Download Physician Compliance With the HEDS Recommendation of Antiviral

Physician Compliance With the HEDS
Recommendation of Antiviral
Prophylaxis in Patients Diagnosed With
Herpetic Stromal Keratitis at KEI
Sameen Zaidi M.D. - PGY-4
Amanda Ismail - MS3
Frank Hwang M.D.
The authors have no financial interest to disclose
Introduction

Infection of the eye by herpes simplex virus (HSV) is
a leading cause of corneal blindness in the United
States and other countries.

The infection can lead to corneal scarring and
neovascularization, permanent endothelial
dysfunction, corneal edema, secondary glaucoma,
and cataract.
Herpetic Eye Disease Study
• Acyclovir Prevention Trial:
HEDS-APT evaluated the benefit of
long-term acyclovir treatment in
patients with a recent history of HSV
eye disease but no current active
disease.
• To be eligible, a patient must have
experienced any kind of ocular herpes
simplex infection (blepharitis,
conjunctivitis, keratitis, or iridocyclitis)
in the preceding year.
• The infection must have been inactive
and untreated for at least the previous
30 days.
• Patients were randomized to receive
either oral acyclovir (400 mg twice a
day) or placebo for 1 year

The cumulative probability of a
recurrence of any type of ocular
HSV disease during the 12month treatment period was 19
percent in the acyclovir group and
32 percent in the placebo group
(P<0.001).

Among the 337 patients with a
history of stromal keratitis, the
cumulative probability of recurrent stromal keratitis was 14
percent in the acyclovir group and
28 percent in the placebo group
(P=0.005).

There was no rebound in the rate
of HSV disease in the six months
after treatment with acyclovir was
stopped.
Purpose of Study

To assess physician compliance with the Herpetic Eye
Disease Study’s recommendation of antiviral
prophylaxis in preventing recurrences of HSV disease at
our institution.

Our hypothesis is that there is 100% physician
compliance with the Herpetic Eye Disease Study’s
antiviral prophylaxis recommendation.
Method
Inclusion Criteria:


Age >18,
Clinical diagnosis of Herpetic stromal
keratitis
Exclusion criteria:


Any ocular or systemic medical
condition that may, in the opinion of
the investigator, preclude safe
administration of oral antivirals.
Pediatric age group.
Recruiting:
 Retrospective chart review (
2007-present), after IRB approval.
 Corneal ulcer, Corneal opacity
and Herpes Simplex Keratitis Billing codes were used to select
charts.
 2,200 charts were reviewed out of
which 76 charts were selected for
analysis.
 Approximately 25 charts were
excluded from the study
conforming to our exclusion
criteria.
Method
Consent:
 A consent was not necessary as there was no planned intervention.
Confidentiality:
 All patients were assigned a numerical code and only PI and associate PI
were privy to the code/patient relationship. The information was kept in a
password protected file which will be destroyed at the end of chart review
and analysis.
Data collection:
 Age, Gender, Ethnicity, Ocular history, Medical history, Treatment plan of
herpetic stromal keratitis and Clinic location (private clinic or resident’s clinic)

The primary outcome was prescription of oral prophylactic anti-viral to
patients who were diagnosed with ocular HSV stromal keratitis in the
preceding year.
Statistical Analysis:
 Chi Squared test
Results
No. of Patients
by Age
N = 76
No. of Patients
by Gender
40
No. of Patients by
Ethnicity
N = 76
N = 76
36
35
32
28
27
15
13
2
21-40
41-60
61-92
M
F
C
AA
ME
NS
C: Caucasian, AA: African American, ME: Middle Eastern, NS: Not Specified in EMR
Results: Treatment by Clinic Type
Anti Viral Prophylaxis

No Anti Viral Prophylaxis
100%

80%
60%
79%
84%

40%

20%
21%
16%
PC
RC
0%
N = 39
N = 37

The chart looks at patients by
clinic type
Of all the patients who went
to Private Clinic, 79.5% were
treated appropriately
Of all the patients who went
to Resident Clinic, 83.7%
were treated appropriately
P-value : 0.8517
No significant difference
was found between the two
groups.
Results: Treatment in Private Clinic:
Cornea Specialist vs. non Cornea Specialist
Anti Viral Prophylaxis

No Anti Viral Prophylaxis
100%

80%
60%
69%
86%

40%
20%
31%
0%
14%

Non K
Specialist
K Specialist
N = 13
N = 42

The chart looks at patients
in PC, by K Specialist or non
K Specialist
Of all the patients who were
seen by a non K Specialist,
69.2 % of them were treated
appropriately
Of all the patients who were
seen by a K Specialist, 85.7%
of them were treated
appropriately
P-value: 0.3459
No significant difference
between the two groups was
observed.
Results

16 out of 76 (21%) patients with a diagnosis of herpetic
stromal keratitis were not prescribed antiviral
prophylaxis

Of the 16: 6 (37.5%)were treated in Resident’s clinic and
10 (62.5%) were managed in Private clinic respectively.

Of the 10: 6 (60%) were treated by a cornea specialist and
4 (40%) were treated by a non cornea specialist.

Of the 62 patients who were prescribed antiviral
prophylaxis , 31 (50%) were seen in private clinic while
31 (50%) were seen in resident’s clinic.
Conclusion

There is 81.6% physician compliance with the HEDS – Acyclovir
Prevention Trial at our institution.

Cornea specialists had higher rates of compliance compared to noncornea specialists.

We did not observe any statistical significance in rates of
compliance in private compared to resident clinics or cornea
specialists compared to non-cornea specialists.

Next steps include:
 Increase the sample size by including more related CPT codes.
 Assessing the reason for non compliance.
 Addressing the reason for non compliance.
 Gain insight into physician Knowledge, Attitude, and Practice.
Positives and Negatives
Study Positives:

One of the first studies
to survey compliance
with Herpetic Eye
Disease Study, hoping
that it leads to formal
standardized protocol
formation for
physicians to follow to
reach 100% compliance.
Study Negatives:
No statistical
significance in the
comparison of clinic
type (RC vs. PC) or
specialist (K vs. non-K)
 Study is underpowered.
Data collection will be
continued.
 Snap-shot analysis of
data collected at one
facility
