FAIR Header Reference genome: a TRUSTworthy standard

The lack of interoperable data standards among reference genome data-sharing platforms inhibits cross-platform analysis while increasing the risk of data provenance loss. Here, we describe the FAIR bioHeaders Reference genome (FHR), a metadata standard guided by the principles of Findability, Accessibility, Interoperability and Reuse (FAIR) in addition to the principles of Transparency, Responsibility, User focus, Sustainability and Technology. The objective of FHR is to provide an extensive set of data serialisation methods and minimum data field requirements while still maintaining extensibility, flexibility and expressivity in an increasingly decentralised genomic data ecosystem. The effort needed to implement FHR is low; FHR's design philosophy ensures easy implementation while retaining the benefits gained from recording both machine and human-readable provenance.

DATA RESOURCES AND ANALYSES FAIR Header Reference genome: A TRUSTworthy standard

The lack of interoperable data standards among reference genome data-sharing platforms inhibits cross-platform analysis while increasing the risk of data provenance loss. Here, we describe the FAIR-bioHeaders Reference genome (FHR), a metadata standard guided by the principles of Findability, Accessibility, Interoperability, and Reuse (FAIR) in addition to the principles of Transparency, Responsibility, User focus, Sustainability, and Technology (TRUST). The objective of FHR is to provide an extensive set of data serialisation methods and minimum data field requirements while still maintaining extensibility, flexibility, and expressivity in an increasingly decentralised genomic data ecosystem. The effort needed to implement FHR is low; FHR's design philosophy ensures easy implementation while retaining the benefits gained from recording both machine and human-readable provenance.

Trends in Imaging Utilization Among United States Medicare Beneficiaries and the Impact of the COVID-19 Pandemic

This study characterizes trends in ophthalmic imaging volume and utilization in the United States among and assesses the potential impact of the COVID-19 pandemic using data from the Centers for Medicare and Medicaid Services. Utilization of macular optical coherence tomography (OCT), optic nerve OCT, and fundus photography steadily increased from 2013 to 2020 and was not impacted by the COVID-19 pandemic. At the same time, there was minimal adoption of anterior segment OCT and a decline in the utilization of dye-based angiography. Utilization patterns may be impacted by the advent of new technologies, role of the clinician, and alignment with treatment paradigms. [Ophthalmic Surg Lasers Imaging Retina 2023;54:661-665.].

Time-driven Activity-based Costing Analysis of Fluorescein Angiography

PURPOSE

To use electronic health record (EHR) time logs and time-driven activity-based costing (TDABC) to calculate the complete cost profile of office-based fluorescein angiography (FA).

DESIGN

Economic analysis.

SUBJECTS

Patients undergoing routine FA (Current Procedural Terminology [CPT] 92235) at Vanderbilt Eye Institute in fiscal year 2022.

METHODS

Process flow mapping for routine FA was used to define the care episode after manual observation. Deidentified time logs were sourced from the EHR and all manually validated to calculate durations for each stage. The cost of materials was calculated from internal financial figures. Cost per minute for space, equipment, and personnel were based on internal figures. Published fluorescein costs were used for base-case analysis with scenario analysis based on a range of internal figures from pharmacy quotes. These inputs were used for a TDABC analysis.

MAIN OUTCOME MEASURES

Time-driven activity-based costing of FA episode of care. Secondary scenario analyses focus on breakeven scenarios for key inputs, including medication costs RESULTS: Cost analysis of office-based FA resulted in an average total cost of $152.95 (nominal) per interpreted study per patient, which was $36.52 more than the maximum Medicare reimbursement for CPT 92235 in Mac Locality for Tennessee 10312 for fiscal year 2022 ($116.43; $76.11 [technical component] and $40.33 [physician component]). The negative contribution margin is strongly influenced by the cost of fluorescein, which comprises 39.8% of the episode costs, excluding overhead.

CONCLUSIONS

The current analysis here shows that the recently increased cost of fluorescein has driven up the cost of office-based FA relative to the current maximum allowable Medicare reimbursement, leading to a negative contribution margin and financial loss. Given conservative cost estimates here, it is unlikely for profitability to be achieved without changes in the cost of fluorescein or increased reimbursement. These results may be informative for policy discussion regarding appropriate reimbursement for codes using injectable fluorescein.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

BILATERAL CHOROIDAL VASCULAR MALFORMATIONS IN HEREDITARY HEMORRHAGIC TELANGIECTASIA

PURPOSE

To describe a case of bilateral choroidal vascular malformations in a patient with hereditary hemorrhagic telangiectasia.

METHODS

Case report.

RESULTS

A 78-year-old man with hereditary hemorrhagic telangiectasia was incidentally noted to have focal, large deep choroidal vessels on optical coherence tomography with corresponding elevation of the overlying retina. Indocyanine green angiography revealed dilated, intensely fluorescent vessels in arterial phase emptying into massively dilated choroidal veins consistent with choroidal arteriovenous malformation.

CONCLUSION

This case presents multimodal imaging findings of choroidal arteriovenous malformations in hereditary hemorrhagic telangiectasia. Choroidal vascular malformations may represent an underrecognized clinical feature of this syndrome.

Effectiveness of bevacizumab step therapy for neovascular age-related macular degeneration

OBJECTIVE

To determine the effectiveness of bevacizumab step therapy for neovascular age-related macular degeneration (nAMD) in routine clinical practice.

METHODS

In this retrospective case series, eyes initiating treatment for nAMD at an academic medical centre from 2011-2019 were included. Exclusion criteria included previous intravitreal anti-VEGF injections, prior non-cataract intraocular surgery, <1 year of treatment, and not starting on monthly bevacizumab therapy. Of 895 eligible eyes, 548 were excluded, yielding 347 eyes in the study population. These eyes were treated for nAMD under the bevacizumab step therapy protocol with an option to switch to another agent in the event of predefined treatment failure. Treatment failure was defined as losing 15 or more Early Treatment Diabetic Retinopathy Study letters or switching to an alternative anti-VEGF agent. Eyes that did not meet these criteria were deemed treatment successes. Annual change in mean VA from baseline (ΔVA) was the primary outcome. Secondary outcomes included treatment success rate, medication switch rate, and post-switch ΔVA.

RESULTS

After 1 year, mean ΔVA was +8.4 letters (95% CI: +6.1 to +10.6 letters). 86% had treatment success, and 6% of eyes had switched to aflibercept. In years 2-7, ΔVA ranged from +7.0 to -0.7 letters, and treatment success rates ranged from 68 to 82%. 11% (n = 38) of eyes were switched to aflibercept. The post-switch ΔVA in these eyes was -7.1 letters (95% CI: -13.3 to -0.1) after a mean of 17.7 ± 12.6 injections over an average of 2.7 ± 2.0 years.

CONCLUSION

A bevacizumab step therapy protocol in routine clinical practice is effective for long-term treatment of nAMD.

Perspectives of Patients About Immediate Access to Test Results Through an Online Patient Portal

Importance

The 21st Century Cures Act Final Rule mandates the immediate electronic availability of test results to patients, likely empowering them to better manage their health. Concerns remain about unintended effects of releasing abnormal test results to patients.

Objective

To assess patient and caregiver attitudes and preferences related to receiving immediately released test results through an online patient portal.

Design, Setting, and Participants

This large, multisite survey study was conducted at 4 geographically distributed academic medical centers in the US using an instrument adapted from validated surveys. The survey was delivered in May 2022 to adult patients and care partners who had accessed test results via an online patient portal account between April 5, 2021, and April 4, 2022.

Exposures

Access to test results via a patient portal between April 5, 2021, and April 4, 2022.

Main Outcomes and Measures

Responses to questions related to demographics, test type and result, reaction to result, notification experience and future preferences, and effect on health and well-being were aggregated. To evaluate characteristics associated with patient worry, logistic regression and pooled random-effects models were used to assess level of worry as a function of whether test results were perceived by patients as normal or not normal and whether patients were precounseled.

Results

Of 43 380 surveys delivered, there were 8139 respondents (18.8%). Most respondents were female (5129 [63.0%]) and spoke English as their primary language (7690 [94.5%]). The median age was 64 years (IQR, 50-72 years). Most respondents (7520 of 7859 [95.7%]), including 2337 of 2453 individuals (95.3%) who received nonnormal results, preferred to immediately receive test results through the portal. Few respondents (411 of 5473 [7.5%]) reported that reviewing results before they were contacted by a health care practitioner increased worry, though increased worry was more common among respondents who received abnormal results (403 of 2442 [16.5%]) than those whose results were normal (294 of 5918 [5.0%]). The result of the pooled model for worry as a function of test result normality was statistically significant (odds ratio [OR], 2.71; 99% CI, 1.96-3.74), suggesting an association between worry and nonnormal results. The result of the pooled model evaluating the association between worry and precounseling was not significant (OR, 0.70; 99% CI, 0.31-1.59).

Conclusions and Relevance

In this multisite survey study of patient attitudes and preferences toward receiving immediately released test results via a patient portal, most respondents preferred to receive test results via the patient portal despite viewing results prior to discussion with a health care professional. This preference persisted among patients with nonnormal results.

Association of Socioeconomic, Demographic, and Health Care Access Disparities With Severe Visual Impairment in the US

Importance

Approximately 13% of US adults are affected by visual disability, with disproportionately higher rates in groups impacted by certain social determinants of health (SDOH).

Objective

To evaluate SDOH associated with severe visual impairment (SVI) to ultimately guide targeted interventions to improve ophthalmic health.

Design, Setting, and Participants

This quality improvement study used cross-sectional data from a telephone survey from the Behavioral Risk Factor Surveillance System (BRFSS) that was conducted in the US from January 2019 to December 2020. Participants were noninstitutionalized adult civilians who were randomly selected and interviewed and self-identified as "blind or having serious difficulty seeing, even while wearing glasses."

Exposures

Demographic and health care access factors.

Main Outcomes and Measures

The main outcome was risk of SVI associated with various factors as measured by odds ratios (ORs) and 95% CIs. Descriptive and logistic regression analyses were performed using the Web Enabled Analysis Tool in the BRFFS.

Results

During the study period, 820 226 people (53.07% female) participated in the BRFSS survey, of whom 42 412 (5.17%) self-identified as "blind or having serious difficulty seeing, even while wearing glasses." Compared with White, non-Hispanic individuals, risk of SVI was increased among American Indian/Alaska Native (OR, 1.63; 95% CI, 1.38-1.91), Black/African American (OR, 1.50; 95% CI, 1.39-1.62), Hispanic (OR, 1.65; 95% CI, 1.53-1.79), and multiracial (OR, 1.33; 95% CI, 1.15-1.53) individuals. Lower annual household income and educational level (eg, not completing high school) were associated with greater risk of SVI. Individuals who were out of work for 1 year or longer (OR, 1.78; 95% CI, 1.54-2.07) or who reported being unable to work (OR, 2.90; 95% CI, 2.66-3.16) had higher odds of SVI compared with the other variables studied. Mental health diagnoses and 14 or more days per month with poor mental health were associated with increased risk of SVI (OR, 1.87; 95% CI, 1.73-2.02). Health care access factors associated with increased visual impairment risk included lack of health care coverage and inability to afford to see a physician.

Conclusions and Relevance

In this study, various SDOH were associated with SVI, including self-identification as being from a racial or ethnic minority group; low socioeconomic status and educational level; long-term unemployment and inability to work; divorced, separated, or widowed marital status; poor mental health; and lack of health care coverage. These disparities in care and barriers to health care access should guide targeted interventions.

Implications of the presence of private equity in ophthalmology: an academic perspective

PURPOSE OF REVIEW

Private equity acquisitions of ophthalmology private practices have been steadily increasing over the past decade with far-reaching implications. Ophthalmology departments at academic medical centers are not insulated from the impact of this trend.

RECENT FINDINGS

The limited data on this subject in the ophthalmology literature identify the growing number of practice acquisitions. However, the lack of transparency obfuscates a clear understanding of the effect on patients and practice patterns.

SUMMARY

Leaders at academic medical centers need to be aware of surrounding practice consolidation because of private equity as this could affect revenue streams and patient referral patterns, accelerating expansion. Trainees are entering an uncertain job marketplace that may create a compelling argument to practice in an academic medical center ophthalmology department.

The Impact of the American Academy of Ophthalmology's Leadership Development Program: Experience from the First 20 Years

Objective This study aimed to analyze the effectiveness of the American Academy of Ophthalmology (AAO)'s Leadership Development Program (LDP), report the program's impact on participants in attaining ophthalmic leadership positions, and identify opportunities to improve future LDP programming.

Design An open cohort study was performed on AAO LDP graduates by using an online questionnaire and retrospective monitoring.

Participants and Methods AAO LDP graduates from 1999 to 2019 participated in the study. A Likert-scale survey was distributed via email. Online responses were submitted anonymously to a team at the Berkeley Haas School of Business for analysis. A separate review of gender demographics and ophthalmic leadership positions held by graduates was performed.

Main Outcomes Measures Regression analysis was performed to determine whether survey results supported a meaningful relationship between the measured impact and the AAO LDP program's perceived effectiveness. Ascension into leadership positions of AAO-related organizations at the national, regional, state, and subspecialty level by AAO LDP graduates was collated.

Results Of 381 potential respondents, 203 survey responses were returned (53.3%). 158 reported that they are currently holding a leadership position (77.8%). Statistical analyses indicated that the overall value of the program was seen as highly effective (M = 4.6), and that the development programs combined contributed significantly to AAO LDP being judged as effective overall, F (11,191) = 24.79; p < 0.001 with an R 2 of 0.59. Longitudinal tracking of the 383 graduates revealed that 268 (70.0%) have served as AAO committee/task force members, councilors, or representatives to outside organizations. A total of 242 (63.2%) graduates have served as president or chair of a state, subspecialty, or specialized interest ophthalmology society. 25 (6.5%) have served at the highest level of AAO leadership and two have been elected AAO President. A higher percentage of participants identifying as female was found in the LDP program compared with both U.S. overall and trainee ophthalmic populations.

Conclusion The AAO LDP has fulfilled its initial goals of effectively developing a large cohort of ophthalmologists interested in and prepared to take on leadership roles across the profession. Development of more specific outcome measures to evaluate the program, as well as direct optimal programming, are needed to further the success of its aims.

Leadership Development in Ophthalmology: Current Impact and Future Needs

Importance There is a lack of peer-reviewed literature on leadership development programs (LDP) in ophthalmology. Research into LDP demographics, outcomes, and methodology is needed.

Objective The aim of the study is to evaluate the extent to which LDPs targeting ophthalmologists meet the needs of emerging leaders.

Design The design type of the study is cross-sectional analysis.

Setting This study involves international setting.

Participants The participants involved were ophthalmologists at any career level.

Methods Routine internet search was used to identify LDPs targeting ophthalmologists. LDPs identified were categorized by the outcome data available into four levels based on prior literature. Participants were assessed using previously validated software for gender (Gender-API, 2020) and race or ethnicity (NamSor, 2020)

Results Nine programs were identified which were classified into LDP generations. The first LDP in ophthalmology was the American Academy of Ophthalmology (AAO) LDP, which served as the nidus for the formation of four multinational LDPs, together forming the Global LDP. These LDPs were similar in size and scope; program size ranging from nine to 30 participants; a length of 1 to 2 years; with similar curricular offerings; with funding primarily derived from cost-sharing with a nominating society. The second generation of ophthalmology LDPs in the United States has targeted female scientists or faculty (Women's LDP by ARVO) and academic ophthalmology leaders (Academic LDP by Association of University Professors of Ophthalmology).

The AAO's LDP appears increasingly diverse with approximately 13% women at inception, gradually increasing from 40 to 65% women in the last 5 years (n = 389). There has also been a notable increase in ethnic diversity.

Conclusion and Relevance AAO LDP is the preeminent leadership training program for ophthalmologists, and it has influenced the creation of a new generation of LDP offerings. There remains a paucity of LDP evaluation metrics and reported outcomes. Newer iterations are successfully targeting academic leadership and attempting to address known disparities in gender and race or ethnicity. Further expansion of LDPs and related research can ensure equity and diversity in the pipeline.

Cost Analysis of Routine Vitrectomy Surgery

PURPOSE

To use electronic health record (EHR) time logs to calculate the complete cost profiles of routine pars plana vitrectomy surgery.

DESIGN

Economic analysis.

PARTICIPANTS

Patients undergoing elective vitrectomy procedures (Current Procedural Terminology codes 67040, 67041, and 67042) at Vanderbilt University Medical Center in fiscal year 2019.

METHODS

Process flow mapping for routine vitrectomy surgery was used to define the operative episode. De-identified time logs were sourced from an internal perioperative data warehouse to calculate procedure-level durations. The costs of materials and overhead were calculated from internal financial management software. Costs per minute for space, equipment, and personnel were based on internal figures. These inputs were used for a time-driven activity-based costing (TDABC) analysis.

MAIN OUTCOME MEASURES

Complete cost profile of routine pars plana vitrectomy surgery.

RESULTS

Cost analysis of routine vitrectomy surgery resulted in a total cost of $7169.79 per patient, which was $2053.85 more than the maximum Medicare reimbursement for the equivalent episode, $5115.93. Vitrectomy cases do not break even unless the case duration is fewer than 26.81 minutes, overhead is reduced by 53.78%, or reimbursement is increased by 40.15%. Reimbursement does not compensate for variable costs alone for cases lasting longer than 55.09 minutes. In the cohort used here, 68% of cases are completely unprofitable, with increasing losses directly proportional to the length of the case.

CONCLUSIONS

This analysis showed that true costs for routine vitrectomy procedures are significantly more than the maximum allowable Medicare reimbursement. Academic ophthalmology departments may benefit from more accurate costing approaches using existing EHR data. These approaches may be informative for policy discussion regarding appropriate reimbursement.

Utility of Ophthalmologic Screening for Patients With Candida Bloodstream Infections: A Systematic Review

Importance

The Infectious Diseases Society of America recommends ophthalmologic examinations for everyone with positive Candida blood culture results (candidemia) to screen for endophthalmitis, a practice that remains controversial because of multiple concerns for its limited usefulness and potential for harm.

Objective

To determine guideline efficacy by reconciling discrepancies in the incidence of endophthalmitis and evaluating outcomes of studies assessing ophthalmologic screening for candidemia.

Evidence Review

PubMed literature searches, including the search terms candidemia, fungemia, chorioretinitis, and endophthalmitis, identified longitudinal studies prior to 2018 of patients who underwent ophthalmologic evaluations in the setting of positive fungal blood culture results regardless of symptoms or clinical status. Additional studies not captured by these queries were found by manually scanning references within the articles captured by the queries. Ambiguous studies of patients with concomitant bacterial or viral infections were excluded.

Findings

Thirty-eight applicable studies of 7472 patients who underwent ophthalmologic screening for candidemia or fungemia were identified. Criteria were compared with the conventional definition of endophthalmitis based on present (concordant) or absent (discordant) frank vitreous involvement. Concordant (59 of 6693 [0.9%]) and discordant (114 of 779 [14.6%]) endophthalmitis incidence rates differed by 13.8% (95% CI, 11.4%-16.4%; P < .001). Visual acuity for each case was recorded verbatim as subjective report provided by each study, when available. None of the concordant endophthalmitis cases reported direct, intraocular, microscopic evidence of Candida or other fungal organisms. Outcomes were available for 19 patients with concordant endophthalmitis; 6 died within 4 weeks of screening. The rate of substantial vision loss was associated (φ = 0.58; 95% CI, 0.01-0.86; P = .046) with additional invasive intervention (3 of 6 [50.0%]) compared with medical management alone (0 of 6).

Conclusions and Relevance

In this systematic review without meta-analysis, inconsistent definitions of endophthalmitis accounted for discrepancies of its incidence and overreporting among patients with candidemia, contributing to bias and resulting in the construction of guidelines. As few as 3 of 7472 patients had potential improvement, while routine examination overall could lead to additional interventions and harm in this population. These findings suggest that indiscriminate screening based on candidemia alone does not appear to be supported by the literature and should be reevaluated for inclusion as a recommendation from the Infectious Diseases Society of America.

Prophylaxis measures for postinjection endophthalmitis

Intravitreal injections have become the most commonly performed ophthalmic procedure, transforming modern retina practice. Postinjection endophthalmitis, while rare, remains the most feared potential complication. Prophylaxis measures including topical antisepsis, hand hygiene, gloves, masks, and drapes have all been proposed to help prevent postinjection endophthalmitis; however, there remains significant variation in protocol, given the lack of agreement among retina specialists on which steps are crucial to prevent endophthalmitis. With millions of injections performed annually, collating data have helped us better understand risk factors for endophthalmitis after intravitreal injection. We summarize the consensus guidelines for intravitreal injection technique and comprehensively review the literature on prevention of postinjection endophthalmitis.

Analysis of Anti-Vascular Endothelial Growth Factor Injection Claims Data in US Medicare Part B Beneficiaries From 2012 to 2015

Importance

The frequency of anti-vascular endothelial growth factor (VEGF) injections has grown exponentially with the introduction of bevacizumab, ranibizumab, and most recently aflibercept. The cost associated with these medications has garnered significant national attention, warranting a granular analysis of their use.

Objective

To analyze trends in anti-VEGF injections for US Medicare Part B beneficiaries from 2012 to 2015.

Design, Setting, and Participants

This observational cohort study used 2012-2015 data from the Centers for Medicare & Medicaid Services Medicare Part B Provider Utilization Files to analyze trends in intravitreal injections of anti-VEGF medications among Medicare Part B beneficiaries and their health care professionals.

Main Outcomes and Measures

The primary outcome measure was distribution of and change over time in the number of anti-VEGF injections performed for ranibizumab, aflibercept, and bevacizumab.

Results

A total of 2 574 124 intravitreal injections were performed by 3348 ophthalmologists in the outpatient setting for Medicare Part B beneficiaries during the 2015 calendar year; 100 ophthalmologists (3.0%) performed the highest volume of intravitreal injections. The total number of intravitreal injections administered in 2015 was 870 843 for aflibercept, 697 412 for ranibizumab, and 1 147 432 for bevacizumab. Ranibizumab injections decreased by 7.1% from 2012 to 2015 and bevacizumab injections decreased by 17.1%. From 2013 to 2015, aflibercept injections increased by 69.4%. The 100 ophthalmologists performing the highest volume of ranibizumab injections, as gauged by number of injections administered, accounted for 31.0% (95% CI, 30.994%-30.997%) of all ranibizumab injections nationally. The 100 ophthalmologists performing the highest volume of aflibercept injections accounted for 17.6% (95% CI, 17.638%-17.641%) of all aflibercept injections and the 100 ophthalmologists performing the highest volume of bevacizumab injections accounted for 19.6% (95% CI, 19.649%-19.653%) of all bevacizumab injections administered nationally to Medicare Part B beneficiaries. The highest number of injections per 1000 Medicare Part B beneficiaries occurred in Nebraska (aflibercept), Tennessee (ranibizumab), and South Dakota (bevacizumab).

Conclusions and Relevance

A total of 3.0% of ophthalmologists account for 17.6% to 31.0% of the total number of anti-VEGF injections administered nationally in the Medicare Part B population. Overall, bevacizumab and ranibizumab injections have decreased, coinciding with a 69.4% increase in aflibercept injections.

Evolving Concepts in the Management of Retinopathy of Prematurity

PURPOSE

The introduction of anti-vascular endothelial growth factor (VEGF) agents has stimulated considerable reexamination of treatment strategies for the management of retinopathy of prematurity (ROP). Herein we summarize and review evolving concepts and provide a personal perspective on clinical management today and future directions of treatment.

DESIGN

Literature review.

METHODS

To synthesize the evolving management concepts for diagnosis and treatment of retinopathy of prematurity and to provide interpretation and perspective on current emerging therapies.

RESULTS

Although initial treatment strategies focused on ablative therapy for threshold ROP, earlier treatment for type 1 or pre-threshold disease has been found to decrease unfavorable visual and structural outcomes. Vascular endothelial growth factor has emerged as a significant contributor to retinal-vascular diseases in the previous 2 decades. The potential role of anti-VEGF treatment for type 1 ROP has become a focus in recent years, but the protracted recurrence of disease and unknown adverse ocular and systemic effects have caused concern from some clinicians. In addition, the use of telemedicine technologies may provide the ability to screen remote areas with a shortage of ROP providers, thereby reducing the burden of disease.

CONCLUSIONS

The diagnosis and management of ROP has changed over the past 40 years; the role of anti-VEGF therapy remains to be established in current treatment strategies. Screening for initial disease and progression will likely be impacted by the increasing prevalence of telemedicine and relative shortage of clinicians.

Association Between Ophthalmologist Age and Unsolicited Patient Complaints

IMPORTANCE

Understanding the distribution of patient complaints by physician age may provide insight into common patient concerns characteristic of early, middle, and late stages of careers in ophthalmology. Most previous studies of patient dissatisfaction have not addressed the association with physician age or controlled for other characteristics (eg, practice setting, subspecialty) that may contribute to the likelihood of patient complaints, unsafe care, and lawsuits.

OBJECTIVE

To assess the association between ophthalmologist age and the likelihood of generating unsolicited patient complaints (UPCs) among a cohort of ophthalmologists.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study with variable duration of follow-up. The study assessed time to first complaint between 2002 and 2015 in 1342 attending ophthalmologists or neuro-ophthalmologists who had graduated from medical school before 2010 and were affiliated with an organization that participates in Vanderbilt University Medical Center's Patient Advocacy Reporting System. Participants were stratified into 5 age bands and were followed up from the time of their employment to receipt of their first complaint. Trained coders categorized UPCs into 34 specific types under 6 major categories.

MAIN OUTCOMES AND MEASURES

Time to first recorded complaint. Multivariable Cox proportional hazards model was used to measure the association between time to first complaint and ophthalmologist age after adjustment for predetermined covariates.

RESULTS

The median physician age was 47 years, with 9% who were 71 years or older. The cohort was 74% male, 90% held MD degrees, and 73% practiced in academic medical centers. The mean follow-up period was 9.8 years. Ophthalmologists older than 70 years had the lowest complaint rate (0.71 per 1000 follow-up days vs 1.41, 1.84, 2.02, and 1.88 in descending order of age band). By 2000 days of follow-up (or within 5.5 years), the youngest group had an estimated UPC risk of 0.523. By 4000 days (>10 years), participants in the older than 70 years age band had an estimated risk of UPC of only 0.364. The 2 youngest age bands were associated with a statistically significant shorter time to first complaint. Compared with those aged 71 years or older, the risk of incurring a UPC for those aged 41 to 50 years was 1.73-fold higher (hazard ratio [HR], 1.73; 95% CI, 1.21-2.46; P = .002). Similarly, participants aged 31 to 40 years had a 2.36 times higher risk of incurring a UPC (HR, 2.36; 95% CI, 1.64-3.40; P < .001).

CONCLUSIONS AND RELEVANCE

This study suggests that older ophthalmologists are less likely to receive UPCs than younger ones. Although limitations in the study design could affect the interpretation of these conclusions, the findings may have practical implications for patient safety, clinical education, and clinical practice management.

Association Between Opioid Prescribing Patterns and Abuse in Ophthalmology

Importance

Drug overdoses have become the number 1 cause of mortality in American adults 50 years and younger. Prescription opioid abuse is a growing concern that has garnered widespread attention among policymakers and the general public.

Objective

To determine the opioid prescribing patterns among ophthalmologists and elucidate their role in the prescription opioid abuse epidemic.

Design, Setting, and Participants

In this observational cohort study, beneficiaries and their physicians were analyzed using 2013 to 2015 Medicare Part D Prescriber Data. The Centers for Medicare and Medicaid Services Medicare Part D Prescriber Public Use Files for 2013, 2014, and 2015 were accessed. Analysis began in June 2017. Data were collected and analyzed regarding the prescribing patterns for opioid drugs (eg, number of prescriptions written including refills, number of days' supply, and prescriber rates) for all participating ophthalmologists.

Main Outcomes and Measures

The mean number of opioid prescriptions written annually by ophthalmologists; prescriber rates compared with all prescriptions written; and geographic distribution of opioid prescriptions written per ophthalmologist.

Results

In 2013, 4167 of 19 615 ophthalmologists were women (21.2%). Consistently, most ophthalmologists (88%-89%) wrote 10 opioid prescriptions or fewer annually. Approximately 1% (0.94%-1.03%) of ophthalmologists wrote more than 100 prescriptions per year. On average, ophthalmologists wrote 7 opioid prescriptions per year (134 290 written annually by 19 638 physicians, on average) with a mean supply of 5 days. The 6 states with the highest volume of opioid prescriptions written annually per ophthalmologist were located in the southern United States.

Conclusions and Relevance

In general, ophthalmologists show discretion in their opioid prescribing patterns. The present opioid abuse epidemic should prompt physicians to consider revisiting their prescribing protocols given the high risk for dependency.