Regional Variations and Trends in the Prevalence of Diagnosed Glaucoma in the Medicare Population

Inequities in glaucoma research: an analysis of Cochrane systematic reviews and randomized trials

OBJECTIVES

To understand the level of equity considerations within Cochrane systematic reviews (CSR) on glaucoma and their primary studies.

METHODS

A review of equity considerations in systematic reviews on glaucoma published in The Cochrane Library from inception (2003) to January 31, 2024 and a sample of recently published primary studies included in those reviews (n = 122). Extraction was performed by two independent reviewers using a prepiloted extraction form based on a validated, contemporary, structured equity framework. If consensus could not be reached, a third reviewer was involved.

RESULTS

A total of 40 CSRs on glaucoma were identified, all of which exclusively included randomized control trials (RCTs) or quasi-RCTs. Twenty-nine (72.5%) reviews acknowledged populations experiencing inequities in glaucoma care; none were able to perform subgroup analysis due to data unavailability in primary studies. Six (15.0%) reviews considered equity-relevant factors when discussing applicability or limitations of study findings to specific populations. Seventy-four (46.8%) review authors were women, while 84 (53.2%) were men. Most review authors were primarily affiliated with institutions in the European Region (85, 53.8%) or the Americas (55, 34.8%), while none were primarily affiliated with institutions in Africa or low-income countries. Most RCTs were conducted in the Americas (32.8%), European Region (27.9%), or in high-income countries (72.1%). While most RCTs reported gender or sex of participants (107, 87.7%), only half reported race or ethnicity (61, 50.0%). No RCTs reported place of residence, occupation, socioeconomic status (SES), or social capital of participants. Approximately half (51.7%) of the participants in these RCTs were female.

CONCLUSION

Equity considerations can be better addressed in research on glaucoma. Reporting of patient sociodemographic in RCTs, particularly race and ethnicity, as well as global representation were insufficient. This may limit the generalizability and applicability of intervention efficacy to populations experiencing inequities and people from low-income countries.

Prevalence of Glaucoma Among US Adults in 2022

Importance

Glaucoma is the leading cause of irreversible blindness worldwide and, in the US, disproportionately affects people from racial and ethnic minority groups. Glaucoma prevalence has not been estimated for the US in more than a decade, and state- and county-level estimates are not available.

Objective

To estimate glaucoma and vision-affecting glaucoma prevalence by demographic factors and US state and county for the Centers for Disease Control and Prevention's Vision and Eye Health Surveillance System (VEHSS).

Data Sources

This meta-analysis used data from the National Health and Nutrition Examination Survey (2005-2008), Medicare fee-for-service claims (2019), IBM MarketScan commercial insurance claims (2016), population-based studies of eye disease (1985-2003), and 2022 population estimates from the US Census Bureau.

Study Selection

PubMed was searched for population-based studies of glaucoma prevalence published between 1991 and 2016.

Data Extraction and Synthesis

Bayesian meta-regression methods were used to estimate the prevalence of glaucoma and vision-affecting glaucoma stratified by age, undifferentiated sex/gender (a measure that captures an unclear mix of aspects of sex and or gender), race and ethnicity, and US county and state.

Main Outcomes and Measures

Prevalence of any type of glaucoma (open or closed angle) among people 18 years or older and vision-affecting glaucoma, defined as glaucoma and a visual field abnormality.

Results

For 2022, an estimated 4.22 million people (95% uncertainty interval [UI], 3.46 million to 5.23 million) in the US were living with glaucoma, with a prevalence of 1.62% (UI, 1.33%-2.00%) among people 18 years or older and 2.56% (UI, 2.10%-3.16%) among people 40 years or older. An estimated 1.49 million people (UI, 1.17 million to 1.90 million) were living with vision-affecting glaucoma, with a prevalence of 0.57% (UI, 0.45%-0.73%) among people 18 years or older and 0.91% (UI, 0.71%-1.16%) among people 40 years or older. Prevalence of glaucoma among people 18 years or older ranged from 1.11% (UI, 0.89%-1.40%) in Utah to 1.95% (UI, 1.57%-2.39%) in Mississippi. Black adults had a prevalence of 3.15% (UI, 2.32%-4.09%) compared with 1.42% (UI, 1.10%-1.85%) among White adults; adults in the Hispanic and all other racial and ethnic categories combined had a prevalence of 1.56% (UI, 1.13%-2.06%).

Conclusions and Relevance

This meta-analysis found that an estimated 2.56% of people 40 years or older have glaucoma, slightly more than estimated by previous studies. Black individuals are disproportionately affected. Prevalence estimates at the state and county level can help guide public health planning.

Patterns and Disparities in Recorded Gonioscopy During Initial Glaucoma Evaluations in the United States

PURPOSE

To assess patterns in gonioscopy during initial glaucoma evaluations in the United States.

DESIGN

Retrospective, case-control study.

METHODS

Patients undergoing initial glaucoma evaluation between 2009-2020 were identified in the Optum Clinformatics DataMart. Initial evaluation was defined as follows: (1) glaucoma suspect, anatomical narrow angle (ANA), or primary/secondary glaucoma diagnosed by an ophthalmologist; (2) continuously observable during a 36-month lookback period; (3) no history of glaucoma medications, laser, or surgical procedures; and (4) optical coherence tomography (OCT) or visual field performed within 6 months of initial diagnosis. Logistic regression models were developed to identify factors associated with no record of gonioscopy based on Current Procedural Terminology (CPT) codes.

RESULTS

Among 198,995 patients, 20.4% and 29.5% had recorded gonioscopy on the day of diagnosis or within 6 months, respectively. On multivariable analysis, odds of recorded gonioscopy within 6 months of initial evaluation was lower (P < .001) among non-Hispanic Whites (OR=0.84) but similar for Blacks (OR=1.02) and Hispanics (OR=0.96) compared with Asians. Age ≥60 years (OR<0.82), pseudophakia/aphakia (OR=0.58), or residence outside of the Northeast region (OR=0.66-0.84) conferred lower odds of recorded gonioscopy (P < .001). Angle closure glaucoma (OR=0.85), secondary glaucoma (OR=0.31), or open angle glaucoma/suspect (OR=0.12/0.24, respectively) patients were less likely to have recorded gonioscopy compared to ANA patients (P < .01).

CONCLUSIONS

More than 70% patients undergoing initial glaucoma evaluation in the United States do not have a record of gonioscopy, especially elderly, non-Hispanic White, and pseudophakic patients in non-Northeast regions. This pattern does not conform to current practice guidelines and could contribute to misdiagnosed disease and suboptimal outcomes.

Impact of the Coronavirus Disease 2019 Pandemic on Surgical Volumes Among Fellowship-Trained Glaucoma Subspecialists

PRCIS

The change in glaucoma surgical volumes due to the coronavirus disease 2019 pandemic was not uniform across procedure types and was unequal between rural and urban practice locations.

PURPOSE

To quantify the impact of the coronavirus disease 2019 pandemic on surgical volumes performed by fellowship-trained glaucoma subspecialists.

MATERIALS AND METHODS

This retrospective cohort analysis of the Centers for Medicare and Medicaid Services Medicare Public Use File extracted all glaucoma surgeries, including microinvasive glaucoma surgeries (MIGSs), trabeculectomy, goniotomy, lasers, and cataract surgery, performed by fellowship-trained glaucoma surgeons in rural and urban areas between 2016 and 2020. Predicted estimates of 2020 surgical volumes were created utilizing linear squares regression. Percentage change between predicted and observed 2020 surgical volume estimates was analyzed. Statistical significance was achieved at P <0.05.

RESULTS

In 2020, fellowship-trained glaucoma surgeons operated mostly in urban areas (N = 810, 95%). A 29% and 31% decrease in predicted cataract surgery volumes in urban and rural areas, respectively, was observed. Glaucoma surgeries experienced a 36% decrease from predicted estimates (N = 56,781). MIGS experienced an 86% and 75% decrease in rural and urban areas, respectively. Trabeculectomy in rural areas experienced a 16% increase relative to predicted estimates while urban areas experienced a decrease of 3% ( P > 0.05). The number of goniotomies decreased by 10% more in rural areas than in urban areas (-22% and -12%, respectively). Laser procedures decreased by 8% more in urban areas than in rural areas (-18% and -10%, respectively).

CONCLUSIONS

Among glaucoma-trained surgeons, glaucoma surgeries experienced a greater volume loss than cataract surgeries. In urban US areas, relative reductions in MIGS and goniotomy volumes in urban areas may have been compensated by greater laser and trabeculectomy volumes. Trabeculectomies in rural areas were the only group exceeding predicted estimates. Glaucoma subspecialists may utilize these findings when planning for future events and in overcoming any remaining unmet need in terms of glaucoma care.

Glaucoma in Black Individuals: How Far Have We Come and Where Do We Go From Here?

PURPOSE

To provide updates on the key scientific discoveries made and sociological theories put forth that have allowed for a better understanding of the disproportionate burden of glaucoma among Black individuals, and to provide insights into future directions for this important field of work.

DESIGN

Perspective with a scoping review of the literature.

METHODS

Review, synthesis, and critical appraisal of selected literature on the impact of glaucoma in Black Americans. Important studies within and outside of ophthalmology are considered to allow for a greater understanding of the historical, sociopolitical, and encompassing medical contexts surrounding this complex issue.

RESULTS

A historical overview of key epidemiologic studies highlights the repeated and unequivocal demonstration of increased risk of glaucoma in Black individuals. To begin to understand this multi-layered racial disparity, a historical review of race as a social-legal construct is provided. A careful examination of genetic ancestry is considered as a partial means by which increased glaucoma risk is conferred among Black individuals. The growing body of work examining social determinants as an important driver for racial disparities in glaucoma is also reviewed. Finally, the pitfalls and dangers of race-based medicine are highlighted through illustrative cases before providing insights to future directions.

CONCLUSIONS

Though our understanding of the disparities in glaucoma in Black individuals has grown over the past decades, gaps persist, particularly due to deficient data driven by a lack of studies in this disproportionately burdened group. Though the use of race as a variable may become increasingly less relevant with the rise of precision medicine, it remains a crucial, though flawed concept that continues to be our best means by which to measure, investigate, and intervene upon these disparities in our efforts to achieve health equity.

Identifying, Understanding, and Addressing Disparities in Glaucoma Care in the United States

Glaucoma is the leading cause of irreversible blindness worldwide, currently affecting around 80 million people. Glaucoma prevalence is rapidly rising in the United States due to an aging population. Despite recent advances in the diagnosis and treatment of glaucoma, significant disparities persist in disease detection, management, and outcomes among the diverse patient populations of the United States. Research on disparities is critical to identifying, understanding, and addressing societal and healthcare inequalities. Disparities research is especially important and impactful in the context of irreversible diseases such as glaucoma, where earlier detection and intervention are the primary approach to improving patient outcomes. In this article, we first review recent studies identifying disparities in glaucoma care that affect patient populations based on race, age, and gender. We then review studies elucidating and furthering our understanding of modifiable factors that contribute to these inequities, including socioeconomic status (particularly age and education), insurance product, and geographic region. Finally, we present work proposing potential strategies addressing disparities in glaucoma care, including teleophthalmology and artificial intelligence. We also discuss the presence of non-modifiable factors that contribute to differences in glaucoma burden and can confound the detection of glaucoma disparities.

Translational Relevance

By recognizing underlying causes and proposing potential solutions, healthcare providers, policymakers, and other stakeholders can work collaboratively to reduce the burden of glaucoma and improve visual health and clinical outcomes in vulnerable patient populations.

Validity of Administrative Claims and Electronic Health Registry Data From a Single Practice for Eye Health Surveillance

Importance

Diagnostic information from administrative claims and electronic health record (EHR) data may serve as an important resource for surveillance of vision and eye health, but the accuracy and validity of these sources are unknown.

Objective

To estimate the accuracy of diagnosis codes in administrative claims and EHRs compared to retrospective medical record review.

Design, Setting, and Participants

This cross-sectional study compared the presence and prevalence of eye disorders based on diagnostic codes in EHR and claims records vs clinical medical record review at University of Washington-affiliated ophthalmology or optometry clinics from May 2018 to April 2020. Patients 16 years and older with an eye examination in the previous 2 years were included, oversampled for diagnosed major eye diseases and visual acuity loss.

Exposures

Patients were assigned to vision and eye health condition categories based on diagnosis codes present in their billing claims history and EHR using the diagnostic case definitions of the US Centers for Disease Control and Prevention Vision and Eye Health Surveillance System (VEHSS) as well as clinical assessment based on retrospective medical record review.

Main Outcome and Measures

Accuracy was measured as area under the receiver operating characteristic curve (AUC) of claims and EHR-based diagnostic coding vs retrospective review of clinical assessments and treatment plans.

Results

Among 669 participants (mean [range] age, 66.1 [16-99] years; 357 [53.4%] female), identification of diseases in billing claims and EHR data using VEHSS case definitions was accurate for diabetic retinopathy (claims AUC, 0.94; 95% CI, 0.91-0.98; EHR AUC, 0.97; 95% CI, 0.95-0.99), glaucoma (claims AUC, 0.90; 95% CI, 0.88-0.93; EHR AUC, 0.93; 95% CI, 0.90-0.95), age-related macular degeneration (claims AUC, 0.87; 95% CI, 0.83-0.92; EHR AUC, 0.96; 95% CI, 0.94-0.98), and cataracts (claims AUC, 0.82; 95% CI, 0.79-0.86; EHR AUC, 0.91; 95% CI, 0.89-0.93). However, several condition categories showed low validity with AUCs below 0.7, including diagnosed disorders of refraction and accommodation (claims AUC, 0.54; 95% CI, 0.49-0.60; EHR AUC, 0.61; 95% CI, 0.56-0.67), diagnosed blindness and low vision (claims AUC, 0.56; 95% CI, 0.53-0.58; EHR AUC, 0.57; 95% CI, 0.54-0.59), and orbital and external diseases (claims AUC, 0.63; 95% CI, 0.57-0.69; EHR AUC, 0.65; 95% CI, 0.59-0.70).

Conclusion and Relevance

In this cross-sectional study of current and recent ophthalmology patients with high rates of eye disorders and vision loss, identification of major vision-threatening eye disorders based on diagnosis codes in claims and EHR records was accurate. However, vision loss, refractive error, and other broadly defined or lower-risk disorder categories were less accurately identified by diagnosis codes in claims and EHR data.

Racial Disparities Affecting Black Patients in Glaucoma Diagnosis and Management

Black patients are more affected by glaucoma and suffer from more advanced disease. Diagnostic challenges among black patients with glaucoma include lower rates of diagnostic testing and thinner average central corneal thickness, the latter of which affects intraocular pressure measurement. Treatment challenges include poor follow-up, medication adherence, and trust in providers. Black patients undergoing trabeculectomy have higher rates of failure compared to white patients. Race is not a definitive factor affecting success for tube shunts, laser trabeculoplasty, cyclophotocoagulation, and micro-invasive glaucoma surgeries, but the body of evidence is limited by low inclusion of black patients in these studies. Future steps should include increased attention toward improving trust between patients and providers, improving access to care, and increased representation of black patients in glaucoma research to better understand factors affecting racial disparities in glaucoma management and outcomes in this population disproportionately affected by the disease.

Applications of Artificial Intelligence and Deep Learning in Glaucoma

Diagnosis and detection of progression of glaucoma remains challenging. Artificial intelligence-based tools have the potential to improve and standardize the assessment of glaucoma but development of these algorithms is difficult given the multimodal and variable nature of the diagnosis. Currently, most algorithms are focused on a single imaging modality, specifically screening and diagnosis based on fundus photos or optical coherence tomography images. Use of anterior segment optical coherence tomography and goniophotographs is limited. The majority of algorithms designed for disease progression prediction are based on visual fields. No studies in our literature search assessed the use of artificial intelligence for treatment response prediction and no studies conducted prospective testing of their algorithms. Additional challenges to the development of artificial intelligence-based tools include scarcity of data and a lack of consensus in diagnostic criteria. Although research in the use of artificial intelligence for glaucoma is promising, additional work is needed to develop clinically usable tools.

Racial Disparities Affecting Black Patients In Glaucoma Diagnosis And Management

Black patients are more affected by glaucoma and suffer from more advanced disease. Diagnostic challenges among black patients with glaucoma include lower rates of diagnostic testing and thinner average central corneal thickness, the latter of which affects intraocular pressure measurement. Treatment challenges include poor follow-up, medication adherence, and trust in providers. Black patients undergoing trabeculectomy have higher rates of failure compared to white patients. Race is not a definitive factor affecting success for tube shunts, laser trabeculoplasty, cyclophotocoagulation, and micro-invasive glaucoma surgeries, but the body of evidence is limited by low inclusion of black patients in these studies. Future steps should include increased attention toward improving trust between patients and providers, improving access to care, and increased representation of black patients in glaucoma research to better understand factors affecting racial disparities in glaucoma management and outcomes in this population disproportionately affected by the disease.

The Glaucoma Suspect Problem: Ways Forward

The diagnosis of glaucoma depends upon indentification of characteristic damage to the optic nerve and retinal fiber layer. In many cases, however, clinicians find it difficult to ascertain whether glaucomatous damage is present or absent. These patients are often labeled as "glaucoma suspects," which creates a subpopulation of individuals without clear-cut disease who nonetheless must remain under surveillance. Most will never go on to develop glaucoma, yet the need for ongoing monitoring burdens clinics and health care systems. In this perspective, we illustrate possible directions and novel approaches that can be used to remedy this situation by integrating current technologies into clinical practice. In particular, we suggest that optical coherence tomography be better utilized to methodologically classify these eyes into glaucomatous and healthy categories.

Disparities in Vision Health and Eye Care

Significant disparities in vision health and eye care exist. To achieve health equity, we must understand the root causes and drivers of health disparities and inequities, including social determinants of health and systemic racism.

Racial and Sociodemographic Disparities in the Detection of Narrow Angles before Detection of Primary Angle-Closure Glaucoma in the United States

PURPOSE

To assess the proportion of newly diagnosed cases of primary angle-closure glaucoma (PACG) with and without prior diagnosis of anatomical narrow angle (ANA) and to identify sociodemographic risk factors for late detection (PACG without prior ANA diagnosis).

DESIGN

Retrospective cohort study.

METHODS

One hundred two thousand six hundred seventeen patients with PACG were identified from the Optum Clinformatics Data Mart Database (2007-2019). Patients with newly diagnosed PACG met the following criteria: (1) diagnosis made by an ophthalmologist, (2) disease observable for at least 12 months before diagnosis, and (3) no history of treatment before diagnosis unless preceded by a diagnosis of ANA. Multivariate logistic regression modeling was performed to identify sociodemographic risk factors for late detection.

MAIN OUTCOME MEASURES

Proportion of patients with newly diagnosed PACG without prior ANA diagnosis and sociodemographic factors associated with late detection.

RESULTS

Thirty-one thousand forty-four patients were eligible. More than 70% of PACG cases were detected without prior ANA diagnosis, regardless of patient age, sex, or race. The odds of late detection were significantly higher (P < 0.001) among men (odds ratio [OR], 1.32; 95% confidence interval [CI], 1.25-1.40), Black patients (OR, 1.25; 95% CI, 1.15-1.37), and patients 80 years of age or older (OR, 1.28; 95% CI, 1.11-1.47) or living in Southern (OR, 1.30; 95% CI, 1.22-1.40) or Pacific (OR, 1.27; 95% CI, 1.16-1.36) regions. Findings were similar for patients with PACG with a record of gonioscopy and treatment or with a 24-month lookback period.

CONCLUSIONS

Most patients who receive a new diagnosis of PACG in the United States do not have a prior diagnosis of ANA. The elderly, men, and Black patients are at higher risk of late detection. A need exists for increased disease awareness among providers and more accessible tools to detect patients at risk of developing PACG.

Incremental Health Care Expenditures Associated With Glaucoma in the United States: A Propensity Score-matched Analysis

PRCIS

Adjusting for sociodemographics and comorbidities, patients with glaucoma incur an annual incremental economic burden of $1863.17, translating to $9.2 billion nationally. When analyzed by the health care service sector, prescription medication expenditures were higher for glaucoma patients.

PURPOSE

The purpose of this study was to estimate the incremental health care burden, defined as attributable costs solely due to a diagnosis, of patients with diagnosed glaucoma, controlling for comorbidities, and sociodemographics.

DESIGN

A retrospective cross-sectional analysis of Medical Expenditure Panel Survey (MEPS) participants (age above 18 y) between 2016 and 2018.

METHODS

A cross-validated 2-part generalized linear regression model estimated the incremental glaucoma expenditures in aggregate and by sociodemographic subgroups and health care service sector [inpatient, outpatient (including surgical procedures), emergency room, home health, and medications] after 1:3 propensity matching.

RESULTS

After 1:3 propensity matching for sociodemographics and the Charlson Comorbidity Index, this study analyzed 1521 glaucoma patients (mean expenditures: $13,585.68±1367.03) and 4563 patients without glaucoma (mean expenditures: $12,048.92±782.49). A higher proportion of glaucoma patients are female, elderly, publicly insured (Medicare/Medicaid), college educated, identify ethnically as non-Hispanic, reside in the Northeast, and have more comorbidities (P<0.001). There were no differences in health care burden based on sex, income, insurance status, education, and year of care received for patients with glaucoma. Controlling for comorbidities and socioeconomic factors, propensity-matched glaucoma patients incur an annual incremental health care burden of $1863.17 (95% confidence interval, 393.44-3117.23, P=0.013), translating into an additional $9.2 billion in population-level US health care expenditures. By health care service sector, the expenditure ratio for health care expenditures was higher for prescription medications (expenditure ratio=1.20, 95% confidence interval, 1.02-1.42, P=0.031).

CONCLUSIONS

Glaucoma patients have a substantial incremental economic health care burden after accounting for demographics and comorbidities, largely secondary to prescription medications. There is a need to continue identifying and studying treatment options for patients with glaucoma to maintain vision while minimizing health care expenditures.

Correlation Between Ophthalmology Market Saturation and Medicare Utilization Rates

PURPOSE

To characterize usage of ophthalmologic services by Medicare Fee-For-Service (FFS) beneficiaries relative to geography-specific market saturation, demographics, and contextual factors DESIGN: Cross-sectional study METHODS: Data sets from Centers for Medicare & Medicaid Services, US Census Bureau, US Department of Agriculture, and Housing and Urban Development, were used to calculate county- and state-level ophthalmologic service usage, market saturation, and demographic characteristics. Negative binomial regression models were used to evaluate the association between results and demographic or population-specific variables.

RESULTS

Ophthalmologic service usage ranged from 58.2% to 15.2%, whereas saturation ranged from 21,763 to 91.4 FFS beneficiaries per registered ophthalmologist. Usage was significantly associated with demographic characteristics in each geography: lower proportion of African American (P = .009), Hispanic (P < .001), and other race beneficiaries (P < .001), relative to white beneficiaries; a higher proportion of female (P < .001) relative to male; a higher proportion of adults having completed an associate degree or some college (P = .001), or holding a bachelor's degree or higher (P < .001), relative to a high school diploma; a lower proportion of adults in each geography experiencing poverty (P = .009), geographies with lower Multidimensional Deprivation Index (P < .001); a higher urban-influence code (P < .001). There was no significant correlation between the usage of ophthalmologic services and the geographic market saturation of ophthalmologists (Spearman rho, -0.030, P = .227).

CONCLUSIONS AND RELEVANCE

Ophthalmologic service usage is significantly influenced by population demographics; however, increased provider density alone appears insufficient to promote the usage of eye care services.

The Prevalence of Undiagnosed Age-Related Sight-Threatening Diseases in Self-Proclaimed Healthy Individuals

Background

Age-related conditions such as glaucoma, age-related macular degeneration, diabetic retinopathy, and cataract have become the major cause of visual impairment and blindness in high-income countries. The aim of the current study is to investigate the prevalence of these eye diseases in a cohort of self-proclaimed healthy elderly and thus get a rough estimation of the prevalence of undiagnosed age-related eye conditions in the Belgian population.

Methods

Individuals aged 55 and older without ophthalmological complaints were asked to fill in a general medical questionnaire and underwent an ophthalmological examination, which included a biomicroscopic examination, intraocular pressure measurement, axial length measurement, and acquisition of fundus pictures and optical coherence tomography scans. Information regarding follow-up was collected in those who received the advice of referral to an ophthalmologist or the advice to have more frequent follow-up visits, based on their study evaluation.

Results

The cohort included 102 people and comprised 46% men (median age 70 years, range 57–85 years). Referral for additional examinations was made in 26 participants (25%). The advice to have more regular follow-up ophthalmologist visits was given to nine additional participants (9%). No significant correlations between baseline characteristics and the need for referral could be identified. Follow-up information was available for 25 out of 26 referred volunteers. Out of these, four underwent a therapeutic intervention based on study referral, up until 18 months after study participation. All four interventions took place in the age group 65–74 years.

Conclusions

This study shows that, even in an elderly population with self-proclaimed healthy eyes and good general health, a significant proportion of subjects showed ocular findings that need regular follow-up and/or intervention. The frequency of prior ophthalmological examinations does not seem to be relevant to this proportion, meaning that everyone above 55 years old needs a routine ophthalmological evaluation.

Risk Factors for Repeat Keratoplasty after Endothelial Keratoplasty in the Medicare Population

PURPOSE

To evaluate long-term rates of repeated keratoplasty after endothelial keratoplasty (EK), and to explore risk factors associated with graft failure.

DESIGN

Retrospective, cohort study.

METHODS

Population-based using 2010-2019 Medicare carrier claims.

STUDY POPULATION

Medicare beneficiaries aged ≥65 years who underwent endothelial keratoplasty (EK) procedures. Main outcome measures were 1) occurrence of repeated keratoplasty for the overall cohort as well as stratified by clinical indication, and 2), risk factors associated with repeated keratoplasty. The probability of undergoing repeated keratoplasty for different indications was estimated using the Kaplan-Meier method and compared using the log-rank test. A Cox proportional hazards regression model was constructed to determine patient and physician factors associated with the risk of repeated keratoplasty.

RESULTS

A total of 94,829 Medicare EK procedures (N = 71,040 unique patients) were included in the analysis. Over the study period, 11,013 of 94,829 EK procedures were followed by repeated keratoplasty. The overall probability of receiving a repeated keratoplasty was 6.1% at 6 months, 7.6% at 1 year, 14.3% at 5 years and 16.9% at 8 years. The probability of repeated keratoplasty was highest for procedures performed for prior failed grafts: 10.2% at 1 year, 29.9% at 8 years. Whereas 6.4% and 11.4% of grafts performed for Fuchs' endothelial dystrophy (FED) required repeated keratoplasty at 1 and 8 years of follow-up, respectively. For bullous keratoplasty and/or corneal edema, 8.6% and 22% of grafts underwent repeated keratoplasty at 1 and 8 years, respectively. In a multivariate analysis, patient factors associated with increased risk of repeated keratoplasty were black (hazard ratio [HR]: 1.29; 95% confidence interval [CI]: 1.20-1.38) or Asians (HR: 1.26; 95% CI: 1.10-1.45) having a glaucoma diagnosis (HR: 1.53; 95% CI: 1.46-1.60), prior glaucoma surgery (HR: 1.26; 95% CI: 1.18-1.35), and concurrent glaucoma surgery (HR: 1.31; 95% CI: 1.20-1.44). Surgeons with higher EK volumes had a decreased risk of repeated keratoplasty. Physicians who graduated medical school >30 years previously had increased risk of repeated keratoplasty compared to those who graduated within 10 years (HR: 1.16; 95% CI: 1.10-1.23).

CONCLUSIONS

Blacks or Asians, comorbid glaucoma, concurrent or prior glaucoma surgery, and lower volumes of surgery are associated with increased risk of repeated keratoplasty. Racial disparities identified in this study warrant further investigation.

GlaucoMap - Distribution of Glaucoma Surgical Procedures in the United States

PURPOSE

To understand the distribution of trabeculectomies, glaucoma drainage implants (GDI) and micro-invasive glaucoma surgeries (MIGS) performed in the United States through geospatial mapping.

METHODS

We performed an observational cohort study to evaluate glaucoma surgeries in patients age ≥65. The most recently released data from Centers for Medicare Part B Carrier Summary Files were queried to determine the number of glaucoma surgeries performed per state during the year of 2017. We created choropleth maps, titled "GlaucoMap", to characterize the rates of various surgeries performed across the United States, defined as the number of procedures performed per 10,000 individuals. A chi-squared analysis was further used to evaluate differences in surgical preferences across geographic region. Standardized residuals (SR) were calculated to determine regional influences on surgical distribution.

RESULTS

There were 174,788 glaucoma surgeries performed: 22,862 trabeculectomies (13.1%), 19,991 GDI (11.4%) and 131,935 (75.5%) MIGS. The Northeast had the highest trabeculectomy rate, GDI was highest in the Southeast and MIGS were highest in the Southwest. There was a statistically significant difference in proportional use of conventional surgeries versus MIGS across various regions in the United States (p < 0.0001). Given the high trabeculectomy and GDI rates and relatively low MIGS adoption in the Southeast, we observed a +7.03 SR for conventional surgeries and -4.01 SR for MIGS. The Southwest and Western states had the highest MIGS rate and contributed +3.29 and +3.24 SR toward disproportional MIGS preference, respectively. The preference for conventional surgeries in the Northeast (SR = +2.93) and MIGS in the Midwest (SR = +0.99) also contribute to the overall differences in glaucoma surgeries across the United States.

CONCLUSION

GlaucoMap is useful for visualizing the distribution of glaucoma surgeries in the United States. The heterogeneity in surgical preferences points to regional differences in glaucoma management.

Prostaglandin Coverage and Costs to Medicare and Medicare Beneficiaries, 2009-2017

BACKGROUND

Prostaglandin analogs are the most effective treatment for glaucoma, a common condition among older adults. Despite the availability of generic drugs, the costs associated with these prescription drugs are rising.

OBJECTIVE

To characterize Medicare prescription drug plan (PDP) formulary coverage and beneficiary out-of-pocket cost for prostaglandin analogs from 2009 to 2017 and Medicare spending on prostaglandin analogs from 2013 to 2017.

METHODS

This study was a retrospective analysis. We used 2009, 2013, and 2017 Medicare PDP formulary, beneficiary cost, and pricing files to determine beneficiary first-prescription out-of-pocket costs and plan coverage (unrestricted, restricted, or not covered) of branded latanoprost 0.005%, travoprost 0.004%, bimatoprost 0.03% and 0.01%, and tafluprost 0.0015% and of generic latanoprost 0.005% and generic bimatoprost 0.03%. We also used Medicare Part D spending data to determine aggregate spend in 2013 and 2017.

RESULTS

In 2009, 92% of plans covered branded latanoprost, 83% covered branded bimatoprost; and 49% covered branded travoprost, whereas in 2017, 6% of plans covered branded latanoprost; 95% covered branded bimatoprost; and 96% covered branded travoprost. Although generic latanoprost was universally covered, generic bimatoprost was only covered by 35% of plans in 2017. Median out-of-pocket cost of branded prostaglandins without generic equivalents was $35 (IQR = $29-$40) in 2009, $45 (IQR = $42-$101) in 2013, and $90 (IQR = $45-$159) in 2017. Median out-of-pocket cost of all available generic prostaglandins was $10 (IQR = $5-$33) in 2013 and $10 (IQR = $4-$15) in 2017. In 2013, Medicare spent $733 million on prostaglandin analogs; in 2017, this increased to $1.09 billion, with $943 million (86%) spent on branded prostaglandins and $148 million (14%) spent on generics.

CONCLUSIONS

Medicare PDP coverage of branded prostaglandins remained stable from 2009 to 2017. While median beneficiary out-of-pocket costs associated with generic prostaglandins remained stable, those associated with branded prostaglandins increased nearly 3-fold.

DISCLOSURES

Research reported in this publication was supported by National Heart, Lung and Blood Institute of the National Institutes of Health under Award Number T35HL007649. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung, and Blood Institute or the National Institutes of Health. Shah has received research support through Mayo Clinic from the U.S. Food and Drug Administration (FDA) to establish Yale-Mayo Clinic Center for Excellence in Regulatory Science and Innovation (CERSI) program (U01FD005938); the Centers of Medicare and Medicaid Innovation under the Transforming Clinical Practice Initiative (TCPI); the Agency for Healthcare Research and Quality (U19HS024075, R01HS025164, R01HS025402, R03HS025517); and the National Heart, Lung and Blood Institute of the National Institutes of Health (NIH) (R56HL130496, R01HL131535), National Science Foundation, and the Patient Centered Outcomes Research Institute to develop a clinical data research network. Ross has received research support through Yale University from Johnson & Johnson to develop methods of clinical trial data sharing; Medtronic and the FDA to develop methods for postmarket surveillance of medical devices (U01FD004585); the FDA to establish Yale-Mayo Clinic Center for Excellence in Regulatory Science and Innovation program (U01FD005938); the Blue Cross Blue Shield Association to better understand medical technology evaluation; the Centers of Medicare & Medicaid Services to develop and maintain performance measures that are used for public reporting (HHSM-500-2013-13018I); the Agency for Healthcare Research and Quality (R01HS022882); the National Heart, Lung and Blood Institute of the NIH (R01HS025164); and the Laura and John Arnold Foundation to establish the Good Pharma Scorecard at Bioethics International and the Collaboration on Research Integrity and Transparency at Yale. The other authors have nothing to disclose.

[Glaucoma in inpatient care in Germany in 2015]

AIM

Analysis of structural characteristics of inpatient treatment of glaucoma in clinical units run by affiliated physicians and those run by hospital physicians in Germany are described. The frequency and distribution of glaucoma diagnoses as the main and secondary diagnosis at different departments and glaucoma diagnoses, number of cases, surgeries and procedures and patient characteristics of the four glaucoma-specific diagnosis-related groups (DRG) are presented.

METHOD

Secondary data analysis using the G‑DRG browser from 2015/2016 provided by the German Institute for Remuneration Systems in Hospitals.

RESULTS

In 30% of the 156,524 cases glaucoma was classified as the main diagnosis, in 24% as secondary diagnosis in ophthalmological departments and 46% as secondary diagnosis in other departments. Primary open angle glaucoma was reported most frequently (40%), whilst non-ophthalmological departments mainly coded as "other" or "unspecified types of glaucoma". Glaucoma was coded in 20 DRGs as the main diagnosis and in all ophthalmic DRGs as secondary diagnosis. The number of cases and procedures differed among the four glaucoma-specific DRGs (C06Z, C07A, C07B, C64Z), the diagnostic spectrum, however, was similar. Patients were mainly women, older and with few comorbidities or complications. The C64Z was mainly characterized by cases with "suspected glaucoma" and only conservative procedures. Only 6% of the glaucoma patients were treated in clinical units run by affiliated physicians. In contrast to units run by hospital physicians surgical DRGs and operations prevailed but the diagnostic spectrum and patient characteristics were not different.

DISCUSSION AND CONCLUSION

With 20% of the main diagnoses, glaucoma was highly relevant for inpatient ophthalmological care. Glaucoma as a secondary diagnosis was also common in other medical specialties, though no diagnostic differentiation was made here. Patients with glaucoma are mainly treated in clinical units run by hospital physicians. Nevertheless, patients of affiliated physicians showed the same characteristics.

Anterior Segment Imaging for Angle Closure

PURPOSE

To summarize the role of anterior segment imaging (AS-imaging) in angle closure diagnosis and management, and the possible advantages over the current standard of gonioscopy.

DESIGN

Literature review and perspective.

METHODS

Review of the pertinent publications with interpretation and perspective in relation to the use of AS-imaging in angle closure assessment focusing on anterior segment optical coherence tomography and ultrasound biomicroscopy.

RESULTS

Several limitations have been encountered with the reference standard of gonioscopy for angle assessment. AS-imaging has been shown to have performance in angle closure detection compared to gonioscopy. Also, imaging has greater reproducibility and serves as better documentation for long-term follow-up than conventional gonioscopy. The qualitative and quantitative information obtained from AS-imaging enables better understanding of the underlying mechanisms of angle closure and provides useful parameters for risk assessment and possible prediction of the response to laser and surgical intervention. The latest technologies-including 3-dimensional imaging-have allowed for the assessment of the angle that simulates the gonioscopic view. These advantages suggest that AS-imaging has a potential to be a reference standard for the diagnosis and monitoring of angle closure disease in the future.

CONCLUSIONS

Although gonioscopy remains the primary method of angle assessment, AS-imaging has an increasing role in angle closure screening and management. The test should be integrated into clinical practice as an adjunctive tool for angle assessment. It is arguable that AS-imaging should be considered first-line screening for patients at risk for angle closure.

Glaucomatocyclitic Crises May Occur in Patients with Narrow or Closed Angles

Purpose

To report cases of glaucomatocyclitic crises and discuss the possibility of occurrence in patients with narrow or closed angles.

Background

The prevalence of angle closure is much higher among Asians than among the Western population. Currently, there is no evidence for a direct relationship between the etiology and angle structure.

Design

A retrospective and observational case series.

Methods

We retrospectively collected data from nine adult patients (three males and six females) who were diagnosed with a glaucomatocyclitic crisis and a shallow anterior chamber over a 21-year period, from 1995 to 2016, at the Kaohsiung Medical University Hospital. A narrow angle was defined as a grade less than the Shaffer system grade II. Ophthalmic examinations, including anterior segment biomicroscopy, direct ophthalmoscopy, intraocular pressure measurements, anterior chamber reaction, visual field tests, and the grade of the anterior chamber angle according to the Shaffer system, were reviewed.

Results

These patients experienced at least one typical unilateral ocular hypertensive episode that fulfilled the criteria of a glaucomatocyclitic crisis without the angle feature. All patients had gonioscopically narrow or closed angles with or without peripheral anterior synechiae.

Conclusions

The coexistence of narrow or closed angles and a glaucomatocyclitic crisis is possible, especially in patients of Asian descent. In patients with shallow anterior chambers, a glaucomatocyclitic crisis may be a cause of acute glaucoma episodes.

Geographic and Demographic Variation in Use of Ranibizumab Versus Bevacizumab for Neovascular Age-related Macular Degeneration in the United States

PURPOSE

To examine demographic and geographic variation in the use of ranibizumab and bevacizumab for the treatment of neovascular age-related macular degeneration (AMD) among Medicare beneficiaries.

DESIGN

Retrospective cohort study.

METHODS

Using a 100% sample of Medicare claims data, we evaluated Medicare beneficiaries (N = 195 812) with an index claim for neovascular AMD between July 1, 2006, and June 30, 2009, to determine whether beneficiaries first received ranibizumab or bevacizumab following initial diagnosis.

RESULTS

The overall proportion of beneficiaries that first received ranibizumab for neovascular AMD was 35%, and varied significantly (0.9%-84.6%) across the 306 US hospital referral regions (median = 33%, interquartile range = 17%-49%). Based on hierarchical logistic regression models, the likelihood of receiving ranibizumab declined over time (adjusted odds ratio (aOR) comparing treatment in 2009 vs 2006 = 0.39, P < .001). After we controlled for year of treatment, black beneficiaries were 45% less likely to receive ranibizumab compared to non-blacks (P < .0001). Beneficiaries residing in urban areas (aOR vs isolated rural towns = 1.12, P < .001), in zip codes with higher median incomes, and in the New England and East South Central census regions (aOR vs Pacific census region = 5.57, P < .001; aOR = 3.58, P < .001, respectively) had increased odds of receiving ranibizumab.

CONCLUSIONS

The odds of receiving bevacizumab vs ranibizumab as initial therapy for neovascular AMD among US Medicare beneficiaries varied substantially across geographic and demographic groups. Relatively fewer patients received ranibizumab for initial neovascular AMD treatment in 2009 vs 2006. Future research should study the drivers of variation in utilization of these interventions, the extent this variation indicates differential access to these agents, and whether treatment choice impacts patient outcomes.

Undetected angle closure in patients with a diagnosis of open-angle glaucoma

OBJECTIVE

The aim of this study was to identify the proportion of patients referred to a tertiary glaucoma centre with a diagnosis of open-angle glaucoma (OAG) who were found to have angle closure glaucoma.

DESIGN

Retrospective chart review.

METHODS

Consecutive new patients referred for glaucoma management to a tertiary centre between July 2010 and December 2011 were reviewed. Patients whose referrals for glaucoma assessment specified angle status as "open" were included. The data collected included glaucoma specialist's angle assessment, diagnosis, and glaucoma severity. The status of those with 180 degrees or more Shaffer angle grading of 0 was classified as "closed."

RESULTS

From 1234 glaucoma referrals, 179 cases were specified to have a diagnosis of OAG or when angles were known to be open. Of these, 16 (8.9%) were found on examination by the glaucoma specialist to have angle closure. Pseudoexfoliation was present in 4 of 16 patients (25%) in the missed angle-closure glaucoma (ACG) group and 22 of 108 patients (13.5%) in the remaining OAG group. There was no difference found in demographic or ocular biometric parameters between those with confirmed OAG versus those with missed ACG.

CONCLUSIONS

Almost 1 in 11 patients referred by ophthalmologists to a tertiary glaucoma centre with a diagnosis of OAG were in fact found to have angle closure. Given the different treatment approaches for ACG versus OAG, this study suggests a need to strengthen angle evaluations.

Trends in Prevalence of Diagnosed Ocular Disease and Utilization of Eye Care Services in American Veterans

PURPOSE

To assess trends in prevalence of diagnosed ocular disease and use of eye care services in the Veterans Affairs (VA) health care system.

DESIGN

Prevalence study.

METHODS

We performed a retrospective study of all eligible veterans in the VA Capitol Health Care Network from 2007 to 2011. The VA database was used to abstract demographic and socioeconomic variables, including age, race, sex, marital status, service connection, prescription copay, homelessness, and VA facility. Primary outcome measures were the prevalence of diagnosed ocular disease and use of eye care. Ocular diagnoses were determined by International Classification of Diseases, 9th revision codes and use by prescription medication fills, visits to eye care clinics, and cataract surgery frequency.

RESULTS

The average age of veterans ranged from 59.8-60.9, most veterans were male (88.1-89.8%), and there was a high proportion of African Americans (29.5-30%). The prevalence of all ocular diagnoses increased from 20.5% in 2007 to 23.3% in 2011 (P < .01), a 13.7% increase. Similarly, the prevalence of diagnosed cataract increased by 35.7% (P = .02) from 7.1% in 2007 to 9.6% in 2011. Diagnosed glaucoma prevalence increased by 9.4% (P = .03) from 6.7 to 7.4%. The percent of patients seen in eye clinics increased 11.6%% in the 5-year study period to 24.0% in fiscal year 2011 (P = .05). The use of ophthalmic medications increased 20% (P < .01). The rate of cataract surgery did not change significantly during the study period.

CONCLUSIONS

The prevalence of diagnosed eye conditions among American Veterans is increasing, as is the use of eye care services. Cataract surgery rates did not increase, which may indicate a need to increase availability of these services.

Potential Limitations of E-mail and Text Messaging in Improving Adherence in Glaucoma and Ocular Hypertension

PURPOSE

To determine how receptive patients are to the use of e-mail and text message reminders for appointments and medications.

METHODS

We conducted a consecutive cross-sectional survey of eligible patients with glaucoma or ocular hypertension at a private glaucoma subspecialty practice with 3 locations from February 2011 to January 2012. Main outcome measures were answers to survey questions regarding how receptive patients are to e-mail and text messaging reminders for appointments and medications.

RESULTS

Of 989 patients, 404 (40.8%) patients reported that e-mail reminders would help remember appointments and 185 (18.7%) reported that they would help for medications. Among those with access to text messaging, 280 (68.9%) reported text messaging would help them remember appointments and 193 (47.5%) reported it would help with medications. Patients who reported e-mail would help them remember medications were more likely to live in an urban location [P=0.05, odds ratio (OR)=1.84], check the internet at least daily (P≤0.001, OR=1.04), check e-mail when not at home or the office (P=0.02, OR=1.62), and know how to open attachments (P=0.03, OR=1.87). Patients who reported that text messaging would help them remember their medications were more likely to be 40 or less (P≤0.001, OR=8.54) and African American (P<0.001, OR=2.59).

CONCLUSIONS

E-mail and text messaging reminders currently may have a limited utility in improving adherence in the general glaucoma population but may be useful in younger patients with glaucoma.

Geographic and facility variation in inpatient stroke rehabilitation: multilevel analysis of functional status

OBJECTIVE

To examine geographic and facility variation in cognitive and motor functional outcomes after postacute inpatient rehabilitation in patients with stroke.

DESIGN

Retrospective cohort design using Centers for Medicare and Medicaid Services (CMS) claims files. Records from 1209 rehabilitation facilities in 298 hospital referral regions (HRRs) were examined. Patient records were analyzed using linear mixed models. Multilevel models were used to calculate the variation in outcomes attributable to facilities and geographic regions.

SETTING

Inpatient rehabilitation units and facilities.

PARTICIPANTS

Patients (N=145,460) with stroke discharged from inpatient rehabilitation from 2006 through 2009.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Cognitive and motor functional status at discharge measured by items in the CMS Inpatient Rehabilitation Facility-Patient Assessment Instrument.

RESULTS

Variation profiles indicated that 19.1% of rehabilitation facilities were significantly below the mean functional status rating (mean ± SD, 81.58±22.30), with 221 facilities (18.3%) above the mean. Total discharge functional status ratings varied by 3.57 points across regions. Across facilities, functional status values varied by 29.2 points, with a 9.1-point difference between the top and bottom deciles. Variation in discharge motor function attributable to HRR was reduced by 82% after controlling for cluster effects at the facility level.

CONCLUSIONS

Our findings suggest that variation in motor and cognitive function at discharge after postacute rehabilitation in patients with stroke is accounted for more by facility than geographic location.

The Maccabi Glaucoma Study: prevalence and incidence of glaucoma in a large israeli health maintenance organization

PURPOSE

To investigate the prevalence and incidence of glaucoma in a large health maintenance organization (HMO) in Israel.

DESIGN

A population-based retrospective cohort study, conducted using electronic medical database.

METHODS

Collected data included personal and medical characteristics.

SETTING

Maccabi Healthcare Services, the second-largest HMO in Israel, insuring 2 million members and serving 25% of the population with a nationwide distribution.

STUDY POPULATION

Maccabi members from January 2003 to December 2010.

MAIN OUTCOME MEASURES

Prevalence and incidence of glaucoma according to the International Classification of Diseases, 9th revision, Clinical Modification diagnostic codes.

RESULTS

A total of 15,708 prevalent glaucoma patients were identified among active members of Maccabi in December 2010. A total of 15,332 (97.6%) were 40 years or older, with a point prevalence of 2.2%. Prevalence of glaucoma was strongly associated with age, ranging from 0.28% at age 40-50 to 9.2% among elderly aged 80 or above. The 5 most prevalent diagnoses were open-angle glaucoma (1.61%), exfoliation glaucoma (0.20%), unspecified glaucoma (0.17%), angle closure (0.11%), and normal tension glaucoma (0.06%). We identified 6674 incident glaucoma patients diagnosed between 2003 and 2010. The observed incidence density rate among 40+-year-old members was 1.84 (1.79-1.88) new cases per 1000 person-years. Median age at diagnosis was 64 years old. The risk of glaucoma was similar between sexes up to age 70 years, and was significantly (P<.01) higher in men in older ages.

CONCLUSIONS

Glaucoma affects nearly 10% of the elderly population in Maccabi, with the highest risk of diagnosis at age 70-74. Since glaucoma leads to irreversible vision loss, the present estimates of morbidity should be of significant concern.

The prevalence of primary angle closure glaucoma in adult Asians: a systematic review and meta-analysis

BACKGROUND

Primary angle closure glaucoma (PACG) is higher in Asians than Europeans and Africans, with over 80% of PACG worldwide in Asia. Previous estimates of PACG were based largely on early studies, mostly using inappropriate case definitions. Therefore, we did a systematic review and meta-analysis to estimate the prevalence of PACG in adult Asian populations and to quantify its association with age, gender, and region.

METHODS

All primary reports of population-based studies that reported the prevalence of PACG in adult Asian populations were identified. PACG case definition was compatible with the ISGEO definition. Twenty-nine population-based studies were included. The overall pooled prevalence estimates were calculated using a random effect model, and ethnicity-, age- and gender-specific pooled prevalence estimates were also calculated.

RESULTS

The overall pooled prevalence of PACG in those of adult Asians was 0.75% (95% CI, 0.58, 0.96). Ethnicity-specific pooled prevalence estimates were 0.97% (0.22, 4.27) in Middle East group, 0.66% (0.23, 1.86) in South East Asia group, 0.46% (0.32, 0.64) in India group, 1.10% (0.85, 1.44) in China group, and 1.19% (0.35, 3.98) in Japan group, respectively. Age-specific prevalence was 0.21% (0.12, 0.37) for those 40-49 years, 0.54% (0.34, 0.85) for those 50-59 years, 1.26% (0.93, 1.71) for those 60-69 years, and 2.32% (1.74, 3.08) for those 70 years or above. The overall female to male ratio of the PACG prevalence was 1.51∶1 (95% CI 1.01, 2.28).

CONCLUSIONS

PACG affects approximately 0.75% adult Asians, increasing double per decade, and 60% of cases being female. The prevalence rates vary greatly by ethnic region.

Resident compliance with the american academy of ophthalmology preferred practice pattern guidelines for primary open-angle glaucoma

PURPOSE

To examine resident adherence to preferred practice pattern (PPP) guidelines set up by the American Academy of Ophthalmology for follow-up care of primary open-angle glaucoma (POAG) patients.

DESIGN

Retrospective chart review.

PARTICIPANTS

One hundred three charts were selected for analysis from all patients with an International Classification of Diseases, Ninth Revision, code of open-angle glaucoma or its related entities who underwent a follow-up evaluation between July 2, 2003, and December 15, 2004, at the resident ophthalmology clinic in the Durham Veteran Affairs Medical Center.

METHODS

Follow-up visits of POAG patients were evaluated for documentation of 19 elements in accordance to PPP guidelines.

MAIN OUTCOME MEASURES

Compliance rates for the 19 elements of PPP guidelines first were averaged in all charts, and then were averaged per resident and were compared among 8 residents between their first and second years of residency.

RESULTS

The overall mean compliance rate for all 19 elements was 82.6% for all charts (n = 103), 78.8% for first-year residents, and 81.7% for second-year residents. The increase from first to second year of residency was not significant (P>0.05). Documentation rates were high (>90%) for 14 elements, including all components of the physical examination and follow-up as well as most components of the examination history and management plan. Residents documented adjusting target intraocular pressure downward, local or systemic problems with medications, and impact of visual function on daily living approximately 50% to 80% of the time. Documentation rates for components of patient education were the lowest, between 5% and 16% in all charts.

CONCLUSIONS

Residents' compliance with PPP guidelines for a POAG follow-up visit was very high for most elements, but documentation rates for components of patient education were poor. Adherence rates to PPP guidelines can be used as a tool to evaluate and improve resident performance during training. However, further studies are needed to establish the advantages of using PPP guidelines for resident education and to determine if such assessments can lead to improved patient care.