Effectiveness of Conventional Digital Fundus Photography-Based Teleretinal Screening for Diabetic Retinopathy and Diabetic Macular Edema: A Report by the American Academy of Ophthalmology.

PURPOSE: This American Academy of Ophthalmology Ophthalmic Technology Assessment aims to assess the effectiveness of conventional teleretinal screening (TS) in detecting diabetic retinopathy (DR) and diabetic macular edema (DME). METHODS: A literature search of the PubMed database was conducted most recently in July 2023 to identify data published between 2006 and 2023 on any of the following elements related to TS effectiveness: (1) the accuracy of TS in detecting DR or DME compared with traditional ophthalmic screening with dilated fundus examination or 7-standard field Early Treatment Diabetic Retinopathy Study photography, (2) the impact of TS on DR screening compliance rates or other patient behaviors, and (3) cost-effectiveness and patient satisfaction of TS compared with traditional DR screening. Identified studies then were rated based on the Oxford Centre for Evidence-Based Medicine grading system. RESULTS: Eight level I studies, 14 level II studies, and 2 level III studies were identified in total. Although cross-study comparison is challenging because of differences in reference standards and grading methods, TS demonstrated acceptable sensitivity and good specificity in detecting DR; moderate to good agreement between TS and reference-standard DR grading was observed. Performance of TS was not as robust in detecting DME, although the number of studies evaluating DME specifically was limited. Two level I studies, 5 level II studies, and 1 level III study supported that TS had a positive impact on overall DR screening compliance, even increasing it by more than 2-fold in one study. Studies assessing cost-effectiveness and patient satisfaction were not graded formally, but they generally showed that TS was cost-effective and preferred by patients over traditional surveillance. CONCLUSIONS: Conventional TS is an effective approach to DR screening not only for its accuracy in detecting referable-level disease, but also for improving screening compliance in a cost-effective manner that may be preferred by patients. Further research is needed to elucidate the ideal approach of TS that may involve integration of artificial intelligence or other imaging technologies in the future. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Intravitreal Pharmacotherapies for Diabetic Macular Edema: A Report by the American Academy of Ophthalmology.

PURPOSE: To review the evidence on the safety and efficacy of current anti-vascular endothelial growth factor (VEGF) and intravitreal corticosteroid pharmacotherapies for the treatment of diabetic macular edema (DME). METHODS: Literature searches were last conducted on May 13, 2020, in the PubMed database with no date restrictions and limited to articles published in English. The combined searches yielded 230 citations, of which 108 were reviewed in full text. Of these, 31 were deemed appropriate for inclusion in this assessment and were assigned a level of evidence rating by the panel methodologist. RESULTS: Only the 21 articles with level I evidence were included in this assessment. Seventeen articles provided level I evidence for 1 or more anti-VEGF pharmacotherapies, including ranibizumab (14), aflibercept (5), and bevacizumab (2) alone or in combination with other treatments for DME. Level I evidence was identified in 7 articles on intravitreal corticosteroid therapy for treatment of DME: triamcinolone (1), dexamethasone (4), and fluocinolone acetonide (2). CONCLUSIONS: Review of the available literature indicates that intravitreal injections of anti-VEGF agents and corticosteroids are efficacious treatments for DME. Elevated intraocular pressure and cataract progression are important potential complications of corticosteroid therapy. Further evidence is required to assess the comparative efficacy of these therapies. Given the limited high-quality comparative efficacy data, choice of therapy must be individualized for each patient and broad therapeutic access for patients is critical to maximize outcomes.

Differences in Clinical Activity and Medicare Payments for Female vs Male Ophthalmologists.

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 16 111 ophthalmologists (3078 women [19.1%] and 13 033 men [80.9%]) in 2012 and 16 179 ophthalmologists (3206 women [19.8%] and 12 973 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.

Representation of Women With Industry Ties in Ophthalmology.

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 21 380 (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 $11 419 compared with $20 957 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 21 531 (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 $14 848 compared with $30 513 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.