Evaluating Access to Laser Eye Surgery by Driving Times Using Medicare Data and Geographical Mapping.

Importance: Recently, several states have granted optometrists privileges to perform select laser procedures (laser peripheral iridotomy, selective laser trabeculoplasty, and YAG laser capsulotomy) with the aim of increasing access. However, whether these changes are associated with increased access to these procedures among each state's Medicare population has not been evaluated. Objective: To compare patient access to laser surgery eye care by estimated travel time and 30-minute proximity to an optometrist or ophthalmologist. Design, Setting, and Participants: This retrospective cohort database study used Medicare Part B claims data from 2016 through 2020 for patients accessing new patient or laser eye care (laser peripheral iridotomy, selective laser trabeculoplasty, YAG) from optometrists or ophthalmologists in Oklahoma, Kentucky, Louisiana, Arkansas, and Missouri. Analysis took place between December 2021 and March 2023. Main Outcome and Measures: Percentage of each state's Medicare population within a 30-minute travel time (isochrone) of an optometrist or ophthalmologist based on US census block group population and estimated travel time from patient to health care professional. Results: The analytic cohort consisted of 1 564 307 individual claims. Isochrones show that optometrists performing laser eye surgery cover a geographic area similar to that covered by ophthalmologists. Less than 5% of the population had only optometrists (no ophthalmologists) within a 30-minute drive in every state except for Oklahoma for YAG (301 470 [7.6%]) and selective laser trabeculoplasty (371 097 [9.4%]). Patients had a longer travel time to receive all laser procedures from optometrists than ophthalmologists in Kentucky: the shortest median (IQR) drive time for an optometrist-performed procedure was 49.0 (18.4-71.7) minutes for YAG, and the the longest median (IQR) drive time for an ophthalmologist-performed procedure was 22.8 (12.1-41.4) minutes, also for YAG. The median (IQR) driving time for YAG in Oklahoma was 26.6 (12.2-56.9) for optometrists vs 22.0 (11.2-40.8) minutes for ophthalmologists, and in Arkansas it was 90.0 (16.2-93.2) for optometrists vs 26.5 (11.8-51.6) minutes for ophthalmologists. In Louisiana, the longest median (IQR) travel time to receive laser procedures from optometrists was for YAG at 18.5 (7.6-32.6) minutes and the shortest drive to receive procedures from ophthalmologists was for YAG at 20.5 (11.7-39.7) minutes. Conclusions and Relevance: Although this study did not assess impact on quality of care, expansion of laser eye surgery privileges to optometrists was not found to lead to shorter travel times to receive care or to a meaningful increase in the percentage of the population with nearby health care professionals.

Evaluation of a Disposable Vascular Pressure Device for Pre- and Postmembrane Pressure Monitoring During Venovenous Extracorporeal Membrane Oxygenation.

Membrane pressure monitoring during extracorporeal membrane oxygenation (ECMO) is integral to monitoring circuit health. We compared a disposable vascular pressure device (DVPD) to the transducer pressure bag arterial line (TPBAL) monitoring system to determine whether the DVPD can reliably and accurately monitor membrane pressures during venovenous extracorporeal membrane oxygenation (VV ECMO). We analyzed existing quality assurance data collected at a single center as part of routine circuit performance monitoring and process improvement on a convenience sample of four VV ECMO circuits. We placed and zeroed a DVPD in line with the pre- and postmembrane TPBAL setups in coordination with a standard transducer setup. We recorded DVPD and TPBAL pressure measurements every 4 hours for 2.5 days on the four separate VV ECMO circuits. We compared the standard and DVPD pressures using Bland-Altman plots and methods that accounted for repeated measures in the same subject. We recorded 58 pre/postmembrane pressures. Mean membrane pressure values were similar in the DVPD (pre: 208 mmHg [SD, 50.8]; post: 175 mmHg [46.3]) compared to the standard TPBAL setup (pre: 205 mmHg [52.0]; post: 177 mmHg [46.3]). Using Bland-Altman methods, premembrane pressures were found to be 2.2 mmHg higher (95% confidence interval [CI]: -5.3 to 9.7) in the standard TPBAL setup compared to DVPD and 1.8 mmHg higher (95% CI: -5.3 to 8.9) than the postmembrane pressures. The DVPD provided an accurate measurement of circuit pressure as compared to the TPBAL setup. Across the range of pre- and postmembrane pressures, both methods reliably agreed. Future trials should investigate DVPD accuracy in different environments such as prehospital field cannulation or critical care transport of ECMO patients.