Facility patient volume and survival among individuals diagnosed with malignant central nervous system tumors.

PURPOSE: Prior research indicates that the volume of central nervous system (CNS) tumor patients seen by a facility is associated with outcomes. However, most studies have focused on short-term survival and specific CNS tumor subtypes. Our objective was to examine whether facility CNS tumor patient volume is associated with longer-term CNS tumor survival overall and by subtype. METHODS: We obtained National Cancer Database (NCDB) data including individuals diagnosed with CNS tumors from 2004 to 2016. Analyses were stratified by age group (0-14, 15-39, 40-64, and ≥ 65 years) and tumor type. We used Cox Proportional Hazards (PH) regression and restricted mean survival time (RMST) analyses to examine associations between survival and facility patient volume percentile category adjusting for potential confounding factors. RESULTS: Our analytic dataset included data from 130,830 individuals diagnosed with malignant first primary CNS tumors. We found a consistently reduced hazard rate of death across age groups for individuals reported by higher vs. lower (> 95th vs. ≤ 70th percentile) volume facilities (hazard ratio (HR)0-14 = 0.78, 95% confidence interval (CI) 0.64-0.95; HR15-39 = 0.87, 95% CI 0.78-0.96; HR40-64 = 0.82, 95% CI 0.76-0.88; HR≥65 = 0.80, 95% CI 0.75-0.86). Significantly longer survival times within 5 years for higher vs. lower volume facilities were observed ranging from 1.20 months (15-39) to 3.08 months (40-64) higher. Associations varied by CNS tumor subtype for all age groups. CONCLUSIONS: These results suggest facility factors influence CNS tumor survival with longer survival for patients reported by higher volume facilities. Understanding these factors will be critical to developing strategies that eliminate modifiable differences in survival times.

Mental health and social support among glaucoma patients enrolled in the NIH All of Us COVID-19 Participant Experience (COPE) survey.

BACKGROUND: The COVID-19 pandemic created many challenges for our society. In this study, we explore how measures of mental health, coping strategies, and social support during the pandemic varied by glaucoma status. METHODS: A cohort of patients aged 40 and over enrolled in the NIH All of Us Research Program, a nationwide longitudinal cohort, who answered the COVID-19 Participant Experience (COPE) survey was obtained. We analyzed several measures of mental health, coping strategies, and social support used during the early stages of the COVID-19 pandemic. Surveys were recurring and answered from May 2020 to February 2021. Demographics and the most recently answered survey responses were obtained and stratified by glaucoma status. Pearson's Chi-squared tests and multivariable logistic regressions adjusting for age, gender, race, ethnicity, and income were used to generate p-values, odds ratios (ORs) and 95% confidence intervals (CIs) between outcome measures and glaucoma status. RESULTS: Of 42,484 patients who responded to All of Us COPE survey items, 2912 (6.9%) had a diagnosis of glaucoma. On Pearson's Chi-squared tests glaucoma patients were less likely to report drinking alcohol (P = 0.003), eating more food than usual (P = 0.004), and using marijuana (P = 0.006) to cope with social distancing than those without a diagnosis of glaucoma. Further, glaucoma patients had lower rates of probable mild, moderate, or severe depression as calculated by Patient Health Questionnaire-9 (PHQ-9) scores (P < 0.001) and had lower rates of reporting some or a lot of stress from social distancing (P < 0.001). However, glaucoma patients were less likely to report having someone to help prepare meals (P = 0.005) or help with daily chores (P = 0.003) if they became sick with COVID-19. In multivariable logistic regression analyses adjusting for confounding factors, no differences were found for measures of mental health or social support. CONCLUSIONS: Glaucoma patients did not fare worse on many measures of mental health and coping strategies during the early stages of the COVID-19 pandemic compared those without glaucoma. However, a substantial proportion of glaucoma patients still endorsed stress, social isolation, and probable depression, representing challenges for disease management.

Evaluation of Depression and Anxiety in a Diverse Population With Thyroid Eye Disease Using the Nationwide NIH All of Us Database.

PURPOSE: To evaluate the prevalence of depression and anxiety among individuals with thyroid eye disease (TED) and identify sociodemographic risk factors using the NIH All of Us database. METHODS: Three hundred ninety eight cases with TED were compared with 1,592 controls with demographics matching the 2020 US Census. Primary outcomes were diagnosed depression or anxiety; Patient Health Questionnaire-9 (PHQ-9) scores and General Anxiety Disorder-7 (GAD-7) scores were included as secondary outcomes. We performed multivariable logistic regression to generate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between TED and depression and anxiety. RESULTS: Patients with TED were more likely to have depression (OR 2.72, 95% CI 2.08-3.56, p < 0.001) and anxiety (OR 2.82, 95% CI 2.16-3.70, p < 0.001) than controls. In patients with TED, female gender was an independent risk factor for both depression (OR 1.72; 95% CI 1.00-5.07, p = 0.05) and anxiety (OR 2.17, 95% CI 1.25-3.85, p = 0.006). Unemployment (OR 1.72, 95% CI 1.03-2.94, p = 0.04) and lower income (OR 0.88 for income as a continuous variable, 95% CI 0.79-0.99, p = 0.03) were risk factors for anxiety. Risk factors for more severe depression as assessed by PHQ-9 included lower income (OR 0.70, 95% CI 0.57-0.85, p < 0.001), and protective factors included Black race (OR 0.12, 95% CI 0.02-0.45, p = 0.002). Lower income was associated with more severe anxiety as assessed by GAD-7 (OR 0.77, 95% CI 0.64-0.94, p = 0.009). CONCLUSIONS: Patients with TED were more likely to develop depression and anxiety compared with controls. This study highlights the psychosocial impact of TED and associated socioeconomic risk factors.

Associations Between Thyroid Eye Disease and Glaucoma Among Those Enrolled in the National Institutes of Health All of Us Research Program.

PURPOSE: To assess the association between thyroid eye disease (TED) and glaucoma. METHODS: Patients 18 years of age and over enrolled in the NIH All of Us Research Program, a nationwide cohort, were extracted. Those with conditions relating to TED were identified and compared with 2020 US Census-matched controls without a diagnosis of TED in a 1:4 ratio. The authors used Pearson's χ 2 tests to study demographics by TED status, and logistic regression to generate odds ratios and 95% confidence intervals to evaluate the association between TED and glaucoma (any type, including glaucoma suspect), using those without TED as the reference group. Multivariable models were adjusted for age, gender, race/ethnicity, eye doctor visits, and smoking status. RESULTS: A total of 393 cases of TED and 1,572 US Census-matched controls were identified. The median age of the cohort was 63 years (interquartile range: 48-73 years). Age, gender, and race/ethnicity varied by TED status ( p < 0.001). Overall, 114 (29.0%) of TED cases had a diagnosis of glaucoma, compared with 94 (6.0%) of non-TED controls. On bivariate logistic regression models, those diagnosed with TED were significantly more likely to be diagnosed with glaucoma compared with controls (odds ratio: 6.42; 95% confidence interval: 4.76-8.70; p < 0.001). This trend persisted on multivariable logistic regression controlling for confounding factors (odds ratio: 3.37; 95% confidence interval: 1.85-6.20 p < 0.001). CONCLUSIONS: Individuals with TED were significantly more likely to be diagnosed with glaucoma. Clinicians caring for patients with TED should be aware of this elevated risk and arrange glaucoma evaluation, accordingly.

Racial and ethnic disparities in brain tumour survival by age group and tumour type.

PURPOSE: The extent to which racial/ethnic brain tumour survival disparities vary by age is not very clear. In this study, we assess racial/ethnic brain tumour survival disparities overall by age group and type. METHODS: Data were obtained from the Surveillance, Epidemiology, and End Results (SEER) 18 registries for US-based individuals diagnosed with a first primary malignant tumour from 2007 through 2016. Cox proportional hazards regression was used to compute adjusted hazard ratios (HRs) and 95% confidence intervals (95% CIs) for the association between race/ethnicity and brain tumour survival, stratified by age group and tumour type. RESULTS: After adjusting for sex, socioeconomic status, insurance status, and tumour type, non-Hispanic (NH) Blacks (HR: 1.26; 95% CI: 1.02-1.55), NH Asian or Pacific Islanders (HR: 1.29; 95% CI: 1.01-1.66), and Hispanics (any race) (HR: 1.28; 95% CI: 1.09-1.51) all showed a survival disadvantage compared with NH Whites for the youngest age group studied (0-9 years). Furthermore, NH Blacks (HR: 0.88; 95% CI: 0.91-0.97), NH Asian or Pacific Islanders (HR: 0.84; 95% CI: 0.77-0.92), and Hispanics (any race) (HR: 0.91; 95% CI: 0.85-0.97) all showed a survival advantage compared with NH Whites for the 60-79 age group. Tests for interactions showed significant trends, indicating that racial/ethnic survival disparities disappear and even reverse for older age groups (P < 0.001). This reversal appears to be driven by poor glioblastoma survival among NH Whites (P < 0.001). CONCLUSION: Disparities in brain tumour survival among minorities exist primarily among children and adolescents. NH White adults show worse survival than their minority counterparts, which is possibly driven by poor glioblastoma biology.

Associations between geographic residence and US adolescent and young adult cancer stage and survival.

BACKGROUND: Multiple studies have indicated that place of residence can influence cancer survival; however, few studies have specifically focused on geographic factors and outcomes in adolescents and young adults (AYAs) with cancer. The objective of this study was to evaluate evidence for geographic disparities in cancer diagnosis stage and overall survival in AYAs and to examine whether stage mediated survival associations. METHODS: National Cancer Database data on AYAs aged 15 to 39 years who were diagnosed with cancer from 2010 to 2014 were obtained. Residence in Metropolitan (metro), urban, or rural counties at the time of diagnosis was defined using Rural-Urban Continuum Codes. Distance between the patient's residence and the reporting hospital was classified as short (≤2.5 miles), intermediate (>12.5 to <50 miles), or long (≥50 miles). Logistic and Cox proportional hazards regression models were used for analyses. RESULTS: The stage and survival analyses included 146,418 and 178,688 AYAs, respectively. The odds of a late versus early stage at diagnosis (stages III and IV vs I and II) were 1.16 (95% CI, 1.05-1.29) times greater for AYAs living in rural versus metro counties and 1.20 (95% CI, 1.16-1.25) times greater for AYAs living at long versus short distances to the reporting hospital. The hazard of death was 1.17 (95% CI, 1.05-1.31) and 1.30 (95% CI, 1.25-1.36) times greater for those living in rural versus metro counties, respectively, and for long versus short distances to the reporting hospital, respectively. Disease stage mediated 54% and 31% of the associations between metro, urban, or rural residence and residential distance categories and survival. CONCLUSIONS: Rural residence and living long distances from the reporting hospital were associated with later stage diagnoses and lower survival in AYAs with cancer. Further research is needed to understand mechanisms. LAY SUMMARY: Adolescents and young adults (AYAs) with cancer are a vulnerable population because cancer is of low suspicion in this population and may not be diagnosed in a timely manner. The authors evaluated evidence for geographic disparities in cancer stage at diagnosis and survival in the AYA population. The findings indicate that AYAs living in rural versus metropolitan US counties and those living farther from the diagnosis reporting hospital are more likely to be diagnosed at a later cancer stage, when it is generally less treatable, and have lower survival compared with AYAs living in metropolitan counties.

Residential distance from the reporting hospital and survival among adolescents, and young adults diagnosed with CNS tumors.

PURPOSE: Prior research shows that residential distance to a treatment facility may be an important factor in central nervous system (CNS) tumor outcomes. Our goal was to examine residential distance to the reporting hospital and overall survival in adolescents and young adults (AYA) diagnosed with CNS tumors. METHODS: National Cancer Database data on AYA 15-39 years old diagnosed with CNS and Other Intracranial and Intraspinal Neoplasms (CNS tumors) from 2010 to 2014 were obtained. Distance between the case's residence at diagnosis or initial treatment and the reporting hospital was classified in miles as short (≤ 12.5), intermediate (> 12.5 and < 50), and long (≥ 50). Cox proportional hazards regression models were used for analyses. RESULTS: Among 9335 AYA diagnosed with CNS tumors, hazard ratios (HRs) were 1.06 (95% CI 0.96-1.17) and 0.82 (95% CI 0.73-0.93) for those with residences at intermediate and long vs. short distances, respectively, after adjusting for age, sex, race/ethnicity, and zip-code level education and income. After adjusting for the facility volume of CNS tumor patients, the association was attenuated for long vs. short distance residences (HR 0.92, 95% CI 0.81-1.04). The HRs varied by tumor type, race/ethnicity, and zip-code level income with significantly lower hazards of death for those with residences at long vs. short distances for low-grade astrocytic tumors, ependymomas, non-Hispanic Whites, and those from higher-income areas. CONCLUSIONS: Living at long distances for CNS tumor care may be associated with better survival in AYA patients. This may be explained by travel to facilities with more experience treating CNS tumors.

Rural/urban residence and childhood and adolescent cancer survival in the United States.

BACKGROUND: To the authors' knowledge, no previous study has examined the relationship between rural/urban residence and childhood or adolescent cancer survival in the United States. Using the Surveillance, Epidemiology, and End Results 18 registries database, the authors examined childhood and adolescent cancer survival by rural/urban residence as defined by Rural-Urban Continuum Codes (RUCCs). METHODS: The authors obtained data from Surveillance, Epidemiology, and End Results 18 registries for individuals diagnosed at ages birth to 19 years with a first primary malignant cancer from 2000 through 2010. Rural/urban residence at the time of diagnosis was defined using both metropolitan/nonmetropolitan county classifications and individual RUCC categories. Cox proportional hazards regression was used to compute adjusted hazard ratios (HRs) and 95% confidence intervals (95% CIs) for the association between rural/urban residence and cancer survival. The authors also examined effect modification by age group, sex, race/ethnicity, and cancer type. RESULTS: Among 41,879 cancer cases, approximately 54.7% were non-Hispanic white, 54.3% were male, and 90.4% lived in a metropolitan county. Individuals living in nonmetropolitan counties versus metropolitan counties had a similar risk of cancer death (HR,  1.03; 95% CI, 0.94-1.13) as did those living in nonmetropolitan rural counties with <2500 individuals nonadjacent to a metropolitan area versus those living in metropolitan counties of ≥1 million individuals (HR,  0.98; 95% CI, 0.71-1.37). Evidence for effect modification largely was absent. CONCLUSIONS: The results of the current study suggest that childhood and adolescent cancer survival in the United States does not vary by rural/urban residence at the time of diagnosis as defined by RUCCs. The widespread availability of public health insurance for children and adolescents and a nationwide network of pediatric cancer providers may explain this finding.

The impact of rural residence on adult brain cancer survival in the United States.

PURPOSE: Rural/urban disparities in brain cancer survival have been reported. However, disparities by cancer type or in the United States as a whole remain poorly understood. Using the Surveillance, Epidemiology, and End Results (SEER) 18 registries database, we examined brain cancer survival by rural/urban residence defined by Rural-Urban Continuum Codes (RUCCs). METHODS: We obtained data from SEER 18 registries for individuals aged 20 years and older with a first primary malignant brain cancer from 2001 to 2011. Rural/urban residence at diagnosis was defined using both metropolitan/non-metropolitan county classifications and individual RUCC categories. We used Cox proportional hazards regression to compute adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between rural/urban residence and brain cancer survival. RESULTS: Among 37,581 cancer cases, 77.9% were non-Hispanic White, 56.5% were male, and 88.7% lived in a metropolitan county. Brain cancer patients living in the most rural counties had a significant increased risk of cancer death compared to those living in the most urban counties (HR 1.15; 95% CI 1.01-1.31). Those living in non-metropolitan counties had a similar risk of cancer death compared to those living in metropolitan counties (HR 1.01; 95% CI 0.97-1.06). Effect modification was observed overall by cancer type, with non-specified oligodendroglioma (HR 1.35; 95% CI 1.01-1.81) showing the greatest effect. CONCLUSION: After adjusting for confounding factors, our results suggest that rural residence has a modest effect on brain cancer survival, and that this disparity may vary by cancer type. Future research should explore differences in treatment strategies between rural and urban brain cancer patients.

Evaluation and Optimization of Diabetic Retinopathy Screenings for Uninsured Latinx Patients in a Resource-Limited Student-Run Free Clinic.

Background: Diabetic retinopathy (DR) is a sight-threatening condition that causes progressive retina damage. Student-run free clinics represent a valuable opportunity to provide DR screenings to high-risk populations. We characterized the patient population, evaluated the performance, and conducted a needs assessment of DR screenings at the University of California, San Diego Student-Run Ophthalmology Free Clinic, which provides care to predominantly uninsured, Latino patients. Methods: Retrospective chart review was conducted of all patients seen at the free clinic since 2019 with a diagnosis of type II diabetes. Date and outcome of all DR-related screenings or visits from 2015 onward, demographics information, and DR risk factors such as A1c and insulin dependence were recorded. Predictors of diabetic retinopathy and frequency of DR screenings for each patient were analyzed using multiple logistic regression, t-test for equality of means, and Pearson's correlation. Results: Of 179 uninsured diabetic patients receiving care at the free clinic, 71% were female and average age was 59. 83% had hypertension, 93% had hyperlipidemia, and 79% had metabolic syndrome. Prevalence of non-proliferative DR was 34% and that of proliferative DR was 15% in diabetic patients. The free clinic capacity in recent years plateaued at just under 50% of patients seen for DR screening or visit per year, though average wait time was over 2 years between visits. Patients with higher no-show rates had less frequent DR screenings. Chronic kidney disease and poor glycemic control were the strongest predictors of DR. Conclusion: The student-run free ophthalmology clinic has been effective in providing screening and follow-up care for DR patients. Creation of a protocol to identify which patients are at highest risk of DR and should be seen more urgently, addressing no-shows, and implementation of a tele-retina program are potential avenues for improving clinic efficiency in a resource-limited setting for vulnerable populations.

Healthcare Access and Utilization Among Glaucoma Patients in a Nationwide Cohort.

PRCIS: Despite having lower socioeconomic status on several measures, glaucoma patients do not report more barriers to healthcare access and utilization than non-glaucoma patients. PURPOSE: To characterize measures of socioeconomic status and barriers to healthcare access and utilization between patients with and without a diagnosis of glaucoma. METHODS: Patients aged 65 years and over who enrolled in the NIH All of Us Research Program, a nationwide longitudinal cohort, were extracted. We analyzed demographic information and several measures of socioeconomic status and healthcare access and utilization. Survey responses were compared by glaucoma status (any type) with Pearson χ 2 tests, univariable logistic regression, and multivariable logistic regression adjusting for age, gender, race/ethnicity, and insurance status. RESULTS: Of the 49,487 patients who answered at least 1 question on the All of Us Healthcare Access and Utilization Survey, 4441 (9.0%) had a diagnosis of glaucoma. Majority of the cohort was female (28,162, 56.9%) and nonHispanic White (42,008, 84.9%). Glaucoma patients were observed to have lower rates of education ( P =0.004), employment ( P <0.001), and home ownership ( P <0.001) on χ 2 tests. On multivariable logistic regression models, those with glaucoma were significantly more likely to speak to an eye doctor (Odds ratio: 2.46; 95% confidence interval: 2.16 to 2.81) and significantly less likely to have trouble affording eyeglasses (OR: 0.85 95% CI: 0.72 to 0.99) in the prior year than those without a diagnosis of glaucoma. No significant association was found for other measures of healthcare access and utilization by glaucoma status. CONCLUSION: Although glaucoma patients aged 65 years and over fared worse on several measures of socioeconomic status, no significant difference was found in measures of healthcare access and utilization.

Racial Disparities in Barriers to Care for Patients With Diabetic Retinopathy in a Nationwide Cohort.

Purpose: To ascertain specific barriers of care among patients with diabetic retinopathy (DR) from different racial/ethnic groups. Methods: In this cross-sectional study, we included adult participants in the National Institutes of Health All of Us Research Program with DR who answered questions in the Healthcare Access & Utilization survey and Social Determinants of Health (SDoH) survey. Logistic regression was used to study the association between barriers to care and race/ethnicity. Results: Our cohort included 885 DR patients who answered the Healthcare Access & Utilization survey and 385 DR patients who responded to the SDoH survey. After adjusting for confounders, Hispanic individuals were more likely than non-Hispanic White individuals to report delaying getting medical care due to not being able to get child care (odds ratio [OR] = 6.57 [95% confidence interval {CI}, 1.67-27.8]). Furthermore, compared to non-Hispanic White individuals, non-Hispanic Black individuals were significantly more likely to report being treated with less respect (OR = 2.62 [95% CI, 1.15-5.80]), treated with less courtesy (OR = 2.51 [95% CI, 1.01-5.92]), and receive poorer service than other people (OR = 2.85 [95% CI, 1.25-6.34]) when they go to a doctor's office or other healthcare provider. Conclusions: We found that Hispanic and non-Hispanic Black individuals with DR reported greater delays/barriers to care compared to non-Hispanic White individuals even after controlling for individualized socioeconomic factors. Translational Relevance: This study highlights the importance of taking steps to promote health equity, such as increasing access to child care resources and reducing implicit bias among eye care providers, to increase access to care and prevent vision loss from DR.

Associations between Socioeconomic Factors and Visit Adherence among Patients with Glaucoma in the All of Us Research Program.

PURPOSE: To identify socioeconomic factors associated with visit adherence among patients with glaucoma in a nationwide cohort. DESIGN: Cross-sectional study. SUBJECTS: All subjects were participants in the National Institutes of Health All of Us Research Program. This study cohort consists of participants who were diagnosed with glaucoma and who answered the question on the Health Care Access and Utilization Survey regarding whether they have seen an eye care provider in the last 12 months. METHODS: Descriptive analyses were conducted based on participant age, gender, race/ethnicity, insurance status, level of education, and income bracket. Multivariable logistic regression adjusting for these factors was used to generate odds ratios (ORs) for the association between socioeconomic factors and visit adherence. MAIN OUTCOME MEASURE: Visit adherence, defined as reporting seeing an eye care provider in the last 12 months. RESULTS: Among 4517 patients with glaucoma, 730 (16.3%) indicated that they had not seen or spoken to an eye doctor in the last 12 months. In multivariable models, those with some college education (OR: 1.91; 95% confidence interval [CI]: 1.19-3.04) and those with a college degree or advanced degree (OR: 2.25; 95% CI: 1.39-3.60) and those with the highest annual income of ≥ $200 000 (OR: 1.64; 95% CI: 1.10-2.45) were more likely to have seen an eye doctor in the past year compared with those in the lowest education and income categories, respectively. CONCLUSION: Lower income and education levels were significantly associated with lower odds of seeing an eye doctor in the past year among all patients with glaucoma in All of Us. This highlights an important health disparity and may inform subsequent interventions to promote improved adherence to clinical guidelines regarding eye care for glaucoma monitoring and management. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Gender Disparities in Depression, Stress, and Social Support Among Glaucoma Patients.

Purpose: To understand differences in measures of depression, stress, and social support by gender among those diagnosed with glaucoma. Methods: We obtained a cohort of glaucoma patients (any type) ages 18 years and over who answered the COVID-19 Participant Experience (COPE) survey of the NIH All of Us Research Program. We analyzed several measures of depression, stress, and social support by gender. Logistic regression was used to evaluate the association among reported stress associated with social distancing, depression (using Patient Health Questionnaire-9 [PHQ-9] scores), and measures of social support by self-reported gender, with men as the reference group. Multivariable models were adjusted for age, race and ethnicity, health insurance status, education, and income. Results: Of 3633 glaucoma patients, 56.8% were women. Many patients had a PHQ-9 score > 4 (33.3%), indicating mild, moderate, or severe depression. In multivariable models, women were significantly more likely to report a PHQ-9 score > 4 (odds ratio [OR] = 1.40; 95% confidence interval [CI], 1.20-1.62; P < 0.001) and some or a lot of stress (OR = 1.34; 95% CI, 1.14-1.57; P < 0.001) compared with men. Further, women were significantly less likely to report having help all or most of the time if they needed someone to prepare meals (OR = 0.78; 95% CI, 0.67-0.92; P = 0.002) or perform daily chores (OR = 0.79; 95% CI, 0.67-0.91; P = 0.003) than men. Conclusions: Women with glaucoma were more likely to experience depression and stress and were less likely to have social support on some measures than men. Translational Relevance: The disproportionate burden of psychosocial factors among women may complicate glaucoma management.

Cilioretinal artery occlusion in antiphospholipid syndrome and the decision to anticoagulate.

A patient in her late 50s with antiphospholipid syndrome presented to general ophthalmology clinic for annual hydroxychloroquine retinopathy screening. She had taken 400 mg hydroxychloroquine daily for over a decade. She denied any visual changes and visual acuity was 20/20. Her examination and fundus photos were normal, but macular optical coherence tomography of the right eye demonstrated inner retinal atrophy and visual field tests revealed a corresponding paracentral scotoma, consistent with a prior cilioretinal artery occlusion. Prior testing from visits with other ophthalmologists revealed that this occlusion had occurred previously, but she had only been informed of not having hydroxychloroquine retinopathy. The possibility of vision loss prompted her to reconsider her prior decision to discontinue anticoagulation. This case demonstrates how anchoring bias may lead clinicians astray, and how the risk of blindness is a strong motivator for patients regarding anticoagulation.

Racial and Ethnic Disparities in Cost-Related Barriers to Medication Adherence Among Patients With Glaucoma Enrolled in the National Institutes of Health All of Us Research Program.

IMPORTANCE: Ability to afford medication is a major determinate of medication adherence among patients. OBJECTIVE: To determine cost-related barriers to medication adherence by race and ethnicity in a nationwide cohort of patients with glaucoma. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study included patients with glaucoma enrolled in the National Institutes of Health All of Us Research Program, a nationwide longitudinal cohort of US adults, with more than 300 000 currently enrolled. Individuals with a diagnosis of glaucoma based on electronic health record diagnosis codes who participated in the Health Care Access and Utilization survey and had complete data on all covariates were studied. Data were collected from June 2016 to March 2021, and data were analyzed from August to November 2021. EXPOSURES: Race and ethnicity defined as non-Hispanic African American, non-Hispanic Asian, Hispanic, and non-Hispanic White. MAIN OUTCOMES AND MEASURES: Logistic regression was used to evaluate the association between reported cost-related barriers to medication adherence (could not afford prescription medication, skipped medication doses to save money, took less medication to save money, delayed filling a prescription to save money, asked for lower-cost medication to save money, bought prescriptions from another country to save money, and used alternative therapies to save money) and race and ethnicity, adjusting multivariable models by age, gender, health insurance status, education, and income. Odds ratios of these barriers were obtained by race and ethnicity, with non-Hispanic White race as the reference group. RESULTS: Of 3826 included patients with glaucoma, 481 (12.6%) were African American, 119 (3.1%) were non-Hispanic Asian, 351 (9.2%) were Hispanic, and 2875 (75.1%) were non-Hispanic White. The median (IQR) age was 69 (60-75) years, and 2307 (60.3%) were female. After adjusting for confounders, non-Hispanic African American individuals (odds ratio, 1.82; 95% CI, 1.34-2.44) and Hispanic individuals (odds ratio, 1.77; 95% CI, 1.25-2.49) were more likely than non-Hispanic White individuals to report not being able to afford medications. Further, despite having the lowest rate of endorsing difficulty affording medications, non-Hispanic White individuals were equally likely to ask for lower-cost medication from their clinicians as individuals of racial and ethnic minority groups. CONCLUSIONS AND RELEVANCE: In this study, there was significantly higher odds of self-reported difficulty affording medications among non-Hispanic African American and Hispanic individuals compared with non-Hispanic White individuals. Clinicians should be proactive and initiate discussions about costs in an effort to promote medication adherence and health equity among patients.

Approaches for monitoring and treating cardiomyopathy among cancer survivors following anthracycline or thoracic radiation treatment.

BACKGROUND: Anthracycline chemotherapy and thoracic radiation therapy (RT) are known causes of cardiomyopathy among cancer survivors, however, management guidelines for this population are lacking. In this study we describe our single institution management approach for cancer survivors with low left ventricular ejection fraction (LVEF) secondary to cancer treatment. METHODS: We conducted a retrospective descriptive study of childhood and young adult (CAYA) cancer survivors in the Adult Long-Term Follow-Up Clinic at Memorial Sloan Kettering Cancer Center enrolled between November 2005 and July 2019. Those included were treated with anthracycline and/or thoracic RT as a part of their cancer therapy and had recorded a LVEF of < 55% on at least one post-treatment echocardiogram. Details regarding survivor characteristics, screening, and management were abstracted. Differences in management approaches among survivors with LVEF of 50-54.9%, 40-49.9%, and < 40% were described. Qualitative management approaches were abstracted as well. RESULTS: Among 668 CAYA survivors in the initial cohort, 80 were identified who had received anthracycline and/or thoracic RT and had a LVEF of < 55%. Median age at cancer diagnosis was 16.1 years, median time from cancer diagnosis was 25.8 years, and 55% of survivors were female. Cardiology referrals, nuclear stress tests, multi-gated acquisition scans, angiograms, echocardiograms, treatment with angiotensin converting enzyme inhibitors or receptor blockers, beta-blockers, diuretics, aldosterone antagonists, aspirin, and insertion of pacemaker or implantable cardioverter-defibrillators differed by LVEF category. Documentation suggested uncertainty regarding management of survivors with borderline low-LVEF, with low-LVEF that improved on follow-up, and with subsequent cancers requiring additional treatment. CONCLUSIONS: The management of CAYA cancer survivors with low-LVEF largely followed guidelines designed for the general population, however, uncertainty remains for issues specific to cancer survivors. Cardiomyopathy management guidelines that address issues specific to cancer survivors are needed.

Assessing Usability of Smartwatch Digital Health Devices for Home Blood Pressure Monitoring among Glaucoma Patients.

Glaucoma is a leading cause of blindness worldwide. Blood pressure (BP) dysregulation is a known risk factor, and home-based BP monitoring is increasingly used, but the usability of digital health devices to measure BP among glaucoma patients is not well studied. There may be particular usability challenges among this group, given that glaucoma disproportionately affects the elderly and can cause visual impairment. Therefore, the goal of this mixed-methods study was to assess the usability of a smart watch digital health device for home BP monitoring among glaucoma patients. Adult participants were recruited and given a smartwatch blood pressure monitor for at-home use. The eHEALS questionnaire was used to determine baseline digital health literacy. After a week of use, participants assessed the usability of the BP monitor and related mobile app using the Post-study System Usability Questionnaire (PSSUQ) and the System Usability Scale (SUS), standardized instruments to measure usability in health information technology interventions. Variations in scores were evaluated using ANOVA and open-ended responses about participants' experience were analyzed thematically. Overall, usability scores corresponded to the 80th-84th percentile, although older patients endorsed significantly worse usability based on quantitative scores and additionally provided qualitative feedback describing some difficulty using the device. Usability for older patients should be considered in the design of digital health devices for glaucoma given their disproportionate burden of disease and challenges in navigating digital health technologies, although the overall high usability scores for the device demonstrates promise for future clinical applications in glaucoma risk stratification.