Download ARVO 2014 Annual Meeting Abstracts 507 Health care delivery

ARVO 2014 Annual Meeting Abstracts
507 Health care delivery around the world
Thursday, May 08, 2014 8:30 AM–10:15 AM
Exhibit/Poster Hall SA Poster Session
Program #/Board # Range: 5547–5596/A0156–A0205
Organizing Section: Clinical/Epidemiologic Research
Contributing Section(s): Retina
Program Number: 5547 Poster Board Number: A0156
Presentation Time: 8:30 AM–10:15 AM
Reporting of Harms by Randomized Controlled Trials in
Ophthalmology
Roderick O’Day1, 3, Richard Walton3, Richard Blennerhassett2,
Mark C. Gillies3, Daniel Barthelmes3, 4. 1Royal Victorian Eye and
Ear Hospital, East Melbourne, VIC, Australia; 2Westmead Hospital,
Sydney, NSW, Australia; 3Save Sight Institute, University of Sydney,
Sydney, NSW, Australia; 4Ophthalmology, University Hospital
Zurich, Zurich, Switzerland.
Purpose: To evaluate the reporting of harms by randomized
controlled trials investigating intravitreal therapies for diabetic
macular edema.
Methods: A thorough literature search identified eligible reports.
Two authors independently extracted data from these using a
prospectively created checklist. The main outcome measure was
compliance with the 10 recommendations of the 2004 Consolidated
Standards of Reporting Trials statement extension for better harms
reporting. Secondary outcomes were the predictors of the number
of recommendations met and the amount of space devoted to harms
reporting.
Results: Thirty-six articles involving 7246 eyes met the criteria
for analysis. The fidelity of the data extraction was excellent, with
Cohen’s kappa coefficient of 0.90 for all items extracted. The median
number of recommendations met was 6, interquartile range 5 to 7.
Recommendation four (describe how harms-related information was
collected) was met by 97% of articles and recommendation eight
(present the absolute risk of each adverse event) by 92%. The least
frequently met recommendations were numbers three (list addressed
adverse events with definitions of each), 31% of articles, and six
(describe participant withdrawals because of harms), 36% of articles.
The following article characteristics were associated with meeting
more recommendations by univariate analyses: articles reporting
trials that were placebo-controlled, involved a dose comparison, had
more than the median sample size, were multi-centered and were
commercially funded; and articles that were published in journals
with an impact factor more than 3. However, none of these article
characteristics were found to be associated with the number of
recommendations met using a binomial regression analysis. The
mean percentage of the results section devoted to harms-related data
was 25.8%, standard deviation 10.8%.
Conclusions: Harms reporting in published reports of trials of
intravitreal therapies for diabetic macular edema is still not entirely
adequate despite increased attention and efforts to standardise it.
Commercial Relationships: Roderick O’Day, None; Richard
Walton, None; Richard Blennerhassett, None; Mark C. Gillies,
Allergan (C), Bayer (C), Novartis (C); Daniel Barthelmes, None
Program Number: 5548 Poster Board Number: A0157
Presentation Time: 8:30 AM–10:15 AM
Importance of Different Barriers to Glaucoma Medication
Adherence
Paula Anne Newman-Casey1, Taylor Blachley1, Karen B. Farris2,
Alan L. Robin3, 4, Paul P. Lee1. 1Ophthalmology & Vis Sci, Kellogg
Eye Center, University of Michigan, Ann Arbor, MI; 2College of
Pharmacy, University of Michigan, Ann Arbor, MI; 3Ophthalmology,
Johns Hopkins, Baltimore, MD; 4International Health, Johns
Hopkins, Baltimore, MD.
Purpose: Adherence to glaucoma medications is often poor and
has many potential barriers. We identified 11 barriers to adherence
that have been repeatedly cited in the literature. We hypothesized
that each glaucoma patient would have a unique set of barriers
to overcome to achieve optimal adherence. We administered a
questionnaire to determine which barriers were most common.
Methods: We surveyed a convenience sample of 185 glaucoma
patients. Subjects rated 11 barriers’ importance on a 20-point
response scale anchored with “very important” to “not important.”
We measured patient reported adherence using a validated
instrument, the Morisky Adherence Scale. We assessed sociodemographic characteristics. We conducted descriptive analyses
and principal component analysis to identify the structure of the
relationships among the adherence variables. Logistic regression
was used to predict the association of the principal components with
medication adherence.
Results: Each of the eleven barriers was cited as significant by 30%52% of subjects, who had glaucoma for a mean of 11.5±10.8 years.
26.5% of subjects were non-adherent by self-report. The principal
component analysis revealed two factors. The first factor included
all of the barriers and had a 48% increased odds of non-adherence,
OR=1.48 [95% CI 1.03-2.12, p=0.04], meaning that the more barriers
a person reported, the more likely they were to be non-adherent.
The second factor revealed that those who had good adherence
reported that a poor doctor-patient relationship along with beliefs
and knowledge about their disease and medications were important
barriers to medication adherence, OR=0.50 [95% CI 0.32-0.80, p =
0.004]. Those who were non-adherent reported that difficulties with
their medication schedule, forgetfulness, a lack of confidence, too
much other stress, medication side effects, cost and lack of ability to
instill the drops were important barriers to taking their medications.
Conclusions: No single barrier to adherence emerged as most
important to all glaucoma patients, though barriers did differ for
those patients who were and were not adherent. Since poor adherence
is associated with disease progression, it is imperative to develop
individualized interventions to help glaucoma patients improve their
self-management.
Commercial Relationships: Paula Anne Newman-Casey, None;
Taylor Blachley, None; Karen B. Farris, None; Alan L. Robin,
Aerie (C), Biolight (C), Glaukos (C), Ioptima (C), Merck (C); Paul P.
Lee, GlaxoSmithKline (I), Merck (I), Pfizer (I)
Support: National Eye Institute Michigan Vision ClinicianScientist Development Program (K12EY022299); Heed Foundation
Fellowship
©2014, Copyright by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. Go to iovs.org to access the version of record. For permission
to reproduce any abstract, contact the ARVO Office at [email protected].
ARVO 2014 Annual Meeting Abstracts
Program Number: 5549 Poster Board Number: A0158
Presentation Time: 8:30 AM–10:15 AM
Evaluation of two metrics for identifying poor glaucoma
medication adherence compared to objective adherence
measurements
Jaya Badhwar1, 4, Hayden Bosworth2, 4, Betsy Sleath3, Susanne
Danus4, Logan Christensen1, Kelly W. Muir1, 4. 1Department of
Ophthalmology, Duke University, Durham, NC; 2Department of
Medicine, Duke University, Durham, NC; 3School of Pharmacy,
University of North Carolina, Chapel Hill, NC; 4Health Services
Research and Development, Durham VA Medical Center, Durham,
NC.
Purpose: Poor adherence to the prescribed glaucoma medication
regimen may lead to preventable blindness. Previous work suggests
that providers may not accurately identify nonadherent patients.
The purpose of this project was to compare 2 screening methods for
identifying nonadherence on the criteria of feasibility and correlation
with objective adherence measurements from an electronic monitor.
Methods: Patients from 2 eye clinics (a university practice and a
VA hospital) with medically-treated glaucoma were given a survey
of medication adherence including the question “how many times
did you miss your drops in the last week” and a visual analog scale
(VAS) on which patients mark on a line how much of the time
they take their drops as prescribed. Participants received electronic
monitors to record when the medication was accessed until the next
clinic visit. The 2 measures were evaluated for feasibility (how many
participants responded), sensitivity and specificity for detecting
nonadherence.
Results: Adherence was defined as the proportion of prescribed doses
taken according to the monitor. Of 142 participants, 132 returned the
monitors, average duration of use 179 days (SD 69, median=179).
Mean percent of the prescribed doses taken was 83.3 (SD 23, median
94). For the question, “how many times did you miss your drops
last week?”, 23 failed to answer; 100 responded that they had not
missed any drops in the last week. 2 failed to complete VAS, 124
responding with <100% adherence. In regards to detecting adherence
of <80%, a VAS score <1 was 90% sensitive and 13% specific. A
response of >1 on the item “how many times did you miss your drops
in the past week” was 26% sensitive and 88% specific for detecting
nonadherence.
Conclusions: More participants responded to the VAS than to the
question regarding missed drops. Possible explanations include that
the VAS is easier to interpret or is associated with less perceived
stigma than admitting to a specific number of missed doses. The VAS
was more sensitive at detecting poor adherence than the question
regarding missed drops, but less specific. The low specificity of the
VAS suggests that although the tool may be a useful screener for
nonadherence, clinicians must delve more deeply if the screen is
positive to determine the nature of the patient’s difficulty with the
prescribed regimen.
Commercial Relationships: Jaya Badhwar, None; Hayden
Bosworth, None; Betsy Sleath, None; Susanne Danus, None;
Logan Christensen, None; Kelly W. Muir, None
Support: VA Health Services Research & Development Career
Development Award 10-019-2, American Glaucoma Society
Clinician Scientist Award
Program Number: 5550 Poster Board Number: A0159
Presentation Time: 8:30 AM–10:15 AM
Association between Anxiety and Depression with the Frequency
of Eye Drops in Inflammatory Eye Disease Patients
Georgios Vakros1, James Hodson2, Philip I. Murray1, Saaeha
Rauz1. 1Academic Unit of Ophthalmology, Centre for Translational
Inflammation Research, University of Birmingham, Birmingham,
United Kingdom; 2Wolfson Computer Laboratory, Queen Elizabeth
Hospital, Birmingham, United Kingdom.
Purpose: Patients with chronic inflammatory eye disease (IED) often
require lifelong treatment including the use of frequently applied
topical therapy. Therapeutic regimens are arduous and maintaining
adherence can impact upon daily activities and general wellbeing.
We wished to assess anxiety, depression and quality of life in patients
with IED and if there is an association with the administration of
topical medication.
Methods: 200 consecutive patients with IED - Ocular Surface
Disease (OSD, 100) and Uveitis (100) - completed a selfadministered questionnaire that comprised a patient reported measure
of ocular symptoms (Ocular Surface Disease Index (OSDI)) and
validated wellbeing questionnaires (Hospital Anxiety and Depression
(HAD), World Health Organisation Quality of Life-BREF (WHO
QOL-BREF)), together with supplemental questions on the frequency
of eye drops and the use of systemic glucocorticoids. Descriptive
and non-parametric tests were used to analyse the impact of topical
medication on depression, anxiety and quality of life scores within
the group as a whole and when stratified into the two clinical groups.
Results: Patients (126(63%) female, 74(37%) male) with a mean
(±SD) age 54±5 years (OSD, 56±1; uveitis, 51±1; p=0.032) from
a variety of ethnic backgrounds (White 132(66%), Black 8(18%),
South Asian 45(23%) and Other 5(3%)) reported moderate/severe
ocular symptoms as measured by the OSDI. Forty patients (20%)
were found to be clinically depressed and 33(16.5%) had clinical
anxiety. There was no difference between the two groups. The
frequency of the eye drops had a direct impact on both anxiety
and depression with a more pronounced effect in the OSD patients
(p<0.001). The use of systemic glucocorticoids was also a significant
factor linked to anxiety and depression (p=0.005). In patients who
demonstrated anxiety or depression, quality of life was reduced in all
four domains measured (physical, psychological, social relationships,
environmental (p<0.001)).
Conclusions: The use of frequent topical medications impacts
upon and positively correlates with the psychological status of IED
patients with 1:5 developing anxiety and depression. These patients
also demonstrate a poorer quality of life. This highlights the need for
counselling in the IED clinic either through a clinical psychologist or
eye clinic liaison officer.
Commercial Relationships: Georgios Vakros, None; James
Hodson, None; Philip I. Murray, None; Saaeha Rauz, None
Program Number: 5551 Poster Board Number: A0160
Presentation Time: 8:30 AM–10:15 AM
Real-World Analysis of the Time Associated with Adding a
Second Glaucoma Therapy in Newly Diagnosed OAG/OHT
Patients
William Wong1, Ashley L. Cole2, Jenny Chia2. 1GHOSR, Allergan,
Irvine, CA; 2CHDA, Allergan, Irvine, CA.
Purpose: Determine the time associated with moving from
monotherapy (1 glaucoma drug class) to adding a 2nd glaucoma drug
class in newly diagnosed patients.
Methods: Patients with at least 2 diagnoses at least 1 week apart
of ocular hypertension or open-angle glaucoma between 20092011, initiated on monotherapy, with at least 12 months continuous
©2014, Copyright by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. Go to iovs.org to access the version of record. For permission
to reproduce any abstract, contact the ARVO Office at [email protected].
ARVO 2014 Annual Meeting Abstracts
enrollment before and after initial diagnosis were identified from
a longitudinal database (MarketScan®) of medical and pharmacy
claims for >43 million patients. Newly diagnosed patients were
identified as those having no glaucoma drug, procedure or diagnosis
1 year prior to the index diagnosis. Kaplan-Meier survival analyses
were used to assess the time to failure, defined as prescription drug
fills for 2 different glaucoma drug classes ≤15 days apart. Drug
classes were defined as follows: Prostaglandin analog or prostamide
(PGA), beta blocker (BB), carbonic anhydrase inhibitor (CAI) and
alpha agonist (AA). Patients were followed until addition of a 2nd
drug class or the end of enrollment (max of 4 years).
Results: Among newly diagnosed patients, 53% did not fill a
prescription for a glaucoma drug within 1 year of initial diagnosis,
leaving in total, 34,165 patients included in the base case analysis.
By 4 years, 27.5% of at risk patients added a 2nd drug class. This
proportion differed by initial therapy (PGA: 26.5%, BB: 29.5%,
AA: 32.1%, CAI: 48.0%, p<0.0001 for log-rank test). Among those
patients adding a 2nd drug class, 50% added a 2nd class by 8.7
months (mean of 11.7 months). The mean and median time to adding
a 2nd drug class also differed by the initial therapy (Drug class:
mean/median (months), PGA: 11.8/9.5, BB: 11.1/8.7, AA: 8.6/6.5,
CAI: 6.8/3.2). PGAs and fixed combination products were most
commonly used in multiple medication regimens.
Conclusions: Clinical studies have shown a benefit for early
treatment however in this analysis >50% of patients were not
receiving medications within a year of diagnosis, suggesting
many may be at increased risk of disease progression. This study
also suggests that in the real-world, patients may be receiving
fewer medications than required to control intraocular pressure as
demonstrated in clinical trials. Of those patients who add a 2nd
drug class, a majority require the additional therapy within 1 year
emphasizing the importance of choosing the most effective initial
treatment regimen.
Commercial Relationships: William Wong, Allergan (E); Ashley
L. Cole, Allergan (E); Jenny Chia, Allergan (E)
Program Number: 5552 Poster Board Number: A0161
Presentation Time: 8:30 AM–10:15 AM
Use of eye care services among US adults
Asel Ryskulova, Rebecca Hines. NCHS, CDC, Hyattsville, MD.
Purpose: To provide national self-reported data on use of eye care
services and evaluate demographic and socio-economic disparities by
analyzing the data from National Health Interview Survey (NHIS).
Methods: Regular use of eye care services can help to diagnose
eye diseases on their early treatable stages and prevent vision loss.
The data from the 2012 NHIS, and 2002 and 2008 Vision Health
supplement of NHIS, a nationally representative sample of the
U.S. population were used. We included bivariate and multivariate
analyses to determine dilated eye examination use, visit to eye care
professional, and inability to buy eyeglasses in the past 12 months by
selected socio-demographic covariates, health insurance, and diabetes
status.
Results: In 2008 55.0% of U.S. adults had dilated eye examination
in the past 2 years. In 2012 37.1% of persons visited eye doctor or
eye health professional in the past 12 months, and 7.7% of adults
needed but could not afford to buy eyeglasses in the past 12 months.
Women were more likely than men to receive eye exam, visit eye
doctor, and could not afford to buy eye glasses. Hispanics, persons
with less than high school education, and adults without health
insurance were less likely to use eye care services. American Indians
and Alaska Natives and black persons reported inability to buy
eyeglasses more frequently compared with other race/ethnic groups.
Age was a significant predictor of eye care services utilization: the
rate of eye examination and visits to eye care providers for adults 65
year and older was almost twice of the rate for persons 18-24 years.
Persons with diabetes were two times more likely to have dilated
eye examination and report inability to buy eyeglasses than persons
without diabetes history.
Conclusions: The number of visits to eye doctors and inability to buy
eyeglasses increased since 2002; however, there were no significant
changes in use of dilated eye exam between 2002 and 2008. The
national data demonstrate that use of eye care services varies by
socio-demographic factors and diabetes status. Collaborative efforts
of eye care providers and public health professionals are needed to
increase use of regular eye services.
Commercial Relationships: Asel Ryskulova, None; Rebecca
Hines, None
Program Number: 5553 Poster Board Number: A0162
Presentation Time: 8:30 AM–10:15 AM
Ophthalmic Use of City Hospital Emergency Services
Ilyse D. Haberman, Elisabeth J. Cohen, Anam Qureshi, Lisa Park.
Ophthalmology, New York University, New York, NY.
Purpose: To investigate demographics and characteristics of
ophthalmology consults in a city hospital emergency department
(ED) after the economic recession of 2008.
Methods: A retrospective chart review was performed to assess
the nature of ophthalmic use of a large city ED after the economic
recession of 2008. Consults to a busy ophthalmology residency
program were reviewed for 2007-2013. The first 10 consults from
each month May-August were reviewed as a representative sample
of consults received. These months were chosen as they bring in
different numbers and types of consults as the new residency year
begins (Fig. 1). Results from before and after the recession were
statistically analyzed using a z-test for comparison of proportions.
Results: From 2007-2013, a total of 4245 ED consults were done by
the ophthalmology department (Fig. 2). After 2008, the population
visiting the ED was predominantly Hispanic (30.8%), Black (25.8%),
and white (24.1%). 47.0% had no insurance, 21.7% had Medicaid
only, and 9.6% were in police custody. 62.1% of consults walked
in, while 24.6% arrived to the ED by ambulance. About one third
(33.75%) of the consults were status post blunt trauma; orbital wall
fracture was the most common diagnosis (17.9% of consults). 17.1%
were called for routine or chronic matters (i.e. dry eye, blepharitis,
conjunctivitis, cataract). Only 10% of consults seen were patients
previously known to the outpatient clinic. Of the consults, 84.2%
were advised to follow up in our outpatient clinic; 67.3% of these
patients were lost to follow up before 3 months or completion of
treatment. There was no significant difference in these percentages
when compared to data from 2007.
Conclusions: A third of urgently called consults are post-trauma,
but a large proportion of consults are called on routine ophthalmic
problems. Consults appear unchanged since the recession.
Knowledge of the epidemiology and follow-up patterns of consults
seen in a city hospital ED can aide in triage, treatment, and patient
counseling to encourage follow-up.
©2014, Copyright by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. Go to iovs.org to access the version of record. For permission
to reproduce any abstract, contact the ARVO Office at [email protected].
ARVO 2014 Annual Meeting Abstracts
Figure 1: May/June and July/August were chosen as representative
months as we tend to see different numbers and types of consults in
those months as the seasons and experience of ED residents evolve
Figure 2: Total ED consults called to ophthalmology per year. * Of
note, the ED was closed secondary to Hurricane Sandy from Nov and
Dec 2012. **Numbers up until Sept 2013 (further data will be added
until the end of 2013).
Commercial Relationships: Ilyse D. Haberman, None; Elisabeth
J. Cohen, None; Anam Qureshi, None; Lisa Park, None
Program Number: 5554 Poster Board Number: A0163
Presentation Time: 8:30 AM–10:15 AM
Characteristics of Inpatient Ophthalmology Consults
Associated with Ocular Pathology and Need for Ophthalmologic
Intervention
Jason Mayer1, Zachary Landis1, Ming Wang2, Ingrid U. Scott1.
1
Ophthalmology, Penn State Hershey Eye Center, Hershey, PA;
2
Department of Public Health Sciences, Penn State College of
Medicine, Hershey, PA.
Purpose: To identify, among inpatient ophthalmology consults,
clinical examination findings predictive of ocular pathology and need
for ophthalmologic intervention
Methods: The medical records of patients evaluated by the
ophthalmology consultation service at Penn State Hershey Medical
Center between 9/1/2012 and 8/31/2013 were reviewed. Consults
for retinopathy of prematurity and non-accidental trauma were
excluded. Data collected include demographic characteristics,
reason for consult, ophthalmology exam findings, primary/
secondary ophthalmic diagnoses, procedure/intervention performed
as a result of the consult, length of hospitalization prior to consult,
and duration of hospitalization. Data were analyzed to investigate
associations between exam findings (specifically visual acuity, pupil
and extraocular muscle [EOM] exam) and the presence of ocular
pathology and need for intervention.
Results: To date, data have been collected from 173 patients. The
study population includes 96 (55.5%) men and the mean patient
age is 40 years. Decreased vision (30.0%) was the most common
reason for consultation followed by “rule out ocular/orbital trauma”
(24.3%) and eye pain (8.7%). Services requesting the most consults
were trauma (17.9%), pediatrics (15.0%) and medicine (13.3%). The
most common primary ophthalmic diagnoses were orbital fracture
(15.6%), normal ocular exam (12.1%) and fungal endophthalmitis
ruled out (7.5%). Forty-three percent of consults resulted in no
intervention, while the most common interventions were outpatient
follow-up (23.1%), medication (20.8%) and further imaging (8.1%).
Abnormalities on pupil exam and decreased visual acuity (defined
as 20/40 or worse as measured with a near card) were significant
predictors of the need for intervention (p=0.005 and p=0.03,
respectively). Abnormal EOM exam was not a significant predictor of
the need for intervention (p=0.47).
Conclusions: Ophthalmological inpatient consultation makes a
significant difference in the care of hospitalized patients, with over
half of ophthalmology consults resulting in interventions such as
medications, further imaging/labwork, or surgery. For busy inpatient
consult services, visual acuity and pupil exam findings communicated
to the ophthalmology service by the primary team can help triage
how likely a patient is to need intervention and how urgently a patient
needs to be evaluated.
Commercial Relationships: Jason Mayer, None; Zachary Landis,
None; Ming Wang, None; Ingrid U. Scott, None
Program Number: 5555 Poster Board Number: A0164
Presentation Time: 8:30 AM–10:15 AM
The Scope of an Inpatient Ophthalmology Consult Service Before
and After Hurricane Sandy
Anam Qureshi, Elisabeth J. Cohen, Ilyse D. Haberman, Lisa Park.
Ophthalmology, New York University, New York, NY.
Purpose: To profile patient demographics, volume, and eye disease
seen by the Inpatient Ophthalmology Consult Service of a large
public hospital before and after Hurricane Sandy
Methods: A total of 1,269 consults were seen from 11/1/2011 to
11/30/2013, including the time of closure of the Inpatient Consult
Service from 10/31/2012 to 2/9/2013 following Hurricane Sandy.
We reviewed inpatient medical records, discharge summaries, and
Ophthalmology Consultation Service notes of the first 10 new
consults each month for a total of 220 patients.
Results: 708 consults with an average of 59 consults per month
were seen prior to Hurricane Sandy. 561 consults with an average
of 56.1 consults per month were seen after Hurricane Sandy. Of
220 consultation requests reviewed, the mean age was 45.6 years
with predominance of male (155, 70.5%) over female (65, 29%)
patients. The most common reason for inpatient consultation prehurricane and post-hurricane was as follows: decreased vision (18
(15%) and 26 (26%)), eye trauma (28 (23%) and 15 (15%)), rule
out systemic disease involvement (12 (10%) and 13 (13%)), and eye
pain (10 (8%) and (8) 8%). The most common primary diagnosis was
normal exam or refractive error (41 (34%) and 28 (28%)), orbital
fracture (18 (15%) and 6 (6%)), blepharitis or dry eye syndrome (11
(9%) and 9 (9%)), and diabetic retinopathy (3 (2%) and 6 (6%)).
Of the total consultations seen, 84 (70%) pre-hurricane and 63
(63%) post-hurricane patients were recommended follow up in the
©2014, Copyright by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. Go to iovs.org to access the version of record. For permission
to reproduce any abstract, contact the ARVO Office at [email protected].
ARVO 2014 Annual Meeting Abstracts
Ophthalmology Clinic, and 25 (20%) pre-hurricane and 13 (13%)
post-hurricane patients actually followed up. Pre-hurricane insurance
status was similar to post-hurricane insurance status: uninsured (53
(44%) and 50 (50%)), Medicaid (38 (32%) and 25 (25%)), other
insurance type (14 (12%) and 16 (16%)), and Prison Health Service
or Police Custody (13 (11%) and 8 (8%)). For 43 (36%) patients
before and 49 (49%) patients after the hurricane, the current inpatient
admission was their first admission to Bellevue Hospital. *Note:
Results through 2/9/2014 (one year after reopening of the Inpatient
Consult Service) will be presented.
Conclusions: This study profiled common diagnosis, follow up
rates, volume, and demographics of patients at a large public hospital
affected by a major natural disaster. Despite closure for greater than
three months, the inpatient consult service recovered without much
change in these outcome measures.
Commercial Relationships: Anam Qureshi, None; Elisabeth J.
Cohen, None; Ilyse D. Haberman, None; Lisa Park, None
Program Number: 5556 Poster Board Number: A0165
Presentation Time: 8:30 AM–10:15 AM
Surgical outreach eye programs: a comparison of communitybased vs. hospital-based cataract surgery delivery
Sushant Wagley1, Emily Cole2, Badri Badhu3, Manoj Sharma4.
1
College of Human Medicine, Michigan State University, East
Lansing, MI; 2Tufts University School of Medicine, Boston, MA;
3
Ophthalmology, BP Koirala Institute of Health Sciences, Dharan,
Nepal; 4Ophthalmology, Royal Australasian College of Surgeons,
Dili, Timor-Leste.
Purpose: To compare systems indicators and delivery methods for
community-based vs. hospital-based surgical outreach eye programs
conducted by various eye care institutions in Nepal over a year.
Methods: Programmatic data from 18 community-based and 8
hospital-based eye camps conducted through various eye care
institutions in Nepal were analyzed for systems and delivery
indicators including: the total number and type of camps, number
and type of healthcare provider present at each camp, total number of
patients screened, total number of surgeries performed, number and
type of cataract surgeries/non-cataract procedures performed, and
post operative follow-up protocol utilized by each institution.
Results: From the 26 eye camps included in this sample, 16784
patients were screened for eye pathologies and 2330 received cataract
removal - with a majority (98.39%) getting PC-IOL implantation.
There was no significant difference in the number of males and
females treated at these camps. The total number of ophthalmologists
at the various eye care institutions ranged from 2 to 25, however,
usually only one ophthalmologist was present at each eye camp.
Average team size was 10 at community-based surgical camp vs. 8 at
hospital-based surgical camps. Average follow up ranged from 1 to
30 days post-operative care, with 65.3% of the programs conducting
only one-day post-operative follow-up care.
Conclusions: Eye care institutions in Nepal organized more
hospital-based surgical outreach eye programs than community-based
surgical camps per year. Both types of camps effectively screened
and operated on a large numbers of patients. Clinical protocols and
systems delivery protocols utilized to carry out the hospital-based
vs. community-based eye camps did not differ between institutions.
Further studies analyzing financial data and resource utilization for
surgical outreach eye programs are necessary to increase cataract
surgery coverage in resource limited settings throughout the world.
Commercial Relationships: Sushant Wagley, None; Emily Cole,
None; Badri Badhu, None; Manoj Sharma, None
Program Number: 5557 Poster Board Number: A0166
Presentation Time: 8:30 AM–10:15 AM
Detection of Non-Glaucomatous Ocular Pathology and Barriers
to Follow-Up in a Community Glaucoma Detection Program
Wanda D. Hu1, Cindy X. Hu1, Judie Tran1, Edward Pequignot2,
Michael Waisbourd1, Lisa A. Hark1, L Jay Katz1. 1Glaucoma, Wills
Eye Hospital, Philadelphia, PA; 2Pharmacology and Experimental
Therapeutics, Thomas Jefferson University, Philadelphia, CA.
Purpose: To evaluate the detection rates of non-glaucomatous ocular
pathology requiring follow-up care and to identify the barriers to
this follow-up care in a Centers for Disease Control and Prevention
(CDC)-sponsored community glaucoma detection program.
Methods: Subjects 18 or older participated in a CDC-sponsored
community-based exam to detect glaucoma throughout Philadelphia,
Pennsylvania. An ophthalmologist conducted a slit lamp examination,
gonioscopy, and an undilated fundus exam. Octopus® perimetry
and optic nerve head photography were also performed. Subjects
who were recommended for follow-up ophthalmic care at their own
eye care provider for non-glaucomatous ocular pathology were also
recorded. These subjects were given a telephone survey to assess
rates of follow-up and to evaluate potential barriers to follow-up.
Survey results were correlated with attendance of a follow-up exam
using the Wilcoxon nonparametric test and Fisher’s exact test.
Results: Eight hundred and ninety-nine (899) subjects were
examined from January 2013 to August 2013. One hundred three
(103) subjects (11%) diagnosed with non-glaucomatous ocular
pathology were recommended follow-up ophthalmic care for visually
significant cataracts (6.9%), diabetic retinopathy (1.0%), macular
degeneration (1.7%) and other ocular pathology (2.2%). Fifty-eight
of the 103 subjects (56%) responded to the telephone survey. The
average age of respondents was 58 years and females (64%) and
African-Americans (69%) predominated. Of the respondents, 29%
attended a follow-up appointment. Subjects who did not remember
their results and recommendations were less likely to attend their
follow-up appointment (p=0.036 and 0.039, respectively). Subjects’
primary language (p=0.73), education level (p=0.68), type of
transportation (p=1.0), type of health insurance (p=0.18), and interval
of time between their last visit to an eye specialist and the glaucoma
exam (p=0.053) were not significantly associated with attending their
follow-up appointment.
Conclusions: A community-based glaucoma exam is able to detect a
significant amount of non-glaucomatous ocular pathology requiring
further ophthalmic follow-up. However, actual follow-up rates at
participants’ own eye care provider are poor and warrant the need to
continue follow-up eye care at these community sites.
Commercial Relationships: Wanda D. Hu, None; Cindy X. Hu,
None; Judie Tran, None; Edward Pequignot, None; Michael
Waisbourd, None; Lisa A. Hark, None; L Jay Katz, Aerie Pharm
(C), Aerie Pharm (F), Alcon (C), Allergan (C), Allergan (F), Bausch
& Lomb (C), Bausch & Lomb (F), Glaukos (C), Glaukos (I), Inotek
(C), Merck (F), Sensimed AG (C), Sucampo (C)
Support: CDC grant number 1U58DP004060-02
Program Number: 5558 Poster Board Number: A0167
Presentation Time: 8:30 AM–10:15 AM
Foundation and Applications of the Universal EYE Exam
Translator
Samir I. Sayegh. EYE Ctr Anterior- Vitreoretinal Surg, Eye Center/
The Retina Center, Champaign, IL.
Purpose: To provide an accurate, practical and universal tool to
interact with patients undergoing an eye examination, regardless of
their spoken language.
©2014, Copyright by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. Go to iovs.org to access the version of record. For permission
to reproduce any abstract, contact the ARVO Office at [email protected].
ARVO 2014 Annual Meeting Abstracts
Methods: A basic script for an interactive eye examination was
developed based on experience in a variety of languages and eye
examination contexts. The script and a translation template were
assigned to a number of collaborators including ophthalmologists,
physicians in other specialties, health care professionals, linguists
and other professionals, who transferred it to their respective mother
tongue. The template included four categories: language of origin, a
translation, transliteration and audio. Specific attention was directed
to the peculiarities of each language and translations to different
dialects of the same language were included. A web interface to allow
new contributions as well as access the tool has been designed. The
site includes the list of all contributors to the project.
Results: All continents and languages covering over 75% of the
world’s population have been covered and a number of languages
clinically tested with good success and facilitation of eye examination
and communication with a diverse population of patients.
Conclusions: We have developed a universal tool to develop and
field a system of multilingual access to an eye examination. The
applications to onsite examination for a diverse population, education
of opthalmologists and other health professionals, telemedicine and
computer assisted communication of a richer medical vocabulary
have been demonstrated. The methods and results can be extended
to other subspecialties as well as primary care medicine. This can
be done in a highly efficient way based on web based access for
contributors and users alike.
Commercial Relationships: Samir I. Sayegh, None
Program Number: 5559 Poster Board Number: A0168
Presentation Time: 8:30 AM–10:15 AM
Tele-Ophthalmology Research in Post Phacoemulsification
Diagnostic Outcomes (TORPEDO) Study - Phase 1 and 2 Results
Xiu Ling Tan1, 2, Francine Yang1, 2, Hon Kiat Wong1, 2, Tock Han Lim1,
2 1
. Ophthalmology, Tan Tock Seng Hospital, Singapore, Singapore;
2
National Healthcare Group Eye Institute, Singapore, Singapore.
Purpose: To evaluate the accuracy of tele-medicine in detecting
post-phacoemulsification outcomes and complications at the onemonth post-operative visit, as compared to a face-to-face clinical
consultation. Phase 1 (validation phase) aims to assess the accuracy
of tele-ophthalmology in detecting clinical parameters relevant to
a one-month post-phacoemulsification review; while Phase 2 is a
pilot trial of a targeted and novel telemedicine workflow (TeleOph)
specifically designed for a one-month post-phacoemulsification
consultation.
Methods: In phase 1, 80 patients who had undergone
phacoemulsification surgery were recruited. This consisted of 20
patients with corneal pathology post-phacoemulsification, 20 with
anterior chamber inflammation, 20 with intraocular lens or posterior
capsule-related pathology and 20 controls. Anterior segment
photography was performed. In phase 2, a prospective study of 30
patients who underwent uneventful phacoemulsification surgery was
conducted. At the one-month post-operative visit, patients underwent
the TeleOph work-flow which included refraction, intraocular
pressure measurement, and slit-lamp and fundus photography. In
both phases, images were then read by a masked investigator and
compared against the clinical findings of a face-to-face consultation
conducted at the same visit.
Results: In Phase 1, anterior segment photography detected corneal
pathology with a sensitivity and specificity of 100%; anterior
chamber inflammation with a sensitivity of 100% and specificity of
95% and the presence of intraocular lens or posterior capsule-related
pathology with a sensitivity of 95% and specificity of 85%. In Phase
2, TeleOph detected corneal and wound-related complications with
a sensitivity and specificity of 100%; anterior chamber inflammation
with a sensitivity of 75% and specificity of 92.3% and the presence
of posterior capsular opacification with a sensitivity of 100% and
specificity of 96.6%.
Conclusions: Tele-medicine detects post-phacoemulsification
outcomes and complications with a high level of sensitivity and
specificity. It best detects corneal and intraocular lens-related
complications; with a lower sensitivity and specificity in detecting
anterior chamber inflammation.
Commercial Relationships: Xiu Ling Tan, None; Francine Yang,
None; Hon Kiat Wong, None; Tock Han Lim, None
Program Number: 5560 Poster Board Number: A0169
Presentation Time: 8:30 AM–10:15 AM
Pilot Study Using Mobile Health to Coordinate the Diabetic
Patient, Diabetologist and Ophthalmologist
Irena Tsui1, Andrew Drexler2, Annette Stanton3, Jenny Kageyama1,
Bradley R. Straatsma1. 1Ophthalmology, JSEI, Los Angeles, CA;
2
Endocrinology, UCLA, Los Angeles, CA; 3Psychology, UCLA, Los
Angeles, CA.
Purpose: To use a mobile app to empower patients and increase
communication among the diabetic patient, diabetologist and
ophthalmologist.
Methods: Patients with Type 1 or Type 2 diabetes mellitus and access
to a mobile device were invited to participate. Intervention was use
of SightBook™, a free mobile app that monitors visual acuity at
home and allows communication between the patient and multiple
physicians. Outcome measures included psychosocial surveys,
use of the mobile app, and participation by the diabetologist and
ophthalmologist.
Results: Sixty patients were enrolled with a mean age of 45
years (range 23 - 81).
Self-administered health psychology
questionnaires in 45 patients showed varied diabetes knowledge
and disease perception. At baseline, mean A1c was 8.6 and 30% of
patients had diabetic retinopathy. Twenty-nine patient profiles (48%)
were successfully complete 3 months after enrollment (Table).
Conclusions: Diabetic patients responded enthusiastically to using
mHealth; however, heavily burdened physicians were reluctant to
take on the task of entering data that duplicated medical records.
Additional study is required to improve mHealth technology for
better incorporation into patient care.
Commercial Relationships: Irena Tsui, None; Andrew Drexler,
None; Annette Stanton, None; Jenny Kageyama, None; Bradley
R. Straatsma, None
Support: Oppenheimer Grant
Clinical Trial: NCT01983917
©2014, Copyright by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. Go to iovs.org to access the version of record. For permission
to reproduce any abstract, contact the ARVO Office at [email protected].
ARVO 2014 Annual Meeting Abstracts
Program Number: 5561 Poster Board Number: A0170
Presentation Time: 8:30 AM–10:15 AM
Association between government-insured general eye exams and
incidence of self-reported glaucoma, cataracts and uncorrectable
vision loss
Yaping Jin1, 2, Elizabeth Badley3, 2, Graham E. Trope1, Yvonne M.
Buys1, Christina Chan3. 1Ophthalmology & Vis Sci, University of
Toronto, Toronto, ON, Canada; 2Dalla Lana School of Public Health,
University of Toronto, Toronto, ON, Canada; 3Arthritis Research and
Evaluation Unit, Toronto Western Research Institute, Toronto, ON,
Canada.
Purpose: To determine if there is an association between
government-insured general/routine eye exams and incidence of
self-reported glaucoma, cataracts and uncorrectable vision loss (i.e.
unable to see close or distance with eyeglasses).
Methods: We analyzed self-reported data from the Canadian
longitudinal National Population Health Survey run from 1994/1995
to 2010/2011, which represents a 16-year follow-up. Standardized
questionnaires were used to collect data every two years. White
respondents aged 65+ in 1994/1995 were included (n=2,618). Three
cohorts were established at baseline: those free of glaucoma, those
free of cataracts and those free of uncorrectable vision loss. Incident
cases were identified through self-reporting of the conditions in
question in the follow-up period. Government insurance for general/
routine eye exams was assigned based on reported respondent’s
province of residence in 1994/1995 and their corresponding
provincial health insurance policy. Incidence rate ratios (IRRs) were
calculated to compare the risk of incidence in government insured
versus uninsured populations, controlling for age, sex, education, and
smoking.
Results: The incidence rate (per 1000 person-years) of self-reported
glaucoma was higher in government-insured seniors (12.8, 95%
confidence interval [CI] 10.5-15.1) than uninsured seniors (8.1, 95%
CI 5.5-10.7). For cataracts, the incidence was also higher in the
insured: 75.7 (95% CI 69.2-82.2) versus 67.2 per 1000 person-years
(95% CI 55.7-78.6). For uncorrectable vision loss, the incidence was
lower in the insured: 22.5 (95% CI 20.0-25.5) versus 26.6 per 1000
person-years (95% CI 20.2-33.0). Adjusting for confounding factors,
insured seniors were associated with a 59% increased risk of being
diagnosed with glaucoma (IRR 1.59; 95% CI 1.07-2.37), a 13%
greater risk of being diagnosed with cataracts (IRR 1.13, 95% CI
0.93-1.37) and a 12% reduced risk of reporting uncorrectable vision
loss (IRR 0.88, 95% CI 0.67-1.16).
Conclusions: Government-funded general/routine eye exams are
associated with a higher incidence of self-reported glaucoma and
cataracts, likely due to better detection. Insured eye exams are also
associated with a lower incidence of uncorrectable vision loss, likely
due to better access to eye care and earlier treatment for preventable/
avoidable vision loss.
Commercial Relationships: Yaping Jin, None; Elizabeth Badley,
None; Graham E. Trope, None; Yvonne M. Buys, None; Christina
Chan, None
Support: CIHR SEC 117120, CIHR HRA 126901
Program Number: 5562 Poster Board Number: A0171
Presentation Time: 8:30 AM–10:15 AM
Low Utilization of Eye Care Providers by Newfoundland and
Labrador Seniors: Barriers and Vision Health Outcomes
Kangping Cui1, Graham E. Trope1, 2, Yvonne M. Buys1, 2, Christina
Chan2, Kednapa Thavorn3, Yaping Jin1, 4. 1Ophthalmology and Vision
Siences, University of Toronto, Toronto, ON, Canada; 2Toronto
Western Research Institute, University Health Network, Toronto, ON,
Canada; 3Keenan Research Centre, Li Ka Shing Knowledge Institute,
St. Michaels Hospital, Toronto, ON, Canada; 4Dalla Lana School of
Public Health, University of Toronto, Toronto, ON, Canada.
Purpose: A prior study revealed significantly lower use of eye
care providers in Newfoundland and Labrador (NFLD) than other
Canadian provinces. We examined factors associated with this low
use and evaluated vision health outcomes.
Methods: Descriptive analyses with 95% confidence intervals (CI)
were performed using self-reported data from Caucasians aged 65+
who participated in the Canadian Community Health Survey Healthy
Aging 2008/09 (n=14,925).
Results: The NFLD government, along with PEI, NB, and SK,
does not insure seniors without eye disease for routine eye exams.
All other Canadian provinces insure seniors regardless of eye
conditions. Among people without self-reported glaucoma, cataracts
and diabetes, the use of eye care providers in NFLD (36.3%) was
the lowest compared to provinces with (50.7%, p<0.05) and without
(42.2%, p>0.05) insured eye exams. Among seniors with an eye
disease, who are insured in all provinces, use in NFLD (63.1%) was
still lower than other provinces (69.4%-71.3%, p>0.05).
Lower levels of socioeconomic status and living in non-urbanized
areas were associated with reduced use of eye care providers across
Canada. Compared to the national average, NFLD seniors had
significantly lower levels of education (46.4% vs. 57.8% for postsecondary education), income (11.9% vs. 21.5% for earning above
the 70th national income percentile) and urban dwelling (59.4% vs.
81.1%). After adjusting for confounding effects, seniors in NFLD
were 15% (prevalence ratio [PR] 0.85, 95% CI 0.77-0.94) and 9%
(PR 0.91, 95% CI 0.82-1.02) less likely to use an eye care provider
than those in provinces with and without government-insured routine
eye exams.
The prevalence of self-reported glaucoma was significantly lower
in NFLD (3.8%) than in provinces with (7.0%) and without (6.7%)
government-insured routine eye exams. The same was true for selfreported cataracts: 16.7% in NFLD vs. 23.2% in insured provinces.
The prevalence of uncorrectable vision loss (i.e. unable to see close
or distance with eyeglasses) was higher in NFLD than in insured
provinces (4.0% vs. 3.5%, p>0.05).
Conclusions: Lack of government insurance, low levels of income
and education, living in non-urbanized areas may contribute to the
underutilization of eye care providers in NFLD. This low utilization
seems to be associated with reduced detection of eye disease and
increased prevalence of uncorrectable vision loss.
Commercial Relationships: Kangping Cui, None; Graham E.
Trope, None; Yvonne M. Buys, None; Christina Chan, None;
Kednapa Thavorn, None; Yaping Jin, None
Support: The Canadian Institutes of Health Research (CIHR) (CIHR
SEC 117120, CIHR HRA 126901) and Institute of Medical Sciences
(IMS) summer research program joint funding award (University of
Toronto)
©2014, Copyright by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. Go to iovs.org to access the version of record. For permission
to reproduce any abstract, contact the ARVO Office at [email protected].
ARVO 2014 Annual Meeting Abstracts
Program Number: 5563 Poster Board Number: A0172
Presentation Time: 8:30 AM–10:15 AM
: Inter-observer agreement and sensitivity – specificity analysis of
a technology led, remote review glaucoma clinic
Jonathan C. Clarke, Renata Puertas, Paul J. Foster, Keith Barton.
NIHR Biomedical Research Centre for Ophthalmology, Moorfields
Eye Hospital NHS Foundation Trust and UCL Institute of
Ophthalmology, London, United Kingdom.
Purpose: Patients with well controlled glaucoma and ocular
hypertension are suitable for follow up assessment in “remote review
clinics”. The clinical findings and investigations are collected at one
site and the results analysed by a glaucoma physician at another site
at a later time. The separation of data acquisition and clinical decision
making can lead to an improved patient experience and workflow.
Although this type of clinic set up exists, there is little information
concerning the safety or physician agreement. We investigate the
safety and level of clinical agreement of a remote review glaucoma
clinic.
Methods: Low risk patients were selected by reviewing the clinical
notes of a general adult glaucoma clinic. Patients were reviewed
clinically after all the appropriate investigations to assess glaucoma
were performed. A decision about stability was made. More than 1
year later, the same clinicians reviewed the data collected and decided
whether the glaucoma appeared stable or unstable. These outcomes
are compared between physicians as a measure of inter-observer
agreement. A sensitivity and specificity assessment comparing
clinical decision making and remote decision making is performed.
Results: The records of 871 patients were assessed and 286 were
invited to participate and 217 accepted. There were sufficient
data collected by both clinical systems to allow accurate decision
making in 200 patients. Inter-observer agreement was moderate with
kappa scores of 0.50 (95% CI 0.374 to 0.619). For the more senior
physician, 8 of 116 patients (6.9%) were progressing in the clinical
examination and 6 of these patients were identified remotely with
sensitivity of 75.0% and specificity 79.6%. The remaining 2 patients
were slowly progressing and diagnosis is likely to have been made if
imaging data were available in the remote review system.
Conclusions: Telemedicine and remote review medical assessments
are increasingly common systems for treating patients. The safety of
these systems has not been reliably assessed. We conclude that there
is moderate agreement between two assessors of a group of stable
glaucoma patients. Sensitivity of the system to detect progression
is likely to improve if the data is presented systematically by an
electronic patient record.
Commercial Relationships: Jonathan C. Clarke, None; Renata
Puertas, None; Paul J. Foster, None; Keith Barton, None
Program Number: 5564 Poster Board Number: A0173
Presentation Time: 8:30 AM–10:15 AM
Comparison of two diabetic retinopathy screening program
models within a single primary care practice
Kristina Holbrook, Kerry Cotter, Paul A. Yates. Ophthalmology,
University of Virginia, Charlottesville, VA.
Purpose: To evaluate factors that determine the effectiveness of
tele-ophthalmic screening programs for diabetic retinopathy (DR) by
comparing two successive implementations at a primary care practice
that serves the largest population (N=2570) of adults with diabetes
mellitus at the University of Virginia.
Methods: In 2006, a DR screening program was established using
the Optos wide-field retinal imager (Optos Program). Digital images
of each eye using the non-mydriatic, 200-degree retina view were
obtained by multiple nurses at physician request and read by a UVA
ophthalmologist in a time frame consistent with the patient’s ongoing
consultations. Results were communicated to the ordering physician.
The program was active until 2009, when the system was removed
due to unsatisfactory outcome measures relative to cost-effectiveness.
In September 2011, a revised DR screening program was established
at UMA (DRS Program). A single medical assistant obtained one
45° macula-centered image of each eye using a refurbished nonmydriatic camera (Topcon TRC-45N). The images were read by an
ophthalmologist. Results and ophthalmic follow-up recommendations
were shared with the ordering physician and patient within 48 hours
of screening.
To evaluate program success, we compared number of patients
screened, number of cases of DR, number of patients identified
with other retinal pathology, and the ophthalmic follow-up visit
compliance rate in patients with suspected DR.
Results: The Optos Program screened 186 patients in 36 months
and the DRS Program screened 1348 in 26 months. DR was detected
in 29 (16%) patients in the Optos Program and 253 (19%) in the
DRS Program. Positive screens (with DR) identified via the DRS
Program were more compliant with their ophthalmic follow-up visit
recommendation (71% compliance) than those identified via the
Optos Program (34% compliance).
Conclusions: Multiple factors enabled the success of the latter
program. The designation of a full-time nurse / photographer and
integration of screening into the nursing workflow (a standing order
is used) contributed to program success. Time associated with image
transmission, review, and communication of results (< 48 hours)
was decreased through the latter program. Directly involving the
patient in the scheduling of the ophthalmic follow-up appointments
contributed to the improved follow-up appointment completion rate.
Commercial Relationships: Kristina Holbrook, None; Kerry
Cotter, None; Paul A. Yates, Genentech / Roche (C), RetiVue, LLC
(E), RetiVue, LLC (I), University of Virginia (P)
Program Number: 5565 Poster Board Number: A0174
Presentation Time: 8:30 AM–10:15 AM
Attitudes Toward Tele-ophthalmology
Patricia Ple-plakon1, Paul P. Lee1, Taylor Blachley1, David C.
Musch1, 2, Maria A. Woodward1. 1Ophthal & Visual Sciences,
University of Michigan, Ann Arbor, MI; 2Epidemiology, University
of Michigan, Ann Arbor, MI.
Purpose: With the rapid rise of e-health and remote care systems, we
sought to evaluate perspectives on and familiarity with telemedicine
among eye care providers (ophthalmologists and optometrists)
and emergency department (ED) physicians at a large tertiary care
medical center.
Methods: Anonymous surveys were administered to eye care
providers and ED physicians at the University of Michigan to gauge
current practice patterns and willingness to adopt telemedicine for
eye care. Results were compared among trainees (residents and
fellows) and faculty members and across specialties.
Results: A total of 76 ED physicians (55.1% trainees, 42.3% faculty,
2.6% physician assistants and others) and 58 eye care providers
(31.0% trainees, 69.0% faculty) completed surveys (response rates
of 72% and 62%, respectively). Among eye care providers, while
a majority of both faculty and trainees were willing to participate
in telemedicine services, trainees were more likely to be willing to
interpret photographs than faculty (p=0.04). Most respondents (71%)
indicated that they did not use telemedicine, yet over half received
photographs (via internet or email) for interpretation from referring
physicians (54%) or patients (56%) within the past 3 months. At the
same time, a majority (59%) had low confidence in remote screening
for eye care as the only source of information for patient care.
©2014, Copyright by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. Go to iovs.org to access the version of record. For permission
to reproduce any abstract, contact the ARVO Office at [email protected].
ARVO 2014 Annual Meeting Abstracts
Among ED physicians, 65% were already utilizing telemedicine for
various specialties, and most were interested in tele-ophthalmology. A
majority (80%) felt telemedicine in eye care was under-utilized in the
ED. Interestingly, ED faculty were more likely than trainees to feel
confident in using telemedicine services to decide upon appropriate
patient eye care without an in-person ophthalmology consultation
(p=0.01).
Conclusions: While many providers see telemedicine as part of the
future of eye care and its use is accepted by most, the majority of eye
care providers (but not ED providers) had confidence issues regarding
the use of telemedicine services alone in the care of patients.
Commercial Relationships: Patricia Ple-plakon, None; Paul P.
Lee, None; Taylor Blachley, None; David C. Musch, None; Maria
A. Woodward, None
Support: Dr. Maria Woodward with NIH K23 Career Development
Award NIH1K23EY023596-01
Program Number: 5566 Poster Board Number: A0175
Presentation Time: 8:30 AM–10:15 AM
Frequency of Gonioscopy and Pachymetry on First Visit
Glaucoma Patients
Stephanie Ma1, Satyesh Rana1, Justin Tannir2, Bret Hughes2, Aman
Shukairy2, Saya Nagori2, Mark S. Juzych2, Anju Goyal2. 1Wayne State
University School of Medicine, Detroit, MI; 2Ophthalmology, Kresge
Eye Institute, Detroit, MI.
Purpose: To study the frequency that gonioscopy and pachymetry is
done and billed for on first visit glaucoma patients and measure lost
revenue.
Methods: The most recent patients for first ophthalmology visits
given the diagnosis of glaucoma with an ICD code of 365.xx at the
Kresge Eye Institute were used to form a patient list. These patients
were seen from May 2013 to Aug 2013. Patients were then organized
as being seen by a glaucoma specialist or non-glaucoma specialist.
All patients were further identified as seen in a private clinic or
resident clinic. 980 right eyes were used in the study using electronic
medical records to obtain relevant data. We recorded whether
gonioscopy and pachymetry was completed during this first visit. A
revenue analysis was done using a percentage of patients on various
insurance coverage plans, as well as the reimbursement given by each
plan for gonioscopy and pachymetry.
Results: Our results indicate that gonioscopy and pachymetry
are under utilized. Among the 980 patients in our study, 17.96%
of patients had gonioscopy performed on their initial visit. The
specialty training of the ophthalmologist seeing the patient as well
as the setting of the initial visit appeared to play a role in whether
or not gonioscopy was done. Gonioscopy was performed more
often by glaucoma doctors in their private clinics 47.57% than by
non-glaucoma doctors in private clinic 5.88% (P-value <0.0001).
Gonioscopy was performed even less often by glaucoma doctors
in resident clinic 18.75% and by non-glaucoma doctors in resident
clinic 8.14% compared to glaucoma doctors in private clinic (P-value
<0.0001). Pachymetry was performed more often by glaucoma
doctors in their private clinics 67.04% than by non-glaucoma doctors
in private clinic 23.74%. Pachymetry was performed even less often
by glaucoma doctors in resident clinic 12.5% than by non-glaucoma
doctors in resident clinic 14.50%. These differences were statistically
significant (P-value <0.0001). Based on insurance types and
reimbursement for the Kresge Eye Institute, we estimate lost revenue
to be $32,265.40 in these 980 patients during 5/3/13-09/13/13.
Conclusions: Goniscopy and pachymetry are not optimally
performed or billed for on first visit glaucoma patients at the Kresge
Eye Institute. Practice patterns for glaucoma can be ignored and
institutions can lose revenue failing to bill for these procedures.
Commercial Relationships: Stephanie Ma, None; Satyesh Rana,
None; Justin Tannir, None; Bret Hughes, None; Aman Shukairy,
None; Saya Nagori, None; Mark S. Juzych, None; Anju Goyal,
None
Program Number: 5567 Poster Board Number: A0176
Presentation Time: 8:30 AM–10:15 AM
An Analysis of Optometry Referrals to Ophthalmology for
Glaucoma Suspects
Catriona Barrett1, 2, Colm J. O’Brien2, James Loughman1.
1
Optometry, Dublin Institute of Technology, Dublin, Ireland;
2
Ophthalmology, Mater Misericordiae University Hospital, Dublin,
Ireland.
Purpose: The glaucoma care pathway in Ireland comprises an
optometrist-led glaucoma screening service, with referrals channeled
into ophthalmology services. Recent findings indicate a 31% false
positive referral rate for suspect glaucoma, a factor that exacerbates
the problem of escalating waiting lists in an under-resourced public
health system. This study was designed to assess the quality of
glaucoma referrals from optometry as a means to understand current
practice in the context of a critical need to enhance the public health
optometry role.
Methods: This study involved an analysis of glaucoma referrals from
all 59 optometrists participating in a joint optometry/ophthalmology
glaucoma referral refinement scheme at the National Optometry
Centre, Dublin. Each of the 181 referrals included was assessed
in terms of the (i) screening techniques used, (ii) clinical findings
provided and (iii) comparison with clinical findings in the glaucoma
clinic.
Results: Non-contact tonometry (NCT) emerged as the primary
clinical finding reported in the majority of referrals (98%), compared
to optic disc description (87%), visual field assessment (70%),
risk factor profile (62%) and cup-disc ratio (61%). Only 39% of
referrals contained a copy of the visual field plot, while a disc height
measurement was only provided in one referral (the method of disc
assessment was typically not provided). Only 5% of intraocular
pressure (IOP) measures were taken using Goldmann tonometry
(GAT), and corneal thickness (CCT) measures reported in 3 cases.
A statistically significant difference was observed between NCT
values reported by the optometrists and both the raw GAT (mean
difference = 0.99; p = 0.002, Bland Altman limits of agreement of ±
8.18mmHg), and CCT corrected GAT (mean difference = 2.39; p =
0.000, Bland Altman limits of agreement of 11.47mmHg) obtained in
the glaucoma clinic. Cup-disc ratio measures reported in the referrals
were not significantly different from those recorded in the clinic
(mean difference ± SD = 0.01 ± 0.11; p = 0.393), although Bland
Altman limits of agreement of ± 0.22 were observed.
Conclusions: Glaucoma referrals show a pattern of reliance on
NCT and isolated CD ratios, which provide measures that are
outside clinically acceptable limits of agreement with gold standard
techniques. To improve the accuracy of glaucoma referrals,
optometrists should adopt the use of GAT, CCT, disc measurement
and dilated examination.
Commercial Relationships: Catriona Barrett, None; Colm J.
O’Brien, None; James Loughman, None
Support: Support grant from the Association of Optometrists Ireland
©2014, Copyright by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. Go to iovs.org to access the version of record. For permission
to reproduce any abstract, contact the ARVO Office at [email protected].
ARVO 2014 Annual Meeting Abstracts
Program Number: 5568 Poster Board Number: A0177
Presentation Time: 8:30 AM–10:15 AM
Comparison of eye disease diagnosis by optometrists and
ophthalmologists in Ampang, Malaysia
Duratul A. Hussin1, Andrew Carkeet1, Peter Hendicott1, Philip
Baker2, Ai-Hong Chen3. 1School of Optometry & Vision Science,
Queensland University of Technology, Kelvin Grove, QLD,
Australia; 2School of Public Health & Social Work, Queensland
University of Technology, Kelvin Grove, QLD, Australia;
3
Department of Optometry, Universiti Teknologi MARA, Puncak
Alam, Malaysia.
Purpose: Optometrists in Malaysia receive a minimum of 4 years
university training and have skills comparable with optometrists in
many developed countries. However, as primary eye care clinicians,
these optometrists’ skills are relatively underutilized. To assess the
potential to improve health care efficiency, we assessed the diagnostic
abilities of Malaysian-trained optometrists against ophthalmologists
in detecting presence of cataract, diabetic retinopathy and glaucoma.
Methods: Two consultation rooms were set-up at a community clinic
and a hospital eye clinic in Ampang, Malaysia. Eight optometrists
and four ophthalmologists participated. Initially optometrists received
a refresher course in diagnosis and management decision making
for common eye diseases, and eye examination skills. Consecutive
patients who gave written informed consent were initially examined
by an optometrist and then re-examined by an ophthalmologist
masked to the optometrist’s diagnosis.
Results: Fifty-six patients participated, of whom, 42 patients had
been already diagnosed with diabetes mellitus prior to recruitment
to the study. Of these patients, 43 (86 eyes) were re-examined
by an ophthalmologist and included in the analysis. Of these,
26 patients were known to have diabetes mellitus. Optometrists
diagnosed cataracts in 37 eyes, diabetic retinopathy in 9 eyes
and suspected glaucoma in 16 eyes. Ophthalmologists diagnosed
cataracts in 39 eyes, diabetic retinopathy in 11 eyes and suspected
glaucoma in 18 eyes. Diagnostic test characteristics and predictive
values for optometrists diagnosis (compared with the standard of
ophthalmologist diagnosis) for the three conditions are shown below.
Conclusions: In this study, Malaysian optometrists, even when
inexperienced in primary eye care, could demonstrate high
accuracy in detecting presence of a disease particularly cataract and
glaucoma. However, based on the small number of cases detected by
ophthalmologists (6 eyes), optometrists’ performance in detecting the
presence of diabetic retinopathy was moderate. Better sensitivity may
be achieved as Malaysian optometrists gain more experience with
disease detection and diagnosis.
Diagnostic test and predictive values for detecting presence of
cataract, diabetic retinopathy and glaucoma by the optometrists
Commercial Relationships: Duratul A. Hussin, None; Andrew
Carkeet, None; Peter Hendicott, None; Philip Baker, None; AiHong Chen, None
Support: MRG Grant ID11483, Ministry of Health Malaysia.
Program Number: 5569 Poster Board Number: A0178
Presentation Time: 8:30 AM–10:15 AM
The Effectiveness of Vision Screening for Visual Problems in
School Children
Ellen Svarverud, Trine Langaas, Helle K. Falkenberg. Dept of
Optometry and Visual Science, Buskerud and Vestfold University
College, Kongsberg, Norway.
Purpose: As an integral part of their clinical training, Norwegian
optometry students participate in vision screening in Kongsberg’s 13
primary schools for children aged 7, 10 and 15 years. The screening
is a unique agreement between the optometry department and the
municipality as no national guidelines exists for eye examinations in
school children after the age of four years. The screening includes
a symptom questionnaire and assessment of best corrected visual
acuity (BCVA), retinoscopy, phorias, convergence, accommodation,
ocular motility, and stereo and color vision. All children failing the
screening criteria are referred to the departmental clinic for a full eye
examination. This study aims to validate the vision screening scheme
with regards to relevance of criteria and the ability to correctly
identify children who need vision treatment and follow up.
Methods: Screening records from 7658 children aged 7 (34%), 10
(34%) and 15 (33%) years between 2002 and 2012 were evaluated.
Records from children referred to the clinic were analyzed with
regards to reasons for referral and the outcome of the full eye
examination.
Results: 1126 (14.7%) children were referred. The most frequent
reason for referral was visual symptoms (39%, 53% and 33% for
7, 10 and 15 year olds, respectively). Significant hypermetropia
was measured in 14%, 16% and 9% of the 7, 10 and 15 year olds,
and myopia in 3%, 7% and 16%. Other reasons for referral were
reduced BCVA in the 7 year olds (15%), reduced accommodation,
convergence and stereo vision in the 7 and 10 year olds (15-18%),
while these reasons for referral were less frequent in 15 year olds
(10-11%). Of the 856 who attended the clinic, treatment or further
follow up was recommended in 594 (69%) cases. The number of true
referrals increased with age and was 63%, 77% and 86% for 7, 10
and 15 year olds, respectively.
Conclusions: Our results suggest that visual screening correctly
identifies many school children who have undetected visual
problems, and that visual problems differ across age groups.
However, the false referral rate is high in the youngest age group,
which may be due to insufficient routines and lack of experience in
assessing vision in young children. Currently, improvements to the
vision screening scheme include discussion of criteria for referral,
student training prior to screening, check lists for supervisors and
screening facilities.
Commercial Relationships: Ellen Svarverud, None; Trine
Langaas, None; Helle K. Falkenberg, None
Support: Norwegian Association of Optometry
Program Number: 5570 Poster Board Number: A0179
Presentation Time: 8:30 AM–10:15 AM
Outcomes of Large Sample Vision Screening among School
Children Aged 7-15 Years in Norway
Helle K. Falkenberg, Trine Langaas, Ellen Svarverud. Department
of Optometry and Visual Science, Buskerud and Vestfold University
College, Kongsberg, Norway.
Purpose: As part of their clinical training, Norwegian optometry
students vision screen 7, 10 and 15 year olds children in Kongsberg’s
13 primary schools. All children failing the screening criteria are
referred to the departmental clinic. This study presents visual function
data from school children between 2002 and 2012.
©2014, Copyright by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. Go to iovs.org to access the version of record. For permission
to reproduce any abstract, contact the ARVO Office at [email protected].
ARVO 2014 Annual Meeting Abstracts
Methods: 1126 (14.7%) of 7658 children, were referred, and
856 attended a full eye examination. Outcomes and visual status,
including symptoms, refractive error, best corrected visual logMAR
acuity (BCVA), binocular vision assessment and ocular health were
analyzed.
Results: 594 (69%) children needed treatment, and recommendations
were: glasses (60%), vision training (12%), further follow-ups (30%),
referral to an ophthalmologist (4%). Glasses were recommended
primarily for low hypermetropia in 7 year olds and for near vision
problems in 10 yearl olds. There was a significant increase in
the number of myopes in 15 year olds. Vision training was also
recommended for 10 and 15 year olds. The most prevalent symptoms
were near vision problems (33%), headaches (29%), and reduced
distance vision (25%). BCVA was -0.03 ± 0.1, -0.08 ± 0.11, and -0.06
± 0.11 for 7, 10 and 15 year olds respectively. Refractive (spherical
equivalent) errors were +0.8 ± 0.7 DS, +0.5 ± 1.1 DS, and -0.2 ±
1.0 DS, and binocular accommodation was 14 ± 4.5 DS, 13 ± 4.5
DS, and 11 ± 3.5 DS respectively. Heterophorias were 0,8 ± 2,7
exophoria for distance and 2,5 ± 4 exophoria for near, and near point
of convergence was 8 ± 7 cm across all children. False referrals were
37%, 23% and 14% for the three age groups.
Conclusions: The results show that visual screening correctly
identifies many school children who have undetected visual
problems. Importantly, most of these problems can be helped with
glasses and/or vision training. This study shows that the overall visual
status of Norwegian school children on average are as expected with
regards to their age, and that the visual system continues to develop
during primary school. Further, the type of visual problem changes
over time which stresses the importance of eye examinations at
regular intervals, and raised awareness among parents and teaching
staff.
Commercial Relationships: Helle K. Falkenberg, None; Trine
Langaas, None; Ellen Svarverud, None
Support: The Norwegian Association of Optometry
Program Number: 5571 Poster Board Number: A0180
Presentation Time: 8:30 AM–10:15 AM
National Burden of Eye Diseases in Iran 1990-2010; Findings
from the Global Burden of Disease Study 2010
Elham Hatef Naimi1, Seyed Farzad Mohammadi2, Elham Ashrafi2,
Cyrus Alinia2, Mehrdad Mohammadi2, Farshad Farzadfar3. 1General
Preventive Medicine Residency Program, Johns Hopkins University,
Baltimore, MD; 2Eye Research Center, Farabi Eye Hospital, Tehran
University of Medical Sciences, Tehran, Islamic Republic of Iran;
3
Non-Communicable Diseases Research Center, Tehran University of
Medical Sciences, Tehran, Islamic Republic of Iran.
Purpose: To evaluate national burden of eye diseases in Iran and to
compare changes in the burden from 1990 to 2010 by age and sex.
Methods: Disability-adjusted life-years (DALYs) in Iran is
reported for 4 different eye diseases including cataract, refraction/
accommodation (functional) disorders, macular degeneration,
and glaucoma, using “the Global Burden of Disease Study 2010.
Iran Global Burden of Disease Study 2010 (GBD 2010) Results
1990-2010. Seattle, United States: Institute for Health Metrics and
Evaluation (IHME), 2013”. DALY for each disease is compared
between 1990 and 2010, among 20 age groups from early neonatal
phase to 80 years of age and older and among males and females.
Results: In Iran, cataract, refraction/accommodation (functional)
disorders, macular degeneration, and glaucoma were the 84th,
87th, 138th, and 151st causes of DALY in 1990 and 89th, 72nd,
99th, and 137th in 2010, respectively. Cataract accounted for
0.085% of national DALY in 1990 and 0.09% in 2010, refraction/
accommodation (functional) disorders accounted for 0.42% in 1990
and 0.47% in 2010, macular degeneration accounted for 0.017% in
1990 and 0.071% in 2010, and glaucoma accounted for 0.0099%
in 1990 and 0.025% in 2010. There was steady increase in DALY
with age for each eye disease for both genders and among males and
females in 1990 to 2010. The point-by-point comparison of DALY
attributed to cataract and refraction/accommodation (functional)
disorders showed a decrease for each specific age group from 1990
to 2010 for both sexes and among males and females. For macular
degeneration it showed an increase for each specific age group from
1990 to 2010 for both sexes and among males and females. For
glaucoma it showed slight change for each specific age group from
1990 to 2010 for both sexes and among males and females with slight
decrease in some age groups and slight increase in others.
Conclusions: Total DALY and relative contribution to national
disease burden of vision-impairing conditions have increased
which underscore the age-related nature of blinding conditions and
epidemiologic transition. This is most evident in case of macular
degeneration. The point-by-point decrease in DALY related to
functional visual impairment and cataract is attributable to the
treatability of these conditions and popularity and effectiveness of
cataract surgery.
Commercial Relationships: Elham Hatef Naimi, None; Seyed
Farzad Mohammadi, None; Elham Ashrafi, None; Cyrus Alinia,
None; Mehrdad Mohammadi, None; Farshad Farzadfar, None
Program Number: 5572 Poster Board Number: A0181
Presentation Time: 8:30 AM–10:15 AM
Demographic and Clinical Profile of a Homeless Population
Presenting to an Ophthalmology Outreach Clinic
Brian Stagg, Brad Henriksen, Max Padilla, Bryce Radmall, Erica
Liu, Jason Jensen, Aabid Farukhi, Jeff Pettey, Albert T. Vitale. John A
Moran Eye Center, Salt Lake City, UT.
Purpose: To evaluate the demographics, chief complaint, and
diagnoses of patients presenting to an ophthalmology clinic for
homeless populations.
Methods: Retrospective chart review of all patients seen at an eye
clinic dedicated to homeless patients from 2008 to 2013.
Results: 178 individual patients were seen, with a total of 238 clinic
visits. All patients were homeless with 66% male and 34% female.
The average age was 50. The most common chief complaint was
decreased vision (29% of visits) followed by diabetic eye screening
(27%), glaucoma evaluation (9%), eye pain (5%), growth on eye
(3%), and red eye (3%). Only 2.5% of the patients evaluated had a
normal exam. The most common diagnosis was cataract (35% of
visits), followed by NPDR (13%), refractive error (11%), glaucoma
(8%), glaucoma suspect (7%), dry eye syndrome (7%), thyroid
eye disease (4%), ocular misalignment (3%), pterygium (3%), and
conjunctivitis (3%). Follow-up was recommended in 60% of visits;
however, of these patients, only 36% were seen again.
Conclusions: This study provides an important snapshot of ocular
health in a relatively unstudied patient population. In this setting,
homeless patients were very likely to have ocular pathology, with
only 2.5% having a normal eye exam. Chronic blinding diseases such
as diabetic retinopathy and glaucoma were present in a significant
portion of the homeless population. These chronic diseases are
especially difficult to treat in a population with socioeconomic
challenges to consistent follow-up. Concerted efforts focused on the
treatment and longitudinal follow-up of chronic ocular disease in
indigent populations are necessary.
Commercial Relationships: Brian Stagg, None; Brad Henriksen,
None; Max Padilla, None; Bryce Radmall, None; Erica Liu, None;
Jason Jensen, None; Aabid Farukhi, None; Jeff Pettey, None;
Albert T. Vitale, None
©2014, Copyright by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. Go to iovs.org to access the version of record. For permission
to reproduce any abstract, contact the ARVO Office at [email protected].
ARVO 2014 Annual Meeting Abstracts
Program Number: 5573 Poster Board Number: A0182
Presentation Time: 8:30 AM–10:15 AM
Stakeholder Perceptions and Practices Regarding the Ocular
Effects of Hyperbaric Oxygen Therapy
Arjun J. Dirghangi1, Brian K. Lee2, Amanda Allan4, Krish Gandhi3,
Amanda Y. Lehman1. 1Department of Ophthalmology, Drexel
University College of Medicine, Philadelphia, PA; 2Department of
Epidemiology and Biostatistics, Drexel University School of Public
Health, Philadelphia, PA; 3Drexel University College of Medicine,
Philadelphia, PA; 4Drexel University School of Health Professions,
Philadelphia, PA.
Purpose: The purpose of this study is to determine the perceptions
and practices of practitioners of hyperbaric oxygen therapy (HBOT)
regarding its ocular effects. HBOT is a commonly used therapy with
many indications (most commonly used for non-healing diabetic
ulcers and burn injuries), but a highly limited evidence base regarding
ocular risks and benefits. Patients receiving HBOT are referred
to ophthalmologists to “clear” them prior to therapy based upon
theoretical risks of oxidative stress; this incurs a significant burden
upon the health system, with unclear benefits and clinical follow-up.
Methods: This study uses a combination of quantitative and
qualitative research methods, primarily relying upon quantitative
KAP (knowledge, attitudes, and practices) survey techniques
administered to physicians and technicians evaluating and treating
patients for HBOT (general surgeons, radiation oncologists,
and ophthalmologists) in an urban academic teaching hospital.
Additionally, focus group discussions (FGDs) were held with
smaller groups, including HBOT patients, to collect complementary
qualitative data. Finally, a retrospective chart review was conducted
of all patients consulted for ophthalmic evaluation prior to initiation
of HBOT over the past two years.
Results: The knowledge base of surveyed practitioners was
variable. Though 69% of respondents stated ophthalmic clearance
was necessary prior to initiation of HBOT, 63% of respondents had
only some or no knowledge of why such clearance was needed.
Additionally, of those who felt clearance was necessary, none were
able to correctly identify a contraindication to therapy without
prompting. A significant percentage misidentified glaucoma (43%)
and macular degeneration (14%) as contraindications to therapy. 60%
felt HBOT causes either short- or long-term harm to the eye. Finally,
an extremely low (2%) rate of outpatient follow-up of HBOT patients
was found for subsequent ophthalmic evaluation.
Conclusions: The current study reveals practice patterns instructive
to relevant practitioners involved with this common treatment. Gaps
in knowledge identified in our study regarding HBOT’s effects
upon the eye present targets for intervention, as well as a low rate
of outpatient follow-up examinations, and will inform a prospective
study of the direct ocular effects of HBOT, and an evidence-based
protocol regarding ophthalmic evaluation of these patients.
Commercial Relationships: Arjun J. Dirghangi, None; Brian K.
Lee, None; Amanda Allan, None; Krish Gandhi, None; Amanda
Y. Lehman, None
Program Number: 5574 Poster Board Number: A0183
Presentation Time: 8:30 AM–10:15 AM
Positioning-Related Ocular Complications of Minimally-Invasive
Radical Prostatectomies
Frank S. Siringo1, 2, Timothy Wen4, Christopher Diebert3, Benjamin
Spencer3, 4. 1Ophthalmology, University of Colorado School of
Medicine, Denver, CO; 2Ophthalmology, Columbia University
College of Physicians and Surgeons, New York, NY; 3Urology,
Columbia University College of Physicians and Surgeons, New York,
NY; 4Epidemiology, Columbia University Mailman School of Public
Health, New York, NY.
Purpose: To characterize positioning-related ocular complications
of robotic-assisted radical prostatectomy, (RARP), compared to
open radical prostatectomy (ORP), and laparascopic-assisted radical
prostatectomy (LRP).
Methods: A retrospective study using 2008-09 discharge information
data in the Healthcare Cost and Utilization Project Nationwide
Inpatient Sample (NIS). Patients diagnosed with prostate cancer
undergoing ORP, LRP, or RARP were included. Outcome measures
included a positioning-related complication, increased inpatient
costs, prolonged length of stay, and in-hospital mortality. Chi-square,
Fisher’s exact tests and multivariable logistic regression models
compared groups and assessed associations between covariates and
outcomes of interest.
Results: 175,699 patients diagnosed with prostate cancer underwent
radical prostatectomy in 2008-09; some 61,656 (35.1%) had
RARP, 2,682 (1.5%) LRP, and 111,361 (63.4%) ORP. A total
of 698 (0.4%) patients experienced a positioning complication.
Ocular complications were most common, (51.1%), with nonsignificant differences in rates of 0.22% in ORP/LRP, vs 0.17% in
RARP (p<0.110). Visually threatening ocular complication rates
(retinal vascular occlusion, angle closure glaucoma, ischemic
optic neuropathy, unilateral blindness) for ORP/LRP and RARP
were 0.15% and 0.07%, respectively. The only significant hospital
covariate was high annual RP case volume (>101 procedures), and it
was protective (OR = 0.45, 95% CI: 0.27, 0.72, p-value = 0.0011).
Conclusions: This study is one of the first to assess positioning
related ocular complications in a national population-based database.
Despite prolonged steep trendelenburg positioning during RARP,
vision-threatening ocular complications were more common in
ORP/LRP. The primary limitation of the study was the use of
administrative claims data, which lack detailed clinical information.
However, the large national sample size increases the generalizability
of our results.
Commercial Relationships: Frank S. Siringo, None; Timothy
Wen, None; Christopher Diebert, None; Benjamin Spencer, None
©2014, Copyright by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. Go to iovs.org to access the version of record. For permission
to reproduce any abstract, contact the ARVO Office at [email protected].
ARVO 2014 Annual Meeting Abstracts
Program Number: 5575 Poster Board Number: A0184
Presentation Time: 8:30 AM–10:15 AM
Morbidity and Mortality Conference Using an Anonymous
Audience Response System to Address Core Competencies in
Ophthalmology
Jessica Prince1, Lewis A. Eisen2, Jamie B. Rosenberg1.
1
Ophthalmology, Montefiore Med Ctr/Albert Einstein, Bronx, NY;
2
Critical Care, Montefiore Med Ctr/Albert Einstein, Bronx, NY.
Purpose: To assess whether implementation of Morbidity and
Mortality (M&M) conferences with anonymous audience response
system enhances residency education in the ACGME core
competencies.
Methods: Every other month starting June 2013, an M&M
conference was held for the ophthalmology department. Residents
presented patients who had suffered morbidity such as vision loss or
unexpected need for reoperation. In each presentation, the level of
training (student, resident, fellow, attending) was asked, followed by
5-7 multiple choice questions throughout the presentation addressing
one of the 6 core competencies. All questions were powered by www.
polleverywhere.com, which allowed each participant to respond by
text message and displayed all responses anonymously. The poll
responses were discussed in real time, including a determination
of which core competency was applicable. The last question in
each presentation asked audience members if this format of M&M
conference was useful. The responses were collected and analyzed.
Results: Three cases were presented during two conferences using
audience response polling software. During the case discussions,
the following issues were addressed: appropriate patient follow-up,
diagnostic evaluations, complete ophthalmologic examinations,
surgical errors, and post-operative complications. The questions
addressed all 6 core competencies: patient care, medical knowledge,
practice based learning and improvement, systems based practice,
professionalism, and interpersonal skills and communication. Sixteen
people attended the first conference and fifteen people attended
the second. Most audience members (54.8%) were residents, with
medical students (25.8%), fellows (3.2%), and attending physicians
(16.1%) also participating. The majority of participants (84.6%)
agreed or strongly agreed that the format of the M&M conference
was useful.
Conclusions: M&M conferences play an integral role in residency
education. Anonymous audience response systems can provide a
method of addressing all core competencies in a way that promotes
active participation.
Commercial Relationships: Jessica Prince, None; Lewis A. Eisen,
None; Jamie B. Rosenberg, None
Support: Research to Prevent Blindness
Methods: We identified all beneficiaries age ≥40 years old in a U.S.
managed care network who underwent ≥1 cataract surgeries from
2001-2011. Next, we identified all enrollees who required inpatient
hospitalization within 7, 14, 30, and 90 days following their initial
cataract surgery. Logistic regression was performed to identify
sociodemographic factors, medical comorbidities, and other factors
that increased the odds of requiring hospitalization following cataract
surgery.
Results: Among the 72,160 persons who underwent cataract surgery,
the proportions hospitalized within 7, 14, 30, and 90 days after
surgery were 0.3%, 0.6%, 1.3%, and 4.1%, respectively. Among the
subset of 11,795 persons who went into the surgery with no major
medical comorbidities, the proportions hospitalized within 7, 14, 30,
and 90 days were 0.12%, 0.22%, 0.45%, and 1.42%, respectively, or
roughly one third the rate. Enrollees with a prior history of congestive
heart failure, myocardial infarction, and renal disease had a 46%,
49%, and 62% increased odds of hospitalization within 7 days,
relative to those without these conditions (p<0.05 for all conditions).
Patients with dementia had a 117% increased odds of hospitalization
(p<0.01). The odds of hospitalization increased by 39% with the
presence of each additional comorbidity (p<0.0001). Those with
≥1 prior inpatient hospitalizations had a 124% increased odds of
hospitalization within 7 days of cataract surgery (p<0.0001).
Conclusions: The risk of hospitalization after cataract surgery is
low, and is very low among those with no major pre-existing medical
comorbidities. Opportunities may exist to reduce overall healthcare
costs without adversely impacting patient safety by limiting the need
for comprehensive preoperative evaluation and testing to those who
have serious pre-existing medical comorbidities.
Program Number: 5576 Poster Board Number: A0185
Presentation Time: 8:30 AM–10:15 AM
Determinants of hospitalization after cataract surgery in a large
managed-care United States population
Sophia Y. Wang1, 2, Taylor Blachley1, John Ayanian3, Paul P. Lee1,
Joshua D. Stein1. 1Department of Ophthalmology and Visual
Sciences, W. K. Kellogg Eye Center, University of Michigan, Ann
Arbor, MI; 2Department of Ophthalmology, University of California,
San Francisco, San Francisco, CA; 3Department of Health Care
Policy, Harvard Medical School, Boston, MA.
Purpose: Because little is known regarding the extent to which
patients undergoing outpatient cataract surgery are at risk for
requiring post-operative hospitalization, we sought to determine
the proportion of patients undergoing cataract surgery who require
subsequent inpatient hospitalization during the immediate postoperative period and to identify risk factors for hospitalization.
©2014, Copyright by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. Go to iovs.org to access the version of record. For permission
to reproduce any abstract, contact the ARVO Office at [email protected].
ARVO 2014 Annual Meeting Abstracts
This information would help train residents on how to provide eye
care safely and effectively.
Methods: A survey comprised of multiple choice and Likert-style
questions was printed, packed, and mailed to residents’ care of their
ophthalmology department addresses. The residents were given the
option to respond on paper using the pre-stamped return envelope
or online through a link provided to an identical online survey
created through DatStat Illume 5.1. Two follow-up reminder letters
were mailed in two-week intervals to those who had not responded.
Descriptive statistics were used to analyze the survey results.
Results: The survey was mailed to the 1049 US ophthalmology
residents; 365 completed the survey, yielding a response rate of
34.7%. The majority of the respondents (88.5%; 323/365) indicated
that their programs provided specific training in the prevention
surgical errors. Most commonly, this training consisted of observing
attending physicians (90%; 293/324) and adhering to OR policies
or protocols (91%; 295/324). Most respondents (73%; 237/323)
indicated that their training in the prevention of surgical errors was
not formally assessed. A majority of respondents (66%; 205/309)
reported that the most effective training was “Hands on experience
with guidance from attending physician.” Most respondents (78.9%;
276/363) agreed that their respective programs provided adequate
training on the prevention of surgical errors and 84% (305/363)
agreed that the public expected them to receive this training.
Conclusions: This survey provides an educational blueprint for
ophthalmic GME in preventable surgical errors that is responsive
to resident preferences. It suggests that ophthalmology residents
believed that hands-on experience with guidance from attending
physicians was the most effective training to minimize surgical
errors. This survey provides insight on how to improve the
educational experience for residents with the goal of lowering the risk
of preventable surgical errors in the future.
Commercial Relationships: Allison Chen, None; Annika Havnaer,
None; Paul B. Greenberg, None
Commercial Relationships: Sophia Y. Wang, None; Taylor
Blachley, None; John Ayanian, None; Paul P. Lee, None; Joshua
D. Stein, None
Support: National Eye Institute K23 Mentored Clinician Scientist
Award (1K23EY019511) (JDS); Research to Prevent Blindness
Physician Scientist Award (JDS)
Program Number: 5577 Poster Board Number: A0186
Presentation Time: 8:30 AM–10:15 AM
Training on the Prevention of Surgical Errors in Ophthalmology:
the Resident Perspective
Allison Chen, Annika Havnaer, Paul B. Greenberg. Alpert Medical
School of Brown University, Providence, RI.
Purpose: Surgical errors involving the wrong patient, wrong site (e.g.
wrong eye) or wrong procedure (e.g. wrong intraocular lens implant)
can have devastating consequences and are largely preventable by
adherence to specific protocols. Little is known about the resident
perspective on current training in the prevention of surgical errors.
Program Number: 5578 Poster Board Number: A0187
Presentation Time: 8:30 AM–10:15 AM
Improving the Transition to Ophthalmology Residency: A Survey
of First-Year Ophthalmology Residents
Travis Redd1, Akshay Thomas2, Thomas S. Hwang2. 1School of
Medicine, Oregon Health & Science University, Portland, OR;
2
Ophthalmology, Casey Eye Institute, Oregon Health & Science
University, Portland, OR.
Purpose: The transition from internship to residency is a highly
stressful period for ophthalmologists in training. This study quantifies
the impact of this process and identifies ways to ease the transition.
Methods: A 20-question electronic survey was sent to all directors
of accredited ophthalmology residency programs in the US for
distribution to their 1st year trainees. Statistical analysis included
frequency tables and comparative testing using χ2 and t-tests.
Results: 91 1st year residents responded, with an unknown
denominator (minimum response rate 20%). 63% identified
the transition to ophthalmologic training as more stressful than
internship. Residents did little advance preparation for ophthalmology
residency, and 50% regretted this. Comparative testing showed that
independent preparation (p 0.002) and doing an ophthalmology
rotation during internship (p 0.04) significantly reduced stress, and
that those doing a transitional year were significantly more likely to
do either (p 0.008). During orientation to ophthalmology residency,
trainees identified hands-on exam sessions as most helpful, and
didactic sessions as least helpful. Comparative testing showed that
orientations dedicating more time to exam skills (p 0.005) and
relationship-building (p 0.04) were associated with significantly
©2014, Copyright by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. Go to iovs.org to access the version of record. For permission
to reproduce any abstract, contact the ARVO Office at [email protected].
ARVO 2014 Annual Meeting Abstracts
lower stress, while residents who felt inadequately oriented to
logistics (p 0.01) and had relatively shorter buddy-call systems (p
0.02) were significantly more stressed.
Conclusions: This survey identified the transition to ophthalmology
residency as a highly stressful period. Key findings include: 1) Time
spent preparing for ophthalmology residency is crucial to easing this
transition. 2) A transitional PGY-1 year affords more opportunity to
prepare for ophthalmology residency than preliminary medicine or
surgery. 3) Orientations which provide more hands-on experience,
relationship-building, and familiarity with logistics reduce stress
among new residents, whereas longer orientations and didactic
teaching do not. 4) Longer buddy-call systems produce significantly
lower stress. These results can inform better independent preparation
on the part of trainees and development of more effective orientation
programs among ophthalmology residencies.
Stress experienced during the first two months of ophthalmology
residency, grouped by survey responses regarding level of preparation
and orientation experience.
Commercial Relationships: Travis Redd, None; Akshay Thomas,
None; Thomas S. Hwang, None
Program Number: 5579 Poster Board Number: A0188
Presentation Time: 8:30 AM–10:15 AM
Mindfulness Training to Increase Resilience and Decrease Stress
and Burnout in Ophthalmology Residents: a Pilot Study
Jullia A. Rosdahl1, Karen Kingsolver2. 1Ophthalmology, Duke
University, Durham, NC; 2Family Medicine, Duke University,
Durham, NC.
Purpose: Our hypothesis is that Mindfulness practice would decrease
the stress and burnout in resident physicians. This pilot study was
done to test this hypothesis in Ophthalmology residents and to inform
the design of a larger study including residents in other specialties at
our institution.
Methods: Ophthalmology residents completed an optional and
anonymous web-based survey before and after a Mindfulnessbased session, planned during a period thought to be stressful for
the residents. The web-based survey included 3 validated survey
instruments of stress and burnout: the Depression-Anxiety-Stress
Scale (DASS-21), the Oldenburg Burnout Inventory (including
Disengagement and Exhaustion subscales), and 10 questions from
the Cognitive Failures Questionnaire. The Mindfulness-based session
consisted of a 3-hour class introducing the concepts of Mindful
Awareness, with practical exercises for nurturing resilience. The
web-based survey was completed 1 week prior to the session, and 4-6
weeks after the session.
Results: Sixty-six percent of the residents completed the initial
survey (12 of 18 residents). 62% of the residents who participated
in the Mindfulness-based session completed both the initial survey
and the follow-up survey (5 of 8 residents). Baseline Stress scores
and baseline Burnout Disengagement subscale scores were within
the normal range; however, the residents had more symptoms of
Exhaustion on the Burnout subscale (8 of 12 residents with scores >
2.25). Of the residents who completed the before and after surveys, 4
of 5 showed improvements in Stress and Burnout metrics.
Conclusions: After a single Mindfulness-based session,
Ophthalmology residents showed improvements in Stress and
Burnout. Recommendations from the pilot study have been
included in the on-going larger study, including shorter sessions
(two 1-hour sessions instead of a single long session) and the use
of paper-based surveys with protected time for completion to aid in
study participation. Results from this pilot study support the use of
Mindfulness-based techniques for decreasing stress and burnout as
well as enhancing resilience in physicians.
Commercial Relationships: Jullia A. Rosdahl, None; Karen
Kingsolver, None
Support: Arnold P. Gold Foundation (KK), NEI K12 grant
EY016333-08 (JAR)
Program Number: 5580 Poster Board Number: A0189
Presentation Time: 8:30 AM–10:15 AM
Breaking Bad News: Evaluating the Impact of a
Multidisciplinary Training Program for Ophthalmology
Residents
Sarah M. Hilkert1, 2, Shelly G. Jain1, Colleen M. Cebulla1, Sheryl
A. Pfeil1, Susan C. Benes1, Janie Boyer1, Shira L. Robbins2.
1
Ophthalmology, Havener Eye Institute, the Ohio State University,
Columbus, OH; 2Ophthalmology, Ratner Children’s Eye Center,
University of California, San Diego, San Diego, CA.
Purpose: Breaking bad news (BBN) is a common occurrence in
medicine, and ophthalmologists are not exempt. To the best of our
knowledge, there are no formal programs to train ophthalmologists
©2014, Copyright by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. Go to iovs.org to access the version of record. For permission
to reproduce any abstract, contact the ARVO Office at [email protected].
ARVO 2014 Annual Meeting Abstracts
in this important task. We implemented a multidimensional training
program to emphasize communication skills during difficult
conversations with ophthalmology patients. The purpose of this
study was to evaluate the impact of such formal training on BBN for
ophthalmology residents.
Methods: Residents at the Havener Eye Institute participated in
a Grand Rounds series on BBN. This included a practice session
delivering a difficult diagnosis to 3 standardized (actor) patients, a
lecture on the SPIKES protocol for BBN, and a panel discussion with
3 real ophthalmology patient volunteers. To assess the efficacy of this
program, residents were invited to complete anonymous, voluntary,
IRB-approved surveys. After Grand Rounds, residents were asked
to evaluate each aspect of the program using a 5-point Likert scale.
Before and after training, residents were asked to report their current
confidence level with respect to 12 different aspects of the bad
news encounter, each derived from the original SPIKES protocol.
Responses were compared using the matched-pairs ordinal test. The
impact of this training program was evaluated by the overall rating of
the program and by improvements in resident confidence.
Results: Eleven ophthalmology residents completed the training. All
11 reported that they would use the SPIKES protocol in the future
with ophthalmology patients. The mean Likert score for the overall
program was 4.5. Most residents (67%) felt that the patient panel
discussion was the most useful aspect of the program. Comparing
matched surveys from before and after training, resident confidence
in BBN increased significantly (P < 0.05) in 7 of the 12 measures.
The most significant improvement was noted in the measure “setting
realistic expectations without destroying hope” (p = 0.0095).
Conclusions: Formal training can improve resident confidence;
therefore, teaching communication skills for BBN should be
integrated into ophthalmology residency education. As part of
this training, the SPIKES protocol may serve as a useful template.
Volunteer patients, who are willing to share their personal
experiences, may offer valuable wisdom and insight into the bad
news encounter.
Commercial Relationships: Sarah M. Hilkert, None; Shelly G.
Jain, None; Colleen M. Cebulla, None; Sheryl A. Pfeil, None;
Susan C. Benes, None; Janie Boyer, None; Shira L. Robbins, None
Support: This project has been supported in part by the Ohio Lions
Eye Research Foundation - Grant K08EY022672, by the Clinical
Skills Education and Assessment Center at the Ohio State University,
and by P30EY022589 core grant funding at UC San Diego.
Program Number: 5581 Poster Board Number: A0190
Presentation Time: 8:30 AM–10:15 AM
Gender trends and practice differences of Canadian
ophthalmologists
Yvonne M. Buys1, Chryssa McAlister1, Yaping Jin1, 2, Rosa BragaMele1, Béatrice Des Marchais3. 1Ophthalmology & Vision Sciences,
University of Toronto, Toronto, ON, Canada; 2Dalla Lana School
of Public Health, University of Toronto, Toronto, ON, Canada;
3
Médecine-Dép. d, Université Lava, Quebec City, QC, Canada.
Purpose: To describe the changing demographic of ophthalmologists
in Canada and gender differences in practice patterns and lifestyle.
Methods: The Canadian Institute for Health Information database
was used to determine the yearly number, mean age and gender
of licensed ophthalmologists and all other physicians in Canada
from 1970-2011. A 48-item questionnaire was sent to Canadian
ophthalmologists asking about practice patterns and lifestyle issues.
Results were analyzed using χ2 and Fisher’s exact test where
appropriate.
Results: The ophthalmology workforce is aging from a mean
age of 44.7 in 1970 to 53.1 in 2011. The proportion of female
ophthalmologists has also increased from 3.1% in 1970 to 21.4%
in 2011. Compared to all other physicians, ophthalmologists were
significantly older by a mean of 2.4±0.9 years and the proportion
of women was significantly less (36.8% for all other physicians in
2011) with the gender gap between ophthalmologists and all other
physicians increasing from 4.8% in 1970 to 16.3% in 2011.
©2014, Copyright by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. Go to iovs.org to access the version of record. For permission
to reproduce any abstract, contact the ARVO Office at [email protected].
ARVO 2014 Annual Meeting Abstracts
385 (102 female) ophthalmologists (30% response rate) completed
the survey. 51% of women reported operating <2 days per month
as compared to 36% of men (p=0.01) despite similar clinical hours.
No statistically significant differences were found in other practice
pattern parameters including laser refractive surgery, hospital
affiliation, university appointment/rank and # of peer-review
publications.
90% of males and 81% of females report having ≥1 child, but men
report larger families (p<0.001). Women are commonly the primary
caregivers while men report their partners as primary caregivers
(p<0.001). Men report having part-time (41%) or unemployed
partners (15%) who work in allied healthcare professions (p<0.001);
women more commonly report full-time employed partners (72%)
who are physicians or not in healthcare (p<0.001). 52% of women are
unhappy with the amount of parental leave (p<0.001). 51% of women
feel childbearing slowed or markedly slowed career progress, as
compared to 15% of men (p<0.001).
Conclusions: Ophthalmology workforce planning needs to consider
the aging and feminization of the workforce since the way older
physicians and female physicians practice will assume greater
influence. The cause of differences in gender practice patterns, such
as women reporting significantly less surgical time, needs to be
explored to determine if this is due to barriers or choice.
Commercial Relationships: Yvonne M. Buys, None; Chryssa
McAlister, None; Yaping Jin, None; Rosa Braga-Mele, None;
Béatrice Des Marchais, None
Program Number: 5582 Poster Board Number: A0191
Presentation Time: 8:30 AM–10:15 AM
A systematic review and cost-effectiveness analysis of disinfection
methods for Goldmann Applanation Tonometry
Omar Akhtar1, 2, Hargurinder Singh1, 2, William Hodge1, 2.
1
Ophthalmology, Western University, London, ON, Canada;
2
Epidemiology and Biostatistics, Western University, London, ON,
Canada.
Purpose: Goldmann applanation tonometry presents the problem
of being one of the most widely used pieces of equipment in the
ophthalmic clinic and a known risk factor for the transmission of
epidemic keratoconjunctivitis. The purpose of the current review is
to assess the effectiveness of three methods of disinfection – alcohol
swabs, immersion in peroxide and the use of disposable prisms. An
economic evaluation is undertaken to assess the cost-effectiveness of
the three alternatives. In doing so, we contribute an evidence-based
overview of the issue at an opportune time, as several jurisdictions
are developing protocols regarding tonometer tip disinfection.
Methods: A comprehensive literature review was undertaken with
a librarian, comprising searches of 6 electronic databases and hand
searches of the grey literature. A three-level screening process was
undertaken by two reviewers according to pre-specified inclusion/
exclusion criteria. Values from included papers were used to inform
a cost-effectiveness analysis undertaken using a decision tree model
implemented in TreeAge. The analysis was undertaken from the
hospital perspective and included all equipment and labour costs.
Results: Synthesis of in vitro data indicates that all three are
plausible methods of disinfection with a 64% reduction in log
growth of EKC when peroxide is used compared to alcohol swabs.
The ICERs from the cost-effectiveness analysis were $12,000/case
averted using peroxide and $61,000/case averted with Tonosafe as
compared to alcohol.
Conclusions: Assuming clinical infection rates match in vitro
disinfection data, the cost of bleach is high and the cost of Tonosafe
is unacceptably high to reduce one potential case of adenoviral
keratoconjunctivitis.
Commercial Relationships: Omar Akhtar, None; Hargurinder
Singh, None; William Hodge, None
Support: AMOSO Innovation Fund (INN 12-010). Ontario, Canada;
Ontario Graduate Scholarship, Canada
Program Number: 5583 Poster Board Number: A0192
Presentation Time: 8:30 AM–10:15 AM
Evaluating surgical efficiency in the transition from the Accurus
to the Constellation Vision System for microincisional vitrectomy
surgery (MIVS) from an operations management perspective
Daniel Gologorsky1, Timothy G. Murray1, 2. 1Bascom Palmer Eye
Institute, Miami, FL; 2Murray Ocular Oncology & Retina, Miami,
FL.
Purpose: This study compares surgical efficiencies, complications,
and user perceptions associated with the transition from the Accurus
to the next generation Constellation platform. The results are
evaluated from an operations management framework.
Methods: Electronic health records were obtained for all vitreoretinal
surgical procedures at the Bascom Palmer Eye Institute during two
discrete 12-month time periods, each reflecting dedicated usage of
the Accurus and Constellation Vision systems. Data were limited
to a single surgeon and evaluated on a number of metrics related
to surgical efficiency. All records were evaluated for intraoperative
complications.
Results: Over a two-year study period, 514 eligible patients who
underwent MIVS were identified: 281 with the Accurus and 233
with the Constellation. The transition in platforms was accompanied
by statistically significant measures: an increase in the total number
of patients operated on per day, a decrease in operating room
time, and a decrease in MIVS procedure time. Combined MIVS/
phacoemulsification surgery saw similar declines in surgical room
and procedure times. No increases in surgery-related complications
were noted by quality assurance reviews.
Conclusions: Statistically significant improvements were noted in
three important measures of surgical efficiency: operative number of
patients per day, operating room time, and surgical procedure time.
These improvements reflect the positive impact of the combined
and integrated, posterior and anterior, Constellation surgical
platform. Hospital quality assurance review and surgeon evaluation
of operative complications showed no increased safety or setup
concerns during the transition. Operations management and queuing
theory maintain that such an improvement in surgical capacity alone
should lead to a valuable decrease in patient wait times. Revenues
can be generated by increasing surgical volume, assuming the
additional category of procedure yields a positive net present value.
Increased revenues can be shunted toward alleviating bottlenecks
in production by hiring staff or purchasing additional equipment.
Ultimately, improved efficiency can be geared towards improving
quality of care, decreasing costs, increasing revenues, improving
employee conditions, or providing a valuable marketing opportunity.
©2014, Copyright by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. Go to iovs.org to access the version of record. For permission
to reproduce any abstract, contact the ARVO Office at [email protected].
ARVO 2014 Annual Meeting Abstracts
Commercial Relationships: Alexander G. Miller, None; Llewelyn
Rao, None; Douglas Y. Rowland, None; Joan Hornik, None
Commercial Relationships: Daniel Gologorsky, None; Timothy G.
Murray, None
Program Number: 5584 Poster Board Number: A0193
Presentation Time: 8:30 AM–10:15 AM
The Effect of Requiring Patient-specific Prescriptions on the
Utilization of Intravitreal Bevacizumab
Alexander G. Miller, Llewelyn Rao, Douglas Y. Rowland, Joan
Hornik. Retina Associates of Cleveland, Beachwood, OH.
Purpose: To evaluate the change in the use of bevacizumab (B)
following the requirement for patient-specific prescriptions (PSP).
Methods: We retrospectively analyzed the utilization of B, 0.5mg
ranibizumab (R), 0.3mg ranibizumab (R-DME), and aflibercept (A)
within a nine-member single retinal specialty practice over a threemonth period both before (May-July 2012 [pre-PSP]) and after (MayJuly 2013 [post-PSP]) the requirement of PSP for B by the Ohio
Board of Pharmacy. Using a Likert Scale (LS) approach (strongly
disagree to strongly agree), we surveyed all nine physicians in this
group practice regarding three possible reasons (PSP, efficacy, safety)
for the change in drug utilization. The relative proportions were
calculated; the 95% confidence intervals for those estimates were
calculated using the modified Wald method. The chi-squared test of
proportions was used to compare frequencies in different years. P <
0.05 was taken as being statistically significant.
Results: There was a significant decrease in the number of B
injections (Inj), going from 2,752 (61.32% of pre-PSP Inj) to 1,503
(28.61% of post-PSP Inj), a change of 1,249 B injections (-29.35%
as a percent of B total injections over both years). There was a
significant increase in the number of R injections, going from 1,122
(25% of pre-PSP Inj) to 1,838 (34.99% of post-PSP Inj), a change of
716 R injections (24.19% as a percent of R total Inj over both years).
There was a significant increase in the number of R-DME Inj, going
from 0 (0% of pre-PSP Inj; R-DME became FDA-approved in August
2012) to 429 (4.40% of post-PSP Inj), a change of 429 R-DME Inj
(100% as a percent of R-DME total Inj over both years). There was a
significant increase in the number of A Inj, going from 614 (13.68%
of pre-PSP Inj) to 1,483 (28.23% of post-PSP Inj), a change of 869 A
Inj (41.44% as a percent of A total Inj over both years).
The LS results showed the following responses for decreased B
use: PSP (median category, 1st quartile, 3rd quartile [M, 1st, 3rd]:
all strongly agree), safety (M, 1st, 3rd : strongly disagree, strongly
disagree, disagree) and efficacy (M, 1st, 3rd: all disagree).
Conclusions: There was significantly less B utilization year over year
following the requirement for PSP of B. This change corresponded
more with the notion of PSP requirement than either safety or
efficacy concerns in this practice.
Program Number: 5585 Poster Board Number: A0194
Presentation Time: 8:30 AM–10:15 AM
Use of Statistical Analyses in the Ophthalmic Literature
Renato Lisboa, Daniel Meira-Freitas, Andrew J. Tatham, Amir
Marvasti, Lucie Sharpsten, Felipe A. Medeiros. Ophthalmology,
Hamilton Glaucoma Center, La Jolla, CA.
Purpose: To identify the most commonly used statistical analyses
in the ophthalmic literature and to determine the likely gain in
comprehension of the literature that readers could expect if they were
to sequentially add knowledge of more advanced techniques to their
statistical repertoire.
Methods: All articles published from January 2012 to December
2012 on Ophthalmology, American Journal of Ophthalmology and
Archives of Ophthalmology were reviewed. A total of 780 peerreviewed articles were included in this cross sectional study. Two
reviewers examined each article and assigned categories to each one
depending on the type of statistical analyses used. Discrepancies
between reviewers were resolved by consensus. Total number and
percentage of articles containing each category of statistical analysis
were obtained. Additionally we estimated the accumulated number
and percentage of articles that a reader would be expected to be able
to interpret depending on their statistical repertoire.
Results: Readers with little or no statistical knowledge would be
expected to be able to interpret the statistical methods presented in
only 20.8% of articles. In order to understand more than half (51.4%)
of the articles published, readers were expected to be familiar with at
least 15 different statistical methods. Knowledge of 21 categories of
statistical methods was necessary to comprehend 70.9% of articles,
while knowledge of more than 29 categories was necessary to
comprehend more than 90% of articles. Retina and glaucoma showed
a tendency for using more complex analysis when compared to
cornea.
Conclusions: Readers of clinical journals in ophthalmology need to
have substantial knowledge of statistical methodology to understand
all the results of published studies in the literature. The results of
this study could provide guidance to direct the statistical learning of
clinical ophthalmologists, researchers and educators involved in the
design of courses for residents and medical students.
Commercial Relationships: Renato Lisboa, None; Daniel MeiraFreitas, None; Andrew J. Tatham, None; Amir Marvasti, None;
Lucie Sharpsten, None; Felipe A. Medeiros, Alcon (F), Allergan
(F), Carl-Zeiss Meditec, Inc (F), Heildelberg Engineering, GmBH
(F), Reichert (F), Topcon (F)
Program Number: 5586 Poster Board Number: A0195
Presentation Time: 8:30 AM–10:15 AM
Comparing Quality Performance Measures Publicly Reported by
Ophthalmic Organizations
Monica M. Michelotti1, Jennifer S. Weizer1, Joshua D. Stein1, Simon
P. Kelly4, Declan W. Flanagan2, Anne C. Odergren3, Paul P. Lee1,
Melanie Hingorani2. 1University of Michigan, Ann Arbor, MI;
2
Moorfields Eye Hospital, London, United Kingdom; 3St Erik’s
Eye Institute, Stockholm, Sweden; 4Royal Bolton Hospital, Bolton,
United Kingdom.
Purpose: There is increasing global interest in evaluating health care
quality by measuring clinical and patient-reported outcomes in all
specialties and publishing these outcomes for the medical field and
for the lay public. Several ophthalmic provider groups now publicly
report performance, but the metrics used differ. Better understanding
may advance work in improving the care of ophthalmic patients.
©2014, Copyright by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. Go to iovs.org to access the version of record. For permission
to reproduce any abstract, contact the ARVO Office at [email protected].
ARVO 2014 Annual Meeting Abstracts
Methods: An online search for quality, especially outcomes, data
for international ophthalmic institutions was performed; results
were compared with published outcomes and performance data. The
World Association of Eye Hospitals provided additional unpublished
hospital-specific measures. Data were available from Aravind Eye
Hospital, Cole Eye Institute, European Registry of Quality Outcomes
for Cataract and Refractive Surgery, University of Michigan
W.K. Kellogg Eye Center, Massachusetts Eye and Ear Infirmary,
Moorfields Eye Hospital, Singapore National Eye Center, and St
Erik’s Eye Hospital.
Results: Multiple institutions reported similar complication rates
for ophthalmic surgery. All measured wound infection rates and 30
day unplanned reoperation rates. Endophthalmitis rates after cataract
surgery ranged from 0.00-0.09% (n=8). Most institutions reported
either postoperative visual acuity (n=6) or difference in refraction
from target after cataract surgery (n=4). The most commonly reported
outcome was best-corrected visual acuity better than or equal to
20/40 (range 84-100%, n=3). Variance in reporting postoperative
visual acuity outcomes occurred in the choice of measuring final or
change in visual acuity, best- or uncorrected visual acuity, and timing
of measurements. Eight institutions reported 22 cataract surgery
outcomes and three reported rates for only uncomplicated patients.
Subspecialty outcomes demonstrated similar trends. Differences in
timing and exclusion criteria limited direct comparisons.
Conclusions: Because published outcomes and quality of care data
in ophthalmology varies by institution, understanding and identifying
metrics that all might agree upon is crucial. Comparing outcomes
by international ophthalmic institutions can provide insight for
assessment for a broader and lay audience, helping ophthalmologists
benchmark services in the timely quest for quality and safety.
Commercial Relationships: Monica M. Michelotti, None; Jennifer
S. Weizer, None; Joshua D. Stein, None; Simon P. Kelly, None;
Declan W. Flanagan, None; Anne C. Odergren, None; Paul P. Lee,
Board of Advisors of AAO Hoskins Center on Quality and Patient
Safety. (S), University of Michigan, Chair (E); Melanie Hingorani,
None
Support: Michigan Ophthalmology Trainee Career Development
Award
Program Number: 5587 Poster Board Number: A0196
Presentation Time: 8:30 AM–10:15 AM
Quality Measures Within a Group Retina Practice - Cultural
Shift and Clinical Outcomes
Brian Joondeph. Colorado Retina Associates, Denver, CO.
Purpose: The purpose of this project is to demonstrate the feasibility
of a group medical practice instituting several quality measures, both
clinical and nonclinical. This involves not only the actual measures,
but also the cultural shift within the practice, which supports quality
measurement and improvement.
Methods: Clinical data within an 11-physician retina-only practice
was obtained over the year 2012 through the electronic medical
record system. Specifically the one operation success rate for surgical
repair of uncomplicated retinal detachment (RD) and macular
hole (MH) were recorded, namely success 3 months following
surgery. Nonclinical measures were based on two survey questions,
measuring patient satisfaction with the practice and their individual
physician, using a survey of 3% of patient visits for the year. Serious
reportable events (SPE) for the year were collected, specifically
intravitreal injections performed on the wrong eye or using the wrong
medication.
Results: Physicians within the practice showed little interest in the
project but offered no resistance. The single operation success rates
for repair of RD was 80% and for MH was 88%, with significant
variation between physicians. Patient satisfaction scores noted 95%
satisfaction with the practice and physicians. SPEs occurred with an
incidence of 0.0125%. Fewer than half of the physicians wanted to
know their surgical outcomes upon completion of the project.
Conclusions: Quality can be measured within a group retina practice
but the cultural shift toward systematic quality measurement remains
challenging. Measures of quality and value are important new metrics
under healthcare reform and such data may provide advantages to
practices under new payment mechanisms. Ultimately it is better for
medical practices to proactively measure quality than to allow the
government or payers to perform these measures using arbitrary or
flawed metrics.
Commercial Relationships: Brian Joondeph, None
Program Number: 5588 Poster Board Number: A0197
Presentation Time: 8:30 AM–10:15 AM
Assessing the development of guidelines for primary open angle
glaucoma using the AGREE II instrument
Todd H. Driver1, Paul P. Lee2, Yvonne Ou3. 1Medical School,
University of California, San Francisco, San Francisco, CA;
2
Department of Ophthalmology, University of Michigan Kellogg Eye
Center, Ann Arbor, MI; 3Department of Ophthalmology, University of
California, San Francisco, San Francisco, CA.
Purpose: As guidelines become increasingly incorporated into
clinical practice through “best practice” efforts and the adoption of
electronic health records, understanding the methods used for their
development may be helpful in assessing their utility. We previously
evaluated primary open-angle glaucoma (POAG) guidelines with
the AGREE instrument and found that there was opportunity to
improve guideline development. We re-evaluated available national
and supranational POAG guidelines to reflect changes in both the
guideline evaluation instrument and the guidelines themselves.
Methods: Four glaucoma fellowship-trained independent reviewers
evaluated the current POAG guidelines published by the American
Academy of Ophthalmology (AAO), South East Asia Glaucoma
Interest Group (SEAGIG), European Glaucoma Society (EGS), and
the UK National Institute for Health and Clinical Excellence (NICE)
using the criteria prescribed by the Appraisal of Guidelines for
Research and Evaluation II instrument (AGREE II). Both printed and
online sources were included in the reviews.
Results: Appraisal using the AGREE II instrument demonstrated
that the AAO guideline scored favorably (>70%) in the domains of
scope and purpose, rigor of development, clarity of presentation,
applicability, and editorial independence, while no domain scored
unfavorably (<50%). The SEAGIG guideline scored favorably in the
scope and purpose domain, while scoring unfavorably in the domains
of stakeholder involvement, rigor of development, applicability, and
editorial independence. The EGS guideline scored favorably in the
domains of clarity of presentation and applicability, while scoring
unfavorably in the domains of scope and purpose, stakeholder
involvement, and rigor of development. The NICE guideline scored
favorably in all domains.
Conclusions: The development of POAG guidelines has improved
over time even while the requisite characteristics for desired
development have been strengthened. Nevertheless, opportunities
exist for guidelines to continue to better meet AGREE II
recommended characteristics.
Commercial Relationships: Todd H. Driver, None; Paul P. Lee,
GlaxoSmithKline (I), Hoskins Center on Quality and Patient Safety
of AAO (S), Merck (I), Pfizer (I); Yvonne Ou, None
©2014, Copyright by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. Go to iovs.org to access the version of record. For permission
to reproduce any abstract, contact the ARVO Office at [email protected].
ARVO 2014 Annual Meeting Abstracts
Program Number: 5589 Poster Board Number: A0198
Presentation Time: 8:30 AM–10:15 AM
Time Motion Study of Electronic Health Record (EHR)
Documentation Time in Ophthalmology Exams
Michelle Hribar1, Sarah Read-Brown2, Maha Pasha1, 2, Leah
Reznick2, Thomas Yackel1, Michael F. Chiang2, 1. 1Medical Informatics
and Clinical Epidemiology, Oregon Health and Science University,
Portland, OR; 2Ophthalmology, Case Eye Institute, Oregon Health
and Science University, Portland, OR.
Purpose: Popular perception is EHR adoption in ophthalmology has
resulted in increased time spent documenting during patient exams.
Documentation time with EHR has been shown to be worse than with
paper charts, with much of the documentation time occurring after the
exam is completed [Chan et al, Am J Ophthalmol 2013], [Chiang et
al, Trans Am Ophthalmol Soc 2013]. The purpose of this study is to
measure the proportion of time spent using an EHR during a patient
encounter using time-motion methods.
Methods: We performed a time-motion study of patient exams in
the Casey Eye Institute at Oregon Health & Science University.
Using paper forms and time stamping software (Emerald Timestamp;
Emerald Sequoia, Los Gatos, CA), data was collected by 2 observers
who shadowed the ophthalmologist. We recorded the duration of
time the ophthalmologist spent documenting in the EHR, talking, and
examining the patient. If the ophthalmologist was multitasking and
talking while either examining or documenting, this was recorded
exclusively as examination or documentation time. Times spent doing
each of the three activities was tabulated during each patient exam.
Patient encounters were categorized for analysis as either “routine”
or “complex” in the opinion of the ophthalmologist. An exam was
considered complex if the diagnosis was difficult or if the patient was
challenging (e.g. a crying infant).
Results: Our observations represent 25 patient exams, on 4 days of
clinic, from a single pediatric ophthalmologist. We found that the
mean proportion of time spend documenting was 18% compared to
30% examining and talking 45% spend talking. This corresponded
to mean ±SD times of 2.1 ± 1.1 minutes for documenting, 3.9 ± 2.7
minutes for examining, and 5.4 ± 2.3 minutes for talking (Table 1).
Between routine vs. complex encounters, there were no statisticallysignificant differences in documentation or talking times between
complex vs. routine exams (p = 0.1276, 0.2808 respectively), but
there were nearly statistically-significant differences in times required
for examining (p=0.0513).
Conclusions: EHR documentation time occupies a significant
proportion of ophthalmology patient encounters. Future EHR designs
that streamline data entry will help reduce the amount of time spent
documenting during ophthalmologic exam, and allow more time for
examination and communication.
Support: NLM Funding Grant 2 T15 LM 7088-21 and unrestricted
departmental funding from Research to Prevent Blindness (New
York, NY).
Program Number: 5590 Poster Board Number: A0199
Presentation Time: 8:30 AM–10:15 AM
Comparing iPhone and Android Smartphone Application
Development in Ophthalmology Using the Ocular Trauma Score
Application as a Prototype
Emily Su1, Kateki Vinod1, Shiang Luong2, Omar B. Ozgur3, Paul
Latkany1, Omar Ozgur1. 1Ophthalmology, The New York Eye and Ear
Infirmary, New York, NY; 2University of California, Irvine, Irvine,
CA; 3Irvine High School, Irvine, CA.
Purpose: Apple® (iOS) and Android® (aOS) based smartphones are
in use by 1.3 billion individuals at the start of 2014 and by 87% of
physicians as part of their professional activity. In one quarter annum,
52.1% of US smartphone subscribers used aOS vs. 43.5% iOS. The
number of total smartphone applications (apps) available on aOS
and iOS are similar. Apps provide unique opportunities to optimize
and predict outcomes of ophthalmology patients. Using a prototype
application we built, the Ocular Trauma Score App (OTSA), we
evaluate the ease of development, cost and time to distribution on
both platforms. The Ocular Trauma Score (OTS) allows physicians
to predict visual acuity outcomes based on initial exam parameters
after eye trauma. Our OTSA provides a user-friendly interface to
input data points based on exam findings in eye trauma patients in a
template manner to calculate their OTS. Our null hypothesis is that
there would not be identical development time between aOS and iOS
for identical tasks.
Methods: We measured the total time and cost for development
and distribution of OTSA on iOS and aOS. We utilized an Agile
Development Process for code development of identical deliverables
on aOS and iOS. We masked hours utilized to the developers.
Results: Although we found similar OTSA production time and
effort on both iOS and aOS, distribution time and cost were different.
For each sprint with an Agile Development Process, a time of
3-4 days was sufficient to complete code development for each
platform. However, distribution cost required a yearly $99 USD
developer fee for iOS, and only an initial $25 USD fee for aOS.
OTSA also required a submission and approval process of 7-14 days
for publication and updates on the iOS app store, but not for aOS.
Functionality and usability were comparable between iOS and aOS.
Conclusions: Using OTSA as an example, we demonstrate that
app development requires customization for each platform, and
less expense and distribution time for aOS. Given current trends
suggesting similar market share between iOS and aOS in the
US, development for both platforms is necessary for widespread
distribution. The evolution of ophthalmic smartphone and tablet
based apps must keep pace with the increasing use of these devices
by ophthalmologists in patient evaluation and management.
Commercial Relationships: Michelle Hribar, None; Sarah ReadBrown, None; Maha Pasha, None; Leah Reznick, None; Thomas
Yackel, None; Michael F. Chiang, None
©2014, Copyright by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. Go to iovs.org to access the version of record. For permission
to reproduce any abstract, contact the ARVO Office at [email protected].
ARVO 2014 Annual Meeting Abstracts
Fig. 1 OTSA patient data input.
Fig. 2 OTSA data score summary.
Commercial Relationships: Emily Su, None; Kateki Vinod, None;
Shiang Luong, None; Omar B. Ozgur, None; Paul Latkany, None;
Omar Ozgur, None
Program Number: 5591 Poster Board Number: A0200
Presentation Time: 8:30 AM–10:15 AM
Feasibility of using OpenEyes to identify potentially eligible
patients for clinical research
Annelie Small, Bill Aylward, Ratna Khan, Carlos E. Pavesio, Maria
Pefkianaki, Praveen J. Patel. NIHR Moorfields Biomedical Research
Centre, Moorfields Eye Hospital NHS Foundation Trust and UCL
Institute of Ophthalmology, London, United Kingdom.
Purpose: Identification of potentially eligible patients for clinical
trials is vital for the success of undertaking clinical research and to
ensure the widest possible access to new and advanced therapies
through research. A new electronic patient record for ophthalmology
(OpenEyes), which is modular and searchable has recently been
developed and introduced at Moorfields Eye Hospital. One of the
key strength of the software is in the clinical research arena where it
can be used to identify patients who may be eligible for clinical trials
therefore potentially reducing the time taken and resource deployed
in meeting recruitment goals for clinical trials while also enabling the
widest possible access of clinical trials to potentially eligible patients.
Methods: In this feasibility analysis, we identified two clinical trials
for the treatment of rare retinal conditions: one trial for patients
with multifocal choroiditis and panuveitis patients and the other
for patients with Behςet’s disease patients who are taking 20mg
of Prednisolone orally. Secondly several search items mapped
to the inclusion criteria of the trials were identified plus a time
frame for the search period. OpenEyes was then used to search the
ophthalmology patient record database for patients at Moorfields
Eye Hospital who meet the search criteria. Finally, a sub-investigator
applied the inclusion criteria and exclusion criteria from the clinical
trial protocols to the electronic patient record to confirm potential
eligibility.
Results: A list of 58 patients for the Behςet’s disease trial [search
time frame = 4 months] of which 5 are eligible for the trial and a list
of 33 patients for the multifocal choroiditis trial [search time frame
= 2 months] of which 1 is eligible for the trial was generated. The
time spent on generating the lists was ≤ 3 minutes in total, including
inputting search items and the system search.
Conclusions: This confirms the feasibility of using OpenEyes
successfully to identify patients who may be eligible for clinical
trials. This novel, searchable system of the ophthalmology database
has great potential to rapidly identify patients who may be eligible
for clinical trials at Moorfields Eye Hospital thereby enabling more
patients to access new therapies through clinical research while
potentially reducing the time and resource needed to complete
clinical trial recruitment.
Commercial Relationships: Annelie Small, None; Bill Aylward,
None; Ratna Khan, None; Carlos E. Pavesio, None; Maria
Pefkianaki, None; Praveen J. Patel, None
Support: The research was funded by the National Institute for
Health Research (NIHR) Biomedical Research Centre at Moorfields
Eye Hospital NHS Foundation Trust and UCL Institute of
Ophthalmology
Program Number: 5592 Poster Board Number: A0201
Presentation Time: 8:30 AM–10:15 AM
Accuracy of the International Classification of Diseases, 9th
Revision (ICD-9) as a research tool for the identification
of patients with polymyalgia rheumatica and concurrent
noninfectious uveitis
Eduardo Uchiyama1, Sepideh Faez1, Humzah Nasir1, Sebastian H.
Unizony2, George N. Papaliodis1, Lucia Sobrin1. 1Ophthalmology,
Massachusetts Eye and Ear Infirmary, Boston, MA; 2Rheumatology,
Massachusetts General Hospital, Boston, MA.
©2014, Copyright by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. Go to iovs.org to access the version of record. For permission
to reproduce any abstract, contact the ARVO Office at [email protected].
ARVO 2014 Annual Meeting Abstracts
Purpose: To report the accuracy of the International Classification
of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)
codes in a hospital-based database for for identifying patients with
polymyalgia rheumatica (PMR) and concurrent noninfectious uveitis.
Methods: IRB approval for database queries and chart review was
obtained. Multiple queries for patients with PMR (ICD-9-CM code
725.00) and all types of uveitis (anterior, intermediate, posterior,
and panuveitis) were executed in the database of two large, general
teaching hospitals using the Research Patient Data Registry (RPDR).
Patients with infectious uveitis or other rheumatologic conditions
were excluded. Patients who suffered from both PMR and concurrent
ocular inflammatory disease were identified. The medical records
of these patients were reviewed to confirm if the ICD-9 codes listed
reflected the actual conditions described in the chart.
Results: The RPDR query produced 10697 patients with the ICD-9
code for PMR and 4154 patients with ICD-9 codes for noninfectious
uveitis. The number of patients with both PMR and noninfectious
uveitis by ICD-9 codes was 66. Upon detailed review of medical
records of these 66 patients, 31 actually had a clinical diagnosis of
PMR, 37 actually had noninfectious uveitis, and only 19 had PMR
with concurrent noninfectious uveitis. The patients who did not
actually have the clinical diagnosis indicated by their ICD-9 code
often had nonspecific joint pains or other causes of red eye instead of
PMR and uveitis, respectively.
Conclusions: While the use of ICD-9 codes has been validated for
medical research of common diseases, our results suggest ICD-9
codes may be of limited value for epidemiological investigations of
rarer diseases which can be more difficult to diagnose. The ICD-9
codes for two rarer diseases, PMR and uveitis, did not reflect the true
clinical problem in a large proportion of patients in this study.
Commercial Relationships: Eduardo Uchiyama, None; Sepideh
Faez, None; Humzah Nasir, None; Sebastian H. Unizony, None;
George N. Papaliodis, None; Lucia Sobrin, None
Support: Massachusetts Lions Eye Research Fund
Program Number: 5593 Poster Board Number: A0202
Presentation Time: 8:30 AM–10:15 AM
Uses of the Word “Macula” in Written English, 1400-Present
Stephen G. Schwartz1, Christopher T. Leffler2. 1Bascom Palmer
Eye Institute, Univ of Miami Miller Sch of Med, Naples, FL;
2
Ophthalmology, Virginia Commonwealth University, Richmond, VA.
Purpose: To review common uses of the word “macula” in written
English from the early 1400s through the present day.
Methods: The word “macula” was searched in multiple databases,
including the Early English Books Online Text Creation Partnership,
America’s Historical Newspapers, the Gale Cengage Eighteenth
Century Collections, the Oxford English Dictionary, Google Scholar,
and the Google n-grams database.
Results: “Macula” has been used: as a non-medical “spot” or “stain”,
literal or figurative, including in astronomy and in Shakespeare;
as a medical skin lesion, occasionally with a following descriptive
adjective, such as a color (macula alba, macula materna); as a corneal
lesion, including the earliest identified use in English, circa 1400;
and to describe the center of the retina. Francesco Buzzi (1751-1805)
first described a yellow color in the posterior pole (“retina tinta di un
color giallo”) in 1782, but did not use the word “macula”. “Macula
lutea” was published by Samuel Thomas von Sömmering (17551830) by 1799, and subsequently used in 1818 by James Wardrop
(1782-1869), which appears to be the first known use in English. The
Google n-gram databse shows a marked increase in the frequencies of
both “macula” and “macula lutea” following the introduction of the
ophthalmoscope in 1850.
Conclusions: “Macula” has been used in multiple contexts in written
English, including many non-medical ones. Modern databases
provide powerful tools to explore historical uses of this term, which
may be underappreciated by contemporary ophthalmologists.
Commercial Relationships: Stephen G. Schwartz, Alimera (C),
Bausch + Lomb (C), Regeneron (R), Santen (C), ThromboGenics
(R); Christopher T. Leffler, None
Program Number: 5594 Poster Board Number: A0203
Presentation Time: 8:30 AM–10:15 AM
Cost Effectiveness of Anti-Oxidant Vitamin + Zinc Treatment
to Prevent the Progression of Intermediate Dry AMD to its Wet
Form. A Singapore Perspective
Shao Onn Yong1, Nakul Saxena2, Pradeep P. George2, Bee Hoon
Heng2, Tock Han Lim1. 1Ophthalmology, Tan Tock Seng Hospital,
Singapore, Singapore; 2Health Services and Outcomes Research,
National Healthcare Group, Singapore, Singapore.
Purpose: To determine if providing high dose anti-oxidant vitamins
+ Zinc treatment (AREDS formulation) to patients with intermediate
Age Related Macular Degeneration (AMD) aged 40-79 years from
Singapore is cost effective in preventing progression to Wet AMD.
Methods: A hypothetical cohort of category 3 & 4 AMD patients
from Singapore was followed for 5 calendar years to determine
the number of patients who would progress to wet AMD given the
following treatment scenarios:
A)
AREDS formulation OR placebo followed by Ranibizumab
(as needed) for wet AMD
B)
AREDS formulation OR placebo followed by Bevacizumab
(monthly) for wet AMD
C) AREDS formulation OR placebo followed by Aflibercept
(VIEW I and II trial treatment regimen)
Costs were estimated for the above scenarios from the providers’
perspective and cost effectiveness was measured by cost per
disability adjusted life year (DALY) averted with a disability weight
of 0.22 for wet AMD. Crude annual mortality rate was incorporated
into the model. **Is this still applicable now that YLLs are no longer
part of the analysis?**
Results: Over 5,400 patients could be prevented from progressing
to Wet AMD cumulatively over five years if AREDS formulation
were prescribed. AREDS formulation followed by ranibizumab
or aflibercept was cost effective compared to either placeboranibizumab or placebo-aflibercept combinations (cost per DALY
averted: SGD$17,078.7 and SGD$14,299.8 respectively - well within
the cost-effectiveness threshold). However, bevacizumab (monthly
injections) alone was more cost effective compared to preventive
anti-oxidant vitamins + Zn followed by bevacizumab. Cost savings
as a result of prescribing AREDS formulation were SGD$46.7M and
SGD$39.1M for ranibizumab and aflibercept arms respectively over
5 years.
Conclusions: Prophylactic treatment with high dose anti-oxidant
vitamins + Zn for intermediate AMD patients, followed by
ranibizumab or aflibercept for patients who progressed to wet AMD
was found to be cost-effective. These findings have implications for
intermediate AMD screening, treatment and healthcare planning in
Singapore.
©2014, Copyright by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. Go to iovs.org to access the version of record. For permission
to reproduce any abstract, contact the ARVO Office at [email protected].
ARVO 2014 Annual Meeting Abstracts
DALYs associated with Wet AMD based on receipt or no receipt of
AREDS formulation over 5 years.
Cost per DALY averted based on possible treatment options for
patients with Wet AMD
Commercial Relationships: Shao Onn Yong, Novartis (C), Novartis
(R); Nakul Saxena, None; Pradeep P. George, None; Bee Hoon
Heng, None; Tock Han Lim, Novartis (C), Novartis (R)
Program Number: 5595 Poster Board Number: A0204
Presentation Time: 8:30 AM–10:15 AM
Cost-effectiveness Analysis of iStent and Phacoemulsification
versus Glaucoma Medications in the Ontario Health Insurance
Plan (OHIP)
Yiannis Iordanous1, Cindy M. Hutnik1, Monali Malvankar1, 2.
1
Ophthalmology, University of Western Ontario, London, ON,
Canada; 2Epidemiology and Biostatistics, University of Western
Ontario, London, ON, Canada.
Purpose: New minimally invasive glaucoma surgeries (MIGS) and
devices are emerging to aid in lowering IOP and reduce patients’
reliance on topical medications. The iStent trabecular micro-bypass
stent (Glaukos Corporation, Laguna Hills, CA) is an example of these
MIGS devices; it has garnered much attention, as it is minimally
invasive and effective in reducing patients’ dependence on glaucoma
medications. It has data supporting its use as adjunctive therapy at the
time of cataract surgery for patients who are on multiple glaucoma
medications. However, a major challenge hindering adoption of these
MIGS has been the perceived cost. With many health care systems
evolving into cost-based models, analyses of cost, as well as efficacy
and safety, are becoming increasingly important.
The purpose of this study is to perform a cost effectiveness analysis
comparing use of the iStent at the time of phacoemulsification versus
the use of glaucoma medication within the Ontario Health Insurance
Plan (OHIP).
Methods: Primary economic analysis was performed by
constructing a Makov model using TreeAge Pro 2013 to conduct
cost-effectiveness analysis from the public third-party payer
(Ontario Health Insurance Plan) perspective. Cost and effectiveness
of three treatment strategies: medical therapy, cataract surgery
and simultaneous iStent insertion, and cataract surgery only were
compared over a 5-year period in managing patients with cataract
and glaucoma whose intra-ocular pressures were not adequately
controlled by two medications. In light of uncertainty of some
parameters, we performed probabilistic sensitivity analysis to
evaluate the robustness of the base-case results.
Results: The primary outcome measure was quality adjusted life
years (QALYs). The incremental cost-effectiveness of iStent at the
time of cataract surgery over glaucoma medications only is $6824
per quality-adjusted life year. By comparison, the incremental costeffectiveness of cataract surgery only over glaucoma medications is
$4179 per quality-adjusted life year.
Conclusions: This analysis suggests that the use of iStent at the
time of phacoemulsification is a cost-effective option for managing
patients with mild to moderate open-angle glaucoma and cataract.
These results, in conjunction with studies of efficacy and safety,
may be useful in delineating the role of the iStent in our glaucoma
treatment paradigm.
Commercial Relationships: Yiannis Iordanous, None; Cindy M.
Hutnik, None; Monali Malvankar, None
Program Number: 5596 Poster Board Number: A0205
Presentation Time: 8:30 AM–10:15 AM
Treatment Patterns and Associated Costs of Anti-VEGF Therapy
for Neovascular Age-Related Macular Degeneration
Szilard Kiss1, Pravin U. Dugel2, Kathleen Wilson3, Alice Huang3,
David Smith3, Helen Varker3, Stephen S. Johnston3, Adam Turpcu4.
1
Ophthalmology, Weill Cornell Medical College, New York, NY;
2
Retina Consultants of Arizona, Phoenix, AZ; 3Truven Health
Analytics, Bethesda, MD; 4Genentech, Inc., South San Francisco,
CA.
Purpose: Compare intravitreal (ITV) anti-VEGF injection totals
and associated costs in patients who received aflibercept (AFB) or
ranibizumab (RBZ) for neovascular age-related macular degeneration
(AMD).
Methods: Patients in this retrospective cohort study of US claims
data received 1st- or 2nd-line ITV anti-VEGF treatment with RBZ
or AFB (index date) from November 18, 2011–July 31, 2013 and
were aged ≥18y on the index date with a ≥12 month baseline
period of continuous insurance prior to this index date. AMD was
diagnosed during the baseline period or on the index date (ICD-9CM 362.52), and patients had ≥6 or ≥12 mo of follow-up post index
date with no switch of anti-VEGF therapy. Number of injections and
their associated costs were assessed for 6- and 12-mo follow-ups.
Multivariable regression comparisons for AFB vs RBZ were adjusted
for baseline patient demographics, comorbidities, and general health
status indices.
Results: A total of 486 AFB patients and 1329 RBZ patients had
≥6-mo of follow-up data (134 and 571, respectively, in 12-mo
analyses). Mean [SD] number of injections was similar at 12-mo
for AFB and RBZ recipients for 1st-line therapy (5.4 [2.9] vs 5.7
[3.7], respectively) and 2nd-line therapy (6.4 [3.3] vs 6.3 [3.5],
respectively; Figure). Mean [SD] anti-VEGF therapy-related costs
were comparable in AFB and RBZ recipients at 6 mo ($7244 [$4208]
©2014, Copyright by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. Go to iovs.org to access the version of record. For permission
to reproduce any abstract, contact the ARVO Office at [email protected].
ARVO 2014 Annual Meeting Abstracts
vs $7858 [$4805], respectively) and 12 mo ($11,046 [$6853] vs
$11,417.81 [$8731], respectively). Multivariable regression showed
that neither the number or costs of injections differed significantly
between AFB and RBZ patients over the first 6- and 12-mo post
index date (reference=RBZ: Incidence Rate Ratio [IRR]=0.97, 95%
confidence interval [CI]=0.92-1.02, P=0.224 [6 mo]; IRR=0.93,
95%CI=0.82-1.05, P=0.224 [12 mo]; Cost Ratio [CR]=0.96,
95%CI=0.90-1.02, P=0.212 [6 mo]; CR=0.91, 95%CI=0.80-1.05,
P=0.182 [12 mo]). Mean days between injections for AFB and RBZ
differed by 2.9 days (44.8 and 41.9 days, respectively) for 1st-line
patients and by 5.9 days (47.7 and 41.7 days, respectively) for 2nd-line
patients.
Conclusions: Injection frequency, days between injections, and
costs did not differ significantly between AFB and RBZ over 6 and
12 mo in this claims analysis of AMD patients. Further follow-up
is warranted; however, this initial analysis suggests AFB and RBZ
treatment patterns and costs in AMD are similar in a real-world
setting.
Regeneron (C); Kathleen Wilson, Genentech, Inc. (C); Alice Huang,
Genentech, Inc. (C); David Smith, Genentech, Inc. (C); Helen
Varker, Genentech, Inc. (C); Stephen S. Johnston, Genentech, Inc
(C); Adam Turpcu, Genentech, Inc. (E), Roche (I)
Support: Genentech, Inc.
Commercial Relationships: Szilard Kiss, Alcon (C), Alimera
(C), Alimera (R), Allergan (C), Allergan (R), Genentech, Inc.
(C), Genentech, Inc. (R), Optos (C), Optos (R), Regeneron (C),
Regeneron (R); Pravin U. Dugel, Genentech, Inc. (C), Novartis (C),
©2014, Copyright by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. Go to iovs.org to access the version of record. For permission
to reproduce any abstract, contact the ARVO Office at [email protected].