RetINal Toxicity And HydroxyChloroquine Therapy (INTACT): protocol for a prospective population-based cohort study.

PURPOSE: Hydroxychloroquine (HCQ) is an important medication for patients with systemic lupus erythematosus (SLE), rheumatoid arthritis (RA) and other rheumatic diseases. Although it is well-tolerated and cost-effective, the risk of HCQ retinal toxicity is of increasing concern. The aim of this study is to re-examine the HCQ retinal toxicity incidence rate, risk factors and clinical course after discontinuation. METHODS: We designed a prospective population-based cohort study in adult patients with SLE or RA, currently receiving HCQ for five or more years, who are residents of British Columbia (BC), Canada. Based on administrative data, we identified 5508 eligible participants (1346 SLE and 4162 RA). They will participate in annual or biannual retinal screening over 5 years in alignment with the recently revised American Academy of Ophthalmology guidelines. To standardise procedures for retinal screening, imaging, diagnostic criteria, severity staging and data transfer, a consensus meeting was convened in December 2019 with participation of BC retinal specialists and the research team. Agreement was attained on: use of spectral domain-optical coherence tomography as the primary objective screening modality; classification of images into categories of normal, equivocal or abnormal; and transferring the equivocal and abnormal images plus corresponding subjective test results via cloud-based server from each clinic to a reading centre. Confirmation of HCQ retinal toxicity diagnoses and severity staging will be performed by three independent and masked reviewers. The incidence of HCQ retinal toxicity will be calculated, accounting for the competing risk of death. Hazard ratios for each risk factor will be calculated for the risk of HCQ retinopathy, after adjusting for confounders. We will also estimate the risk of HCQ retinal toxicity progression over 5 years. ETHICS AND DISSEMINATION: This study has received approval from the University of British Columbia Clinical Research Ethics Board (H20-00736) and the Vancouver Coastal Health Research Institute.

Is fasting required before cataract surgery? A retrospective review.

OBJECTIVE: To investigate the possibility that fasting is not required before cataract surgery. STUDY DESIGN: Retrospective review. PARTICIPANTS: All patients who had cataract surgery alone (not combined with corneal or glaucoma surgery) at Mount St. Joseph Hospital between April 1, 2007, and March 31, 2008. METHODS: Three methods were used to determine whether any cases of aspiration pneumonia after cataract surgery had occurred: recall by the supervising anaesthetist, a search of hospital medical records for admissions with a diagnosis of pneumonia, and recall by the operating surgeons. RESULTS: In 5125 cases of cataract surgery, no case of aspiration pneumonia was found. CONCLUSIONS: This study suggests that it is safe to perform cataract surgery under topical or infiltration anaesthesia with intravenous sedation without fasting prior to surgery.

Appropriateness of healthcare interventions: concepts and scoping of the published literature.

OBJECTIVES: This report is a scoping review of the literature with the objective of identifying definitions, conceptual models and frameworks, as well as the methods and range of perspectives, for determining appropriateness in the context of healthcare delivery. METHODS: To lay groundwork for future, intervention-specific research on appropriateness, this work was carried out as a scoping review of published literature since 1966. Two reviewers, with two screens using inclusion/exclusion criteria based on the objective, focused the research and articles chosen for review. RESULTS: The first screen examined 2,829 abstracts/titles, with the second screen examining 124 full articles, leaving 37 articles deemed highly relevant for data extraction and interpretation. Appropriateness is defined largely in terms of net clinical benefit to the average patient and varies by service and setting. The most widely used method to assess appropriateness of healthcare services is the RAND/UCLA Model. There are many related concepts such as medical necessity and small-areas variation. CONCLUSIONS: A broader approach to determining appropriateness for healthcare interventions is possible and would involve clinical, patient and societal perspectives.

A systematic literature review of the evidence on benchmarks for cataract surgery waiting time.

BACKGROUND: This review offered critical input to the work of Canadian federal-provincial-territorial Deputy Ministers of Health on establishing evidence-based benchmarks for waiting times (WTs) for cataract surgery. The study purpose was to synthesize the evidence regarding the relations among patient characteristics, WT, and health outcomes for patients on waiting lists for cataract surgery. METHODS: A systematic literature review was conducted using the Cochrane methodology. RESULTS: Seventeen studies were considered. The studies varied in their quality, study design, sample characteristics, and outcome measures. Because of the heterogeneity in studies, a qualitative analysis was used. Key findings were: individuals with cataracts are at an increased risk of falls, hip fractures, and motor vehicle crashes, the absence of pre-existing eye disease, and better baseline visual acuity and visual function are associated with better outcomes, and average WTs of 6-12 months are associated with a decline in visual acuity in patients while waiting. INTERPRETATION: Although the evidence does not indicate a precise benchmark, it does support timely access to surgery for individuals undergoing cataract surgery. In December 2005, health ministers set a goal to provide cataract surgery within 16 weeks for patients at high risk.

Patient and physician perspectives of maximum acceptable waiting times for cataract surgery.

BACKGROUND: Lengthy waiting times for cataract surgery are an important issue in countries with publicly funded health care systems. To improve the fairness, timeliness, and certainty of waiting-time management, the Western Canada Waiting List Project has developed priority criteria scores (PCSs) related to urgency and linked to maximum acceptable waiting times (MAWTs). The purpose of our study was to compare patient and physician perspectives of MAWT for different levels of urgency. A second aim was to assess the determinants of patient and surgeon perspectives on MAWT. METHODS: Ophthalmologists assessed consecutive patients waitlisted for cataract surgery. Data included a MAWT, a visual analogue scale of urgency (VAS urgency), and the cataract PCS. Patients were mailed questionnaires to assess their perspectives of MAWT and VAS urgency. They were also sent a measure of visual function called the Visual Function Assessment. We used hierarchical linear regression to assess the determinants of MAWT. RESULTS: The mean age of the 213 patients was 73.9 years; 56.8% were female and 71.8% were booked for first eye surgery. Physician-rated MAWT was significantly longer than patient-rated MAWT (mean 15.1 vs. 9.9 weeks). Median physician MAWTs ranged from 12 (most urgent) to 20 (least urgent) weeks, and patient MAWTs, from 4 to 8 weeks. A 3-step hierarchical linear regression model showed that, after adjusting for age and sex, the priority criteria added significantly to the surgeon model (R2 change = 0.22). Significant predictors were ocular comorbidity, impairment in visual function, and ability to work or live independently or care for dependents. After the addition of VAS urgency, the final model explained 42% of the variance in surgeon MAWT. Significant predictors were age-related macular degeneration and VAS urgency. A 4-step hierarchical regression model for patient MAWT showed that after step 2, sex and visual acuity in the nonsurgery eye were significant predictors. The final model accounted for 11% of the variance in patient MAWT. Significant predictors were sex (males had lower MAWT) and VAS urgency. INTERPRETATION: Patient and physician views on MAWT differ, yet both are critical to a fair process for developing standardized waiting times related to levels of urgency. Results from this study provide initial inputs to the formulation of benchmark waiting times for different levels of the cataract PCS.

The prioritization of patients on waiting lists for cataract surgery: validation of the Western Canada waiting list project cataract priority criteria tool.

PURPOSE: To assess the validity of the Cataract Priority Criteria Score (PCS), developed by the Western Canada Waiting List (WCWL) Project to determine patient prioritization for cataract surgery. METHODS: Ophthalmologists assessed consecutive patients with the PCS and a visual analogue scale of urgency (VAS Urgency). Patients were mailed questionnaires pre- and post-surgery. Outcome measures were the Visual Function Assessment (VFA), EuroQol (EQ-5D), and best-corrected visual acuity. RESULTS: The sample of 253 patients was 58% female (mean age, 73.7 years); 166 completed pre-and post-surgery VFA. The correlation of the PCS and VAS Urgency was 0.65 (p = 0.000). Adjusting for age, first or second eye surgery, and post-operative complication, the PCS predicted improvement in the VFA and visual acuity (p < .05). CONCLUSIONS: These data provide some evidence to support the convergent and predictive validity of the PCS. Multiple patient outcomes should be used in the evaluation of the validity of priority scores.

Developing cataract surgery priority criteria: results from the Western Canada Waiting List Project.

BACKGROUND: The Western Canada Waiting List Project (WCWL) is a federally funded partnership of 19 organizations, including medical associations, health authorities, ministries of health and research organizations, that was created to develop tools to assist in the management of waiting lists. The WCWL cataract surgery panel, one of five panels constituted under this project, developed and tested a set of standardized clinical criteria for prioritizing among patients awaiting cataract surgery. METHODS: The cataract surgery panel was composed of seven academic and community ophthalmologists, two family physicians, an optometrist, a health care services researcher and a health information specialist. The panel met three times between October 1999 and June 2000. The priority criteria were applied to 563 patients in the four western provinces. Regression analysis was used to determine the set of criteria weights that collectively best predicted clinicians' overall ratings of urgency. Interrater and test-retest reliability were assessed, based on clinicians' ratings of videotaped interviews with six hypothetical patients. RESULTS: The resulting criteria accounted for about one-third of the observed variance in clinicians' ratings of overall clinical urgency (R2 = 31.2%). The panel modified the original criteria and weights based on empirical results and clinical judgement. Reliability of the revised criteria items was mixed, with the lowest reliability observed for items dealing with glare and social role. INTERPRETATION: Participating clinicians considered the criteria easy to use and reasonably reflective of expert surgical judgement regarding clinical urgency. Further development and testing of the tool appear warranted.