Paraneoplastic Calmodulin Kinase-Like Vesicle-Associated Protein (CAMKV) Autoimmune Encephalitis.

OBJECTIVES: To report an autoimmune paraneoplastic encephalitis characterized by immunoglobulin G (IgG) antibody targeting synaptic protein calmodulin kinase-like vesicle-associated (CAMKV). METHODS: Serum and cerebrospinal fluid (CSF) samples harboring unclassified antibodies on murine brain-based indirect immunofluorescence assay (IFA) were screened by human protein microarray. In 5 patients with identical cerebral IFA staining, CAMKV was identified as top-ranking candidate antigen. Western blots, confocal microscopy, immune-absorption, and mass spectrometry were performed to substantiate CAMKV specificity. Recombinant CAMKV-specific assays (cell-based [fixed and live] and Western blot) provided additional confirmation. RESULTS: Of 5 CAMKV-IgG positive patients, 3 were women (median symptom-onset age was 59 years; range, 53-74). Encephalitis-onset was subacute (4) or acute (1) and manifested with: altered mental status (all), seizures (4), hyperkinetic movements (4), psychiatric features (3), memory loss (2), and insomnia (2). Paraclinical testing revealed CSF lymphocytic pleocytosis (all 4 tested), electrographic seizures (3 of 4 tested), and striking MRI abnormalities in all (mesial temporal lobe T2 hyperintensities [all patients], caudate head T2 hyperintensities [3], and cortical diffusion weighted hyperintensities [2]). None had post-gadolinium enhancement. Cancers were uterine adenocarcinoma (3 patients: poorly differentiated or neuroendocrine-differentiated in 2, both demonstrated CAMKV immunoreactivity), bladder urothelial carcinoma (1), and non-Hodgkin lymphoma (1). Two patients developed encephalitis following immune checkpoint inhibitor cancer therapy (atezolizumab [1], pembrolizumab [1]). All treated patients (4) demonstrated an initial response to immunotherapy (corticosteroids [4], IVIG [2]), though 3 died from cancer. INTERPRETATION: CAMKV-IgG is a biomarker of immunotherapy-responsive paraneoplastic encephalitis with temporal and extratemporal features and uterine cancer as a prominent oncologic association. ANN NEUROL 2024.

The prevalence of bilateral hearing loss in the United States in 2019: a small area estimation modelling approach for obtaining national, state, and county level estimates by demographic subgroup.

Background: The goal of this study was to re-estimate rates of bilateral hearing loss Nationally, and create new estimates of hearing loss prevalence at the U.S. State and County levels. Methods: We developed small area estimation models of mild, and moderate or worse bilateral hearing loss in the U.S. using data from the National Health and Nutrition Examination Survey (2001-2012, 2015-2018), the American Community Survey (2019), Census County Business Patterns (2019); Social Security Administration Data (2019); Medicare Fee-for-Service and Advantage claims data (2019); the Area Health Resources File (2019), and other sources. We defined hearing loss as mild (>25 dB through 40 dB), moderate or worse (>40 dB), or any (>25 dB) in the better hearing ear based on a 4-frequency pure-tone-average threshold, and created estimates by age group (0-4, 5-17, 18-34, 35-64, 65-74, 75+), gender, race and ethnicity, state, and county. Findings: We estimated that 37.9 million (95% Uncertainty Interval [U.I.] 36.6-39.1) Americans experienced any bilateral hearing loss; 24.9 million (95% U.I. 23.6-26.0) with mild and 13.0 million (95% U.I. 12.1-13.9) with moderate or worse. The prevalence rate of any hearing loss was 11.6% (95% U.I. 11.2%-12.0%). Hearing loss increased with age. Men were more likely to have hearing loss than women after age 35, and non-Hispanic Whites had higher rates of hearing loss than other races and ethnicities. Higher hearing loss prevalence was associated with smaller population size. West Virginia, Alaska, Wyoming, Oklahoma, and Arkansas had the highest standardised rate of bilateral hearing loss, and Washington D.C., New Jersey, New York, Maryland, and Connecticut had the lowest. Interpretation: Bilateral Hearing loss varies by State and County, with variation associated with population age, race and ethnicity, and population size. Geographic estimates can be used to raise local awareness of hearing loss as a problem, to prioritize areas for hearing loss prevention, identification, and treatment, and to guide future research on the hearing loss risk factors that contribute to these differences. Funding: CDC's National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health.

Framework for fiscal impact analysis of managing initial caries lesions with noninvasive therapies.

BACKGROUND: Evidence-based noninvasive caries therapies for initial caries lesions are available in the United States. Fundamental differences between noninvasive therapies and the traditional surgical dental approach warrant a study of the financial scalability. METHODS: The financial costs and benefits of fee-for-service clinics and payors were compared across 11 scenarios simulating the treatment of 1,000 initial caries lesions during a 3-year period. The scenarios included varying combinations of noninvasive therapies (that is, silver diamine fluoride, self-assembling peptide P11-4, and glass ionomer therapeutic sealants), no treatment, and various rates of 1- through 3-surface restorations to an estimated 2022 practice model. We used a decision tree microsimulation model for deterministic and probabilistic sensitivity analyses. We derived assumptions from an initial lesion and noninvasive therapy-focused cohort study with operations data from 16 sites accepting Medicaid in Alabama as a case study and clinical data from all 92 sites. RESULTS: In comparison with the 2022 practice model assumed for this study, scenarios that produce mutually beneficial results for payors' savings and clinics' net profits and profit margins include self-assembling peptide P11-4, silver diamine fluoride on nonesthetic surfaces, and a mix of 3 noninvasive therapies. When considering the limited resources of chair and clinician time, the same scenarios, as well as silver diamine fluoride with restorations, emerged with substantially higher clinic net profit. CONCLUSIONS: Hypothetical scenarios that include noninvasive therapies and minimize restorations achieve improved outcomes for all parties. PRACTICAL IMPLICATIONS: Payors and clinicians should explore and implement noninvasive caries therapies to improve oral health for all. This study was registered at ClinicalTrials.gov. The registration number is NCT04933331.

Prevalence of Diabetic Retinopathy in the US in 2021.

Importance: Diabetic retinopathy (DR) is a common microvascular complication of diabetes and a leading cause of blindness among working-age adults in the US. Objective: To update estimates of DR and vision-threatening diabetic retinopathy (VTDR) prevalence by demographic factors and US county and state. Data Sources: The study team included data from the National Health and Nutrition Examination Survey (2005 to 2008 and 2017 to March 2020), Medicare fee-for-service claims (2018), IBM MarketScan commercial insurance claims (2016), population-based studies of adult eye disease (2001 to 2016), 2 studies of diabetes in youth (2021 and 2023), and a previously published analysis of diabetes by county (2012). The study team used population estimates from the US Census Bureau. Study Selection: The study team included relevant data from the US Centers for Disease Control and Prevention's Vision and Eye Health Surveillance System. Data Extraction and Synthesis: Using bayesian meta-regression methods, the study team estimated the prevalence of DR and VTDR stratified by age, a nondifferentiated sex and gender measure, race, ethnicity, and US county and state. Main Outcomes and Measures: The study team defined individuals with diabetes as those who had a hemoglobin A1c level at 6.5% or more, took insulin, or reported ever having been told by a physician or health care professional that they have diabetes. The study team defined DR as any retinopathy in the presence of diabetes, including nonproliferative retinopathy (mild, moderate, or severe), proliferative retinopathy, or macular edema. The study team defined VTDR as having, in the presence of diabetes, severe nonproliferative retinopathy, proliferative retinopathy, panretinal photocoagulation scars, or macular edema. Results: This study used data from nationally representative and local population-based studies that represent the populations in which they were conducted. For 2021, the study team estimated 9.60 million people (95% uncertainty interval [UI], 7.90-11.55) living with DR, corresponding to a prevalence rate of 26.43% (95% UI, 21.95-31.60) among people with diabetes. The study team estimated 1.84 million people (95% UI, 1.41-2.40) living with VTDR, corresponding to a prevalence rate of 5.06% (95% UI, 3.90-6.57) among people with diabetes. Prevalence of DR and VTDR varied by demographic characteristics and geography. Conclusions and Relevance: US prevalence of diabetes-related eye disease remains high. These updated estimates on the burden and geographic distribution of diabetes-related eye disease can be used to inform the allocation of public health resources and interventions to communities and populations at highest risk.

A Mixed-Methods Approach for Evaluating Implementation Processes and Program Costs for a Hypertension Management Program Implemented in a Federally Qualified Health Center.

Team-based care approaches are effective at improving hypertension control and have been used in clinical practice to improve hypertension outcomes. This study implemented and evaluated the Hypertension Management Program (HMP), which was originally developed in a high-resource health setting, in a health system with fewer resources and a patient population disproportionately affected by hypertension. Our objectives were to describe how a health system could adapt HMP to meet their needs and calculate total program costs. HMP uses a team-based, patient-centered approach involving clinical pharmacists who contribute to managing patients who have hypertension and ultimately preventing premature death due to uncontrolled hypertension. HMP has 10 components (e.g., EHR patient registries and outreach lists, no copayment walk-in blood pressure checks). Our project involved implementing the key components of HMP in a federally qualified health center (FQHC) in South Carolina. Adaptations from the key components of HMP were made to fit the participants' settings. A mixed-methods evaluation assessed implementation processes, program costs, and implementation facilitators and barriers. From September 2018 to December 2019, clinical pharmacists conducted 758 hypertension management visits (HMVs) with 316 patients with hypertension. Total program costs for HMP were $325,532 overall and $16,277 per month. Monthly cost per patient was $3.62. The high engagement among clinical pharmacists, along with provider engagements, followed up by the subsequent referral of patients to HMP, facilitated the implementation process. Staff members observed improvements in hypertension control, which increased participation buy-in. Barriers included staff turnover, the perception among some providers that HMP took too much time, as well as perception of HMP as a pharmacy-specific initiative. A team-based, patient-centered approach to hypertension management can be adapted for FQHCs or similar settings that serve patient populations disproportionately affected by hypertension.

Validity of Administrative Claims and Electronic Health Registry Data From a Single Practice for Eye Health Surveillance.

Importance: Diagnostic information from administrative claims and electronic health record (EHR) data may serve as an important resource for surveillance of vision and eye health, but the accuracy and validity of these sources are unknown. Objective: To estimate the accuracy of diagnosis codes in administrative claims and EHRs compared to retrospective medical record review. Design, Setting, and Participants: This cross-sectional study compared the presence and prevalence of eye disorders based on diagnostic codes in EHR and claims records vs clinical medical record review at University of Washington-affiliated ophthalmology or optometry clinics from May 2018 to April 2020. Patients 16 years and older with an eye examination in the previous 2 years were included, oversampled for diagnosed major eye diseases and visual acuity loss. Exposures: Patients were assigned to vision and eye health condition categories based on diagnosis codes present in their billing claims history and EHR using the diagnostic case definitions of the US Centers for Disease Control and Prevention Vision and Eye Health Surveillance System (VEHSS) as well as clinical assessment based on retrospective medical record review. Main Outcome and Measures: Accuracy was measured as area under the receiver operating characteristic curve (AUC) of claims and EHR-based diagnostic coding vs retrospective review of clinical assessments and treatment plans. Results: Among 669 participants (mean [range] age, 66.1 [16-99] years; 357 [53.4%] female), identification of diseases in billing claims and EHR data using VEHSS case definitions was accurate for diabetic retinopathy (claims AUC, 0.94; 95% CI, 0.91-0.98; EHR AUC, 0.97; 95% CI, 0.95-0.99), glaucoma (claims AUC, 0.90; 95% CI, 0.88-0.93; EHR AUC, 0.93; 95% CI, 0.90-0.95), age-related macular degeneration (claims AUC, 0.87; 95% CI, 0.83-0.92; EHR AUC, 0.96; 95% CI, 0.94-0.98), and cataracts (claims AUC, 0.82; 95% CI, 0.79-0.86; EHR AUC, 0.91; 95% CI, 0.89-0.93). However, several condition categories showed low validity with AUCs below 0.7, including diagnosed disorders of refraction and accommodation (claims AUC, 0.54; 95% CI, 0.49-0.60; EHR AUC, 0.61; 95% CI, 0.56-0.67), diagnosed blindness and low vision (claims AUC, 0.56; 95% CI, 0.53-0.58; EHR AUC, 0.57; 95% CI, 0.54-0.59), and orbital and external diseases (claims AUC, 0.63; 95% CI, 0.57-0.69; EHR AUC, 0.65; 95% CI, 0.59-0.70). Conclusion and Relevance: In this cross-sectional study of current and recent ophthalmology patients with high rates of eye disorders and vision loss, identification of major vision-threatening eye disorders based on diagnosis codes in claims and EHR records was accurate. However, vision loss, refractive error, and other broadly defined or lower-risk disorder categories were less accurately identified by diagnosis codes in claims and EHR data.

Association Between Social Determinants of Health and Examination-Based Vision Loss vs Self-reported Vision Measures.

Importance: Recent evidence suggests that social determinants of health (SDOH) affect vision loss, but it is unclear whether estimated associations differ between clinically evaluated and self-reported vision loss. Objective: To identify associations between SDOH and evaluated vision impairment and to assess whether these associations hold when examining self-reported vision loss. Design, Setting, and Participants: This population-based cross-sectional comparison included participants 12 years and older in the 2005 to 2008 National Health and Nutrition Examination Survey (NHANES), participants of all ages (infants and older) in the 2019 American Community Survey (ACS), and adults 18 years and older in the 2019 Behavioral Risk Factor Surveillance System (BRFSS). Exposures: Five domains of SDOH that are based on Healthy People 2030: economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context. Main Outcomes and Measures: Presenting vision impairment of 20/40 or worse in the better-seeing eye (NHANES) and self-reported blindness or serious difficulty seeing, even with glasses (ACS and BRFSS). Results: Of 3 649 085 included participants, 1 873 893 were female (51.1%) and 2 504 206 were White (64.4%). SDOH across domains of economic stability, educational attainment, health care access and quality, neighborhood and built environment, and social context were significant predictors of poor vision. For example, higher income (poverty to income ratio [NHANES]: OR, 0.91; 95% CI, 0.85-0.98; [ACS]: OR, 0.93; 95% CI, 0.93-0.94; categorical income [BRFSS:<$15 000 reference]: $15 000-$24 999; OR, 0.91; 95% CI, 0.91-0.91; $25 000-$34 999: OR, 0.80; 95% CI, 0.80-0.80; $35 000-$49 999: OR, 0.71; 95% CI, 0.71-0.72; ≥$50 000: OR, 0.49; 95% CI, 0.49-0.49), employment (BRFSS: OR, 0.66; 95% CI, 0.66-0.66; ACS: OR, 0.55; 95% CI, 0.54-0.55), and owning a home (NHANES: OR, 0.85; 95% CI, 0.73-1.00; BRFSS: OR, 0.82; 95% CI, 0.82-0.82; ACS: OR, 0.79; 95% CI, 0.79-0.79) were associated with lower odds of vision loss. The study team identified no differences in the general direction of the associations when using either clinically evaluated or self-reported vision measures. Conclusions and Relevance: The study team found evidence that associations between SDOH and vision impairment track together when using either clinically evaluated or self-reported vision loss. These findings support the use of self-reported vision data in a surveillance system to track trends in SDOH and vision health outcomes within subnational geographies.

Comparing Telephone Survey Responses to Best-Corrected Visual Acuity to Estimate the Accuracy of Identifying Vision Loss: Validation Study.

BACKGROUND: Self-reported questions on blindness and vision problems are collected in many national surveys. Recently released surveillance estimates on the prevalence of vision loss used self-reported data to predict variation in the prevalence of objectively measured acuity loss among population groups for whom examination data are not available. However, the validity of self-reported measures to predict prevalence and disparities in visual acuity has not been established. OBJECTIVE: This study aimed to estimate the diagnostic accuracy of self-reported vision loss measures compared to best-corrected visual acuity (BCVA), inform the design and selection of questions for future data collection, and identify the concordance between self-reported vision and measured acuity at the population level to support ongoing surveillance efforts. METHODS: We calculated accuracy and correlation between self-reported visual function versus BCVA at the individual and population level among patients from the University of Washington ophthalmology or optometry clinics with a prior eye examination, randomly oversampled for visual acuity loss or diagnosed eye diseases. Self-reported visual function was collected via telephone survey. BCVA was determined based on retrospective chart review. Diagnostic accuracy of questions at the person level was measured based on the area under the receiver operator curve (AUC), whereas population-level accuracy was determined based on correlation. RESULTS: The survey question, "Are you blind or do you have serious difficulty seeing, even when wearing glasses?" had the highest accuracy for identifying patients with blindness (BCVA ≤20/200; AUC=0.797). The highest accuracy for detecting any vision loss (BCVA <20/40) was achieved by responses of "fair," "poor," or "very poor" to the question, "At the present time, would you say your eyesight, with glasses or contact lenses if you wear them, is excellent, good, fair, poor, or very poor" (AUC=0.716). At the population level, the relative relationship between prevalence based on survey questions and BCVA remained stable for most demographic groups, with the only exceptions being groups with small sample sizes, and these differences were generally not significant. CONCLUSIONS: Although survey questions are not considered to be sufficiently accurate to be used as a diagnostic test at the individual level, we did find relatively high levels of accuracy for some questions. At the population level, we found that the relative prevalence of the 2 most accurate survey questions were highly correlated with the prevalence of measured visual acuity loss among nearly all demographic groups. The results of this study suggest that self-reported vision questions fielded in national surveys are likely to yield an accurate and stable signal of vision loss across different population groups, although the actual measure of prevalence from these questions is not directly analogous to that of BCVA.

Prevalence of Eye and Vision Disorders in the Military Health System, Fiscal Year 2018.

INTRODUCTION: Eye and vision disorders are estimated to impact 7.08 million people in the United States, including 1.62 million under the age of 40. This study uses the Vision and Eye Health Surveillance System (VEHSS) case definitions to assess the burden of eye and vision disorders in a universally insured, nationally representative population. MATERIALS AND METHODS: This retrospective, cross-sectional study applied the VEHSS case definitions to TRICARE claims data collected from the Military Health System Data Repository and Defense Enrollment Eligibility Reporting System during 2018. Beneficiaries aged 0-64 years during the fiscal year 2018 were identified with inpatient and outpatient codes matching to the VEHSS diagnostic case definitions, which were organized into 17 categories of eye and vision disorders classified by the ICD-10. Beneficiaries were recorded only once per category but allowed to match to multiple categories. Analyses included descriptive statistics of patient demographics and prevalence of eye disorders. RESULTS: We identified 4,548,897 TRICARE Prime/Plus beneficiaries (54.86% men and 45.14% women), of whom 22.93% were diagnosed with at least one disorder in 2018. Of those with a diagnosis, the majority were men (50.13%), adults (74.91%), and of or sponsored by a senior enlisted rank (57.83%), used as socioeconomic proxy. Disorders of refraction and accommodation were most prevalent, followed by infectious and inflammatory diseases. Potentially preventable and treatable conditions, including amblyopia and strabismus, infectious and inflammatory disease, and diabetic complications, affected up to 22% of those with vision disorders. CONCLUSIONS: This study represents the first use of VEHSS measures in a universally insured, socioeconomically diverse population. Identification of potentially treatable or preventable conditions indicates significant opportunity to mitigate the burden of eye and vision disorders in the Military Health System.

Trends in the Prevalence and Treatment of Diabetic Macular Edema and Vision-Threatening Diabetic Retinopathy Among Commercially Insured Adults Aged <65 Years.

OBJECTIVE: Examine the 10-year trend in the prevalence and treatment of diabetic macular edema (DME) and vision-threatening diabetic retinopathy (VTDR) among commercially insured adults with diabetes. RESEARCH DESIGN AND METHODS: We analyzed the 10-year trend (2009-2018) in health care claims for adults aged 18-64 years using the IBM MarketScan Database, a national convenience sample of employer-sponsored health insurance. We included patients continuously enrolled in commercial fee-for-service health insurance for 24 months who had a diabetes ICD-9/10-CM code on one or more inpatient or two or more different-day outpatient claims in the index year or previous calendar year. We used diagnosis and procedure codes to calculate the annual prevalence of patients with one or more claims for 1) any DME, 2) either DME or VTDR, and 3) antivascular endothelial growth factor (anti-VEGF) injections and laser photocoagulation treatment, stratified by any DME, VTDR with DME, and VTDR without DME. We calculated the average annual percent change (AAPC). RESULTS: From 2009 to 2018, there was an increase in the annual prevalence of patients with DME or VTDR (2.1% to 3.4%; AAPC 7.5%; P < 0.001) and any DME (0.7% to 2.6%; AAPC 19.8%; P < 0.001). There were sex differences in the annual prevalence of DME or VTDR and any DME, with men having a higher prevalence than women. Annual claims for anti-VEGF injections increased among patients with any DME (327%) and VTDR with DME (206%); laser photocoagulation decreased among patients with any DME (-68%), VTDR with DME (-54%), and VTDR without DME (-62%). CONCLUSIONS: Annual claims for DME or VTDR and anti-VEGF injections increased whereas those for laser photocoagulation decreased among commercially insured adults with diabetes.

Prevalence of Age-Related Macular Degeneration in the US in 2019.

Importance: Age-related macular degeneration (AMD) is a leading cause of vision loss and blindness. AMD prevalence has not been estimated for the US in over a decade and early-stage AMD prevalence estimates are scarce and inconsistently measured. Objective: To produce estimates of early- and late-stage AMD prevalence overall and by age, gender, race and ethnicity, county, and state. Design, Setting, and Participants: The study team conducted a bayesian meta-regression analysis of relevant data sources containing information on the prevalence of AMD among different population groups in the US. Data Sources: We included data from the American Community Survey (2019), the National Health and Nutrition Examination Survey (2005-2008), US Centers for Medicare & Medicaid Services claims for fee-for-service beneficiaries (2018), and population-based studies (2004-2016). Study Selection: We included all relevant data from the US Centers for Disease Control and Prevention's Vision and Eye Health Surveillance System. Data Extraction and Synthesis: The prevalence of early- and late-stage AMD was estimated and stratified when possible by factors including county, age group, gender, and race and ethnicity. Data analysis occurred from June 2021 to April 2022. Main Outcomes or Measures: The prevalence of early- (defined as retinal pigment epithelium abnormalities or the presence of drusen 125 or more microns in diameter in either eye) and late-stage (defined as choroidal neovascularization and/or geographic atrophy in either eye) manifestations of AMD. Results: This study used data from nationally representative and local population-based studies that represent the populations in which they were conducted. For 2019, we estimated that there were 18.34 million people 40 years and older (95% uncertainty interval [UI], 15.30-22.03) living with early-stage AMD, corresponding to a crude prevalence rate of 11.64% (95% UI, 9.71-13.98). We estimated there were 1.49 million people 40 years and older (95% UI, 0.97-2.15) living with late-stage AMD, corresponding to a crude prevalence rate of 0.94% (95% UI, 0.62-1.36). Prevalence rates of early- and late-stage AMD varied by demographic characteristics and geography. Conclusions and Relevance: We estimated a higher prevalence of early-stage AMD and a similar prevalence of late-stage AMD as compared with earlier studies. State-level and county-level AMD estimates may help guide public health practice.

Trends in Prevalence and Treatment of Diabetic Macular Edema and Vision-Threatening Diabetic Retinopathy Among Medicare Part B Fee-for-Service Beneficiaries.

IMPORTANCE: While diabetes prevalence among US adults has increased in recent decades, few studies document trends in diabetes-related eye disease. OBJECTIVE: To examine 10-year trends (2009-2018) in annual prevalence of Medicare beneficiaries with diabetes with a diagnosis of diabetic macular edema (DME) or vision-threatening diabetic retinopathy (VTDR) and trends in treatment. DESIGN, SETTING, AND PARTICIPANTS: In this cross-sectional study using Centers for Medicare & Medicaid Services research identifiable files, data for patients 65 years and older were analyzed from claims. Beneficiaries were continuously enrolled in Medicare Part B fee-for-service (FFS) insurance for the calendar year and had a diagnosis of diabetes on 1 or more inpatient claims or 2 or more outpatient claims during the calendar year or a 1-year look-back period. MAIN OUTCOMES AND MEASURES: Using diagnosis and procedure codes, annual prevalence was determined for beneficiaries with 1 or more claims for (1) any DME, (2) either DME or VTDR, and (3) anti-vascular endothelial growth factor (VEGF) injections, laser photocoagulation, or vitrectomy, stratified by any DME, VTDR with DME, and VTDR without DME. Racial and ethnic disparities in diagnosis and treatment are presented for 2018. RESULTS: In 2018, 6 960 823 beneficiaries (27.4%) had diabetes; half were aged 65 to 74 years (49.7%), half (52.7%) were women, and 75.7% were non-Hispanic White. From 2009 to 2018, there was an increase in the annual prevalence of beneficiaries with diabetes who had 1 or more claims for any DME (1.0% to 3.3%) and DME/VTDR (2.8% to 4.3%). Annual prevalence of anti-VEGF increased, particularly among patients with any DME (15.7% to 35.2%) or VTDR with DME (20.2% to 47.6%). Annual prevalence of laser photocoagulation decreased among those with any DME (45.5% to 12.5%), VTDR with DME (54.0% to 20.3%), and VTDR without DME (22.5% to 5.8%). Among all 3 groups, prevalence of vitrectomy in 2018 was less than half that in 2009. Prevalence of any DME and DME/VTDR was highest among Hispanic beneficiaries (5.0% and 7.0%, respectively) and Black beneficiaries (4.5% and 6.2%, respectively) and lowest among non-Hispanic White beneficiaries (3.0% and 3.8%, respectively). Among those with DME/VTDR, anti-VEGF was most prevalent among non-Hispanic White beneficiaries (30.3%). CONCLUSIONS AND RELEVANCE: From 2009 to 2018, prevalence of DME or VTDR increased among Medicare Part B FFS beneficiaries alongside an increase in anti-VEGF treatment and a decline in laser photocoagulation and vitrectomy.

The Economic Burden of Vision Loss and Blindness in the United States.

PURPOSE: To estimate the economic burden of vision loss (VL) in the United States and by state. DESIGN: Analysis of secondary data sources (American Community Survey [ACS], American Time Use Survey, Bureau of Labor Statistics, Medical Expenditure Panel Survey [MEPS], National and State Health Expenditure Accounts, and National Health Interview Survey [NHIS]) using attributable fraction, regression, and other methods to estimate the incremental direct and indirect 2017 costs of VL. PARTICIPANTS: People with a yes response to a question asking if they are blind or have serious difficulty seeing even when wearing glasses in the ACS, MEPS, or NHIS. MAIN OUTCOME MEASURES: We estimated the direct costs of medical, nursing home (NH), and supportive services and the indirect costs of absenteeism, lost household production, reduced labor force participation, and informal care by age group, sex, and state in aggregate and per person with VL. RESULTS: We estimated an economic burden of VL of $134.2 billion: $98.7 billion in direct costs and $35.5 billion in indirect costs. The largest burden components were NH ($41.8 billion), other medical care services ($30.9 billion), and reduced labor force participation ($16.2 billion), all of which accounted for 66% of the total. Those with VL incurred $16 838 per year in incremental burden. Informal care was the largest burden component for people 0 to 18 years of age, reduced labor force participation was the largest burden component for people 19 to 64 years of age, and NH costs were the largest burden component for people 65 years of age or older. New York, Connecticut, Massachusetts, Rhode Island, and Vermont experienced the highest costs per person with VL. Sensitivity analyses indicate total burden may range between $76 and $218 billion depending on the assumptions used in the model. CONCLUSIONS: Self-reported VL imposes a substantial economic burden on the United States. Burden accrues in different ways at different ages, leading to state differences in the composition of per-person costs based on the age composition of the population with VL. Information on state variation can help local decision makers target resources better to address the burden of VL.

The Prevalence of Diagnosis of Major Eye Diseases and their Associated Payments in the Medicare Fee-for-Service Program.

PURPOSE: To estimate the prevalence of diagnosis of major eye disorders and their associated payments, in total and per-person diagnosed, among Medicare fee-for-service (FFS) beneficiaries in 2018. METHODS: We analyzed 100% Medicare Part B FFS claims and Part D Events among beneficiaries continuously enrolled for 12 months in 2018 to calculate the proportion of beneficiaries with ≥1 claim indicating age-related macular degeneration (AMD), cataract, diabetic retinopathy (DR), or glaucoma, and their associated payments, including Medicare and patient out-of-pocket. Eye disease and eye care services were identified using case definitions from the Centers for Disease Control and Prevention's (CDC) Vision & Eye Health Surveillance System (VEHSS). Outcomes are reported by disease overall and by age group (0-39, 40-64, 65-84, 85+ years), sex, race/ethnicity, and U.S. state. RESULTS: Among nearly 30 million Medicare Part B FFS beneficiaries in 2018, over 41% (12.4 million) had a claim containing a diagnosis of at least one of the four eye disorders; 33.7% with cataract, 13.3% with glaucoma, 9.2% with AMD and 3.2% with DR. Payments for eye care services and drugs associated with these four conditions were $10.1billion; $3.6 billion for cataract, $3.5 billion for AMD, $2.2 billion for glaucoma and $0.8 billion for DR. The average cost per beneficiary diagnosed was $816: $1,290 for AMD, $781 for DR, $543 for glaucoma, and $360 for cataract. CONCLUSIONS: Major eye disorders are common among Medicare FFS beneficiaries and account for approximately 4.3% of Medicare Part B and 1% of Medicare Part D spending.

Prevalence of Visual Acuity Loss or Blindness in the US: A Bayesian Meta-analysis.

IMPORTANCE: Globally, more than 250 million people live with visual acuity loss or blindness, and people in the US fear losing vision more than memory, hearing, or speech. But it appears there are no recent empirical estimates of visual acuity loss or blindness for the US. OBJECTIVE: To produce estimates of visual acuity loss and blindness by age, sex, race/ethnicity, and US state. DATA SOURCES: Data from the American Community Survey (2017), National Health and Nutrition Examination Survey (1999-2008), and National Survey of Children's Health (2017), as well as population-based studies (2000-2013), were included. STUDY SELECTION: All relevant data from the US Centers for Disease Control and Prevention's Vision and Eye Health Surveillance System were included. DATA EXTRACTION AND SYNTHESIS: The prevalence of visual acuity loss or blindness was estimated, stratified when possible by factors including US state, age group, sex, race/ethnicity, and community-dwelling or group-quarters status. Data analysis occurred from March 2018 to March 2020. MAIN OUTCOMES OR MEASURES: The prevalence of visual acuity loss (defined as a best-corrected visual acuity greater than or equal to 0.3 logMAR) and blindness (defined as a logMAR of 1.0 or greater) in the better-seeing eye. RESULTS: For 2017, this meta-analysis generated an estimated US prevalence of 7.08 (95% uncertainty interval, 6.32-7.89) million people living with visual acuity loss, of whom 1.08 (95% uncertainty interval, 0.82-1.30) million people were living with blindness. Of this, 1.62 (95% uncertainty interval, 1.32-1.92) million persons with visual acuity loss are younger than 40 years, and 141 000 (95% uncertainty interval, 95 000-187 000) persons with blindness are younger than 40 years. CONCLUSIONS AND RELEVANCE: This analysis of all available data with modern methods produced estimates substantially higher than those previously published.

Vision Impairment and Blindness Prevalence in the United States: Variability of Vision Health Responses across Multiple National Surveys.

PURPOSE: To support survey validation efforts by comparing prevalence rates of self-reported and examination evaluated presenting visual impairment (VI) and blindness measured across national surveys. DESIGN: Cross-sectional comparison. PARTICIPANTS: Participants in the 2016 American Community Survey, the 2016 Behavioral Risk Factor Surveillance System, the 2016 National Health Interview Survey, the 2005-2008 National Health and Nutrition Examination Survey (NHANES), and the 2016 National Survey of Children's Health. METHODS: We estimated VI and blindness prevalence rates and confidence intervals for each survey measure and age group using the Clopper-Pearson method. We used inverse variance weighting to estimate the central tendency across measures by age-group, fitted trend lines to age-group estimates, and used the trend-line equations to estimate the number of United States persons with VI and blindness in 2016. We compared self-report estimates with those from NHANES physical evaluations of presenting VI and blindness. MAIN OUTCOME MEASURES: Variability of prevalence estimates of VI and blindness. RESULTS: Self-report estimates of blindness varied between 0.1% and 5.6% for those younger than 65 years and from 0.6% to 16.6% for those 65 or older. Estimates of VI varied between 1.6% and 24.8% for those younger than 65 years and between 2.2% and 26.6% for those 65 years or older. For summarized survey results and NHANES physical evaluation, prevalence rates for VI increased significantly with increasing age group. Blindness prevalence increased significantly with increasing age group for summarized survey responses but not for NHANES physical examination. Based on extrapolations of NHANES physical examination data to all ages, we estimated that in 2016, 23.4 million persons in the United States (7.2%) had VI or blindness, an evaluated presenting visual acuity of 20/40 or worse in the better-seeing eye before correction. Based on weighted self-reported surveys, we estimated that 24.8 million persons (7.7%) had presenting VI or blindness. CONCLUSIONS: Prevalence rates of VI and blindness obtained from national survey measures varied widely across surveys and age groups. Additional research is needed to validate the ability of survey self-report measures of VI and blindness to replicate results obtained through examination by an eye health professional.

Disparities in Receipt of Eye Exams Among Medicare Part B Fee-for-Service Beneficiaries with Diabetes - United States, 2017.

Approximately 30 million persons in the United States have diabetes.* Persons with diabetes are at risk for vision loss from diabetic retinopathy and other eye diseases (1). Diabetic retinopathy, the most common diabetes-related eye disease, affects 29% of U.S. adults aged ≥40 years with diabetes (2) and is the leading cause of incident blindness among working-age adults (1). It is caused by chronically high blood glucose damaging blood vessels in the retina.† Annual dilated eye exams are recommended for persons with diabetes because early detection and timely treatment of diabetic eye diseases can prevent irreversible vision loss§,¶ (3,4). Studies have documented prevalence of annual eye exams among U.S. adults with diabetes (5,6); however, a lack of recent state-level data limits identification of geographic disparities in adherence to this recommendation. Medicare claims from the 50 states, the District of Columbia (DC), Puerto Rico, and U.S. Virgin Islands (USVI) were examined to assess the prevalence of eye exams in 2017 among beneficiaries with diabetes who were continuously enrolled in Part B fee-for-service insurance, which covers annual eye exams for beneficiaries with diabetes.** This report also examines disparities, by state and race/ethnicity, in receipt of eye exams. Nationally, 54.1% of beneficiaries with diabetes had an eye exam in 2017. Prevalence ranged from 43.9% in Puerto Rico to 64.8% in Rhode Island. Fewer than 50% of beneficiaries received an eye exam in seven states (Alabama, Alaska, Kentucky, Louisiana, Nevada, West Virginia, and Wyoming) and Puerto Rico. Non-Hispanic white (white) beneficiaries had a higher prevalence of receiving an eye exam (55.6%) than did non-Hispanic blacks (blacks) (48.9%) and Hispanics (48.2%). Barriers to receiving eye care (e.g., suboptimal clinical care coordination and referral, low health literacy, and lack of perceived need for care) might limit Medicare beneficiaries' ability to follow this preventive care recommendation. Understanding and addressing these barriers might prevent irreversible vision loss among persons with diabetes.