaid have more frequent ocular complications. This knowledge may guide future research on disparity and shape healthcare decision making.

Development of a Glucocorticoid Toxicity Index (GTI) using multicriteria decision analysis.

OBJECTIVES: To develop a Glucocorticoid Toxicity Index (GTI) to assess glucocorticoid (GC)-related morbidity and GC-sparing ability of other therapies. METHODS: Nineteen experts on GC use and outcome measures from 11 subspecialties participated. Ten experts were from the USA; nine from Canada, Europe or Australia. Group consensus methods and multicriteria decision analysis (MCDA) were used. A Composite GTI and Specific List comprise the overall GTI. The Composite GTI reflects toxicity likely to change during a clinical trial. The Composite GTI toxicities occur commonly, vary with GC exposure, and are weighted and scored. Relative weights for items in the Composite GTI were derived by group consensus and MCDA. The Specific List is designed to capture GC toxicity not included in the Composite GTI. The Composite GTI was evaluated by application to paper cases by the investigators and an external group of 17 subspecialists. RESULTS: Thirty-one toxicity items were included in the Composite GTI and 23 in the Specific List. Composite GTI evaluation showed high inter-rater agreement (investigators κ 0.88, external raters κ 0.90). To assess the degree to which the Composite GTI corresponds to expert clinical judgement, participants ranked 15 cases by clinical judgement in order of highest to lowest GC toxicity. Expert rankings were then compared with case ranking by the Composite GTI, yielding excellent agreement (investigators weighted κ 0.87, external raters weighted κ 0.77). CONCLUSIONS: We describe the development and initial evaluation of a comprehensive instrument for the assessment of GC toxicity.

Long-term risk of malignancy among patients treated with immunosuppressive agents for ocular inflammation: a critical assessment of the evidence.

PURPOSE: To critically assess potentially carcinogenic effects of immunosuppressive therapy in the ocular inflammation setting. DESIGN: Focused evidence assessment. METHODS: Relevant publications were identified by MEDLINE and EMBASE queries and reference list searches. RESULTS: Extrapolation from transplant, rheumatology, skin disease, and inflammatory bowel disease cohorts to the ocular inflammation setting suggest that: 1) alkylating agents increase hematologic malignancy risk and cyclophosphamide increases bladder cancer risk, but less so with < or =18 months' duration of therapy and hydration, respectively; 2) calcineurin inhibitors and azathioprine probably do not increase total cancer risk to a detectable degree, except perhaps some other risk factors (uncommon in ocular inflammation patients) might interact with the former to raise risk; 3) tumor necrosis factor (TNF) inhibitors may accelerate diagnosis of cancer in the first six to 12 months, but probably do not increase long-term cancer risk; and 4) changes in risk with methotrexate, mycophenolate mofetil, and daclizumab appear negligible, although nontransplant data are limited for the latter agents. Immunosuppression in general may increase skin cancer risk in a sun exposure-dependent manner. CONCLUSION: Use of alkylating agents for a limited duration seems justifiable for severe, vision-threatening disease, but otherwise cancer risk may be a relevant constraint on use of this approach. Antimetabolites, daclizumab, TNF inhibitors, and calcineurin inhibitors probably do not increase cancer risk to a degree that outweighs the expected benefits of therapy. Monitoring for skin cancer may be useful for highly sun-exposed patients. Data from ocular inflammation patients are needed to confirm the conclusions made in this analysis by extrapolation.