Use of eye care services among the 1991 Medicare population

Advanced Visualization Engineering for Vision Disorders: A Clinically Focused Guide to Current Technology and Future Applications

Head-mounted visualization technology, often in the form of virtual, augmented, and mixed reality (VAMR), has revolutionized how visual disorders may be approached clinically. In this manuscript, we review the available literature on VAMR for visual disorders and provide a clinically oriented guide to how VAMR technology has been deployed for visual impairments. The chief areas of clinical investigation with VAMR are divided include (1) vision assessment, (2) vision simulation, and (3) vision rehabilitation. We discuss in-depth the current literature of these areas in VAMR and upcoming/future applications to combat the detrimental impact of visual impairment worldwide.

Personalized therapeutic strategies for patients with retinitis pigmentosa

INTRODUCTION

Retinitis pigmentosa (RP) encompasses many different hereditary retinal degenerations that are caused by a vast array of different gene mutations and have highly variable disease presentations and severities. This heterogeneity poses a significant therapeutic challenge, although an answer may eventually be found through two recent innovations: induced pluripotent stem cells (iPSCs) and clustered regularly interspaced short palindromic repeats (CRISPR)/Cas genome editing.

AREAS COVERED

This review discusses the wide-ranging applications of iPSCs and CRISPR-including disease modelling, diagnostics and therapeutics - with an ultimate view towards understanding how these two technologies can come together to address disease heterogeneity and orphan genes in a novel personalized medicine platform. An extensive literature search was conducted in PubMed and Google Scholar, with a particular focus on high-impact research published within the last 1 - 2 years and centered broadly on the subjects of retinal gene therapy, iPSC-derived outer retina cells, stem cell transplantation and CRISPR/Cas gene editing.

EXPERT OPINION

For the retinal pigment epithelium, autologous transplantation of gene-corrected grafts derived from iPSCs may well be technically feasible in the near future. Photoreceptor transplantation faces more significant unresolved technical challenges but remains an achievable, if more distant, goal given the rapid pace of advancements in the field.

Gaps in receipt of regular eye examinations among medicare beneficiaries diagnosed with diabetes or chronic eye diseases

OBJECTIVE

To examine a wide range of factors associated with regular eye examination receipt among elderly individuals diagnosed with glaucoma, age-related macular degeneration, or diabetes mellitus (DM).

DESIGN

Retrospective analysis of Medicare claims linked to survey data from the Health and Retirement Study (HRS).

PARTICIPANTS

The sample consisted of 2151 Medicare beneficiaries who responded to the HRS.

METHODS

Medicare beneficiaries with ≥ 1 of the 3 study diagnoses were identified by diagnosis codes and merged with survey information. The same individuals were followed for 5 years divided into four 15-month periods. Predictors of the number of periods with an eye examination evaluated were beneficiary demographic characteristics, income, health, cognitive and physical function, health behaviors, subjective beliefs about longevity, the length of the individual's financial planning horizon, supplemental health insurance coverage, eye disease diagnoses, and low vision/blindness at baseline. We performed logit analysis of the number of 15-month periods in which beneficiaries received an eye examination.

MAIN OUTCOME MEASURES

The primary outcome measure was the number of 15-month periods with an eye examination.

RESULTS

One third of beneficiaries with the study's chronic diseases saw an eye care provider in all 4 follow-up periods despite having Medicare. One quarter only obtained an eye examination at most during 1 of the four 15-month follow-up periods. Among the 3 groups of patients studied, utilization was particularly low for persons with diagnosed DM and no eye complications. Age, marriage, education, and a higher score on the Charlson index were associated with more periods with an eye examination. Male gender, being limited in instrumental activities of daily living at baseline, distance to the nearest ophthalmologist, and low cognitive function were associated with a reduction in frequency of eye examinations.

CONCLUSIONS

Rates of eye examinations for elderly persons with DM or frequently occurring eye diseases, especially for DM, remain far below recommended levels in a nationally representative sample of persons with health insurance coverage. Several factors, including limited physical and cognitive function and greater distance to an ophthalmologist, but not health insurance coverage, account for variation in regular use.

Increasing incidence of cataract surgery: population-based study

PURPOSE

To estimate the incidence of cataract surgery in a defined population and to determine longitudinal cataract surgery patterns.

SETTING

Mayo Clinic, Rochester, Minnesota, USA.

DESIGN

Cohort study.

METHODS

Rochester Epidemiology Project (REP) databases were used to identify all incident cataract surgeries in Olmsted County, Minnesota, between January 1, 2005, and December 31, 2011. Age-specific and sex-specific incidence rates were calculated and adjusted to the 2010 United States white population. Data were merged with previous REP data (1980 to 2004) to assess temporal trends in cataract surgery. Change in the incidence over time was assessed by fitting generalized linear models assuming a Poisson error structure. The probability of second-eye cataract surgery was calculated using the Kaplan-Meier method.

RESULTS

Included were 8012 cataract surgeries from 2005 through 2011. During this time, incident cataract surgery significantly increased (P<.001), peaking in 2011 with a rate of 1100 per 100 000 (95% confidence interval, 1050-1160). The probability of second-eye surgery 3, 12, and 24 months after first-eye surgery was 60%, 76%, and 86%, respectively, a significant increase compared with the same intervals in the previous 7 years (1998 to 2004) (P<.001). When merged with 1980 to 2004 REP data, incident cataract surgery steadily increased over the past 3 decades (P<.001).

CONCLUSION

Incident cataract surgery steadily increased over the past 32 years and has not leveled off, as reported in Swedish population-based series. Second-eye surgery was performed sooner and more frequently, with 60% of residents having second-eye surgery within 3 months of first-eye surgery.

Utilization of Eye Care Services Among Staff of a Tertiary Hospital

PURPOSE

To determine the level of utilization of eye care services and to identify the barriers to uptake of eye care services among the staff in a hospital.

DESIGN

A cross-sectional study conducted at a university teaching hospital.

METHODS

A total of 250 staff members were selected using a proportionate sampling among the segment of study population. Data were collected using semistructured questionnaires, including demographic data, awareness about eye clinic and the services rendered, facilities utilized by staff in receiving eye treatment, and reasons for not utilizing the hospital eye care services. Data analysis was done using SPSS version 15.

RESULTS

The majority (66%) of the staff were younger than 40 years. Around 229 staff members (91.6%) were aware of the clinic, whereas 222 (88.8%) were aware of at least 1 of the various services rendered. They received treatment from chemists (30.7%), private hospitals (26.3%), and optical shops (16.1%). The hospital eye clinic (11.8%) was the least chosen place to receive eye treatment. The reasons for nonutilization of eye care services were lack of finance (42.1%), poor staff attitude (23.7%), fear of damage to the eye (15.3%), high cost of treatment (9.7%), and ignorance of its existence (9.2%). Visual impairment was seen in 14 of the staff (5.6%), whereas blindness was seen in 1 (0.4%).

CONCLUSIONS

The level of utilization of eye care services in the hospital by the staff is poor and very low compared with other facilities, although the majority had previous history of eye complaints.

Eye-Related Medicare Costs for Patients with Age-Related Macular Degeneration from 1995 to 1999

OBJECTIVE

Age-related macular degeneration (AMD) is the leading cause of blindness and severe visual impairment among the elderly in the United States. This study aims to assess eye-related Medicare costs from 1995 to 1999 in patients with both nonneovascular and neovascular AMD as compared with controls, and to delineate whether variations exist across demographic and clinical subgroups in eye-related Medicare costs over 5 years.

DESIGN

Retrospective, observational, population-based analysis.

PARTICIPANTS

Five percent random sample of Medicare beneficiaries.

METHODS

Data were obtained from the 5% random sample of Medicare beneficiaries with diagnoses of nonneovascular and neovascular AMD. A control group was selected based on diagnoses of blepharitis, chronic conjunctivitis, or blepharoconjuctivitis and no diagnosis of AMD. Eye-related claims were totaled and compared for each group over the 5-year study period. Demographic and clinical factors potentially influencing eye-related costs were also examined.

MAIN OUTCOME MEASURES

Eye-related Medicare costs during the 5-year study period.

RESULTS

Median eye-related Medicare costs were estimated at $1607 for neovascular AMD patients, $832 for nonneovascular AMD patients, and $658 for controls. Cost differences across groups were significant based on univariate and multivariate analyses (P<0.001). In linear regression analysis, males and blacks had significantly lower eye-related Medicare costs than females and whites, respectively (P<0.001).

CONCLUSIONS

Age-related macular degeneration represented a significant economic burden to the U.S. health care system for a single ophthalmic disease entity based on Medicare reimbursed eye-related costs before the availability of photodynamic therapy and anti-vascular endothelial growth factor therapy. Given that direct eye-related costs associated with the treatment of neovascular AMD are estimated at $569 million annually before the availability of therapy for subfoveal lesions, effective therapeutic measures may be associated with substantial cost offsets.

Incidence of cataract surgery from 1980 through 2004: 25-year population-based study

PURPOSE

To estimate sex- and age-specific incidence rates of cataract surgery in a defined United States population and evaluate the change in incidence over time.

SETTING

Department of Ophthalmology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA.

METHODS

Rochester Epidemiology Project databases were used to identify all incident cataract surgeries in Olmsted County, Minnesota, residents during the 25-year period from January 1, 1980, through December 31, 2004. Annual incidence rates for each sex and 10-year age group were calculated and adjusted to the 2000 U.S. white population. Change in incidence over time was assessed by fitting generalized linear models assuming a Poisson error structure.

RESULTS

During the study period, 10 245 cataract extractions were performed in 7141 residents of all ages. Overall, the age-adjusted cataract surgery incident rate per 100000 residents was 548 (95% confidence interval [CI], 534-561) for women, 462 (95% CI, 447-478) for men, and 511 (95% CI, 501-521) for all residents. The incidence of cataract surgery increased 500% among women and 467% among men during the study period (P<.001). Overall, the incidence of cataract surgery was highest in residents 70 years and older (3538 surgeries [95% CI, 3322-3764] per 100,000 residents).

CONCLUSIONS

This population-based study found a substantial increase in incident cataract surgery among Olmsted County residents during the 25-year study period. The rate of cataract surgery increased in a nearly linear fashion during a period when phacoemulsification replaced extracapsular cataract extraction in the community.

Surgical treatment of age-related macular degeneration: will there be a role in the future?

Surgical treatment has been shown to be able to improve vision that is lost as a result of age-related macular degeneration. Surgery is complex, such that improvement has always to be weighed against risk of complications. The availability of Ranibizumab and Bevacizumab is set to dramatically alter our management options. Surgical treatment will have a limited role to play in the next few years.

Eye care utilization patterns in Tehran population: a population based cross-sectional study

Background

The aim of this study is to determine eye care visits which are an indicator of eye care service utilization by Tehran population and its determinants.

Methods

Through a population-based, cross-sectional study, 6497 Tehran citizens were sampled. All participants had complete eye examinations and an interview regarding demographic and socioeconomic status variables, past medical and eye history, and their previous and last eye care visits.

Results

Among those sampled, 4565 people participated in the study (response rate of 70.3%). Among these participants, 34.7 % had never visited an ophthalmologist or optometrist (95% confidence interval [CI]: 32.4 to 36.9) and 43.2% had not seen an eye care provider in the last 5 years. Multivariate logistic regression revealed that men (OR = 1.30), younger participants (each year increase in age: OR = 0.98) and the less educated (each year increase in education: OR = 0.93) were more likely, and the visually impaired were less likely (OR = 0.41) to have neglected eye care.

Conclusion

A large proportion of the population, including those in the high risk group who require eye care, has never utilized any eye care service. These data suggest that efforts have to be made to better understand the causes and to optimize the utilization of the available eye care services in the population.

Recent Trends in Upper Eyelid Blepharoplasties in Medicare Patients in the United States from 1995 to 1999

PURPOSE

To present data regarding the rate of upper eyelid blepharoplasty in the Medicare population at both the national and the regional levels from 1995 to 1999 and to analyze these data for any correlation with reimbursement, surgical criteria differences, or the number of ophthalmologists per capita.

METHODS

This was a retrospective cohort study. The subjects consisted of a 5% random sample of the Medicare population who had blepharoplasty from 1995 to 1999. Number, rate, and reimbursements of blepharoplasty of the 10 Health Care Financing Administration (HCFA) regions were compared for the 5-year period. Number of ophthalmologists per capita and differences in the regional criteria for Medicare-approved upper eyelid blepharoplasty were compared among the 10 HCFA regions.

RESULTS

Across the nation, there was a 13% annual increase in the rate of blepharoplasty from 1995 to 1999 in the Medicare-population after adjusting for age, race, sex, and HCFA regions. During the same period, the average reimbursement per surgery decreased by $26.50 annually. There was a statistically significant inverse correlation between reimbursement and rate of blepharoplasty at the national level (r= - 0.74, P< 0.001). On the regional level, this relation was less profound (r= -0.29, P= 0.039). There was no correlation between the rate of blepharoplasty and the number of ophthalmologists per capita or the differences in surgical criteria.

CONCLUSIONS

The inverse relation between rate of Medicare-approved blepharoplasty and reimbursement between 1995 and 1999 was evident at both the national and regional levels. No relation between regional differences in the rates of blepharoplasty and regional differences in surgical criteria or the number of ophthalmologists per capita were identified. Though our study suggests no causal link between annual rate of blepharoplasty and Medicare reimbursement, such inverse correlation is interesting and may have been affected by other factors such as changing clinical indications for this procedure.

Cost-utility analysis of cataract surgery in the second eye

OBJECTIVE

To perform a reference case cost-utility analysis of second-eye cataract surgery by using the current literature on cataract outcomes and complications.

DESIGN

Computer-based econometric modeling.

METHODS

Visual acuity data of patients treated and observed over a 4-month postoperative period were obtained from the U.S. National Cataract Patient Outcomes Research Team report. The results from this prospective study were combined with those of other studies that investigated the complication rates of cataract surgery to complete the cohort of patients and outcomes. These synthesized data were incorporated with time trade-off utility values, which accounted for prior successful cataract surgery in the fellow eye. Cost-utility determinations were made with decision analysis, and present value modeling was used to account for the time value of money and health state consequences.

MAIN OUTCOME MEASURES

The number of quality-adjusted life-years (QALYs) gained was calculated for the study group undergoing second-eye cataract surgery, assuming that the postoperative vision in the second eye was equivalent to the vision in the first eye after surgery (20/27). This was divided into the cost of the procedure to find the number of year 2001 nominal U.S. dollars spent per QALY gained.

RESULTS

Second-eye cataract surgery, as compared with unilateral pseudophakia, resulted in a mean gain of 1.31 undiscounted QALYs per patient treated. A 3% annual discount rate, dependent on the duration of benefit, was used, yielding 0.92 discounted QALYs gained over a 12-year life expectancy. The mean discounted cost of treatment for each patient totaled 2509 US dollars. The cost divided by the QALYs gained (benefit) resulted in 2727 US dollars per QALY gained for this procedure. Sensitivity analysis varying costs and utility values revealed a range from 2045 US dollars to 3649 US dollars per QALY gained.

CONCLUSIONS

Second-eye cataract surgery is an extremely cost-effective procedure when compared with other interventions across medical specialties. The cost-effectiveness of second-eye surgery diminishes only slightly from the 2023 US dollars per QALY gained from first-eye cataract surgery. This suggests that patients with good vision in one eye and visual loss from cataract in the fellow eye derive substantial benefit from cataract extraction.

Incidence of exudative age-related macular degeneration among elderly Americans

PURPOSE

To estimate the 3-year incidence of exudative age-related macular degeneration (AMD) and its treatment by laser photocoagulation in elderly Americans.

DESIGN

Population-based cohort study using insurance claims data.

PARTICIPANTS

A random 5% sample of Medicare beneficiaries, age 65 and older.

METHODS

Incidence of exudative AMD and of laser photocoagulation for this condition was assessed based on four categories of ascertainment criteria that included procedure and diagnosis codes associated with exudative AMD, choroidal neovascularization, and its treatment.

MAIN OUTCOME MEASURES

Incidence of AMD and of associated laser photocoagulation.

RESULTS

Overall, the 3-year incidence of exudative AMD is estimated to be between 9.4 per 1000 and 11.4 per 1000 Americans age 65 and older (depending on ascertainment criteria), based on those diagnosed and treated by ophthalmologists for the condition. These estimates bracket the measured incidence of exudative AMD in the Beaver Dam Eye Study and lie within its 95% confidence interval. The 3-year incidence of exudative AMD with attendant laser photocoagulation was 2.3 per 1000. Women were found to have a slightly higher incidence of AMD than men using all ascertainment criteria (P < 0.001), and white Americans were found to have a fivefold-to-sixfold higher ascertainment criteria than black Americans (P < 0.001).

CONCLUSIONS

The reported incidence of exudative AMD identified in the population of Medicare beneficiaries suggests that measurements on incidence for this condition derived from the Beaver Dam Eye Study can be generalized to the U.S. population.

Indecision about corticosteroids for bacterial keratitis: an evidence-based update

PURPOSE

To quantify the effect of topical corticosteroids on bacterial keratitis.

CLINICAL RELEVANCE

Bacterial keratitis is an economically important infection affecting 1 in 10,000 Americans annually. The predisposing factors, prior ocular health, infecting microorganisms, inflammatory severity, and therapeutic choices can affect the course and outcome. Antibacterial treatment is often curative but does not guarantee good vision. Because many treated patients develop a sight-limiting corneal problem, antiinflammatory therapy has sometimes been recommended.

LITERATURE REVIEWED

Publications from 1950 to 2000 that evaluated the effect of corticosteroids on bacterial keratitis in animal experiments, case reports and series, case-comparison and cohort studies, and clinical trials were systematically identified by electronic and manual search strategies.

RESULTS

The use of a topical corticosteroid before the diagnosis of bacterial keratitis significantly predisposed to ulcerative keratitis in eyes with preexisting corneal disease (odds ratio [OR], 2.63; 95% confidence limits [CL], 1.41, 4.91). Once microbial keratitis occurred, prior corticosteroid use significantly increased the odds of antibiotic treatment failure or other infectious complications (OR, 3.75; 95% CL, 2.52, 5.58). However, the effect of a topical corticosteroid with antibiotics after the onset of bacterial keratitis was unclear. Experimental models suggested likely advantages, but clinical studies did not show a significant effect of topical corticosteroid therapy on the outcome of bacterial keratitis (OR, 0.62; 95% CL, 0.25, 1.54).

CONCLUSIONS

Topical corticosteroids increase the risk of infectious complications affecting the cornea but may or may not have an effect during antibacterial therapy. The unproven role of corticosteroids in the adjunctive treatment of bacterial keratitis highlights the need to collect prospective information that would guide appropriate management for this common eye disease.

Frequency of ophthalmic assessments among elderly whites and African Americans with eye disease and impact on visual function

OBJECTIVES

To study the difference in patterns of utilization of eye-care services among white and African American senior citizens with eye disease and its impact on visual function.

METHODS

This study involved cross-sectional assessments of visual function using the Activities of Daily Vision Scale (ADVS), as well as retrospective self-recall of history of eye disease and frequency of ophthalmic assessments. Participants included 99 consecutive elderly patients with history of eye disease who were attending the outpatient medical clinics at Nassau University Medical Center, a community teaching hospital in Long Island, New York.

RESULTS

White Americans constituted 52% of the study sample and African Americans constituted the remaining 48%. African American subjects were less likely than whites to report visiting an eye specialist over the previous 5 years (69% versus 88%, P < 0.05). African American subjects who reported undergoing ophthalmic assessments over the past 5 years showed a trend of having higher ADVS scores (indicating better visual function) compared with those who did not report such history (86 +/- 12 versus 79 +/- 15, P = 0.098). On the other hand, reporting such history had no apparent relation to the ADVS scores in whites.

CONCLUSIONS

African American elderly ambulatory medical patients with eye disease were less likely than their white counterparts to report use of eye-care services. The use of eye-care services in African American but not white subjects was linked to better visual function as assessed by the ADVS.

Use of eye care services by older Australians: the Blue Mountains Eye Study

PURPOSE

To assess utilization of eye care services in an older Australian population.

METHODS

The Blue Mountains Eye Study examined 3654 permanent residents aged 49 years or older from two New South Wales postcode areas. At interview, we collected information about past attendance to eye care practitioners, demographic and socio-economic status variables and past medical and eye history. Full-time optometric and part-time ophthalmic services were available in this community.

RESULTS

Almost all participants (99%) had seen either an ophthalmologist or optometrist in the past, with 62, 27, 7 and 3% having last attended in the last 2, 2-5, 5-10 and > 10 years, respectively. Among those participants (2251) who had been seen in the last 2 years, 50.2% (1131) last saw an ophthalmologist, 48.6% (1094) last saw an optometrist and 26 (1.2%) could not state whom they saw. After adjusting for age and sex, factors statistically significantly associated with attending an ophthalmologist included older age, female gender, higher socio-economic status, moderate to high myopia and presence of systemic disease (diabetes, hypertension) or any significant eye pathology. Factors statistically significantly associated with attending an optometrist were younger age, living alone, not currently married, being able to go out alone, having better presenting visual acuity, hyperopia and absence of diabetes or significant eye pathology, including moderate to high myopia.

CONCLUSIONS

Findings from this study indicate that whether people use eye care services and whom they visit is mainly driven by need factors. Although there was considerable overlap, this study found relatively appropriate utilization of eye care services by this population.

Eye care utilization by older Americans: the SEE Project. Salisbury Eye Evaluation

OBJECTIVE

To determine eye care utilization patterns among older Americans, particularly characterizing those who sought different types of providers, and the predictive factors for seeking eye care services in general and among those with diabetes and those with visual loss.

DESIGN AND PARTICIPANTS

The SEE Project, a population-based survey of 2520 persons aged 65 to 84 in Salisbury, Maryland, provided cross-sectional data on eye care use. Questions on eye care use, demographics, medical history, and other factors were asked on the home interview.

MAIN OUTCOME MEASURES

Use of an eye care provider in the previous year, with additional outcomes of use of different types of eye care providers.

RESULTS

Blacks were significantly less likely to see any type of eye care provider over 1 year: 50% versus 69% among whites. Those who reported having a vision problem, those with more education, and those in the older age groups were significantly more likely to see either an ophthalmologist or an optometrist. Diabetes and driving a car were predictive factors for seeing an ophthalmologist but not for seeing an optometrist. Self-report of diabetes and eye care problems, and being a current driver, were predictive of seeing an eye care professional among those with visual impairment.

CONCLUSIONS

Although blacks are known to be at greater risk for several age-related eye diseases, they are much less likely to see an eye care provider. Interventions that remove barriers to eye care services should be considered.

Strabismus surgery among aged medicare beneficiaries

OBJECTIVES

The purpose of this study was to investigate the incidence of strabismus surgery among aged patients in the United States.

METHODS

The Medicare Part B claims experience (physician professional fee billing) for 1995 was reviewed for the number of times each strabismus surgical procedure recognized in Physicians' Current Procedural Terminology (CPT) was performed. To determine the indications for the procedures that were performed, a 5% sample of claims was reviewed for the pertinent International Classification of Diseases, Ninth Revision, Clinical Modification, diagnostic codes.

RESULTS

There were 27 million aged Medicare beneficiaries eligible for Part B benefits in 1995 in a fee-for-service setting. During that year physicians reported 9497 strabismus physician services. These represented 6585 separate procedures (CPT codes 67311 to 67343) and 277 botulinum toxin (Botox) injections for strabismus (CPT 67345) performed during 1995. Sixty-nine percent of the surgical procedures were for horizontal correction and 28% were for vertical correction. Adjustable sutures were used for only 1240 cases (1 9%). The add-on procedural code for reoperation surgery or surgery in the presence of restriction of the extraocular muscles was used in just 930 cases (14%). The most common diagnosis for horizontal surgery was exotropia. Paralytic strabismus and thyroid disease were identified for 17% of cases. Three percent of the diagnoses were inappropriate for the procedures performed and may have been reported in error.

CONCLUSIONS

These data confirm a very low incidence of strabismus surgical procedures (2/10,000) and injections (1/100,000) among aged Medicare beneficiaries. The strabismus surgery was most often performed to repair a horizontal deviation. The adjustable suture technique was used infrequently. These data may be extrapolated into the future to aid in determining the strabismus services that will be needed early in the next century.