Facilitators and Barriers to Weight Loss Among Patients With Idiopathic Intracranial Hypertension.

BACKGROUND: Little is known about motivation for weight loss and barriers to weight loss among patients with idiopathic intracranial hypertension (IIH). Such information is crucial for developing tailored weight management recommendations and novel interventions. METHODS: We administered a survey to patients with IIH presenting to neuro-ophthalmology clinics at The University of Michigan Kellogg Eye Center (Michigan, USA) and St. Thomas' Hospital (London, England). Participants rated importance and motivation to lose weight (1-10 scale; 10 = extremely important/motivated). Facilitators and barriers to weight loss were assessed using open-ended survey questions informed by motivational interviewing methodology. Open-ended responses were coded by 2 team members independently using a modified grounded theory approach. Demographic data were extracted from medical records. Descriptive statistics were used to analyze quantitative responses. RESULTS: Of the 221 (43 Michigan and 178 London) patients with IIH (Table 1), most were female (n = 40 [93.0%] Michigan and n = 167 [94.9%] London). The majority of patients in the United States were White (n = 35 [81.4%] Michigan), and the plurality were Black in the United Kingdom (n = 67 [37.6%] London]) with a mean (SD) BMI of 38.9 kg/m2 (10.6 kg/m2) Michigan and 37.5 kg/m2 (7.7 kg/m2) London. Participants' mean (SD) level of importance to lose weight was 8.5 (2.2) (8.1 [2.3] Michigan and 8.8 [2.1] London), but their mean (SD) level of motivation to lose weight was 7.2 (2.2) (6.8 [2.4] Michigan and 7.4 [2.1] London). Nine themes emerged from the 992 open-ended coded survey responses grouped into 3 actionable categories: self-efficacy, professional resources (weight loss tools, diet, physical activity level, mental health, and physical health), and external factors (physical/environmental conditions, social influences, and time constraints). Most responses (55.6%; n = 551) were about barriers to weight loss. Lack of self-efficacy was the most discussed single barrier (N = 126; 22.9% total, 28.9% Michigan, and 20.4% London) and facilitator (N = 77; 17.5% total, 15.9% Michigan, and 18.7% London) to weight loss. Other common barriers were related to physical activity level (N = 79; 14.3% total, 13.2% Michigan, and 14.8% London) and diet (N = 79; 14.3% total, 9.4% Michigan, and 16.3% London). Commonly reported facilitators included improvements in physical activity level (N = 73; 16.6% total, 18.5% Michigan, and 15.1% London) and dietary changes (N = 76; 17.2% total, 16.4% Michigan, and 17.9% London). CONCLUSIONS: Patients with IIH believe weight loss is important. Self-efficacy was the single most mentioned important patient-identified barrier or facilitator of weight loss, but professional resource needs and external factors vary widely at the individual level. These factors should be assessed to guide selection of weight loss interventions that are tailored to individual patients with IIH.

Patient Travel Distance to Neurologist Visits.

BACKGROUND AND OBJECTIVES: The density of neurologists within a given geographic region varies greatly across the United States. We aimed to measure patient travel distance and travel time to neurologist visits, across neurologic conditions and subspecialties. Our secondary goal was to identify factors associated with long-distance travel for neurologic care. METHODS: We performed a cross-sectional analysis using a 2018 Medicare sample of patients with at least 1 outpatient neurologist visit. Long-distance travel was defined as driving distance ≥50 miles 1-way to the visit. Travel time was measured as driving time in minutes. Multilevel generalized linear mixed models with logistic link function, which accounted for clustering of patients within hospital referral region and allowed modeling of region-specific random effects, were used to determine the association of patient and regional characteristics with long-distance travel. RESULTS: We identified 563,216 Medicare beneficiaries with a neurologist visit in 2018. Of them, 96,213 (17%) traveled long distance for care. The median driving distance and time were 81.3 (interquartile range [IQR]: 59.9-144.2) miles and 90 (IQR: 69-149) minutes for patients with long-distance travel compared with 13.2 (IQR: 6.5-23) miles and 22 (IQR: 14-33) minutes for patients without long-distance travel. Comparing across neurologic conditions, long-distance travel was most common for nervous system cancer care (39.6%), amyotrophic lateral sclerosis [ALS] (32.1%), and MS (22.8%). Many factors were associated with long-distance travel, most notably low neurologist density (first quintile: OR 3.04 [95% CI 2.41-3.83] vs fifth quintile), rural setting (4.89 [4.79-4.99]), long-distance travel to primary care physician visit (3.6 [3.51-3.69]), and visits for ALS and nervous system cancer care (3.41 [3.14-3.69] and 5.27 [4.72-5.89], respectively). Nearly one-third of patients bypassed the nearest neurologist by 20+ miles, and 7.3% of patients crossed state lines for neurologist care. DISCUSSION: We found that nearly 1 in 5 Medicare beneficiaries who saw a neurologist traveled ≥50 miles 1-way for care, and travel burden was most common for lower-prevalence neurologic conditions that required coordinated multidisciplinary care. Important potentially addressable predictors of long-distance travel were low neurologist density and rural location, suggesting interventions to improve access to care such as telemedicine or neurologic subspecialist support to local neurologists. Future work should evaluate differences in clinical outcomes between patients with long-distance travel and those without.

Levonorgestrel intrauterine device use and incident idiopathic intracranial hypertension among commercially insured women.

OBJECTIVES: To estimate the hazard of incident idiopathic intracranial hypertension, a potentially blinding condition, among women using levonorgestrel intrauterine devices (LNG-IUD) compared to copper IUD, as conflicting associations have been reported. STUDY DESIGN: This retrospective, longitudinal cohort study identified women ages 18-45 years in a large care network (January 1, 2001, to December 31, 2015) using LNG-IUD, subcutaneous etonogestrel implant, copper IUD, tubal device/surgery, or hysterectomy. Incident idiopathic intracranial hypertension was defined as the first diagnosis code for after 1 year without any codes and following brain imaging or lumbar puncture. Kaplan-Meier analysis estimated time-dependent probabilities of idiopathic intracranial hypertension at 1 and 5 years after incident contraception use, stratified by type. Cox regression estimated the hazard of idiopathic intracranial hypertension associated with LNG-IUD use compared to copper IUD (primary comparison) after adjusting for sociodemographics and factors associated with idiopathic intracranial hypertension (e.g., obesity) or contraception selection. A sensitivity analysis with propensity score-adjusted models was performed. RESULTS: Of 268,280 women, 78,175 (29%) used LNG-IUD, 8715 (3%) etonogestrel implant, 20,275 (8%) copper IUD, 108,216 (40%) hysterectomy, 52,899 (20%) tubal device/surgery, and 208 (0.08%) developed idiopathic intracranial hypertension over a mean follow-up of 2.4 ± 2.4 years. Also, 1-/5-year Kaplan-Meier idiopathic intracranial hypertension probabilities were 0.0004/0.0021 for LNG-IUD and 0.0005/0.0006 for copper IUD users. LNG-IUD use did not show significantly different hazard of idiopathic intracranial hypertension compared to copper IUD (adjusted hazard ratio 1.84 [95% CI 0.88, 3.85]). Sensitivity analyses were similar. CONCLUSIONS: We did not observe a significantly increased hazard of idiopathic intracranial hypertension among women using LNG-IUD compared to copper IUDs. IMPLICATIONS: The lack of an association between LNG-IUD use and idiopathic intracranial hypertension in this large observational study provides reassurance to women considering initiation or continued use of this highly effective contraceptive method.

Predictors of Long-Term Visual Acuity in a Modern Cohort of Patients With Acute Idiopathic and Multiple Sclerosis-Associated Optic Neuritis.

BACKGROUND: For patients with idiopathic or multiple sclerosis (MS)-associated optic neuritis (ON), the largest multicenter clinical trial (Optic Neuritis Treatment Trial [ONTT]) showed excellent visual outcomes and baseline high-contrast visual acuity (HCVA) was the only predictor of HCVA at 1 year. We aimed to evaluate predictors of long-term HCVA in a modern, real-world population of patients with ON and compare with previously published ONTT models. METHODS: We performed a retrospective, longitudinal, observational study at the University of Michigan and the University of Calgary evaluating 135 episodes of idiopathic or MS-associated ON in 118 patients diagnosed by a neuro-ophthalmologist within 30 days of onset (January 2011-June 2021). Primary outcome measured was HCVA (Snellen equivalents) at 6-18 months. Multiple linear regression models of 107 episodes from 93 patients assessed the association between HCVA at 6-18 months and age, sex, race, pain, optic disc swelling, symptoms (days), viral illness prodrome, MS status, high-dose glucocorticoid treatment, and baseline HCVA. RESULTS: Of the 135 acute episodes (109 Michigan and 26 Calgary), median age at presentation was 39 years (interquartile range [IQR], 31-49 years), 91 (67.4%) were women, 112 (83.0%) were non-Hispanic Caucasians, 101 (75.9%) had pain, 33 (24.4%) had disc edema, 8 (5.9%) had a viral prodrome, 66 (48.9%) had MS, and 62 (46.6%) were treated with glucocorticoids. The median (IQR) time between symptom onset and diagnosis was 6 days (range, 4-11 days). The median (IQR) HCVA at baseline and at 6-18 months were 20/50 (20/22, 20/200) and 20/20 (20/20, 20/27), respectively; 62 (45.9%) had better than 20/40 at baseline and 117 (86.7%) had better than 20/40 at 6-18 months. In linear regression models (n = 107 episodes in 93 patients with baseline HCVA better than CF), only baseline HCVA (ß = 0.076; P = 0.027) was associated with long-term HCVA. Regression coefficients were similar and within the 95% confidence interval of coefficients from published ONTT models. CONCLUSIONS: In a modern cohort of patients with idiopathic or MS-associated ON with baseline HCVA better than CF, long-term outcomes were good, and the only predictor was baseline HCVA. These findings were similar to prior analyses of ONTT data, and as a result, these are validated for use in conveying prognostic information about long-term HCVA outcomes.

Sociodemographic and Geographic Variation in Access to Neuro-Ophthalmologists in the United States.

BACKGROUND: Neuro-ophthalmologists have expertise in rare and complex disorders, but the ability of patients to access neuro-ophthalmic care has not been examined at a nationwide level. METHODS: Using the 2020 directory of all 502 members of the North American Neuro-Ophthalmology Society as a reference, we found the practice locations of 461 confirmed practicing members and converted each street address to latitude and longitude coordinates. We calculated the travel distance and time from each census tract to the nearest practice location and calculated population-weighted averages by state, region, and other prespecified factors. Choropleth maps were used to visualize the distribution of travel distances and times across the United States. RESULTS: California had the most practicing neuro-ophthalmologists out of any state (50), whereas 4 states (DE, MT, SD, and WY) had none. Washington, DC and MA had the most neuro-ophthalmologists per capita. The average travel distance and time to the nearest neuro-ophthalmologists were found to be 40.90 miles and 46.50 minutes, respectively, although a large portion of western plains and mountain regions had travel times of over 120 minutes. Patients in rural areas had longer travel times than those in urban areas, and Native American patients had the longest travel times of any racial or ethnic group. CONCLUSION: The travel time to see a neuro-ophthalmologist varies widely by state, region, and rurality, with Native American patients and rural patients being disproportionately affected. By identifying the areas with the greatest travel burdens, future policies can work to alleviate these potential barriers to care.

A Validated Method to Identify Neuro-Ophthalmologists in a Large Administrative Claims Database.

BACKGROUND: Validated methods to identify neuro-ophthalmologists in administrative data do not exist. The development of such method will facilitate research on the quality of neuro-ophthalmic care and health care utilization for patients with neuro-ophthalmic conditions in the United States. METHODS: Using nationally representative, 20% sample from Medicare carrier files from 2018, we identified all neurologists and ophthalmologists billing at least 1 office-based evaluation and management (E/M) outpatient visit claim in 2018. To isolate neuro-ophthalmologists, the National Provider Identifier numbers of neuro-ophthalmologists in the North American Neuro-Ophthalmology Society (NANOS) directory were collected and linked to Medicare files. The proportion of E/M visits with International Classification of Diseases-10 diagnosis codes that best distinguished neuro-ophthalmic care ("neuro-ophthalmology-specific codes" or NSC) was calculated for each physician. Multiple logistic regression models assessed predictors of neuro-ophthalmology specialty designation after accounting for proportion of ophthalmology, neurology, and NSC claims and primary specialty designation. Sensitivity, specificity, and positive predictive value (PPV) for varying proportions of E/M visits with NSC were calculated. RESULTS: We identified 32,293 neurologists and ophthalmologists who billed at least 1 outpatient E/M visit claim in 2018 in Medicare. Of the 472 NANOS members with a valid individual National Provider Identifier, 399 (84.5%) had a Medicare outpatient E/M visit in 2018. The model containing only the proportion of E/M visits with NSC best predicted neuro-ophthalmology specialty designation (odds ratio 1.05 [95% confidence interval 1.04, 1.05]; P < 0.001; area under the receiver operating characteristic [AUROC] = 0.91). Model predictiveness for neuro-ophthalmology designation was maximized when 6% of all billed claims were for NSC (AUROC = 0.89; sensitivity: 84.0%; specificity: 93.9%), but PPV was low (14.9%). The threshold was unchanged when limited only to neurologists billing ≥1% ophthalmology claims or ophthalmologists billing ≥1% neurology claims, but PPV increased (33.3%). CONCLUSIONS: Our study provides a validated method to identify neuro-ophthalmologists who can be further adapted for use in other administrative databases to facilitate future research of neuro-ophthalmic care delivery in the United States.

Population Prevalence of Vision Impairment in US Adults 71 Years and Older: The National Health and Aging Trends Study.

Importance: Existing estimates of the prevalence of vision impairment (VI) in the United States are based on self-reported survey data or measures of visual function that are at least 14 years old. Older adults are at high risk for VI and blindness. There is a need for up-to-date, objectively measured, national epidemiological estimates. Objective: To present updated national epidemiological estimates of VI and blindness in older US adults based on objective visual function testing. Design, Setting, and Participants: This survey study presents a secondary data analysis of the 2021 National Health and Aging Trends Study (NHATS), a population-based, nationally representative panel study of Medicare beneficiaries 65 years and older. NHATS includes community-dwelling older adults or their proxies who complete in-person interviews; annual follow-up interviews are conducted regardless of residential status. Round 11 NHATS data were collected from June to November 2021, and data were analyzed in August 2022. Interventions: In 2021, NHATS incorporated tablet-based tests of distance and near visual acuity and contrast sensitivity with habitual correction. Main Outcomes and Measures: National prevalence of impairment in presenting distance visual acuity (>0.30 logMAR, Snellen equivalent worse than 20/40), presenting near visual acuity (>0.30 logMAR, Snellen equivalent worse than 20/40), and contrast sensitivity (>1 SD below the sample mean). Prevalence estimates stratified by age and socioeconomic and demographic data were calculated. Results: In the 2021 round 11 NHATS sample, there were 3817 respondents. After excluding respondents who did not complete the sample person interview (n = 429) and those with missing vision data (n = 362), there were 3026 participants. Of these, 29.5% (95% CI, 27.3%-31.8%) were 71 to 74 years old, and 55.2% (95% CI, 52.8%-57.6%) were female respondents. The prevalence of VI in US adults 71 years and older was 27.8% (95% CI, 25.5%-30.1%). Distance and near visual acuity and contrast sensitivity impairments were prevalent in 10.3% (95% CI, 8.9%-11.7%), 22.3% (95% CI, 20.3%-24.3%), and 10.0% (95% CI, 8.5%-11.4%), respectively. Older age, less education, and lower income were associated with all types of VI. A higher prevalence of near visual acuity and contrast sensitivity impairments was associated with non-White race and Hispanic ethnicity. Conclusions and Relevance: More than 1 in 4 US adults 71 years and older had VI in 2021, higher than prior estimates. Differences in the prevalence of VI by socioeconomic and demographic factors were observed. These data could inform public health planning.

Nationwide trends in emergency department utilisation for acute retinal ischaemia in the USA, 2011-2018.

BACKGROUND: Guidelines recommend urgent evaluation for transient monocular vision loss (TMVL) and retinal artery occlusion (RAO), but emergency department (ED) utilisation for these conditions is unknown. METHODS: We performed a retrospective longitudinal cross-sectional analysis of the Nationwide Emergency Department Sample (2011-2018), a database of all ED visits from a representative 20% sample of US hospital-based EDs. We identified patients aged 40 and older with a primary diagnosis of TMVL or RAO and calculated the weighted number of total visits and admission rate by year. We used joinpoint regression to analyse time trends and logistic regression to measure differences according to demographic characteristics and comorbidities. RESULTS: There were an estimated 2451 ED visits for TMVL and 2472 for RAO annually in the USA from 2011 to 2018. Approximately 36% of TMVL and 51% of RAO patients were admitted. The admission rate decreased by an average of 4.9% per year for TMVL (95% CI -7.5% to -2.3%) and 2.2% per year for RAO (95% CI -4.1% to -0.4%), but the total number of ED visits did not change significantly over time. Elixhauser Comorbidity Index and hyperlipidaemia were associated with increased odds of hospital admission for both TMVL and RAO. There were also differences in admission rate by insurance payer and hospital region. CONCLUSION: Of the estimated 48 000 patients with TMVL or RAO annually in the USA, few are evaluated in the ED, and admission rates are less than for transient ischaemic attack or ischaemic stroke and are decreasing over time.

Predictors of Glucocorticoid Use for Acute Optic Neuritis in the United States, 2005-2019.

PURPOSE: Acute optic neuritis (ON) is variably treated with glucocorticoids. We aimed to describe factors associated with glucocorticoid use. METHODS: In this retrospective, longitudinal cohort study of insured patients in the United States (2005-2019), adults 18-50 years old with one inpatient or ≥2 outpatient diagnoses of ON within 90 days were included. Glucocorticoid use was classified as none, any dose, and high-dose (>100 mg prednisone equivalent ≥1 days). The primary outcome was glucocorticoid receipt within 90 days of the first ON diagnosis. Multivariable logistic regression models assessed the relationship between glucocorticoid use and sociodemographics, comorbidities, clinician specialty, visit number, and year. RESULTS: Of 3026 people with ON, 65.8% were women (n = 1991), median age (interquartile range) was 38 years (31,44), and 68.6% were white (n = 2075). Glucocorticoids were received by 46% (n = 1385); 54.6% (n = 760/1385) of whom received high-dose. The odds of receiving glucocorticoids were higher among patients with multiple sclerosis (OR 1.61 [95%CI 1.28-2.04]; P < .001), MRI (OR 1.75 [95%CI 1.09-2.80]; P = .02), 3 (OR 1.80 [95%CI 1.46-2.22]; P < .001) or more (OR 4.08 [95%CI 3.37-4.95]; P < .001) outpatient ON visits, and in certain regions. Compared to ophthalmologists, patients diagnosed by neurologists (OR 1.36 [95%CI: 1.10-1.69], p = .005), emergency medicine (OR 3.97 [95%CI: 2.66-5.94]; P < .001) or inpatient clinicians (OR 2.94 [95%CI: 2.22-3.90]; P < .001) had higher odds of receiving glucocorticoids. Use increased 1.1% annually (P < .001). CONCLUSIONS: Demyelinating disease, care intensity, setting, region, and clinician type were associated with glucocorticoid use for ON. To optimize care, future studies should explore reasons for ON care variation, and patient/clinician preferences.

Evaluation of Diplopia by Emergency Medicine Physicians and Consulting Neurologists.

BACKGROUND: Appropriate evaluation of diplopia requires separating serious from benign causes. If providers are not adept in this task, diagnosis of critical conditions may be delayed and unnecessary testing may result. METHODS: We studied the records of 100 consecutive patients who presented to an emergency department between 2010 and 2020 with diplopia as a prominent symptom. We rated the performance of emergency medicine physicians (EMPs) and consulting neurologists (CNs) in the examination, diagnosis, and ordering of diagnostic tests according to standards based on neuro-ophthalmologic consultation and the neuro-ophthalmologic literature. RESULTS: EMPs made no diagnosis or an incorrect diagnosis in 88 (88%) of 100 encounters. They ordered 14 unindicated and 12 incorrect studies, mostly noncontrast computed tomography scans. CNs made an incorrect diagnosis in 13 (31%) encounters. They ordered 6 unindicated and 2 incorrect studies. The total charge for unindicated and incorrect studies ordered by EMPs and CNs was $119,950. CONCLUSIONS: EMPs and CNs made frequent errors in the examination, diagnosis, and ordering of diagnostic studies, leading to inefficient care and unnecessary testing. EMPs largely delegated the evaluation of diplopia to their consultants. If such consultative support were not available, the care of diplopic patients would be delayed. CNs performed more complete examinations, but rarely enough to allow appreciation of the pattern of ocular misalignment, contributing to misdiagnoses and ordering errors. The identification of these provider errors allows for more targeted teaching in the evaluation of diplopia.

Visual Difficulty, Race and Ethnicity, and Activity Limitation Trajectories Among Older Adults in the United States: Findings From the National Health and Aging Trends Study.

OBJECTIVES: To characterize the influence of visual difficulty on activity limitation trajectories in older U.S. adults and investigate whether this varied across racial/ethnic groups. METHODS: We used data from 8,077 participants in the nationally representative National Health and Aging Trends Study from 2011 to 2019. Using mixed-effects regression models, we investigated the association of self-reported visual difficulty and race/ethnicity with activity limitation trajectories. RESULTS: Higher levels of visual difficulty and belonging to a minority racial/ethnic group were associated with greater mobility, self-care, and household activity limitations. Visual difficulty was associated with mobility and self-care activity limitation trajectories, and race/ethnicity was significantly associated with mobility and household activity limitation trajectories. Among those with the highest levels of visual difficulty, non-Hispanic Black participants experienced a faster rate of decline in self-care activities compared to non-Hispanic White participants. DISCUSSION: Promoting optimal aging for all requires an understanding of the factors that influence disparities in key outcomes. Our study provides evidence from a diverse national sample that visual difficulty appears to disproportionately affect activity limitation trajectories among older adults from minority racial/ethnic groups and particularly among non-Hispanic "Black individuals." Further research is needed to determine whether interventions to promote healthy vision may positively affect overall activity and independence and ameliorate disparities in late-life activity limitation trajectories.

Disparities in Eye Care Utilization During the COVID-19 Pandemic.

PURPOSE: To assess the relationship between telemedicine utilization and sociodemographic factors among patients seeking eye care. DESIGN: Comparative utilization analysis. METHODS: We reviewed the eye care utilization patterns of a stratified random sample of 1720 patients who were seen at the University of Michigan Kellogg Eye Center during the height of the COVID-19 pandemic (April 30 to May 25, 2020) and their odds of having a video, phone, or in-person visit compared with having a deferred visit. Associations between independent variables and visit type were determined using a multinomial logistic regression model. RESULTS: Older patients had lower odds of having a video visit (P = .007) and higher odds of having an in-person visit (P = .023) compared with being deferred, and in the nonretina clinic sample, older patients still had lower odds of a video visit (P = .02). Non-White patients had lower odds of having an in-person visit (P < .02) in the overall sample compared with being deferred, with a similar trend seen in the retina clinic. The mean neighborhood median household income was $76,200 (±$33,500) and varied significantly (P < .0001) by race with Blacks having the lowest estimated mean income. CONCLUSION: Disparities exist in how patients accessed eye care during the COVID-19 pandemic with older patients-those for whom COVID-19 posed a higher risk of mortality-being more likely to be seen for in-person care. In our affluent participant sample, there was a trend toward non-White patients being less likely to access care. Reimbursing telemedicine solely through broadband internet connection may further exacerbate disparities in eye care.

The changing landscape of optic neuritis: a narrative review.

Optic neuritis (ON) is an inflammatory optic neuropathy that is often a harbinger of central nervous system (CNS) demyelinating disorders. ON is frequently misdiagnosed in the clinical arena, leading to either inappropriate management or diagnostic delays. As a result, patients may fail to achieve optimal recovery. The treatment response to corticosteroids and long term risk of multiple sclerosis was established in the first clinical trials conducted roughly 30 years ago. Spontaneous resolution was observed in the vast majority of patients and intravenous high-dose corticosteroids hastened recovery; half of the patients eventually developed multiple sclerosis. Over the ensuing decades, the number of inflammatory conditions associated with ON has significantly expanded exposing substantial variability in the prognosis, treatment, and management of ON patients. ON subtypes can frequently be distinguished by distinct clinical, serological, and radiological profiles allowing expedited and specialized treatment. Guided by an increased understanding of the immunopathology underlying optic nerve and associated CNS injuries, novel disease management strategies are emerging to minimize vision loss, improve long-term surveillance strategies, and minimize CNS injury and disability. Knowledge regarding the clinical signs and symptoms of different ON subtypes is essential to guide acute therapy, prognosticate recovery, accurately identify underlying CNS inflammatory disorders, and facilitate study design for the next generation of clinical and translational trials.

Longitudinal Associations Between Vision Impairment and the Incidence of Neuropsychiatric, Musculoskeletal, and Cardiometabolic Chronic Diseases.

PURPOSE: To compare the incidence and hazard of neuropsychiatric, musculoskeletal, and cardiometabolic conditions among adults with and without vision impairment (VI). DESIGN: Retrospective cohort study. METHODS: The sample comprised enrollees in a large private health insurance provider in the United States, including 24 657 adults aged ≥18 years with VI and age- and sex-matched controls. The exposure variable, VI, was based on low vision and blindness International Classification of Diseases, Ninth and Tenth Revision, Clinical Modification (ICD-9-CM and ICD-10-CM), diagnosis codes. Physician-diagnosed incident neuropsychiatric, musculoskeletal, and cardiometabolic diseases were identified using ICD codes. Separate Cox proportional hazards regression models were used to assess the association of VI with incidence of 30 chronic conditions, adjusting for Elixhauser Comorbidity Index. Analyses were stratified by age 18-64 years and ≥65 years. RESULTS: In individuals with VI aged 18-64 years (n=7478), the adjusted hazard of neuropsychiatric (HR 2.1, 95% CI 1.9, 2.4), musculoskeletal (HR 1.8, 95% CI 1.7, 2.0), and cardiometabolic (HR 1.8, 95% CI 1.7, 2.0) diseases was significantly greater than in matched controls (mean 5.5 years follow-up). Similar associations were seen between patients with VI aged ≥65 years (n=17 179) for neuropsychiatric (HR 2.4, 95% CI 2.1, 2.7), musculoskeletal (HR 1.8, 95% CI 1.6, 1.9), and cardiometabolic (HR 1.7, 95% CI 1.4, 2.0) diseases. VI was associated with a higher hazard of each of the 30 conditions we assessed, with similar results in both age cohorts. CONCLUSION: Across the life span, adults with VI had an approximately 2-fold greater adjusted hazard for common neuropsychiatric, musculoskeletal, and cardiometabolic disorders compared with matched controls without VI.

Development and Validation of a Novel Indicator of Visual Disability in the National Health and Aging Trends Study.

BACKGROUND AND OBJECTIVES: The National Health and Aging Trends Study (NHATS) is an ongoing, nationally representative panel study of older adults that collects data on health and disability, including measures on self-reported visual disability (SRVD). Prior studies assessing the association of SRVD with other measures of healthy aging have classified participants as having or not having SRVD, which does not capture the full spectrum of SRVD reported by participants. Therefore, we sought to develop and validate an ordinal indicator of SRVD to facilitate research on the impact of late-life SRVD on health and disability in NHATS. RESEARCH DESIGN AND METHODS: We used 2015 NHATS data with community-dwelling participants who answered survey questions about visual functioning and vision aid use. Based on responses, participants were categorized into one of 6 groups: blind, near and distance SRVD without vision aid use, near and distance SRVD with vision aid use, near or distance SRVD without vision aid use, near or distance SRVD with vision aid use, or no SRVD. Multivariable Poisson regression models assessed convergent validity of the ordinal SRVD scale with functional activity and well-being scores, while adjusting for demographic factors and medical comorbidities. RESULTS: Of the 7061 eligible individuals, 8.3% (n = 742) reported SRVD. Using our novel ordinal indicator of SRVD in NHATS, higher levels of SRVD were significantly associated with lower functional activity scores (p < .001 for all) and subjective well-being (p < .001), except for participants reporting blindness. Significant differences between SRVD groups were found, which could not be captured using a binary SRVD variable. DISCUSSION AND IMPLICATIONS: A novel 6-level SRVD scale in NHATS demonstrated convergent validity with functional activity and well-being scales. This scale provides a new tool with improved measurement precision to study the impact of late-life SRVD on health and disability in a nationally representative study of older adults.

Change in Ophthalmic Clinicians' Attitudes Toward Telemedicine During the Coronavirus 2019 Pandemic.

Background: Ophthalmic clinicians report low confidence in telemedicine-based eye care delivery, but it may have changed given its rapid expansion during the coronavirus 2019 (COVID-19) pandemic. Introduction: The purpose of this study was to determine clinician confidence in telemedicine-based eye care services during COVID-19. Materials and Methods: An electronic survey was sent to clinicians at University of Michigan Kellogg Eye Center (April 17, 2020-May 6, 2020) when nonemergent in-person visits and procedures were restricted. The primary outcome was clinician confidence in using telemedicine-based eye care during COVID-19. Secondary outcomes included telemedicine utilization and its association with clinician confidence using Fisher's exact test. Results: Of the 88 respondents (90.7% response rate; n = 97 total), 83.0% (n = 73) were ophthalmologists and 17.0% (n = 15) were optometrists. Telemedicine utilization increased from 30.7% (n = 27) before the pandemic to 86.2% (n = 75) after the pandemic. Clinicians' confidence in their ability to use telemedicine varied with 28.6% (24/84) feeling confident/extremely confident, 38.1% (32/84) somewhat confident, and 33.3% (28/84) not-at-all confident. Most felt that telemedicine was underutilized (62.1%; 54/87) and planned continued use over the next year (59.8%; 52/87). Confident respondents were more likely to have performed three or more telemedicine visits (p = 0.003), to believe telemedicine was underutilized (p < 0.001), and to anticipate continued use of telemedicine (p = 0.009). Discussion: The majority of clinicians were at least somewhat confident about using telemedicine during the pandemic. Clinician confidence was associated with telemedicine visit volume and intention to continue using telemedicine. Conclusions: Policies that foster clinician confidence will be important to sustain telemedicine-based eye care delivery.