Socially Accountable Academic Health Centers: Pursuing a Quadripartite Mission.

Academic health centers (AHCs) in the United States have had a leading role in educating the medical workforce, generating new biomedical knowledge, and providing tertiary and quaternary clinical care. Yet the health status of the U.S. population lags behind almost every other developed world economy. One reason is that the health care system is not organized optimally to address the major driver of health status, the social determinants of health (SDOH). The United States' overall poor health status is a reflection of dramatic disparities in health that exist between communities and population groups, and these are associated with variations in the underlying SDOH. Improving health status in the United States thus requires a fundamental reengineering of the health delivery system to address SDOH more explicitly and systematically. AHCs' tripartite mission, which has served so well in the past, is no longer sufficient to position AHCs to lead and resolve the intractable drivers of poor health status, such as unfair and unjust health disparities, health inequities, or differences in a population's SDOH.AHCs enjoy broad public support and have an opportunity-and an obligation-to lead in improving the nation's health. This Perspective proposes a new framework for AHCs to expand on their traditional tripartite mission of education, research, and clinical care to include explicitly a fourth mission of social accountability. Through this fourth mission, comprehensive community engagement can be undertaken, addressing SDOH and measuring the health impact of interventions by using a deliberate structure and process, yielding defined outcomes.

The Impact of the Medicare Access and CHIP Reauthorization Act on the Field of Ophthalmology.

PURPOSE: To analyze the impact of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) on the field of ophthalmology. DESIGN: A perspective on the effects of MACRA's Quality Payment Program after analysis of the proposed rule, final rule, and commentary submitted by relevant stakeholders. RESULTS: Physicians will need to use 1 of 2 payment structures: Merit-Based Incentive Payment Systems (MIPS) or Alternative Payment Models (APMs). APMs and MIPS will focus on bundling payments and reimbursing based on "fee-for-service-plus" models, which take into account clinical outcomes, coordination of care, clinical improvement, and electronic information exchange and security. APMs have substantial advantages, with eligible participants receiving a bonus and a higher rate of annual adjustment over the program's life. For most ophthalmology practices, MIPS may be more appropriate owing to its broader applicability and the current paucity of APMs for ophthalmologists. CONCLUSION: The Quality Payment Program is a substantial improvement over the negative adjustments under the repealed Substantial Growth Rate model. Ophthalmologists will likely use the MIPS system; however, its comparatively lower reimbursements, as well as its cost, quality, and other reporting measures, may prove problematic.

Current and Future Status of Diversity in Ophthalmologist Workforce.

IMPORTANCE: Increasing the level of diversity among ophthalmologists may help reduce disparities in eye care. OBJECTIVE: To assess the current and future status of diversity among ophthalmologists in the workforce by sex, race, and ethnicity in the context of the available number of medical students in the United States. DESIGN, SETTING, AND PARTICIPANTS: Data from the Association of American Medical Colleges, the American Medical Association, and US Census were used to evaluate the differences and trends in diversity among ophthalmologists, all full-time faculty except ophthalmology, ophthalmology faculty, ophthalmology residents, medical school students, and the US population between 2005 and 2015. For 2014, associations of sex, race, and ethnicity with physician practice locations were assessed. MAIN OUTCOMES AND MEASURES: Proportions of ophthalmologists stratified by sex, race, and ethnicity between 2005 and 2015. RESULTS: Women and minority groups traditionally underrepresented in medicine (URM)-black, Hispanic, American Indian, Alaskan Native, Native Hawaiian, and Pacific Islander-were underrepresented as practicing ophthalmologists (22.7% and 6%, respectively), ophthalmology faculty (35.1% and 5.7%, respectively), and ophthalmology residents (44.3% and 7.7%, respectively), compared with the US population (50.8% and 30.7%, respectively). During the past decade, there had been a modest increase in the proportion of female practicing ophthalmologists who graduated from US medical schools in 1980 or later (from 23.8% to 27.1%; P < .001); however, no increase in URM ophthalmologists was identified (from 7.2% to 7.2%; P = .90). Residents showed a similar pattern, with an increase in the proportion of female residents (from 35.6% to 44.3%; P = .001) and a slight decrease in the proportion of URM residents (from 8.7% to 7.7%; P = .04). The proportion of URM groups among ophthalmology faculty also slightly decreased during the study period (from 6.2% to 5.7%; P = .01). However, a higher proportion of URM ophthalmologists practiced in medically underserved areas (P < .001). CONCLUSIONS AND RELEVANCE: Women and URM groups remain underrepresented in the ophthalmologist workforce despite an available pool of medical students. Given the prevalent racial and ethnic disparities in eye care and an increasingly diverse society, future research and training efforts that increase the level of diversity among medical students and residents seems warranted.

Racial and Ethnic Health Disparities and the Affordable Care Act: a Status Update.

Persistent racial and ethnic health disparities exist in the USA, despite decades of research and public health initiatives. Several factors contribute to health disparities, including (but not limited to) implicit provider bias, access to health care, social determinants, and biological factors. Disparities in health by race/ethnicity are unacceptable and correctable. The Patient Protection and Affordable Care Act is a comprehensive legislation that is focused on improving health care access, quality, and cost control. This health care reform includes specific provisions which focus on preventive care, the standardized collection of data on race, ethnicity, primary language and disability status, and health information technology. Although some provisions of the Patient Protection and Affordable Care Act have not been implemented, such as funding for the U.S. Public Health Sciences track, which would have addressed the shortage of medical professionals in the USA who are trained to use patient-centered, interdisciplinary, and care coordination approaches, this legislation is still poised to make great strides toward eliminating health disparities. The purpose of this manuscript is to highlight the unprecedented opportunities that exist for the Patient Protection and Affordable Care Act to reduce racial and ethnic disparities in health in the USA.

Racial/Ethnic Disparities in Preventive Care Practice Among U.S. Nursing Home Residents.

OBJECTIVE: To assess racial/ethnic disparities in preventive care practices among U.S. nursing home residents. METHOD: To implement the Institute of Medicine definition of health care disparity, we used the rank-and-replace adjustment method to assess the disparity in receipt of eight preventive care services among residents and evaluate trends in disparities. The sampling design (stratification and clustering) was accounted for using Stata 11. RESULTS: The 2004 National Nursing Home Surveys data show White residents were more likely to have pain management, scheduled toilet plan/bladder retraining, influenza vaccination, and pneumococcal vaccination than Black residents. White residents were also more likely to have scheduled toilet plan/bladder retraining than residents of Other race/ethnicity. Significant Black-White disparities in receipt of influenza vaccination and pneumococcal vaccination were found. Time trend analysis showed that disparities were neither exacerbated nor reduced. CONCLUSION: Persistent racial/ethnic disparities in preventive care among nursing home residents exist. We urge the development and implementation of targeted interventions to improve the quality of preventive care in nursing homes.

Socioeconomic disparity in use of eye care services among US adults with age-related eye diseases: National Health Interview Survey, 2002 and 2008.

IMPORTANCE: Individuals with age-related eye disease (ARED) need to use eye care services for detection, assessment, and care at regular intervals. OBJECTIVE: To explore the association between socioeconomic position (SEP) and use of eye care services among US adults with self-reported ARED during 2002 and 2008. DESIGN: Data were from the National Health Interview Survey 2002 and 2008. We used multiple logistic regression to estimate predictive margins, controlling for other factors, and we used the slope index of inequality to measure the relationship between SEP and use of eye care services across the entire distributions of poverty-income ratio (PIR) and educational attainment. SETTING: A cross-sectional, nationally representative sample of adults, with prevalence estimates weighted to represent the civilian, noninstitutionalized US population. PARTICIPANTS: The sample included US participants in the 2002 (n = 3586) and the 2008 (n = 3104) National Health Interview Survey who were at least 40 years old and reported any ARED (age-related macular degeneration, cataract, diabetic retinopathy, or glaucoma). MAIN OUTCOMES AND MEASURES: Use of eye care services; SEP was measured by the PIR and educational attainment. RESULTS: In 2002, persons with ARED and a PIR of less than 1.50 were significantly less likely than those with a PIR of at least 5 to report visiting an eye care provider (62.7% vs 80.1%; P < .001) or undergoing a dilated eye examination in the past 12 months (64.3% vs 80.4%; P < .001), after adjustment for other factors. Similarly, persons with less than a high school education were less likely than those with at least a college education to report a visit to an eye care provider (62.9% vs 80.8%; P < .001) or dilated eye examination (64.8% vs 81.4%; P < .001). In 2002, the slope index of inequality showed statistically significant differences for eye care provider visits across the levels of education (24.4; P = .006), and in 2008, it showed a significant difference for eye care provider visits across the levels of educational attainment (25.2; P = .049) and PIR (21.8; P = .01). CONCLUSIONS AND RELEVANCE: Significant differences in the use of eye care services by SEP persist among US adults with eye diseases.

The changing face of academic health centers: a path forward for the University of Colorado Denver.

This article describes a decade of major changes at an academic health center (AHC) and university. The authors describe two major changes undertaken at the University of Colorado and its AHC during the past 10 years and the effects of these changes on the organization as a whole. First, the AHC's four health professional schools and two partner hospitals were completely relocated from a space-limited urban campus to a closed Army base. The impact of that change and the management of its potential disruption of academic programs are discussed in detail. In the middle of this total relocation, the AHC campus was consolidated with a general academic campus within the University of Colorado system, compounding the challenge. The authors describe the strategies employed to implement this major consolidation, including changing the organizational structure and selecting the new name of the university--the University of Colorado Denver.

A panel assessment of glaucoma management: modification of existing RAND-like methodology for consensus in ophthalmology. Part I: Methodology and design.

PURPOSE: To examine ways to improve existing methodology to reach appropriate consensus in the treatment of primary open-angle glaucoma. DESIGN: Evidence-based literature and accumulated expert opinion. METHODS: A core nonvoting steering committee composed of four individuals created 148 statements. Another nonvoting individual with expertise in clinical epidemiology reviewed all evidence in support of or against each statement and summarized this information. After review of these summaries, 10 panelists voted on each of the statements both before and after a panel meeting where each question was discussed by the panel. The polling was conducted online using a customized software program for the process. RESULTS: Consensus was reached on most statements both before and after the panel meeting. The proportion of questions where consensus agreement or disagreement was reached increased from 82 of 148 before the panel meeting to 110 of 148 after the meeting. Detailed information regarding the results of the polling are provided in the accompanying article.(1) CONCLUSIONS: Refinements to existing descriptions of modified RAND-like appropriateness methodology was successful in allowing a group of ophthalmology panelists to reach consensus for or against most statements developed by nonpanelists. Future studies should be conducted to compare how robust and valid this methodology is as compared with other methods of determining optimal clinical care decision making.

A panel assessment of glaucoma management: modification of existing RAND-like methodology for consensus in ophthalmology. Part II: Results and interpretation.

PURPOSE: To present the results of a panel consensus assessment of evaluation and therapy relating to primary open-angle glaucoma based on available evidence and expert opinion. DESIGN: A panel consensus assessment of glaucoma diagnosis and therapy using a modified RAND-like appropriateness methodology. METHODS: One hundred and forty-eight questions, most of which related to glaucoma therapy, were created by a core nonvoting executive committee based on common clinical questions. An evidence-based review of the literature pertaining to these questions was provided to 10 voting panelists. These panelists, who did not participate in either the creation of the questions or the conduct of the literature review, then were polled using a modified technique derived from existing methodology. RESULTS: Consensus agreement or disagreement was reached for 55.4% and 74.3% of the polling statements before and after the panel meeting, respectively. This represents a consensus agreement or disagreement on a majority of polling statements both before and after a meeting of all panelists and the two co-chairs of the program. There was an increase in the proportion of statements where consensus agreement was reached after the panel meeting. CONCLUSIONS: Given the paucity of high-quality evidence relating to many of the issues addressed in this assessment and the variability of practice patterns among ophthalmologists, consensus agreement or disagreement was reached for a high proportion of polling statements.

Is cataract surgery cost-effective among older patients with a low predicted probability for improvement in reported visual functioning?

INTRODUCTION: Although cataract surgery has been demonstrated to be effective and cost-effective, 5% to 20% of patients do not benefit functionally from the procedure. This study examines the cost-effectiveness of cataract surgery versus watchful waiting in a subgroup of patients who had less than a 30% predicted probability of reporting improvements in visual function after surgery. METHODS: Randomized trial (first eye surgery vs. watchful waiting) of 250 patients who based on a cataract surgery index (CSI) were felt to have less than a 30% probability of reporting improvements in visual functioning after surgery. Cost was estimated using monthly resource utilization surveys and Medicare billing and payment data. Effectiveness was evaluated at 6 months using the Activities of Daily Vision Scale (ADVS) and the Health Utilities Index, Mark 3 (HUI3). RESULTS: In terms of overall utility, the incremental cost-effectiveness of surgery was Dollars 38,288/QALY. In the subgroup of patients with a CSI score > 11 (< 20% probability of improvement), the cost-effectiveness of cataract surgery was Dollars 53,500/QALY. Sensitivity analysis demonstrated that often this population of patients may not derive a utility benefit with surgery. CONCLUSION: Cataract surgery is cost-effective even in a subpopulation of patient with a lower, < 30%, predicted probability of reporting improved visual functioning after surgery. There may be a subgroup of patients, CSI > 11, for whom a strategy of watchful waiting may be equally effective and considerably less expensive.

An evidence-based assessment of risk factors for the progression of ocular hypertension and glaucoma.

PURPOSE: To critically review the existing literature concerning risk factors for progression of ocular hypertension and glaucoma to assist in assigning levels of risk for individual patients. DESIGN: Evidence-based review. METHODS: A panel of physicians specializing in treatment of glaucoma patients was convened to critically analyze published population-based studies of ocular hypertension and glaucoma progression. The strength of evidence in support of reported risk factors was weighed. RESULTS: Many putative risk factors for progression of ocular hypertension or glaucoma have been reported in the literature. The risk factors most strongly supported by evidence are higher intraocular pressure (IOP), greater cup-to-disk ratio, thinner central corneal measurement, and older age. Black race does not appear to be an independent risk factor, although black individuals tend to have thinner corneas, greater cup-to-disk ratios, and higher IOP, which increase their risk. The limited number of studies in which other suspected risk factors are reported prevents drawing firm conclusions about their importance at this time. CONCLUSIONS: Only a subset of patients with ocular hypertension will eventually develop glaucoma. Decisions regarding the implementation and extent of therapy for ocular hypertension can be difficult and require an understanding of the relative importance of risk factors for progression. This review discusses the strength of evidence supporting reported risk factors and may be useful in assessing the risk for progression of individual patients.

Risk assessment in the management of patients with ocular hypertension.

PURPOSE: To develop a model for estimating the global risk of disease progression in patients with ocular hypertension and to calculate the "number-needed-to-treat" (NNT) to prevent progression to blindness as an aid to practitioners in clinical decision making. DESIGN: Development of a mathematical model for estimating risk of glaucoma progression. METHODS: Population-based studies of patients with ocular hypertension and glaucoma were reviewed by a panel of glaucoma specialists. Measures of disease progression risks derived from three long-term studies and assumptions based on the available data were used to estimate the risk of progression from ocular hypertension to glaucoma and glaucoma to unilateral blindness for untreated and treated patients over a 15-year period. Using these estimates, the NNT (1/absolute risk reduction on treatment) to prevent unilateral blindness in one patient with ocular hypertension was calculated. RESULTS: In untreated patients, the estimated risk of progression from ocular hypertension to unilateral blindness was 1.5% to 10.5% and in treated patients, the estimated risk of progression was 0.3% to 2.4% over 15 years. From these estimates, between 12 and 83 patients with ocular hypertension will require treatment to prevent one patient from progressing to unilateral blindness over a 15-year period. CONCLUSION: Global risk assessment that incorporates all available data plays a vital role in managing patients with ocular hypertension. A more precise understanding of long-term vision loss should be factored into decisions pertaining to the initiation of glaucoma therapy. Undoubtedly, these estimates will evolve and change with the availability of new population-based epidemiologic information and improvements in multivariable model testing.