Connie M. Wu

An evaluation of cataract surgery clinical practice guidelines

Purpose This study used the Appraisal of Guidelines for Research and Evaluation (AGREE) II Instrument to evaluate the methodological quality of clinical practice guidelines (CPG) published by the American Academy of Ophthalmology (AAO), Canadian Ophthalmological Society (COS) and Royal College of Ophthalmologists (RCO) for the management of cataract in adults. Study design An evaluation of the AAO, COS and RCO CPGs using a reliable and validated instrument. Methods Four evaluators independently appraised the three CPGs using the AGREE II Instrument, which covers six domains (Scope and Purpose, Stakeholder Involvement, Rigour of Development, Clarity of Presentation, Applicability and Editorial Independence). The AGREE II includes an Overall Assessment summarising guideline methodological rigour across all domains, using a 7-point scale where perfect adherence equals a score of 7. Results Scores ranged from 36% to 75% for the AAO guideline; 45% to 94% for the COS guideline and 23% to 85% for the RCO guideline. Intraclass correlation coefficients for the reliability of mean scores for the AAO, COS, and RCO were 0.78, 0.74 and 0.80; 95% CIs (0.60 to 0.90), (0.45 to 0.88) and (0.53 to 0.91), respectively. The strongest domains were Scope and Purpose (COS, RCO), Clarity of Presentation (COS, RCO) and Editorial Independence (AAO, COS). The weakest were Stakeholder Involvement (AAO), Applicability (AAO, COS) and Editorial Independence (RCO). Conclusions Cataract surgery practice guidelines can be improved by targeting stakeholder involvement, applicability and editorial independence.

Critical Appraisal of Clinical Practice Guidelines for Age-Related Macular Degeneration.

Purpose. To evaluate the methodological quality of age-related macular degeneration (AMD) clinical practice guidelines (CPGs). Methods. AMD CPGs published by the American Academy of Ophthalmology (AAO) and Royal College of Ophthalmologists (RCO) were appraised by independent reviewers using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument, which comprises six domains (Scope and Purpose, Stakeholder Involvement, Rigor of Development, Clarity of Presentation, Applicability, and Editorial Independence), and an Overall Assessment score summarizing methodological quality across all domains. Results. Average domain scores ranged from 35% to 83% for the AAO CPG and from 17% to 83% for the RCO CPG. Intraclass correlation coefficients for the reliability of mean scores for the AAO and RCO CPGs were 0.74 and 0.88, respectively. The strongest domains were Scope and Purpose and Clarity of Presentation. The weakest were Stakeholder Involvement (AAO) and Editorial Independence (RCO). Conclusions. Future AMD CPGs can be improved by involving all relevant stakeholders in guideline development, ensuring transparency of guideline development and review methodology, improving guideline applicability with respect to economic considerations, and addressing potential conflict of interests within the development group.

Characteristics Associated With Receiving Cataract Surgery in the US Medicare and Veterans Health Administration Populations

Importance Considerable variation exists with respect to the profiles of patients who receive cataract surgery in the United States. Objective To identify patient characteristics associated with receiving cataract surgery within the US Medicare and Veterans Health Administration (VHA) populations. Design, Setting, and Participants In this population-based retrospective cohort study of 3 073 465 patients, Medicare and VHA patients with a cataract diagnosis between January 1, 2002, and January 1, 2012, were identified from the 2002-2012 Medicare Part B files (5% sample) and the VHA National Patient Care Database. Patient age, sex, race/ethnicity, region of residence, Charlson Comorbidity Index (CCI) scores, and comorbidities were recorded. Cataract surgery at 1 and 5 years after diagnosis was identified. Data analysis was performed from July 1, 2016, to July 1, 2017. Main Outcomes and Measures Odds ratios (ORs) of cataract surgery for selected patient characteristics. Results The study sample included 1 156 211 Medicare patients (mean [SD] age, 73.7 [7.0] years) and 1 917 254 VHA patients (mean [SD] age, 66.8 [10.2] years) with a cataract diagnosis. Of the 1 156 211 Medicare patients, 407 103 (35.2%) were 65 to 69 years old, 683 036 (59.1%) were female, and 1 012 670 (87.6%) were white. Of the 1 917 254 VHA patients, 905 455 (47.2%) were younger than 65 years, 1 852 158 (96.6%) were male, and 539 569 (28.1%) were white. A greater proportion of Medicare patients underwent cataract surgery at 1 year (Medicare: 213 589 [18.5%]; VHA: 120 196 [6.3%]) and 5 years (Medicare: 414 586 [35.9%]; VHA: 240 884 [12.6%]) after diagnosis. Factors associated with the greatest odds of surgery at 5 years were older age per 5-year increase (Medicare: OR, 1.24 [95% CI, 1.23-1.24]; VHA: OR, 1.18 [95% CI, 1.17-1.18]), residence in the southern United States vs eastern United States (Medicare: OR, 1.38 [95% CI, 1.36-1.40]; VHA: OR, 1.40 [95% CI, 1.38-1.41]), and presence of chronic pulmonary disease (Medicare: OR, 1.26 [95% CI, 1.24-1.27]; VHA: OR, 1.40 [95% CI, 1.38-1.41]). Within Medicare, female sex was associated with greater odds of surgery at 5 years (OR, 1.14; 95% CI, 1.13-1.15). Higher CCI scores (CCI score ≥3 vs 0-2) were associated with increased odds of surgery among VHA but not Medicare patients at 5 years (Medicare: OR, 0.94 [95% CI, 0.92-0.95]; VHA: OR, 1.24 [95% CI, 1.23-1.36]). Black race vs white race was associated with decreased odds of cataract surgery 5 years after diagnosis (Medicare: OR, 0.79 [95% CI, 0.78-0.81]; VHA: OR, 0.75 [95% CI, 0.73-0.76]). Conclusions and Relevance Within both groups, older age, residence in the southern United States, and presence of chronic pulmonary disease were associated with increased odds of cataract surgery. Findings from this study suggest that few disparities exist between the types of patients receiving cataract surgery who are in Medicare vs the VHA, although it is possible that a smaller proportion of VHA patients receive surgery compared with Medicare patients.

Frequency of a diagnosis of glaucoma in individuals who consume coffee, tea and/or soft drinks

Aims To evaluate the association between consumption of coffee, tea or soft drinks, and glaucoma in the participants of the 2005–2006 National Health and Nutrition Examination Survey (NHANES). Methods The exposures of interest of this retrospective cross-sectional study were caffeinated and decaffeinated coffee, iced tea, hot tea and soft drinks. The outcome of interest was a clinical diagnosis of glaucoma based on the Rotterdam criteria. Analysis of the correlation between the frequency of consumption of each type of beverage and glaucoma was performed using logistic regression modelling while controlling for age, body mass index, gender, ethnicity, smoking status and diabetes. Data were weighted using the multistage NHANES sampling design. Results Among a total of 1678 survey participants, the overall prevalence of glaucoma was 5.1% (n=84). Most participants were non-Hispanic white (n=892; 53.2%). There were no statistically significant associations between consumption of caffeinated and decaffeinated coffee, iced tea and soft drinks, and glaucoma. Participants who consumed at least one cup of hot tea daily had a 74% decreased odds of having glaucoma compared with those who did not consume hot tea (adjusted OR=0.26, 95% CI 0.09 to 0.72, P=0.004 for trend); however, no statistically significant association existed for decaffeinated hot tea and glaucoma. Conclusion In NHANES, participants who consumed hot tea daily were less likely to have glaucoma than those who did not consume hot tea. No significant associations were found between the consumption of coffee, iced tea, decaffeinated tea and soft drinks, and glaucoma risk. This study is limited by its cross-sectional design and use of multiple statistical testing, and larger prospective studies are needed to investigate the proposed association between tea consumption and decreased glaucoma risk.

Reviewing the reviewers: appraisal of the United States Veterans Health Administration report on femtosecond laser-assisted cataract surgery.

In December 2013, the United States Veterans Health Administration (VHA) Quality Enhancement Research Initiative (QUERI) published a systematic review to address questions regarding the effectiveness, safety, adverse consequences, and economic implications of adopting femtosecond laser–assisted cataract surgery into the VHA. It concluded that visual safety and effectiveness outcomes were similar in

Frequency of Bevacizumab and Ranibizumab Injections for Diabetic Macular Edema in Medicare Beneficiaries

BACKGROUND AND OBJECTIVE To describe the frequency and variation of intravitreal bevacizumab (Avastin; Genentech, South San Francisco, CA) and ranibizumab (Lucentis; Genentech, South San Francisco, CA) use for diabetic macular edema (DME) in the United States. PATIENTS AND METHODS The authors obtained a 5% sample of Medicare beneficiaries from the Medicare Part B claims files from 2010 to 2013 and identified beneficiaries with DME using the ICD-9-CM code (362.07). Geographic variation was examined by comparing injection frequencies of bevacizumab and ranibizumab across U.S. census divisions using Chi-squared analysis. RESULTS The sample included 5,290 Medicare beneficiaries with DME. Overall, there was greater bevacizumab use (86.4%) compared to ranibizumab use (13.6%). Frequency of bevacizumab use was highest in the Mountain division (92.2%) and lowest in the Mid-Atlantic (76.0%). The total number of bevacizumab and ranibizumab injections for DME varied significantly between U.S. census divisions (P < .0001). CONCLUSION Bevacizumab is used more frequently than ranibizumab for the treatment of DME among Medicare beneficiaries, with significant geographic variation. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:241-244.].

The use of bevacizumab and ranibizumab for branch retinal vein occlusion in medicare beneficiaries

Purpose To describe the frequency and variation of intravitreal bevacizumab and ranibizumab use for branch retinal vein occlusion (BVO) in the United States (US). Methods We obtained a 5% random sample of Medicare beneficiaries from the Medicare Denominator and Physician/Supplier Part B claims files from 2010 to 2013 and identified all beneficiaries with an ICD-9-CM code for branch retinal vein occlusion (BVO, 362.36). Patient age, gender, race, state of residence and Charlson Comorbidity Index (CCI) scores were collected. Healthcare Common Procedure Coding System (HSCPS) codes for bevacizumab (J3590, J9035, and J3490) and for ranibizumab (J2778) were used to identify the mode of treatment for each patient. Patients who met the following criteria were excluded from this study: (1) under 65 years of age; (2) residence outside of the 50 United States or the District of Columbia; (3) no Part-B coverage or with HMO coverage that was not processed by Centers for Medicare & Medicaid Services (CMS); (4) concomitant diagnosis of diabetic edema (ICD-9: 362.07) or central retinal vein occlusion (ICD-9: 362.35); and (5) received both or none of the above two treatments. Geographic variation was examined by comparing injection frequencies across the nine US census divisions using Chi-squared analysis. Results During 2010–2013, a majority of the 3944 BVO patients who met the inclusion criteria received bevacizumab compared to ranibizumab (76.7% vs 23.3%). Most patients were aged 75–79 (22.0%) or 80–84 (22.0%), female (61.5%), white (88.3%), and had a CCI score of 1–2 (39.8%). The frequencies of bevacizumab and ranibizumab injections for BVO varied significantly between the US census divisions (p < 0.0001). The highest frequencies of bevacizumab use were in the Mountain (90.6%) and Pacific (82.7%) divisions while the highest frequencies of ranibizumab use were in the West North Central (37.9%) and Mid Atlantic (32.7%) divisions. Conclusions and Importance A majority of Medicare beneficiaries with BVO received bevacizumab compared to ranibizumab from 2010 to 2013, with significant geographic variation in the use of the two anti-VEGF agents. Future research into factors driving geographic variation in the use of these agents may help direct cost-effective strategies for the management of BVO.

An Appraisal of Clinical Practice Guidelines for Diabetic Retinopathy

The objective is to evaluate the methodological quality of clinical practice guidelines (CPGs) published by the American Academy of Ophthalmology (AAO), Canadian Ophthalmological Society (COS), and Royal College of Ophthalmologists (RCO) for diabetic retinopathy. Four evaluators independently appraised the CPGs using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument, which covers 6 domains (Scope and Purpose, Stakeholder Involvement, Rigor of Development, Clarity of Presentation, Applicability, and Editorial Independence). Scores ranged from 35% to 78% (AAO), 60% to 92% (COS), and 35% to 82% (RCO). Intraclass correlation coefficients for the reliability of mean scores were 0.78, 0.78, and 0.79, respectively. The strongest domains were Scope and Purpose, and Clarity of Presentation (COS). The weakest were Stakeholder Involvement (AAO), Rigor of Development (AAO, RCO), Applicability, and Editorial Independence (RCO). Diabetic retinopathy practice guidelines can be improved by targeting Stakeholder Involvement, Rigor of Development, Applicability, and Editorial Independence.

Evaluation of primary open-angle glaucoma clinical practice guidelines.

OBJECTIVE To evaluate the methodologic quality of 3 primary open-angle glaucoma (POAG) clinical practice guidelines (CPGs). DESIGN The CPGs were assessed with the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. PARTICIPANTS Four authors (A.M.W., C.M.W., B.K.Y., D.J.W.) performed independent assessments of POAG CPGs. METHODS POAG CPGs published by the American Academy of Ophthalmology (AAO), Canadian Ophthalmological Society (COS), and National Institute for Health and Care Excellence (NICE) were appraised using the AGREE II instruments 6 domains (Scope and Purpose, Stakeholder Involvement, Rigor of Development, Clarity of Presentation, Applicability, and Editorial Independence) and Overall Assessment score summarizing guideline quality across all domains. RESULTS Scores ranged from 28% to 85% for the AAO CPG, 51% to 96% for the COS CPG, and 55% to 97% for the NICE CPG. Intraclass correlation coefficients for the reliability of mean scores for the AAO, COS, and NICE CPGs were 0.89, 0.86, and 0.74; 95% CIs were 0.80 to 0.95, 0.74 to 0.93, and 0.51 to 0.87, respectively. The strongest domains were Scope and Purpose (AAO, COS, NICE) and Clarity of Presentation (COS, NICE). The weakest domains were Stakeholder Involvement (AAO, COS) and Editorial Independence (AAO, COS, NICE). CONCLUSIONS Future POAG CPGs can be improved by addressing potential conflicts of interest within the development group, ensuring transparency of guideline development methodology, and involving all relevant stakeholders in guideline development and review.

Are Clinical Practice Guidelines for Cataract and Glaucoma Trustworthy

Surgical procedures to restore vision from cataract and to preserve vision from primary open-angle glaucoma (POAG) are frequently performed in the United States. Given their importance in preventing blindness and maximizing sight, the American Academy of Ophthalmology (AAO) has devoted considerable resources to developing Cataract in the Adult Eye and Primary Open-Angle Glaucoma Preferred Practice Patterns (PPPs). Each document outlines the best practices for diagnosis and management of cataract and POAG, respectively. However, concerns have been raised about the quality of clinical practice guidelines (CPGs) in general, and in their trustworthiness in particular. In response, the Institute of Medicine (IOM) published a set of 8 standards required for a CPG to be considered trustworthy. This commentary describes the adherence of PPPs for adult cataract and POAG based on the IOM trustworthiness standards and addresses the role that such critiques hold for future improvement of practice guidelines. The analysis was performed by 4 of the authors (BKY, CMW, AMW, PBG) using the methods prescribed by the IOM standards. We required all substandards to be met for a standard to be considered passed. Discrepancies were resolved by discussion among the authors. Table 1 summarizes the results. The adult cataract PPP passed 25% of the IOM standards; the POAG PPP passed 50%. Transparency was not fully established in both PPPs because there was insufficient information to evaluate whether the documents met IOM standards for Conflict of Interest (COI), Development Group Composition, and External Review. Contrary to IOM recommendations, the chair of the PPP panels had COIs, and there was no explanation regarding the potential influence of panel members’ COIs on the guideline development process. It was unclear whether patients or patient advocates were included as developers or external reviewers. Furthermore, because the expertise of panel members was not stated, it was not clear whether or not they comprised a multidisciplinary group. Although the POAG PPP stated that it was externally reviewed by “experts and stakeholders before publication,” it did not specify who these individuals were. Evidence foundations and clarity of recommendations were problematic in the adult cataract PPP. The PPP noted “All studies used to form a recommendation for care are graded for strength of evidence individually.” However, aside from the highlighted recommendations and summary benchmarks, no other statements were graded for evidence making it unclear which statements were recommendations. The main text of the adult cataract PPP was devoid of graded study citations, implying statements such as “applying 5% povidone iodine to the conjunctival cul de sac” were not “recommendation[s] for care.” Additionally, the highlighted recommendations and the summary benchmarks used different grading systems. Finally, some of the highlighted recommendations were not clinically useful; for example, “Cataract surgery is a procedure appropriately utilized in the United States.” We suggest the following changes to improve the 2 AAO PPPs: