Striving Toward Better Eye Health Beyond Our Waiting Rooms: The LXXX Edward Jackson Memorial Lecture

PURPOSE

Visual impairment (VI) negatively impacts the quality of lives of individuals and the optimal health of populations, creating both human and financial costs. Yet, VI has not risen to a level that is considered a priority in population health. This analysis assesses the evidence currently available for strengthening the value proposition for eye health, particularly the demographic characteristics and patient-centered outcomes found in clinical research.

DESIGN

Retrospective cross-sectional analysis.

METHOD

Two searches of the AJO database were performed using relevant key words: Search 1 (S1): NEI-sponsored clinical trials (1970-2023); and Search 2 (S2): Quality of life (2018-2023). The Scopus Cite Score was used as a filter for each search, specifically ≥50 for S1 and ≥20 for S2.

RESULTS

Of the initial 466 articles found, 100 met the preestablished criteria. Age, sex, and race/ancestry/ethnicity were reported across glaucoma, retina, uveitis, cornea, and pediatrics subspecialties in 56% ± 9.7% of the articles; 37% ± 9.5% listed either age only or age, sex, or gender. The characterizations varied and subcategories were rarely reported. Only 2% of S1 and 25% of S2 noted patient-centered outcomes.

CONCLUSIONS

The characterization of study populations in the ophthalmic literature is limited by underreporting of patient-centered outcomes, useful for reaffirming the value of eye and vision health in population health. This analysis highlights the need for paying greater attention to more specific demographic categories and focusing more on patient-centered outcomes in clinical research.

Operationalizing inclusion: moving from an elusive goal to strategic action

To mitigate the structural and institutional biases that contribute to inequities in health, we need a diverse cadre of individuals to feel included and advance within our field in order to bring a multicultural set of perspectives to the studies we conduct, the science we generate, the health and academic systems we design, and the medical and scientific knowledge we impart. There has been increasing focus on diversity, inclusion, and equity in recent years; however, often these terms are presented without adequate precision and, therefore, the inability to effectively operationalize inclusion and achieve diversity within organizations. This narrative review details several key studies, with the primary objective of presenting a roadmap to guide defining, measuring, and operationalizing inclusion within work and learning environments.

Addressing Structural Racism Using a Whole-Scale Planning Process in a Single Academic Center

Purpose

The murder of George Floyd in 2020 prompted a national demand for cultural transformation to confront the systemic racism prevalent in the country. Academic medical centers were not exempt from this urgent call. This article evaluates the efficacy of a strategic process in fostering cultural transformation within an academic medical system.

Methods

A whole-scale strategic planning process was implemented over 13 months, involving multiple working groups representing key stakeholders from each entity across the system, an anonymous survey, a communication plan, and a balanced scorecard to monitor progress. More than 5500 voices, 160 recommendations, 122 data gathering sessions, and town hall meetings contributed to the creation and implementation of vital action items and a strategic framework. The Diversity Engagement Survey (DES) was administered 18 months following the process launch.

Results

Of the 45,554 employees, students, faculty, and trainees, 96.5% completed unconscious bias education within the fiscal year and 76% of action items, termed "Just Do Its," were completed. Mission, vision, values, and strategic priorities were crafted to serve as a framework for intermediate and long-term actions. The DES revealed improvement in the "respect" attribute of an inclusive culture, and 64% of respondents confirmed that action for cultural transformation is addressing racism both within and outside of the institution.

Conclusion

Implementing a shared purpose, engaging multiple working groups representing key stakeholders, and empowerment of stakeholders to implement changes, in conjunction with the development of a strategic framework addressing structural racism, resulted in the completion of vital action items to initiate cultural change.

Asserting Accountability to Address Diversity: Report Card as a System of Measurement

Problem

To the best of our knowledge, there are no standard accountability measures for diversity efforts at the departmental level. Therefore, the purpose of this study is to evaluate a multiprong report card as a structure for evaluation, tracking, and reporting as well as to examine any relationships between expenditures and outcomes.

Approach

We instituted an intervention that offered leadership a report card of metrics related to diversity efforts. Included are diversity expenditures, benchmark demographic and departmental data, applications to support faculty salaries, participation in clerkship programs focused on attracting diverse candidates, and requests for candidate lists. The purpose of this analysis is to demonstrate the impact of the intervention.

Outcomes

A significant relationship was found between faculty funding applications and under-represented minority (URM) representation in a department (0.19; confidence interval [95% CI] 0.17-0.21; p<0.001). An association was also found between total expenditures and URM representation in a department (0.002; 95% CI 0.002-0.003; p<0.001). Other outcomes include the following: (1) women, URM, and minority faculty have all increased in representation since tracking began; (2) diversity expenditures and faculty opportunity fund and presidential professorship applications have increased over time; and (3) a steady decline in departments with zero URM representation after the tracking of diversity expenditures in both clinical and basic science departments.

Next Steps

Our findings suggest that standardized metrics for inclusion and diversity initiatives promote accountability and buy-in from executive leadership. Departmental detail enables tracking of progress longitudinally. Future work will continue to evaluate the downstream effects of diversity expenditures.

Understanding Contributors to Racial/Ethnic Disparities in Emergency Department Throughput Times: a Sequential Mixed Methods Analysis

BACKGROUND

Ensuring equitable care remains a critical issue for healthcare systems. Nationwide evidence highlights the persistence of healthcare disparities and the need for research-informed approaches for reducing them at the local level.

OBJECTIVE

To characterize key contributors in racial/ethnic disparities in emergency department (ED) throughput times.

DESIGN

We conducted a sequential mixed methods analysis to understand variations in ED care throughput times for patients eventually admitted to an emergency department at a single academic medical center from November 2017 to May 2018 (n=3152). We detailed patient progression from ED arrival to decision to admit and compared racial/ethnic differences in time intervals from electronic medical record time-stamp data. We then estimated the relationships between race/ethnicity and ED throughput times, adjusting for several patient-level variables and ED-level covariates. These quantitative analyses informed our qualitative study design, which included observations and semi-structured interviews with patients and physicians.

KEY RESULTS

Non-Hispanic Black as compared to non-Hispanic White patients waited significantly longer during the time interval from arrival to the physician's decision to admit, even after adjustment for several ED-level and patient demographic, clinical, and socioeconomic variables (Beta (average minutes) (SE): 16.35 (5.8); p value=.005). Qualitative findings suggest that the manner in which providers communicate, advocate, and prioritize patients may contribute to such disparities. When the race/ethnicity of provider and patient differed, providers were more likely to interrupt patients, ignore their requests, and make less eye contact. Conversely, if the race/ethnicity of provider and patient were similar, providers exhibited a greater level of advocacy, such as tracking down patient labs or consultants. Physicians with no significant ED throughput disparities articulated objective criteria such as triage scores for prioritizing patients.

CONCLUSIONS

Our findings suggest the importance of (1) understanding how our communication style and care may differ by race/ethnicity; and (2) taking advantage of structured processes designed to equalize care.

Assessment of Cumulative Incidence and Severity of Primary Open-Angle Glaucoma Among Participants in the Ocular Hypertension Treatment Study After 20 Years of Follow-up

Importance

Ocular hypertension is an important risk factor for the development of primary open-angle glaucoma (POAG). Data from long-term follow-up can be used to inform the management of patients with ocular hypertension.

Objective

To determine the cumulative incidence and severity of POAG after 20 years of follow-up among participants in the Ocular Hypertension Treatment Study.

Design, Setting, and Participants

Participants in the Ocular Hypertension Treatment Study were followed up from February 1994 to December 2008 in 22 clinics. Data were collected after 20 years of follow-up (from January 2016 to April 2019) or within 2 years of death. Analyses were performed from July 2019 to December 2020.

Interventions

From February 28, 1994, to June 2, 2002 (phase 1), participants were randomized to receive either topical ocular hypotensive medication (medication group) or close observation (observation group). From June 3, 2002, to December 30, 2008 (phase 2), both randomization groups received medication. Beginning in 2009, treatment was no longer determined by study protocol. From January 7, 2016, to April 15, 2019 (phase 3), participants received ophthalmic examinations and visual function assessments.

Main Outcomes and Measures

Twenty-year cumulative incidence and severity of POAG in 1 or both eyes after adjustment for exposure time.

Results

A total of 1636 individuals (mean [SD] age, 55.4 [9.6] years; 931 women [56.9%]; 1138 White participants [69.6%]; 407 Black/African American participants [24.9%]) were randomized in phase 1 of the clinical trial. Of those, 483 participants (29.5%) developed POAG in 1 or both eyes (unadjusted incidence). After adjusting for exposure time, the 20-year cumulative incidence of POAG in 1 or both eyes was 45.6% (95% CI, 42.3%-48.8%) among all participants, 49.3% (95% CI, 44.5%-53.8%) among participants in the observation group, and 41.9% (95% CI, 37.2%-46.3%) among participants in the medication group. The 20-year cumulative incidence of POAG was 55.2% (95% CI, 47.9%-61.5%) among Black/African American participants and 42.7% (95% CI, 38.9%-46.3%) among participants of other races. The 20-year cumulative incidence for visual field loss was 25.2% (95% CI, 22.5%-27.8%). Using a 5-factor baseline model, the cumulative incidence of POAG among participants in the low-, medium-, and high-risk tertiles was 31.7% (95% CI, 26.4%-36.6%), 47.6% (95% CI, 41.6%-53.0%), and 59.8% (95% CI, 53.1%-65.5%), respectively.

Conclusions and Relevance

In this study, only one-fourth of participants in the Ocular Hypertension Treatment Study developed visual field loss in either eye over long-term follow-up. This information, together with a prediction model, may help clinicians and patients make informed personalized decisions about the management of ocular hypertension.

Trial Registration

ClinicalTrials.gov Identifier: NCT00000125.

Assessment of Perceptions of Professionalism Among Faculty, Trainees, Staff, and Students in a Large University-Based Health System

Importance

With a renewed focus on medical professionalism, an opportunity exists to better define its standards and application to meet the needs of an increasingly diverse workforce given the important association between interprofessional behavior and patient care.

Objective

To examine the context of how professionalism is operationalized and perceived in diverse health care work and learning environments.

Design, Setting, and Participants

A qualitative mixed-methods analysis of survey data collected from February to April 2015, was conducted followed by analysis of narrative data collected in June 2017. The setting was 2 health systems and 4 health professional and graduate schools. Participants were faculty, trainees, staff, and students (3506 survey respondents and 52 narratives) affiliated with the University of Pennsylvania and the University of Pennsylvania Health System. Data analysis was conducted in 2018 and 2019.

Exposures

Independent variables included the following respondent characteristics: gender identity, sexual orientation, race/ethnicity, position, generational age group, length of employment at institution, disability status, belief system or religion, and primary site of work or study.

Main Outcomes and Measures

Survey questions were used to assess participants' perception and experiences of professionalism in the workplace as measured by a 5-point Likert-type scale.

Results

For the survey, there were 3506 respondents from a pool of 18 550 potential respondents (18.9% response rate). Of 3506 survey respondents, 2082 of 3231 (64.4%) were women, 331 of 3164 (10.5%) identified as gender or sexual minority groups, and 360 of 3178 (11.3%) were non-Hispanic Black individuals. In adjusted analyses, women compared with men (adjusted odds ratio [aOR], 1.8; 95% CI, 1.4-2.3) and Asian individuals (aOR, 2.0; 95% CI, 1.7-2.3) and Hispanic individuals (aOR, 2.0; 95% CI, 1.4-2.7) compared with non-Hispanic White individuals were more likely to value institutional professionalism. In addition, gender identity and sexual minority groups compared with heterosexual respondents (aOR, 1.5; 95% CI, 1.2-1.8) and non-Hispanic Black individuals compared with non-Hispanic White individuals (aOR, 1.3; 95% CI, 1.2-1.4) were statistically significantly more likely to consider changing jobs because of unprofessional behavior at work. The qualitative analysis of narratives revealed that marginalized populations (including but not limited to women, gender and sexual minority groups, racial/ethnic minority groups, those who identify as having a disability, and religious minority groups) reported (1) greater infringements on their professional boundaries, as well as increased scrutiny over their professional actions, and (2) a tension between inclusion vs assimilation.

Conclusions and Relevance

The findings of this study highlight the need for health care organizations to revisit how they define and operationalize professionalism to improve inclusivity.

The Influence of Gender and Underrepresented Minority Status on Medical Student Ranking of Residency Programs

BACKGROUND

Physician diversity is linked to improved quality of care of diverse patient populations. The transition from medical school to residency is an opportunity to improve and increase workforce diversity in all specialties. However, there is limited published literature on the factors contributing to the ranking of residency programs on women and underrepresented minorities (URMs).

OBJECTIVE

To characterize factors medical students used to rank residency programs and describe any differences based on race/ethnicity or gender.

METHODS

A mixed-methods study consisting of a web-based survey and semi-structured interviews with National Resident Matching Program (NRMP) participating graduates over a two-year period. The survey assessed demographics and a 6-point Likert scale rating of various factors used to rank residency programs. Unpaired student t-tests were used to compare means. A subset of students was interviewed and a modified grounded theory approach identified decision-making themes as well as the role of gender and URM status.

RESULTS

Out of a total of 316 invitations sent, 148 completed the survey (46.8% response rate), of which 21% of respondents self-identified as URMs. The majority of respondents graduated in 2014 (53%), and were male (51%). Participants ranked program atmosphere, reputation, location, and proximity to family the highest. URM students ranked patient population (p < 0.01), revisit opportunities (p = 0.04), gender diversity (p < 0.01), and ethnic diversity (p < 0.01) significantly higher than non-URM students. Female students ranked patient population (p < 0.01) and gender diversity (p < 0.01) significantly higher than males. Qualitative findings revealed differences in perceptions by URMs and non-URMs of patient population, revisit opportunities, gender diversity, and ethnic diversity.

CONCLUSIONS

While all students prioritized pragmatic factors, women and URM students assess and weigh additional factors related to culture, inclusion, and diversity more than others. By tailoring recruitment strategies to meet the expectations of women and URMs, residency programs can better meet goals in becoming more diverse and inclusive.

Assessment of the Impact of an Endpoint Committee in the Ocular Hypertension Treatment Study

PURPOSE

To assess the impact of a masked Endpoint Committee on estimates of the incidence of primary open-angle glaucoma (POAG) treatment efficacy and statistical power of the Ocular Hypertension Treatment Study-Phase 1, 1994-2002 (OHTS-1).

DESIGN

Retrospective interrater reliability analysis of endpoint attribution by the Endpoint Committee.

METHODS

After study closeout, we recalculated estimates of endpoint incidence, treatment efficacy, and statistical power using all-cause endpoints and POAG endpoints. To avoid bias, only the first endpoint per participant is included in this report.

RESULTS

The Endpoint Committee reviewed 267 first endpoints from 1636 participants. The Endpoint Committee attributed 58% (155 of 267) of the endpoints to POAG. The incidence of all-cause endpoints vs POAG endpoints was 19.5% and 13.2%, respectively, in the observation group and 13.1% and 5.8%, respectively, in the medication group. Treatment effect for all-cause endpoints was a 33% reduction in risk (relative risk = 0.67, 95% confidence interval [CI] of 0.54-0.84) and a 56% reduction in risk for POAG endpoints (relative risk = 0.44, 95% CI of 0.31-0.61). Post hoc statistical power for detecting treatment effect was 0.94 for all-cause endpoints and 0.99 for POAG endpoints.

CONCLUSION

Endpoint Committee adjudication of endpoints improved POAG incidence estimates, increased statistical power, and increased calculated treatment effect by 23%. An Endpoint Committee should be considered in therapeutic trials when common ocular and systemic comorbidities, other than the target condition, could compromise study results.

Is Newer Necessarily Better? The Evolution of Incisional Glaucoma Surgery Over the Last 100 Years

PURPOSE

To examine the progress made in glaucoma incisional surgery and determine if there has been sufficient progress to meet the needs of glaucoma patients.

DESIGN

Perspective (literature review).

METHODS

This is a retrospective assessment of key milestones in the evolution of glaucoma incisional surgery and an evaluation of the risks and the benefits of these procedures. Benefits are defined as effective reduction in intraocular pressure (IOP) and protecting visual function, while risks are defined as safety and complications for our patients. Quality of life is also considered.

RESULTS

Although advances have been made in the last 100 years, the trabeculectomy, a procedure that was described more than 50 years ago, remains the optimal choice for reducing IOP among those patients who require pressures in the teens, who do not respond to medications and prior laser therapy.

CONCLUSIONS

Appropriate patient selection, careful attention to surgical technique, and intensive follow-up of patients will optimize the results of a trabeculectomy. Newer procedures must be carefully studied in well-designed clinical trials to determine comparative levels of safety and efficacy to this gold standard. Advances in drug delivery and minimally invasive glaucoma surgery may ultimately produce the best outcome for glaucoma patients in the future.

Tailored and targeted interventions to encourage dilated fundus examinations in older African Americans

OBJECTIVES

To compare the effects of a tailored (individualized) and targeted (designed for a subgroup) print intervention in promoting dilated fundus examinations (DFEs) in older African Americans and to determine whether other factors (eg, demographics, preventive health practices, health literacy score, behavioral intentions, and DFE rates) are associated with getting a DFE.

METHODS

African Americans aged 65 years or older who had not had a DFE in at least 2 years were recruited from community settings. Participants were randomized to receive either a tailored or targeted newsletter. Telephone follow-up was conducted at 1, 3, and 6 months to ascertain eye examination status. All participant-reported DFEs were confirmed by contacting their eye doctor (optometrist or ophthalmologist) by telephone. Main Outcome Measure  Eye doctor-confirmed DFE at 6 months.

RESULTS

Of the 329 participants enrolled, 128 (38.9%) had an eye doctor-confirmed DFE. No significant difference was noted in this measure by intervention group (relative risk, 1.07; 95% confidence interval, 0.82-1.40), with 66 participants in the tailored group (40.2%) and 62 participants in the targeted group (37.6%) having an eye doctor-confirmed DFE. Based on logistic regression analysis, reading the newsletter (odds ratio, 1.76; 95% confidence interval, 1.08-2.87) and planning to make an appointment for a DFE (odds ratio, 2.46; 95% confidence interval, 1.42-4.26) were significant predictors for DFE.

CONCLUSIONS

The tailored and targeted interventions were equally effective in promoting eye doctor-confirmed DFEs at 6 months. Given the increased cost and effort associated with tailoring, our results suggest that well-designed targeted print messages can motivate older African Americans to get DFEs. Trial Registration  clinicaltrials.gov Identifier: NCT00649766.

Strategic planning as a tool for achieving alignment in academic health centers

After the passage of the Patient Protection and Affordable Care Act in March 2010, there is an urgent need for medical schools, teaching hospitals, and practice plans to work together seamlessly across a common mission. Although there is agreement that there should be greater coordination of initiatives and resources, there is little guidance in the literature to address the method to achieve the necessary transformation. Traditional approaches to strategic planning often engage a few leaders and produce a set of immeasurable initiatives. A nontraditional approach, consisting of a Whole-Scale (Dannemiller Tyson Associates, Ann Arbor, MI) engagement, appreciative inquiry, and a balanced scorecard can, more rapidly transform an academic health center. Using this nontraditional approach to strategic planning, increased organizational awareness was achieved in a single academic health center. Strategic planning can be an effective tool to achieve alignment, enhance accountability, and a first step in meeting the demands of the new landscape of healthcare.

Delaying treatment of ocular hypertension: the ocular hypertension treatment study

OBJECTIVE

To compare the safety and efficacy of earlier vs later treatment in preventing primary open-angle glaucoma (POAG) in individuals with ocular hypertension.

METHODS

One thousand six hundred thirty-six individuals with intraocular pressure (IOP) from 24 to 32 mm Hg in 1 eye and 21 to 32 mm Hg in the fellow eye were randomized to observation or to topical ocular hypotensive medication. Median time of treatment in the medication group was 13.0 years. After a median of 7.5 years without treatment, the observation group received medication for a median of 5.5 years. To determine if there is a penalty for delaying treatment, we compared the cumulative proportions of participants who developed POAG at a median follow-up of 13 years in the original observation group and in the original medication group.

MAIN OUTCOME MEASURES

Cumulative proportion of participants who developed POAG.

RESULTS

The cumulative proportion of participants in the original observation group who developed POAG at 13 years was 0.22 (95% confidence interval [CI], 0.19-0.25), vs 0.16 (95% CI, 0.13-0.19) in the original medication group (P = .009). Among participants at the highest third of baseline risk of developing POAG, the cumulative proportion who developed POAG was 0.40 (95% CI, 0.33-0.46) in the original observation group and 0.28 (95% CI, 0.22-0.34) in the original medication group. There was little evidence of increased adverse events associated with medication.

APPLICATION TO CLINICAL PRACTICE

Absolute reduction was greatest among participants at the highest baseline risk of developing POAG. Individuals at high risk of developing POAG may benefit from more frequent examinations and early preventive treatment.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00000125.

Fixed combination of latanoprost and timolol vs individual components for primary open-angle glaucoma or ocular hypertension: a randomized, double-masked study

OBJECTIVE

To assess the efficacy and safety of fixed-combination latanoprost-timolol (FCLT) vs latanoprost or timolol monotherapy.

METHODS

This 12-week, randomized, double-masked, parallel-group study included patients with open-angle glaucoma or ocular hypertension treated with a beta-blocker and with baseline intraocular pressure (IOP) of 26 through 36 mm Hg. Following washout, eligible patients were randomized to once-daily FCLT in the evening, latanoprost in the evening, or timolol in the morning.

MAIN OUTCOME MEASURES

Postbaseline IOP assessments at 8 am, 10 am, and 4 pm at weeks 2, 6, and 12; statistical superiority of FCLT for the 18 pairwise comparisons between FCLT and the 2 monotherapies, using analysis of variance.

RESULTS

All therapies resulted in significant IOP reductions from baseline. Pairwise comparisons favored FCLT at all time points. When the 18 comparisons were tested simultaneously, FCLT was statistically superior to latanoprost at 7 of 9 time points and at all 9 time points when compared with timolol. In addition, FCLT was associated with greater percentage reductions in diurnal IOP levels and a greater likelihood of achieving lower mean diurnal IOP levels. Diurnal IOP reductions of 30% or more from baseline to week 12 were achieved by 73.5%, 57.5%, and 32.8% of those treated with FCLT, latanoprost, and timolol, respectively (P = .007 for FCLT vs timolol; P < .001 for FCLT vs latanoprost). All therapies were well tolerated.

CONCLUSIONS

Fixed-combination latanoprost-timolol therapy is as safe and effective in lowering IOP in patients with either ocular hypertension or glaucoma as monotherapy with latanoprost or timolol. Combination therapy can be used to treat patients for whom monotherapy does not provide sufficient IOP reduction.

APPLICATION TO CLINICAL PRACTICE

The simplicity, efficacy, and tolerability of FCLT contribute to its utility in clinical practice.

TRIAL REGISTRATION

clinicaltrials.gov Identifier NCT00277498.

Considerations in glaucoma therapy: fixed combinations versus their component medications

Fixed combinations of medications that lower intraocular pressure (IOP) are increasingly used in the treatment of glaucoma and ocular hypertension and offer several potential advantages over combined use of the separate component medications including enhanced convenience, improved adherence, reduced exposure to preservatives, and possible cost savings. This review aims to examine the current role of IOP-lowering fixed combinations in disease management. The results of studies that compared the efficacy and safety of IOP-lowering fixed combinations with their component medications are summarized, including those fixed combinations that consist of a prostaglandin analog and timolol. The fixed combinations currently available for use in the United States are fixed-combination dorzolamide/timolol (FCDT) and fixed-combination brimonidine/timolol (FCBT). Both of these fixed combinations reduce IOP more effectively than their component medications used separately as monotherapy. FCBT therapy also demonstrates a more favorable safety profile and reduced ocular allergy compared to monotherapy with brimonidine, a component medication. Few studies have directly compared the efficacy and safety of FCDT and FCBT, but available evidence suggests that FCBT is at least as effective as FCDT in lowering IOP and is more comfortable and better tolerated. Additional studies are needed to further evaluate the comparative efficacy and tolerability of FCDT and FCBT in the management of glaucoma and ocular hypertension.

Glaucoma medication persistence with a fixed combination versus multiple bottles

OBJECTIVE

To determine if prescribing combination therapy versus two or three separate bottles results in greater persistence among patients with glaucoma.

METHODS

Using a retail pharmacy claims database, three glaucoma patient cohorts were defined and followed for 12 months (January 2004 through December 2004). Patients in cohort 1 had a prescription for a single fixed-combination therapy during the month of January 2004. Cohort 2 consisted of patients with prescriptions for a beta-blocker and one other glaucoma product in the same month. Cohort 3 comprised patients with prescriptions filled for three different glaucoma therapies during the first month. A fixed-combination formulation may have been included in cohorts 2 and 3 as well, but was counted as a single bottle. Persistence rate, defined as the percentage of patients who did not discontinue their medication over the 12-month period, was calculated.

RESULTS

Cohort 1 (one bottle; n = 14 742) was more persistent than cohort 2 (two bottles; n = 18 411), with 35.3% vs. 27.2% of patients remaining on therapy at the end of the study period (p < 0.0001). Cohort 3 (n = 4826), with three separate bottles per patient, had the lowest percentage remaining on therapy (23.9%; p < 0.0001).

CONCLUSION

Analyses of pharmacy database data are limited by the possibilities of misidentifying newly treated patients or misclassifying added versus switched medications. As the number of separate products used for glaucoma therapy increases, patient persistence decreases. A management regimen requiring as few products as possible may enhance glaucoma patient persistence.

Historically black medical schools: addressing the minority health professional pipeline and the public mission of care for vulnerable populations

Substantial changes in not only access to care, cost, and quality of care, but also health professions education are needed to ensure effective national healthcare reform. Since the actionable determinants of health such as personal beliefs and behaviors, socioeconomic factors, and the environment disproportionately affect the poor (and often racial/ethnic minorities), many have suggested that focusing efforts on this population will both directly and indirectly improve the overall health of the nation. Key to the success of such strategies are the ongoing efforts by historically black medical schools (HBMSs) as well as other minority serving medical and health professional schools, who produce a disproportionate percentage of the high-quality and diverse health professionals that are dedicated to maintaining the health of an increasingly diverse nation. Despite their public mission, HBMSs receive limited public support threatening their ability to not only meet the increasing minority health workforce needs but to even sustain their existing contributions. Substantial changes in health education policy and funding are needed to ensure HBMSs as well as other minority-serving medical and health professional schools can continue to produce the diverse, high-quality health professional workforce necessary to maintain the health of an increasingly diverse nation. We explore several model initiatives including focused partnerships with legislative and business leaders that are urgently needed to ensure the ability of HBMSs to maintain their legacy of providing compassionate, quality care to the communities in greatest need.

The public health approach to eliminating disparities in health

Reducing and eliminating disparities in health is a matter of life and death. Each year in the United States, thousands of individuals die unnecessarily from easily preventable diseases and conditions. It is critical that we approach this problem from a broad public health perspective, attacking all of the determinants of health: access to care, behavior, social and physical environments, and overriding policies of universal access to care, physical education in schools, and restricted exposure to toxic substances. We describe the historical background for recognizing and addressing disparities in health, various factors that contribute to disparities, how the public health approach addresses such challenges, and two successful programs that apply the public health approach to reducing disparities in health. Public health leaders must advocate for public health solutions to eliminate disparities in health.

The public health approach to eliminating disparities in health

Reducing and eliminating disparities in health is a matter of life and death. Each year in the United States, thousands of individuals die unnecessarily from easily preventable diseases and conditions. It is critical that we approach this problem from a broad public health perspective, attacking all of the determinants of health: access to care, behavior, social and physical environments, and overriding policies of universal access to care, physical education in schools, and restricted exposure to toxic substances. We describe the historical background for recognizing and addressing disparities in health, various factors that contribute to disparities, how the public health approach addresses such challenges, and two successful programs that apply the public health approach to reducing disparities in health. Public health leaders must advocate for public health solutions to eliminate disparities in health.

Knowledge, attitudes, and beliefs about dilated eye examinations among African-Americans

PURPOSE

To understand factors that influence African-Americans' attitude toward eye examinations.

METHODS

Ten focus groups were conducted with 86 African-Americans. Four focus groups were conducted with people 65 years of age and older who had not received a dilated fundus examination (DFE) in the past 2 years, two groups were held with people 65 years of age and older who had had a recent DFE, and two groups each were held with people 40 to 64 years of age, with and without recent DFEs. Focus group interviews were conducted by using a moderator guide to address perceived benefits of and barriers to getting an eye examination; motivators for getting DFEs; and knowledge of eye examinations, glaucoma, and diabetic retinopathy. Participants also completed a questionnaire that provided demographic information. Quantitative and qualitative analyses were conducted.

RESULTS

Cost or lack of sufficient insurance was identified as the most important barrier to getting a DFE. Also frequently mentioned was not having any symptoms and being too busy. The most frequently cited benefit of getting a DFE was to help prevent eye disease, whereas the most frequently reported motivating factor was experiencing a vision problem. Regarding knowledge, many people did not know the risk factors for glaucoma, but seemed to have a better understanding of how to reduce the effects of diabetes on their eyes.

CONCLUSIONS

Study findings identified important links between financial resources and experiencing a vision problem and the adoption of preventive eye care in an urban African-American population.

Treating ocular hypertension to reduce glaucoma risk: when to treat?

When to treat the patient who presents with ocular hypertension has been a question that has 'stumped' the ophthalmic community for decades. Population-based studies and intervention trials have provided the basis for understanding why we consider treating such patients. Although the EGPS (European Glaucoma Prevention Study) did not demonstrate that reducing intraocular pressure (IOP) with dorzolamide prevented the onset of glaucoma compared with individuals receiving a placebo, the investigators of the OHTS (Ocular Hypertension Treatment Study) found that the treatment of ocular hypertension can be delayed with topical medication when treated patients were compared with an observation group. There are differences in inclusion criteria, study design and retention rates between the EGPS and the OHTS, which may have led to the discrepancies in outcomes between these two studies. These differences provide a basis for understanding the relevance of the findings of both trials to clinical practice. The clinician should consider key risk factors such as age, thin corneal thickness measurements, large cup-to-disc ratio and mean IOP when determining who should be treated. However, the ultimate decision of when to treat will be determined by other issues such as life expectancy, the general health of the patient and the number of risk factors. Clearly, the treatment of only high-risk patients with ocular hypertension should be considered.

Glaucoma and its treatment: a review

PURPOSE

A review of glaucoma and its treatment is presented.

SUMMARY

Glaucoma is a common eye disease that can cause irreversible blindness if left undiagnosed and untreated. Glaucoma is a leading cause of blindness in the United States and other industrialized countries. In most cases, the symptoms of early-stage glaucoma are minimal or nonexistent. There are several different types of glaucoma, and they have been classically divided into the categories of primary or secondary open-angle or angle-closure glaucoma. Secondary forms of glaucoma are caused by various ocular or systemic diseases. Every available treatment to prevent progressive glaucomatous optic neuropathy has potential adverse effects and involves a certain amount of risk and financial expense. Conventional first-line treatment of glaucoma usually begins with the use of a topical selective or nonselective beta-blocker or a topical prostaglandin analog. Second-line drugs of choice include alpha-agonists and topical carbonic anhydrase inhibitors. Parasympathomimetic agents, most commonly pilocarpine, are considered third-line treatment options. For patients who do not respond to antiglaucoma medications, laser trabeculoplasty and incisional surgery are further methods that can be used to lower intraocular pressure. The results of clinical trials have reaffirmed the utility of antiglaucoma medications in slowing the progression of the disease.

CONCLUSION

Glaucoma is a common eye disease that is usually associated with an elevated intraocular pressure. Treatment options for patients with glaucoma include medications, laser therapy, and incisional surgery. The risks and benefits of each type of treatment must be carefully considered to maximize the treatment's benefits while minimizing adverse effects.

Glaucoma and its treatment: a review

PURPOSE

A review of glaucoma and its treatment is presented.

SUMMARY

Glaucoma is a common eye disease that can cause irreversible blindness if left undiagnosed and untreated. Glaucoma is a leading cause of blindness in the United States and other industrialized countries. In most cases, the symptoms of early-stage glaucoma are minimal or nonexistent. There are several different types of glaucoma, and they have been classically divided into the categories of primary or secondary open-angle or angle-closure glaucoma. Secondary forms of glaucoma are caused by various ocular or systemic diseases. Every available treatment to prevent progressive glaucomatous optic neuropathy has potential adverse effects and involves a certain amount of risk and financial expense. Conventional first-line treatment of glaucoma usually begins with the use of a topical selective or nonselective beta-blocker or a topical prostaglandin analog. Second-line drugs of choice include alpha-agonists and topical carbonic anhydrase inhibitors. Parasympathomimetic agents, most commonly pilocarpine, are considered third-line treatment options. For patients who do not respond to antiglaucoma medications, laser trabeculoplasty and incisional surgery are further methods that can be used to lower intraocular pressure. The results of clinical trials have reaffirmed the utility of antiglaucoma medications in slowing the progression of the disease.

CONCLUSION

Glaucoma is a common eye disease that is usually associated with an elevated intraocular pressure. Treatment options for patients with glaucoma include medications, laser therapy, and incisional surgery. The risks and benefits of each type of treatment must be carefully considered to maximize the treatment's benefits while minimizing adverse effects.

Ethnic differences in glaucoma: prevalence, management, and outcome

PURPOSE OF REVIEW

Glaucoma has a disproportionate prevalence among specific ethnic groups. Therefore, the issue of 'race' and glaucoma has been the focus of much discussion. The purpose of this article is to provide a review of the literature regarding the prevalence, management, and outcome of glaucoma among different ethnic populations.

RECENT FINDINGS

This review highlights not only recent reports but also notes key studies from the past regarding glaucoma and ethnicity. Given the variation in presentation and the response to therapy, it is important to individualize one's therapeutic approach in any given patient.

SUMMARY

Our knowledge regarding glaucoma and ethnicity helps us to customize a patient's therapeutic regimen more effectively. Therefore, understanding an individual's heredity and culture is essential to properly identify, treat, and manage individuals at risk and existing patients with glaucoma.

The Ocular Hypertension Treatment Study: topical medication delays or prevents primary open-angle glaucoma in African American individuals

BACKGROUND

The prevalence of glaucoma is higher in African American individuals than in white individuals.

OBJECTIVE

To report the safety and efficacy of topical ocular hypotensive medication in delaying or preventing the onset of primary open-angle glaucoma (POAG) among African American participants in the Ocular Hypertension Treatment Study.

METHODS

Eligibility criteria included age between 40 and 80 years, intraocular pressure between 24 and 32 mm Hg in one eye and between 21 and 32 mm Hg in the other eye, and no evidence of glaucomatous structural or functional damage by standard clinical measures. Participants were randomized to either the observation group or medication group. Of the 1636 participants randomized, 408 were self-identified as African American.

MAIN OUTCOME MEASURE

The primary outcome was the development of reproducible visual field abnormality and/or reproducible optic disc deterioration attributed to POAG.

RESULTS

Among African American participants, 17 (8.4%) of 203 in the medication group developed POAG during the study (median follow-up, 78 months) compared with 33 (16.1%) of 205 participants in the observation group (hazard ratio, 0.50; 95% confidence interval, 0.28-0.90; P =.02).

CONCLUSION

Topical ocular hypotensive therapy is effective in delaying or preventing the onset of POAG in African American individuals who have ocular hypertension.

Antiglaucoma eye drop pulses--increased interleukin-6 secretion by Tenon's capsule fibroblast cultures

PURPOSE

Long-term antiglaucoma eye drop therapy prior to trabeculectomy is a risk factor for surgical failure resulting from Tenon's capsule fibrosis at the fistula site. The study tested the hypothesis that secretion of the proinflammatory cytokine interleukin (IL)-6 by wounded Tenon's capsule-fibroblasts is elevated by prior long-term antiglaucoma eye drop treatment.

METHODS

Fibroblast cultures were established from Tenon's capsule biopsies during trabeculectomy. Twice daily and for four and a half days, confluent secondary (2-4 passages) cultures were treated (30 minutes at 37 degrees C) with the following drugs (diluted at 1:400-1:100): 0.2% brimonidine-tartrate (Alphagan), 2.0% dorzolamide-HCl (Trusopt), 0.5% timolol-maleate (Timoptic), 2.0% dorzolamide-HCl/0.5% timolol-maleate (Cosopt), 2 and 4% pilocarpine-HCl (Akarpine and Pilocar), 0.005% latanoprost (Xalatan), placebos for Trusopt and Timoptic, and 0.01% benzalkonium chloride. Subsequently, cultures were wounded by removing cells grown on half of each culture dishes along with the medium and conditioned for 20 hours in serum-free growth medium, which was then collected for ELISA for IL-6 (and TNF-alpha and IL-1 beta). Cultures were grown for four additional days to show the maintenance of culture sterility.

RESULTS

Latanoprost, pilocarpine-HCl, and timolol-maleate increased IL-6 levels in the conditioned medium in a dilution factor-dependent manner (P < 0.05, ANOVA). IL-6 concentrations were increased most significantly by latanoprost and were (pg/ml; mean +/- SEM; N = 3 cultures) 186 +/- 37, 187 +/- 33, 295 +/- 46 and 336 +/- 76 in cultures treated at 1:400, 1:250, 1:150, and 1:100 dilutions, respectively, whereas those of six control cultures averaged 80 +/- 9. Benzalkonium chloride, brimonidine-tartrate, dorzolamide-HCl, Cosopt placebo, Timoptic placebo, and dorzolamide-HCl/timolol-maleate did not significantly elevate IL-6 concentrations. IL-1 beta and TNF-alpha were not detected in the medium of control cultures and those treated with pilocarpine (1:200).

CONCLUSIONS

The present study demonstrated for the first time that the level of IL-6 secretion by wounded Tenon's capsule fibroblast cell cultures was increased by repeat pulsing of these cultures with some, but not all, antiglaucoma eye drops prior to wounding.