Communication in youth mental health clinical encounters: Introducing the agential stance.

When young people seek support from mental health care practitioners, the encounters may affect the young people's sense of self, and in particular undermine their sense of agency. For this study, an interdisciplinary team of academics and young people collaboratively analysed video-recorded encounters between young people and mental healthcare practitioners in emergency services. They identified five communication techniques that practitioners can use to avoid undermining the young person's sense of agency in the clinical encounter. They conceptualise the use of those techniques as the adoption of an agential stance towards the young person. The agential stance consists of: (a) validating the young person's experiences, (b) legitimising the young person's choice to seek help, (c) refraining from objectifying the young person, (d) affirming the young person's capacity to contribute to positive change, and (e) involving the young person in the decision-making process.

Medicare Incentive Payments to United States Ophthalmologists for Use of Electronic Health Records: 2011-2016.

PURPOSE: To investigate ophthalmologists' rate of attestation to meaningful use (MU) of their electronic health record (EHR) systems in the Medicare EHR Incentive Program and their continuity and success in receiving payments in comparison with other specialties. DESIGN: Administrative database study. PARTICIPANTS: Eligible professionals participating in the Medicare EHR Incentive Program. METHODS: Based on publicly available data sources, subsets of payment and attestation data were created for ophthalmologists and for other specialties. The number of eligible professionals attesting was determined using the attestation data for each year and stage of the program. The proportion of attestations by EHR vendor was calculated using all attestations for each vendor. MAIN OUTCOME MEASURES: Numbers of ophthalmologists attesting by year and stage of the Medicare EHR Incentive Program, incentive payments, and number of attestations by EHR vendor. RESULTS: In the peak year of participation, 51.6% of ophthalmologists successfully attested to MU, compared with 37.1% of optometrists, 50.2% of dermatologists, 54.5% of otolaryngologists, and 64.4% of urologists. Across the 6 years of the program, ophthalmologists received an average of $17 942 in incentive payments compared with $11 105 for optometrists, $16 617 for dermatologists, $20 203 for otolaryngologists, and $23 821 for urologists. Epic and Nextgen were the most frequently used EHRs for attestation by ophthalmologists. CONCLUSIONS: Ophthalmology as a specialty performed better than optometry and dermatology, but worse than otolaryngology and urology, in terms of the proportion of eligible professionals attesting to MU of EHRs. Ophthalmologists were more likely to remain in the program after their initial year of attestation compared with all eligible providers. The top 4 EHR vendors accounted for 50% of attestations by ophthalmologists.

Primary Open-Angle Glaucoma Preferred Practice Pattern(®) Guidelines.

UNLABELLED: PRIMARY OPEN-ANGLE GLAUCOMA PREFERRED PRACTICE PATTERN® GUIDELINES: Evidence-based update of the Primary Open-Angle Glaucoma Preferred Practice Pattern® (PPP) guidelines, describing the diagnosis and management of patients with primary open-angle glaucoma with an algorithm for patient management and detailed recommendations for evaluation and treatment options.

Primary Angle Closure Preferred Practice Pattern(®) Guidelines.

UNLABELLED: PRIMARY ANGLE CLOSURE PREFERRED PRACTICE PATTERN® GUIDELINES: Evidence-based update of the Primary Angle Closure Preferred Practice Pattern® (PPP) guidelines, describing the diagnosis and management of patients with primary angle closure with detailed recommendations for evaluation and treatment options.

Primary Open-Angle Glaucoma Suspect Preferred Practice Pattern(®) Guidelines.

UNLABELLED: PRIMARY OPEN-ANGLE GLAUCOMA SUSPECT PREFERRED PRACTICE PATTERN® GUIDELINES: Evidence-based update of the Primary Open-Angle Suspect Glaucoma Preferred Practice Pattern® (PPP) guidelines, describing the diagnosis and management of patients with primary open-angle glaucoma suspect with detailed recommendations for evaluation and treatment options.

Adoption of electronic health records and preparations for demonstrating meaningful use: an American Academy of Ophthalmology survey.

OBJECTIVE: To assess the current state of electronic health record (EHR) use by ophthalmologists, including adoption rate, user satisfaction, functionality, benefits, barriers, and knowledge of meaningful use criteria. DESIGN: Population-based, cross-sectional study. PARTICIPANTS: A total of 492 members of the American Academy of Ophthalmology (AAO). METHODS: A random sample of 1500 AAO members were selected on the basis of their practice location and solicited to participate in a study of EHR use, practice management, and image management system use. Participants completed the survey via the Internet, phone, or fax. The survey included questions about the adoption of EHRs, available functionality, benefits, barriers, satisfaction, and understanding of meaningful use criteria and health information technology concepts. MAIN OUTCOME MEASURES: Current adoption rate of EHRs, user satisfaction, benefits and barriers, and availability of EHR functionality. RESULTS: Overall, 32% of the practices surveyed had already implemented an EHR, 15% had implemented an EHR for some of their physicians or were in the process of implementation, and another 31% had plans to do so within 2 years. Among those with an EHR in their practice, 49% were satisfied or extremely satisfied with their system, 42% reported increased or stable overall productivity, 19% reported decreased or stable overall costs, and 55% would recommend an EHR to a fellow ophthalmologist. For those with an electronic image management system, only 15% had all devices integrated, 33% had images directly uploaded into their system, and 12% had electronic association of patient demographics with the image. CONCLUSIONS: The adoption of EHRs by ophthalmology practices more than doubled from 2007 to 2011. The satisfaction of ophthalmologists with their EHR and their perception of beneficial effects on productivity and costs were all lower in 2011 than in 2007. Knowledge about meaningful use is high, but the percentage of physicians actually receiving incentive payments is relatively low. Given the importance of imaging in ophthalmology, the shortcomings in current image management systems need to be addressed. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

A vascular syphilitic iris lesion.

Purpose: To describe examination and imaging characteristics of presumed iris papulosa in a case of ocular syphilis. Observations: A 60-year-old man who presented with granulomatous anterior uveitis in his left eye was also noted to have an unusual vascularized iris papule associated with posterior synechiae at the nasal pupillary margin. Anterior segment OCT (AS-OCT) of the iris lesion demonstrated a hyperreflective anterior surface with multiple vascular lumen, internal hyperreflectivity, and shadowing. Ultrasound biomicroscopy (UBM) imaging revealed an echodense mass with relative hyperechogenicity in the anterior portion of the lesion. Systemic work-up confirmed a diagnosis of syphilis, and he was treated with topical steroids and parenteral penicillin. Conclusion and Importance: We characterize the rare finding of iris papulosa that may be encountered in syphilitic uveitis and its distinctive features on both UBM and AS-OCT. This report highlights that syphilis should be considered as a possible diagnosis for an undifferentiated vascular iris mass.

The Wholesome Foods Approach to Trabeculectomy Wet Lab Training.

Purpose In an era when trabeculectomy surgeries in the United States are on the decline, ophthalmology residents may have limited opportunities to practice surgical techniques critical to success. However, key steps of trabeculectomy surgery can be introduced in a wet laboratory using a simple surgical model based on food items. Methods A fresh lime and chicken parts with skin, purchased from a grocery store, were utilized to practice trabeculectomy surgery. The white rind of a lime was used as a surrogate for human sclera and was incised to create a trabeculectomy flap. The flap was then successfully sewn down with 10-0 nylon suture using an operating microscope. The skin of the chicken part was used to re-create a fornix-based and limbus-based conjunctival incision, which was then sutured closed using 6-0 Vicryl suture. A survey of wet laboratory participants was conducted to assess the feasibility and efficacy of this technique. Results Survey respondents were divided into two groups, those who had performed ≥40 incisional glaucoma surgeries and those who had performed <40. Both groups rated the simulation a 4 (mode) out of 5 in terms of how well it prepared them for glaucoma surgery on a human eye and how well the materials replicated human tissue, with 1 being not at all and 5 being very well. Similarly, both groups rated ease of setup and material acquisition a 1 out of 5, 1 being not difficult at all and 5 being extremely difficult. Also, 93.5% of the survey respondents recommended implementing this training model at other teaching hospitals, and none of the respondents recommended against it. Conclusion This trabeculectomy teaching model is inexpensive, clean, and safe, and it provides a reasonably realistic substrate for surgical practice. It does not require cadaver or animal eyes, and no fixatives are needed, thus minimizing the risk of contact with biohazardous materials. Wet laboratory materials are easy to obtain, making this a practical model for practicing glaucoma surgery in both westernized and developing countries.

Special requirements for electronic health record systems in ophthalmology.

UNLABELLED: The field of ophthalmology has a number of unique features compared with other medical and surgical specialties regarding clinical workflow and data management. This has important implications for the design of electronic health record (EHR) systems that can be used intuitively and efficiently by ophthalmologists and that can promote improved quality of care. Ophthalmologists often lament the absence of these specialty-specific features in EHRs, particularly in systems that were developed originally for primary care physicians or other medical specialists. The purpose of this article is to summarize the special requirements of EHRs that are important for ophthalmology. The hope is that this will help ophthalmologists to identify important features when searching for EHR systems, to stimulate vendors to recognize and incorporate these functions into systems, and to assist federal agencies to develop future guidelines regarding meaningful use of EHRs. More broadly, the American Academy of Ophthalmology believes that these functions are elements of good system design that will improve access to relevant information at the point of care between the ophthalmologist and the patient, will enhance timely communications between primary care providers and ophthalmologists, will mitigate risk, and ultimately will improve the ability of physicians to deliver the highest-quality medical care. FINANCIAL DISCLOSURE(S): Proprietary or commercial interest disclosure may be found after the references.

Anxiety, stress, and binge eating tendencies in adolescence: a prospective approach.

BACKGROUND: Recent years have witnessed an increasing prevalence of binge eating tendencies in adolescence-warranting a clearer understanding of their underlying predisposing and precipitating factors. The current study investigated whether the interaction between high levels of anxiety and stress predicted increased levels of binge eating tendencies in a prospective cohort of adolescents (N = 324). METHODS: Measurements were taken over three waves (M ages: 13.33, 14.48, 15.65) as part of the CogBIAS Longitudinal Study. Longitudinal associations between levels of anxiety and stress with binge eating tendencies were estimated using a random intercept cross-lagged panel model (RI-CLPM), which calculates within-person fluctuations over time while accounting for individual trait-like stability and between-person variations. Binge eating tendencies were measured by the Cognitive Restraint, Uncontrolled Eating, and Emotional Eating styles from the Three-Factor Eating Questionnaire-R18. Two models were created for each binge eating tendencies variable: (1) a basic model with anxiety and stress as independent variables; (2) an interaction model with an additional anxiety*stress interaction term. Model fit was assessed by SEM fit indices: X2, CFI, NFI, TLI, RMSEA, SRMR. Superior model fit was ascertained by a chi-square difference test (p < .05). RESULTS: For Cognitive Restraint, the interaction model demonstrated superior fit to the data (p < .05). The anxiety*stress interaction at Waves 1 and 2 was significantly negatively associated with Cognitive Restraint at Waves 2 (ß = -0.18, p = .002) and 3 (ß = -0.14, p = .002)-suggesting that anxiety and stress interacted to predict increased binge eating tendencies linked with cognitive restraint over and above their independent effects. In contrast, the interaction term between anxiety*stress did not predict levels of Uncontrolled Eating or Emotional Eating over time. CONCLUSIONS: The results highlight the importance of increasing awareness of the interaction between concurrently high anxiety and stress as a potential risk factor for binge eating tendencies in young people. TRIAL REGISTRATION: Not applicable.

Binge eating tendencies have become an increasingly common phenomenon in adolescent populations. These behaviours involve consuming large amounts of food in a short period of time, during which one feels out of control and unable to stop. Episodes are often followed by marked emotional distress that can serve to perpetuate and maintain these tendencies. The current study examined a group of adolescents aged 13 to 16 over three testing periods spaced 12 to 18 months apart, to investigate whether high levels of anxiety and stress interacted to increase likelihood of binge eating tendencies in individuals over time. Results revealed that participants who experienced higher anxiety and stress than usual were more likely to score highly on binge eating tendencies measures, compared to when they experienced lower levels of anxiety and stress. Correspondingly, we recommend raising greater awareness in parents, educators, and health professionals of the link between high anxiety and stress and increased risk of binge eating tendencies, in order to facilitate better prevention, detection, and early intervention.

Identification and disruption of a neural mechanism for accumulating prospective metacognitive information prior to decision-making.

More than one type of probability must be considered when making decisions. It is as necessary to know one's chance of performing choices correctly as it is to know the chances that desired outcomes will follow choices. We refer to these two choice contingencies as internal and external probability. Neural activity across many frontal and parietal areas reflected internal and external probabilities in a similar manner during decision-making. However, neural recording and manipulation approaches suggest that one area, the anterior lateral prefrontal cortex (alPFC), is highly specialized for making prospective, metacognitive judgments on the basis of internal probability; it is essential for knowing which decisions to tackle, given its assessment of how well they will be performed. Its activity predicted prospective metacognitive judgments, and individual variation in activity predicted individual variation in metacognitive judgments. Its disruption altered metacognitive judgments, leading participants to tackle perceptual decisions they were likely to fail.

A Comparison of Trabeculectomy Surgery Outcomes With Mitomycin-C Applied by Intra-Tenon Injection Versus Sponge.

PURPOSE: To compare the outcomes of mitomycin-C (MMC) delivered by intra-Tenon injection vs sponge application during trabeculectomy surgery. METHODS: We retrospectively reviewed 566 patients with primary and secondary glaucoma diagnoses who received trabeculectomy surgery with MMC in an academic medical center. Exclusion criteria were age less than 18 years, no light perception vision, combined surgery, previous glaucoma incisional surgery, intraoperative 5-fluorouracil, or follow-up <1 month. Subjects were divided into 2 cohorts: MMC delivered by sponge application or by intra-Tenon injection. Main outcome measures were postoperative intraocular pressure (IOP) level and secondary measures were survival rate for IOP control, glaucoma medication use, complication rate, and vision. RESULTS: After inclusion/exclusion criteria, 316 eyes were available for analysis; 131 eyes had MMC delivered via sponge and 185 eyes via injection. Mean postoperative IOP was not significantly different between treatment groups but change in IOP from baseline was lower in the sponge vs the injection group 24 months after surgery (P = .038). The MMC sponge group had significantly more tense, vascularized, or encapsulated blebs as a late complication (P = .046). Time to failure for postoperative IOP control was not significantly different between MMC treatment groups, but older patient age and limbus-based conjunctival incision were associated with significantly longer time to fail. CONCLUSIONS: The application of MMC by injection was similar to application by sponge in lowering IOP in patients with glaucoma and the safety of both techniques appears to be comparable. Limbus-based conjunctival incision had longer time to failure for postoperative IOP control vs fornix-based incision. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Cost Analysis of Teleophthalmology Screening for Diabetic Retinopathy Using Teleophthalmology Billing Codes.

BACKGROUND AND OBJECTIVE: To evaluate the financial sustainability of teleophthalmology screening for diabetic retinopathy (DR) using telehealth billing codes. PATIENTS AND METHODS: The authors performed an Institutional Review Board-approved retrospective review of medical records, billing data, and quality metrics at the University of California Davis Health System from patients screened for DR through an internal medicine-based telemedicine program using CPT codes 92227 or 92228. RESULTS: A total of 290 patients received teleophthalmology screening over a 12-month period, resulting in an increase in the DR screening rate from 49% to 63% (P < .0001). The average payment per patient was $19.86, with an estimated cost of $41.02 per patient. The projected per-patient incentive bonus was $43.06 with a downstream referral revenue of $39.38 per patient. One hundred seventy-eight clinic visits were eliminated, providing an estimated cost savings of $42.53 per patient. CONCLUSION: Sustainable teleophthalmology screening may be achieved by billing telehealth codes but only with health care incentive bonuses, patient referrals, and by accounting for the projected cost-savings of eliminating office visits. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:S26-S34.].

Retinal Detachment: Patient Perspective and Electronic Health Records.

PURPOSE: To provide a first-hand account of a retinal detachment suffered by one of the authors and how it relates to electronic health record (EHR) interoperability. DESIGN: Single-patient, observational. METHODS: 1) Personal patient perspective - symptom, surgery, recovery and the worry about potential long lasting sequelae, and the need to reiterate detailed medical information several times during a stressful period. 2) U.S. National perspective regarding EHRs. SETTING: Out-patient and community hospital. Patient or Study Population: Single patient. Intervention or Observation Procedure(s): Retinal surgery. MAIN OUTCOME MEASURE(S): Visual acuity. RESULTS: Patient had a favorable outcome, but was required to provide medical history data multiple times to multiple providers. Only 41% of hospitals in the United States have EHR from outside providers or sources when treating a patient. Physicians in outpatient settings fare worse with only 14% of office-based physicians sharing data with providers outside of their organization. CONCLUSIONS: While adoption and use of EHRs are incentivized by the federal government in the United States, the lack of interoperability between different physician and hospital systems means that we are far from achieving meaningful digitization of records. This case report provides a close look at how it may be difficult to receive care in a fragmented health care model in which physician and hospital do not share the same EHR. Information blocking, now prohibited by federal law, still remains an obstacle to interoperability. It will take continued effort and commitment from key stakeholders such as health care providers, patients, the federal government, and industry to bring this dream to fruition.

Epithelial downgrowth after femtosecond laser-assisted cataract surgery.

PURPOSE: To present the case of a 72-year-old female with epithelial downgrowth after femtosecond laser-assisted cataract surgery. OBSERVATIONS: The patient previously underwent YAG vitreolysis after uncomplicated femtosecond laser-assisted cataract surgery and presented 1 year later with epithelial downgrowth causing complete pupillary block and severe angle closure glaucoma. Subsequent management with nd:YAG peripheral iridotomies failed rapidly leading to a confusing presentation with a flat anterior chamber and high intraocular pressure ultimately requiring surgical management. CONCLUSIONS: We describe the occurrence of epithelial downgrowth after femtosecond laser-assisted cataract surgery and illustrate the utility of ultrasound biomicroscopy to differentiate between severe pupillary block and malignant glaucoma.

The impact of conversion to International Classification of Diseases, 10th revision (ICD-10) on an academic ophthalmology practice.

PURPOSE: To determine the financial and clinical impact of conversion from International Classification of Disease, 9th revision (ICD-9) to ICD-10 coding. DESIGN: Retrospective, database study. MATERIALS AND METHODS: Monthly billing and coding data from 44,564 billable patient encounters at an academic ophthalmology practice were analyzed by subspecialty in the 1-year periods before (October 1, 2014, to September 30, 2015) and after (October 1, 2015, to September 30, 2016) conversion from ICD-9 to ICD-10. MAIN OUTCOMES AND MEASURES: Primary outcome measures were payments per visit, relative value units per visit, number of visits, and percentage of high-level visits; secondary measures were denials due to coding errors, charges denied due to coding errors, and percentage of unspecified codes used as a primary diagnosis code. RESULTS: Conversion to ICD-10 did not significantly impact payments per visit ($306.56±$56.50 vs $321.43±$38.12, P=0.42), relative value units per visit (7.15±0.56 vs 7.13±0.84, P=0.95), mean volume of visits (1,887.08±375.02 vs 1,863.83±189.81, P=0.71), or percentage of high-level visits (29.7%±4.9%, 548 of 1,881 vs 30.0%±1.7%, 558 of 1,864, P=0.81). For every 100 visits, the number of coding-related denials increased from 0.98±0.60 to 1.84±0.31 (P<0.001), and denied charges increased from $307.42±$443.39 to $660.86±$239.47 (P=0.002). The monthly percentage of unspecified codes used increased from 25.8%±1.1% (485 of 1,881) to 35.0%±2.3% (653 of 1,864, P<0.001). CONCLUSION: The conversion to ICD-10 did not impact overall revenue or clinical volume in this practice setting, but coding-related denials, denied charges, and the use of unspecified codes increased significantly. We expect these denials to increase in the next year in the absence of Medicare's 1-year grace period.

Adoption of Electronic Health Records and Perceptions of Financial and Clinical Outcomes Among Ophthalmologists in the United States.

Importance: Assessing the rate of electronic health record (EHR) adoption and ophthalmologists' perceptions on financial and clinical productivity is important in understanding how to direct future design and health care policy. Objective: To assess adoption rate and perceptions of financial and clinical outcomes of EHRs among ophthalmologists in the United States. Design, Setting, and Participants: Population-based, cross-sectional study. A random sample of 2000 ophthalmologists was generated on the basis of mailing address zip codes from the 2015 American Academy of Ophthalmology US active membership database, which included more than 18 000 ophthalmologists. A survey was sent by email to assess adoption rate of EHRs, perceptions of financial and clinical productivity, and engagement with Medicare and Medicaid programs that incentivize the use of EHRs. The survey was conducted between 2015 and 2016. Main Outcomes and Measures: Adoption rate of EHRs and perceptions of financial and clinical productivity. Results: The adoption rate of EHRs among surveyed ophthalmologists (348 respondents) was 72.1%. The responding ophthalmologists perceived that their net revenues and productivity have declined and that practice costs are higher with EHR use. Of those who attested for stage 1 of the EHR incentive program, 83% had already or were planning to attest to stage 2, but 9% had no plans. Conclusions and Relevance: The adoption of EHRs by ophthalmologists has more than doubled since a 2011 survey and is similar to that of primary care physicians (79%). In comparison with 2 previous surveys of ophthalmologists, respondents had more negative perceptions of EHR productivity outcomes and effect on practice costs, although financial data were not collected in this survey to support these opinions. These negative perceptions suggest that more attention should be placed on improving the efficiency and usability of EHR systems.