Association of Mentor-to-Program Contact and Applicant Rank Disclosure With Vitreoretinal Fellowship Applicant's Final Match Outcome in 2016 and 2017.

Importance: Communication between applicants, mentors, and training programs is common before the residency and fellowship match. Few studies have examined the association of prematch communication on final match outcomes. Objectives: To report various characteristics of the vitreoretinal surgery fellowship match and to examine the association of mentor-to-program communication and applicant disclosure of their number 1 ranking with the probability of matching number 1. Design, Setting, and Participants: In this cross-sectional study of the 2016 and 2017 vitreoretinal surgery fellowship matches, an online survey examined (1) number of applications submitted, (2) number of programs ranked, (3) rank order of final match, (4) total application and interview-related costs, (5) mentor-to-program contact, (6) applicant disclosure of number 1 ranking, and (7) mentor disclosure of number 1 ranking. A link to an anonymous online survey was sent to 198 matched fellows (105 fellows from the 2016 match and 93 from the 2017 match). Main Outcomes and Measures: Survey responses regarding the vitreoretinal surgery fellowship application process. Results: The survey was sent to 198 matched fellowship applicants, and 152 (77%) completed the survey. Of the 105 matched applicants in 2016, 21 (20%) were women. Of the 93 matched applicants in 2017, 24 (26%) were women. Matched applicants applied to a mean (SD) of 34 (17) programs (range, 1-85) and ranked a mean (SD) of 12 (4) programs (range, 1-27). Of 152 applicants, 66 (43%) matched at their number 1 ranked program, 23 (15%) matched number 2, and 21 (14%) matched number 3. The mean (SD) total cost was $5500 ($2776) (range, $500-$13 500). Two-sided χ2 testing found no association (odds ratio, 0.70; 95% CI, 0.34-1.4; P = .33) between mentor-to-program contact and the probability of applicants matching at their number 1 ranked program. Matched applicants who revealed their number 1 ranking either personally or via a mentor matched at a program ranked lower (more desirable) on their rank list (mean match ranking, 2.8) compared with those who did not reveal their number 1 ranking (mean match ranking, 4.2; 95% CI, 0.2-2.5; P = .01). Applicant disclosure of their intention to rank a program number 1, either personally or via a mentor, was associated with matching number 1 (odds ratio, 2.6; range, 1.1-6.0; P = .03). Conclusions and Relevance: Vitreoretinal fellowship applicants who disclosed their number 1 ranking, either personally or via a mentor, were associated with improved match outcomes compared with their cohorts who did not make such disclosures.

Adjunctive intraocular and peri-ocular steroid (triamcinolone acetonide) versus standard treatment in eyes undergoing vitreoretinal surgery for open globe trauma (ASCOT): study protocol for a phase III, multi-centre, double-masked randomised controlled trial.

BACKGROUND: Eyes sustaining open globe trauma are at high risk of severe visual impairment. Ocular injuries which result in visual loss invariably affect the posterior segment of the eye, and prevention of visual loss involves posterior segment (vitreoretinal) surgery. Despite improvements in vitreoretinal surgical techniques, outcomes in these patients remain unsatisfactory, and development of the intraocular scarring response proliferative vitreoretinopathy is the leading cause. Proliferative vitreoretinopathy is the most common cause of recurrent retinal detachment in these eyes; it is reported to occur in up to 45 % of cases. METHODS/DESIGN: The Adjunctive Steroid Combination in Ocular Trauma (ASCOT) trial is a multi-centre, double-masked, parallel-arm randomised controlled trial with an internal pilot designed to investigate the effectiveness and cost-effectiveness of using intravitreal and sub-Tenon's triamcinolone acetonide peri-operatively in patients undergoing vitrectomy following open globe trauma. In total, 300 eyes of 300 patients will be recruited and randomly allocated to one of two treatment groups. Both groups will receive standard surgical treatment and routine pre-operative and post-operative treatment and care. The treatment group will receive an adjunctive peri-operative steroid combination (triamcinolone acetonide) consisting of 4 mg/0.1 ml into the vitreous cavity and 40 mg/1 ml into the sub-Tenon's space. The trial incorporates a two-stage internal pilot to examine projected recruitment and retention rates. Progression criteria from the internal pilot study will enable us to determine whether to undertake the main trial. Patients and primary outcome assessors will be masked to treatment allocation. The primary outcome will be an improvement from baseline to 6 months of at least 10 on the corrected visual acuity as measured by ETDRS letter score. Secondary outcomes will be development of scarring, retinal detachment, intraocular pressure abnormalities, quality of life and public sector service use. DISCUSSION: This is the first powered, controlled clinical trial to investigate the use of adjunctive triamcinolone in patients undergoing vitrectomy following open globe trauma. TRIAL REGISTRATION: EudraCT2014-002193-37 . Registered on 5 September 2014. ISRCTN30012492 . Registered on 5 September 2014.

Revisión de estudios económicos y análisis de impacto presupuestario de la ocriplasmina como tratamiento de la tracción vitreomacular / Review of economic studies and budget impact analysis of ocriplasmin as a treatment of vitreomacular traction

OBJETIVO: Revisar las pruebas sobre el coste-efectividad de la ocriplasmina para la tracción vitreomacular (TVM) y estimar el impacto presupuestario que supondría su uso en el Sistema Nacional de Salud (SNS). MATERIAL Y MÉTODOS: 1) Revisión sistemática. Se realizaron búsquedas en enero del 2015 en MEDLINE, PREMEDLINE, EMBASE, CRD y The Cochrane Library, y páginas web clave. Se incluyeron evaluaciones económicas completas que comparaban ocriplasmina con tratamiento habitual (espera vigilante y/o vitrectomía) en pacientes con TVM. Las medidas de resultado de interés fueron los costes de las alternativas y la ratio coste-efectividad incremental. También se incluyeron estudios de análisis de impacto presupuestario. Se valoró la calidad metodológica y se realizó una síntesis narrativa de los estudios incluidos. 2) Estimación del impacto presupuestario. Se estimó el impacto presupuestario que supondría incorporar ocriplasmina en el SNS tomando datos de varias fuentes. RESULTADOS: Se identificaron 6 estudios, ninguno realizado en España. Los 2 estudios de mejor calidad concluyen que ocriplasmina es coste-efectiva en sus respectivos ámbitos (Canadá y Reino Unido) pero solo en pacientes con determinadas condiciones (sin membrana epirretiniana, por ejemplo). Los resultados del análisis de impacto presupuestario son contradictorios entre países. El análisis para España encontró que la introducción de ocriplasmina supondría un ahorro para el SNS superior a un millón de euros en 5 años. CONCLUSIONES: El coste-efectividad de ocriplasmina no ha sido demostrado en España aunque buenos estudios realizados en otros países encontraron que ocriplasmina es coste-efectiva en pacientes seleccionados. Dados los precios vigentes en España, ocriplasmina podría suponer un ahorro para el SNS

OBJECTIVE: To review the evidence on the cost-effectiveness of ocriplasmin as a treatment for vitreomacular traction (VMT), and to estimate the impact on the Spanish National Health System (NHS). MATERIAL AND METHODS: 1) Systematic review. The following databases were searched in January 2015: MEDLINE, PREMEDLINE, EMBASE, CRD, the Cochrane Library, and key websites. Selection criteria were: full economic evaluations that compared ocriplasmin with usual care ('watch and wait' and/or vitrectomy) in patients with VMT. The outcomes to extract were costs of the alternatives and the incremental cost-effectiveness ratio. Studies of budget impact analysis were also included. The methodological quality was assessed, and a narrative synthesis of the included studies was carried out. 2) Estimation of budget impact. The impact on the budget as a result of the introduction of ocriplasmin in the NHS was estimated, including data from different sources. RESULTS: Six studies were identified, none of them performed in Spain. The two best studies concluded that ocriplasmin is cost-effective in their respective countries (Canada and United Kingdom), but only in patients with certain conditions (without epiretinal membrane, for example). The results of the budget impact analysis are different between countries. The analysis for Spain showed that the introduction of ocriplasmin would mean a saving over 1 million Euros for the NHS in 5 years. CONCLUSIONS: The cost-effectiveness of ocriplasmin has not been demonstrated in Spain. However, good studies performed in other countries found that ocriplasmin is cost-effective in selected patients. Given the current prices in Spain, ocriplasmin could involve a saving for the Spanish NHS

Nonmedical costs and implications for patients seeking vitreoretinalcare.

PURPOSE: To measure nonreimbursable, nonmedical costs incurred by patients attending a vitreoretinal clinic appointment. METHODS: A nurse-administered questionnaire designed to capture the nonmedical costs for a single clinical appointment was administered to patients attending an appointment at a single-center, single-physician, university-based vitreoretinal clinic. First day postoperative visits were excluded. End points were time commitment, time missing work, and median total nonmedical costs incurred. A subgroup analysis of Medicare patients who lived locally was performed. RESULTS: Three hundred and six patients completed the survey. The median nonreimbursable, nonmedical cost incurred was $23.32; the mean cost was $236.53 (range, $0-$7,259). The largest component of cost was transportation costs ($13.43). The patient took at least a day off from work in 27% cases. An accompanying person attended in 58%, and 27% took at least 1 day off from work to do so. The Medicare cohort who lived locally had similar median costs ($21.53); the mean cost was $51.29 (range, $0-$1,255.80). This cohort also had a lower incidence of missing work (6%), and a higher incidence of an accompanying person (68%) who had a lower incidence of missing work (16%). The costs and distributions varied minimally by visit type. CONCLUSION: Physicians and policymakers may not recognize or consider the potential impediment to care that nonreimbursable costs may present when developing treatment strategies and designing policies.

Preference-based comparative effectiveness and cost­effectiveness: a review and relevance of value-based medicine for vitreoretinal interventions.

PURPOSE OF REVIEW: This analysis discusses the comparative effectiveness and cost-effectiveness of vitreoretinal interventions, measured in quality-adjusted life years (QALYs) and percentage patient value (PPV gain, or improvement in quality of life and/or length of life). The material is relevant since the Patient Protection and Affordable Care Act enacted by Congress with the support of the President has emphasized the critical importance of patient-based preferences. RECENT FINDINGS: The majority of preference-based, comparative effectiveness and cost-effectiveness vitreoretinal interventions assessed in the US healthcare literature are Value-Based Medicine analyses, thus comparable. These interventions confer a mean patient (human) value gain (improvement in quality of life) of 8.3% [SD 6.3%, 95% confidence interval (CI) + 2.6%]. The average cost-utility of these vitreoretinal interventions is US$23 026/QALY (SD US$24 508, 95% CI + US$8770). Most vitreoretinal interventions are very cost effective using a conventional US standard of US$50 000/QALY as the upper anchor for a very cost-effective intervention, and the World Health Organization of approximately US$142 200/QALY as the upper anchor for a cost-effective intervention. CONCLUSIONS: Most vitreoretinal interventions confer considerable patient value and are very cost effective. Further standardization across healthcare is needed in the preference-based, comparative and cost-utility (cost-effectiveness) arena. The metrics of PPV (percentage patient value) gain and US$/PPV (dollars expended per percentage patient value gain) or financial value gain may be more user-friendly than the QALY.