Alternative Payment Models in Pregnancy to Improve Outcomes and Advance Equity.

This Viewpoint reviews the state of alternative payment models (APMs) applied to pregnancy and proposes clinical and policy objectives that could guide model design going forward.

Selective Fetoscopic Laser Photocoagulation or Expectant Management for Stage I Twin-Twin Transfusion: A Cost-Effectiveness Analysis.

BACKGROUND: Selective fetoscopic laser photocoagulation (SFLP) is the preferred intervention for stage II-IV twin-twin transfusion syndrome (TTTS); however, there is no consensus on whether SFLP or expectant management (EM) is the preferred strategy to manage Quintero stage I TTTS. OBJECTIVE: The objective of this study is to estimate whether SFLP or EM is the cost-effective strategy for management of Quintero stage I TTTS. STUDY DESIGN: A decision-analysis (DA) model compared SFLP to EM for 1,000 pregnant people with monochorionic-diamniotic twins affected by stage I TTTS. All subjects were assumed to be appropriate candidates for either SFLP or EM. Probabilities, costs, and utilities were derived from the literature. The DA was conducted from a healthcare payor perspective, and the analytic horizon was over the course of an offspring's lifetime, with primary outcomes of survivorship (i.e., no intrauterine fetal demise or neonatal death) and long-term neurodevelopmental impairment. The model incorporated Markov processes with 4-week cycles throughout pregnancy. Incremental cost-effectiveness ratios (ICER) for each strategy were calculated and compared to estimate marginal cost effectiveness. An ICER of USD 100,000 per quality-adjusted life year was used to define the cost-effectiveness threshold. One-way sensitivity and Monte Carlo analyses (MCA), as well as microsimulations, were performed. RESULTS: For base-case estimates, SFLP was found to be cost-effective compared to EM in the management of stage I TTTS. In one-way sensitivity analysis, varying each variable along pre-specified ranges did not result in changes in the conclusion. MCA projects SFLP as the cost-effective strategy in 100% of runs. CONCLUSIONS: With base-case estimates, SFLP is estimated to be the cost-effective strategy for the treatment of Quintero stage I TTTS when compared with EM. This remained true across a wide range of inputs.

Identifying risk factors for blindness from primary open-angle glaucoma by race: a case-control study.

PURPOSE: To examine the factors associated with blindness from primary open-angle glaucoma (POAG) among black and white patients at our institution. PATIENTS AND METHODS: For this retrospective, case-control study, patients legally blind from POAG ("cases") were matched on age, race, and gender with non-blind POAG patients ("controls"). Thirty-seven black case-control pairs and 19 white case-control pairs were included in this study. Clinical variables were compared at initial presentation and over the course of follow-up. RESULTS: Black case-control pairs and white case-control pairs had similar characteristics at presentation, including cup-to-disc ratio and number of glaucoma medications. However, over the course of follow-up, black cases underwent significantly more glaucoma surgeries than matched controls (2.4 versus 1.2, p=0.001), whereas white cases and controls had no significant difference in glaucoma operations (0.9 versus 0.6, p=0.139). Our analysis found that glaucoma surgery is associated with blindness in black patients (odds ratio [OR] 1.6, 95% CI 1.1-2.2) but not in white patients (OR 1.5, 95% CI 0.7-3.2). CONCLUSION: Black and white case-control pairs with POAG shared similar risk factors for blindness at presentation. However, over the follow-up period, black cases required significantly more glaucoma surgeries compared to black controls, whereas there was no significant difference in surgery between white cases and controls. There was no difference in medication changes in either case-control set.

Relationship Between Race, Insurance Coverage, and Visual Acuity at the Time of Cataract Surgery.

OBJECTIVE: To assess the relationship between sociodemographic variables (including race, age, and insurance coverage) and preoperative best-corrected visual acuity (BCVA) at the time of first-eye cataract surgery. METHODS: Single-center retrospective chart review study at Shiley Eye Institute, University of California, San Diego (UCSD). Medical record data from 600 patients were collected from the appointment immediately preceding cataract surgery, including BCVA in the operated eye converted to the logarithmic minimal angle of resolution (logMAR), insurance coverage, race, sex, age, body mass index, smoking status (including pack years), systemic and ocular comorbidities, and ocular surgical history. Preoperative BCVA in the operated eye was the main outcome measure. RESULTS: Univariate analysis revealed significant differences in BCVA between groups by insurance type (public, private, and uninsured), race (Asian, black, Hispanic, white, and other), and sex (male and female) (P<0.001, P<0.001, and P=0.019, respectively). Further multivariate analysis revealed significant pairwise differences, with better BCVA associated with white race (0.85, logMAR [Snellen 20/140]) than Hispanic race (1.06, [20/230], P=0.017), and better BCVA associated with private insurance (0.79, [20/125]) versus public insurance (0.96, [20/180], P=0.0002). CONCLUSION: Hispanic race and public insurance coverage were each associated with worse preoperative BCVA compared with white race and private insurance, respectively. This suggests that Hispanic race and public insurance may predispose patients to decreased access to cataract surgery. Additional large, prospective studies are required to rigorously test and elaborate on this finding.

Glaucoma Blindness at a Tertiary Eye Care Center.

BACKGROUND: Glaucoma is an important cause of irreversible blindness. This study describes the characteristics of a large, diverse group of glaucoma patients and evaluates associations between demographic and clinical characteristics and blindness. METHODS: Data were gathered via retrospective chart review of patients (N = 1,454) who were seen between July 2007 and July 2010 by glaucoma service providers at Duke Eye Center. Visual acuity and visual field criteria were used to determine whether patients met the criteria for legal blindness. Descriptive and comparative statistical analyses were performed on the glaucoma patients who were not blind (n = 1,258) and those who were blind (n = 196). A subgroup analysis of only those patients with primary open-angle glaucoma was also performed. RESULTS: In this tertiary care population, 13% (n = 196) of glaucoma patients met criteria for legal blindness, nearly one-half of whom (n = 94) were blind from glaucoma, and another one-third of whom (n = 69) had glaucoma-related blindness. The most common glaucoma diagnosis at all levels of vision was primary open-angle glaucoma. A larger proportion of black patients compared with white patients demonstrated vision loss; the odds ratio (OR) for blindness was 2.25 (95% CI, 1.6-3.2) for black patients compared with white patients. The use of systemic antihypertensive medications was higher among patients who were blind compared with patients who were not blind (OR = 2.1; 95% CI, 1.4-3.1). A subgroup analysis including only patients with primary open-angle glaucoma showed similar results for both black race and use of systemic antihypertensive medications. The relationship between use of systemic antihypertensive medications and blindness was not different between black patients and white patients (interaction P = .268). LIMITATIONS: Data were based on chart review, and associations may be confounded by unmeasured factors. CONCLUSIONS: Treated systemic hypertension may be correlated with blindness, and the cause cannot be explained solely by race. In addition, this study demonstrated that there is continued disparity between black patients and white patients with regards to blindness from glaucoma.