Impact of eyewear insurance coverage on utilization of eyecare providers in Ontario, Canada.

OBJECTIVE: To obtain prescription eyewear in Ontario, eye exams must be performed by optometrists or ophthalmologists (eye care providers [ECPs]). In 2004, government-insured routine eye exams were delisted for Ontarians aged 20-64 leaving eye exam coverage only for those aged ≤19 and 65+. We assessed whether having eyewear insurance impacts Ontarians' utilization of ECPs. DESIGN: Cross-sectional survey. PARTICIPANTS: Ontarians aged 12+ without diabetes responding to the Canadian Community Health Survey in 2003, 2005, and 2013/2014. METHODS: We compared the utilization of ECPs by eyewear insurance status and eligibility for government-funded eye exams. Individuals with eyewear insurance funded by employers, government or privately were considered to have insurance. RESULTS: ECP utilization was significantly higher in Ontarians with eyewear insurance versus those without, in all survey years and all age groups, including those eligible for government-funded eye exams (e.g., 66.4% vs 59.1% [p < 0.05] for the 65+). This higher level of utilization was particularly evident among Ontarians aged 20-64 in 2013/2014, when this group no longer had government-funded eye exams (34.9% vs 19.9% among 20-39-year-olds, 43.4% vs 32.9% among 40-64-year-olds, p < 0.05 for both). Adjusting for confounding effects, the likelihood of visiting an ECP was greater among Ontarians with eyewear insurance than those without (adjusted prevalence ratio 1.26 for Ontarians aged 12+ and 1.41 for those aged 20-64; p < 0.05 for both). CONCLUSIONS: Lack of eyewear insurance negatively impacts the utilization of ECPs, even among Ontarians eligible for government-funded eye exams, where the cost barrier for eye exams has been removed by the Ontario government.

Suprachoroidal and vitreous haemorrhage as a presenting feature of metastatic melanoma.

A man in his 70s presented with right ocular pain, vision loss and temporal headache 4 days after undergoing laser peripheral iridotomy. The patient had lost 10 lbs over the preceding 6 weeks and had a medical history significant for a previously excised melanoma of the left arm. During the course of investigations, the patient was referred to oncology for workup, ultimately leading to a diagnosis of metastatic melanoma. Visceral metastases were identified in the lungs, right anterior fourth rib, left femoral distal diaphysis and medial side of the right globe. The patient decompensated and died shortly after his first radiotherapy treatment.This is the first published report of suprachoroidal haemorrhage secondary to metastasis from suspected cutaneous melanoma. The case highlights the importance of considering malignancy on the differential diagnosis for a suprachoroidal haemorrhage of unknown aetiology and involving oncology early for workup and treatment.

Application of the Modified Early Obstetrical Warning System (MEOWS) in postpartum patients in the emergency department.

INTRODUCTION: Over the last two decades, there has been a steady rise in severe maternal morbidity and pregnancy-related deaths in Canada and the USA. The Modified Early Obstetric Warning System (MEOWS) is a risk stratification tool designed to predict severe maternal morbidity and mortality and has been validated for use in obstetrical wards. The objective of this study was to determine if MEOWS could accurately identify patients at risk of severe maternal morbidity and mortality in the ED setting. METHODS: This was a chart review of patients presenting to an academic tertiary care centre (annual ED census 65,000) with a postpartum complaint within 6 weeks of delivery between May 2020 and March 2022. The exposure was the presence of a trigger, defined as one severely abnormal (red) or two mildly abnormal (yellow) physiological measurements during the ED visit. The diagnostic accuracy of the tool to identify patients at risk of severe maternal morbidity severe maternal morbidity or mortality was estimated by calculating the sensitivity, specificity, positive predictive value and negative predictive value. RESULTS: Two hundred and sixty-seven patients were included, of which 21 (7.9%) met the criteria for severe maternal morbidity. There were no maternal deaths. Overall, the sensitivity of the MEOWS tool was 85.7% (95% CI 63.7-97.0%), specificity was 67.9% (95% CI 61.7-73.7%), positive predictive value was 18.6% (95% CI 15.1-22.7%), and negative predictive value was 98.2% (95% CI 95.1-99.4%). Severe preeclampsia and eclampsia were the most common outcome category of severe maternal morbidity, representing 16 (76.2%) cases. Most patients (86.5%) were discharged directly from the ED, and 90.0% did not return within 30 days. CONCLUSIONS: This study is the first to explore the utility of MEOWS in postpartum ED patients. The presence of a MEOWS trigger at ED triage or the first ED nursing assessment was associated with severe maternal morbidity. Thus, MEOWS may be a valuable tool to identify postpartum patients at risk of severe outcomes early in an ED visit.

RéSUMé: INTRODUCTION: Au cours des deux dernières décennies, la morbidité maternelle grave et les décès liés à la grossesse ont connu une augmentation constante au Canada et aux États-Unis. Le système d'alerte précoce en obstétrique modifié (Modified Early Obstetric Warning System, MEOWS) est un outil de stratification des risques conçu pour prédire la morbidité et la mortalité maternelles graves. Il a été validé pour être utilisé dans les services d'obstétrique. L'objectif de cette étude était de déterminer si le MEOWS pouvait identifier avec précision les patientes présentant un risque de morbidité et de mortalité maternelles graves dans le contexte des urgences. MéTHODES: Il s'agit d'une étude des dossiers des patientes qui se sont présentées dans un centre de soins tertiaires universitaires (recensement annuel des urgences : 65 000) avec une plainte post-partum dans les six semaines suivant l'accouchement, entre mai 2020 et mars 2022. L'exposition était la présence d'un facteur déclenchant, défini comme une mesure physiologique gravement anormale (rouge) ou deux mesures légèrement anormales (jaune) au cours de la visite au service des urgences. La précision diagnostique de l'outil pour identifier les patientes à risque de morbidité maternelle grave morbidité maternelle grave ou de mortalité a été estimée en calculant la sensibilité, la spécificité, la valeur prédictive positive et la valeur prédictive négative. RéSULTATS: 267 patientes ont été incluses, dont 21 (7,9 %) répondaient aux critères de morbidité maternelle sévère. Il n'y a pas eu de décès maternel. Globalement, la sensibilité de l'outil MEOWS était de 85,7 % (IC 95 % : 63,7 %-97,0 %), la spécificité de 67,9 % (IC 95 % : 61,7 %-73,7 %), la valeur prédictive positive de 18,6 % (IC 95 % : 15,1 %-22,7 %) et la valeur prédictive négative de 98,2 % (IC 95 % : 95,1 %-99,4 %). La pré-éclampsie sévère et l'éclampsie étaient la catégorie d'issue la plus fréquente de la morbidité maternelle sévère, représentant 16 (76,2 %) cas. La plupart des patients (86,5 %) sont sortis directement des urgences et 90,0 % ne sont pas revenus dans les 30 jours. CONCLUSIONS: Cette étude est la première à explorer l'utilité du MEOWS chez les patientes des urgences post-partum. La présence d'un déclencheur MEOWS lors du triage aux urgences ou de la première évaluation infirmière aux urgences était associée à une morbidité maternelle grave. Ainsi, le MEOWS peut être un outil précieux pour identifier les patientes du post-partum qui risquent d'avoir des conséquences graves dès le début d'une visite aux urgences.

Cost-Effectiveness of Preoperative Topical Antibiotic Prophylaxis for Endophthalmitis Following Cataract Surgery.

PURPOSE: To determine the cost-effectiveness of preoperative topical antibiotic prophylaxis for the prevention of endophthalmitis following cataract surgery. DESIGN: Cost-effectiveness analysis using a decision-analytic microsimulation model. METHODS: Preoperative topical antibiotic prophylaxis vs no-prophylaxis costs and effects were projected over a life-time horizon for a simulated cohort of 500 000 adult patients (≥18 years old) requiring cataract surgery in theoretical surgical centers in the United States. Efficacy and cost (2021 US dollars) values were obtained from the literature and discounted at 3% per year. RESULTS: Based on inputted parameters, the mean incidence of endophthalmitis following cataract surgery for preoperative topical antibiotic prophylaxis vs no-prophylaxis was 0.034% (95% CI 0%-0.2%) and 0.042% (95% CI 0%-0.3%), respectively-an absolute risk reduction of 0.008%. The mean life-time costs for cataract surgery with prophylaxis and no-prophylaxis were $2486.67 (95% CI $2193.61-$2802.44) and $2409.03 (95% CI $2129.94-$2706.69), respectively. The quality-adjusted life-years (QALYs) associated with prophylaxis and no-prophylaxis were 10.33495 (95% CI 7.81629-12.38158) and 10.33498 (95% CI 7.81284-12.38316), respectively. Assuming a cost-effectiveness criterion of ≤$50 000 per QALY gained, the threshold analyses indicated that prophylaxis would be cost-effective if the incidence of endophthalmitis after cataract surgery was greater than 5.5% or if the price of the preoperative topical antibiotic prophylaxis was less than $0.75. CONCLUSIONS: General use of preoperative topical antibiotic prophylaxis is not cost-effective compared with no-prophylaxis for the prevention of endophthalmitis following cataract surgery. Preoperative topical antibiotic prophylaxis, however, would be cost-effective at a higher incidence of endophthalmitis and/or a substantially lower price for prophylaxis.

Co-designing a web-based education platform for patients with early pregnancy loss.

Canadian emergency departments (EDs) frequently provide care to patients undergoing early pregnancy loss. Unfortunately, in this setting, patients commonly have negative experiences, in part due to lack of appropriate follow-up and education on symptoms that may arise after discharge. In response to this gap, our team created a free, web-based, patient-informed educational platform for women to access accurate information on early pregnancy loss. This free and publicly accessible resource was launched in May 2022 at Mount Sinai Hospital in Toronto and was shared with EDs across Canada.

RéSUMé: Les services d'urgence (SU) canadiens fournissent fréquemment des soins aux patientes qui subissent une perte de grossesse précoce. Malheureusement, dans ce contexte, les patientes ont souvent des expériences négatives, en partie à cause du manque de suivi approprié et d'éducation sur les symptômes qui peuvent apparaître après la sortie de l'hôpital. Pour combler cette lacune, notre équipe a créé une plate-forme éducative gratuite, basée sur le Web et informée par les patientes, permettant aux femmes d'accéder à des informations précises sur la perte de grossesse précoce. Cette ressource gratuite et accessible au public a été lancée en mai 2022 à l'hôpital Mount Sinai de Toronto et a été partagée avec les services d'urgence de tout le Canada.