Flora Lum

Risk of Fractures Following Cataract Surgery in Medicare Beneficiaries

CONTEXT Visual impairment is a known risk factor for fractures. Little is known about the association of cataract surgery with fracture risk. OBJECTIVE To determine the association of cataract surgery with subsequent fracture risk in US Medicare beneficiaries with a diagnosis of cataract. DESIGN, SETTING, AND PARTICIPANTS Retrospective study of 1-year fracture incidence in a 5% random sample of Medicare Part B beneficiaries with cataract who received and did not receive cataract surgery from 2002 through 2009. MAIN OUTCOME MEASURES One-year incidence of hip fractures. Analyses were adjusted for age; sex; race/ethnicity; US region of residence; systemic comorbidities, including Charlson Comorbidity Index (CCI) score; ocular comorbidities; cataract severity; and presence of physically limiting conditions. Adjusted odds ratios (ORs) of hip fractures were calculated using logistic regression modeling. RESULTS There were 1,113,640 US Medicare beneficiaries 65 years and older with a diagnosis of cataract between 2002 and 2009 in the 5% random sample; of these patients, 410,809 (36.9%) received cataract surgery during the study period. There were 13,976 patients (1.3%) who sustained a hip fracture during the study period. The most common fracture-related comorbidity was osteoporosis (n = 134,335; 12.1%). The most common ocular comorbidity was glaucoma (n = 212,382; 19.1%). Compared with 1-year hip fracture incidence in patients with cataract who did not have cataract surgery, adjusted OR of hip fracture within 1 year after cataract surgery was 0.84 (95% CI, 0.81-0.87) with an absolute risk difference of 0.20%. Compared with matched subgroups of patients who did not receive cataract surgery, patient subgroups that experienced lower odds of hip fracture after cataract surgery included patients with severe cataract, patients most likely to receive cataract surgery based on propensity score, patients 75 years and older, and patients with a CCI score of 3 or greater. CONCLUSION In a cohort of US Medicare beneficiaries aged 65 years and older with a diagnosis of cataract, patients who had cataract surgery had lower odds of hip fracture within 1 year after surgery compared with patients who had not undergone cataract surgery.

Adoption and Perceptions of Electronic Health Record Systems by Ophthalmologists: An American Academy of Ophthalmology Survey

OBJECTIVE To assess the current state of electronic health record (EHR) use by ophthalmologists, including adoption rate and user satisfaction. DESIGN Population-based, cross-sectional study. PARTICIPANTS A total of 592 members of the American Academy of Ophthalmology (AAO) participated. METHODS A total of 3796 AAO members were randomly selected on the basis of geography and solicited to participate in a study of EHR adoption. Among those solicited, 392 members completed a web-based version of the survey and 200 members completed a telephone-based version. The survey included sections assessing the current level of EHR adoption, the value of various EHR features, the practice demographics, and, for participants with an EHR, the details of their system. Responses were collected and analyzed using univariate statistical tests. MAIN OUTCOME MEASURES Current adoption rate of EHRs, user satisfaction with EHRs, and importance of various EHR features to both users and nonusers. RESULTS Overall, 12% of the practices surveyed had already implemented an EHR, 7% were in the process of doing so, and another 10% had plans to do so within 12 months. Both EHR users and nonusers rated the same EHR features as having the most value to their practices, and the 2 groups rated options for simplifying the EHR selection process similarly. Among those with an EHR in their practice, 69% were satisfied or extremely satisfied with their system, 64% reported increased or stable overall productivity, 51% reported decreased or stable overall costs, and 76% would recommend an EHR to a fellow ophthalmologist. CONCLUSIONS The adoption rate of EHRs by ophthalmology practices is low but comparable to that seen in other specialties. The satisfaction of those ophthalmologists already using an EHR is high. Because EHRs are part of the rapidly changing health information technology marketplace, the AAO Medical Information Technology Committee is planning to update these results on a regular basis.

Ocular Toxocariasis: Epidemiologic, Anatomic, and Therapeutic Variations Based on a Survey of Ophthalmic Subspecialists

PURPOSE To assess the current burden of ocular toxocariasis (OT) and to gain knowledge regarding the diagnostic and treatment practices used in the ophthalmologic community in the United States. DESIGN Web-based, cross-sectional survey. PARTICIPANTS Subspecialty ophthalmologists who are currently practicing in the United States. METHODS An electronic survey was sent to 3020 ophthalmologic subspecialists belonging to the American Uveitis Society (AUS), the American Society of Retina Specialists (ASRS), or the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) to capture demographic, clinical, diagnostic, and treatment data on patients with OT seen in their practices between September 2009 and September 2010. MAIN OUTCOME MEASURES The demographic, epidemiologic, and clinical characteristics of each reported patient with OT. RESULTS A total of 159 patients with OT were reported by 559 respondents (19%). The median patient age was 11.5 years (range, 1-66 years). Seventy-two patients (45%) with OT lived in the Southern region of the United States. Thirty-one (69%) of 45 patients with OT owned a dog or cat. Vision loss was reported in 46 (85%) of 54 patients with OT; 32 (71%) of 45 patients had permanent vision loss, 13 patients (29%) had temporary vision loss, and duration of vision loss was unreported for 1 patient. Of the 32 patients with OT with permanent vision loss, 30 (94%) had a subretinal granulomatous mass/scar, peripheral granuloma with traction bands, or posterior pole granuloma noted on ophthalmologic examination. Subretinal granulomatous mass/scar, vitritis, and scotoma were the most common ophthalmologic signs found on examination of patients with OT. CONCLUSIONS Ocular toxocariasis continues to occur in the United States, where it affects mainly children and causes permanent vision loss in many patients. Healthcare professionals should counsel patients and their family members about prevention strategies in an effort to decrease infection rates and morbidity due to Toxocara. Further improvement of diagnostic and treatment tools is needed to assist ophthalmologists in treating patients with OT. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Special Requirements for Electronic Health Record Systems in Ophthalmology

UNLABELLED The field of ophthalmology has a number of unique features compared with other medical and surgical specialties regarding clinical workflow and data management. This has important implications for the design of electronic health record (EHR) systems that can be used intuitively and efficiently by ophthalmologists and that can promote improved quality of care. Ophthalmologists often lament the absence of these specialty-specific features in EHRs, particularly in systems that were developed originally for primary care physicians or other medical specialists. The purpose of this article is to summarize the special requirements of EHRs that are important for ophthalmology. The hope is that this will help ophthalmologists to identify important features when searching for EHR systems, to stimulate vendors to recognize and incorporate these functions into systems, and to assist federal agencies to develop future guidelines regarding meaningful use of EHRs. More broadly, the American Academy of Ophthalmology believes that these functions are elements of good system design that will improve access to relevant information at the point of care between the ophthalmologist and the patient, will enhance timely communications between primary care providers and ophthalmologists, will mitigate risk, and ultimately will improve the ability of physicians to deliver the highest-quality medical care. FINANCIAL DISCLOSURE(S) Proprietary or commercial interest disclosure may be found after the references.

Adoption of Electronic Health Records and Preparations for Demonstrating Meaningful Use: An American Academy of Ophthalmology Survey

OBJECTIVE To assess the current state of electronic health record (EHR) use by ophthalmologists, including adoption rate, user satisfaction, functionality, benefits, barriers, and knowledge of meaningful use criteria. DESIGN Population-based, cross-sectional study. PARTICIPANTS A total of 492 members of the American Academy of Ophthalmology (AAO). METHODS A random sample of 1500 AAO members were selected on the basis of their practice location and solicited to participate in a study of EHR use, practice management, and image management system use. Participants completed the survey via the Internet, phone, or fax. The survey included questions about the adoption of EHRs, available functionality, benefits, barriers, satisfaction, and understanding of meaningful use criteria and health information technology concepts. MAIN OUTCOME MEASURES Current adoption rate of EHRs, user satisfaction, benefits and barriers, and availability of EHR functionality. RESULTS Overall, 32% of the practices surveyed had already implemented an EHR, 15% had implemented an EHR for some of their physicians or were in the process of implementation, and another 31% had plans to do so within 2 years. Among those with an EHR in their practice, 49% were satisfied or extremely satisfied with their system, 42% reported increased or stable overall productivity, 19% reported decreased or stable overall costs, and 55% would recommend an EHR to a fellow ophthalmologist. For those with an electronic image management system, only 15% had all devices integrated, 33% had images directly uploaded into their system, and 12% had electronic association of patient demographics with the image. CONCLUSIONS The adoption of EHRs by ophthalmology practices more than doubled from 2007 to 2011. The satisfaction of ophthalmologists with their EHR and their perception of beneficial effects on productivity and costs were all lower in 2011 than in 2007. Knowledge about meaningful use is high, but the percentage of physicians actually receiving incentive payments is relatively low. Given the importance of imaging in ophthalmology, the shortcomings in current image management systems need to be addressed. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Use of Health Care Claims Data to Study Patients with Ophthalmologic Conditions

OBJECTIVE To describe what information is or is not included in health care claims data, provide an overview of the main advantages and limitations of performing analyses using health care claims data, and offer general guidance on how to report and interpret findings of ophthalmology-related claims data analyses. DESIGN Systematic review. PARTICIPANTS Not applicable. METHODS A literature review and synthesis of methods for claims-based data analyses. MAIN OUTCOME MEASURES Not applicable. RESULTS Some advantages of using claims data for analyses include large, diverse sample sizes, longitudinal follow-up, lack of selection bias, and potential for complex, multivariable modeling. The disadvantages include (a) the inherent limitations of claims data, such as incomplete, inaccurate, or missing data, or the lack of specific billing codes for some conditions; and (b) the inability, in some circumstances, to adequately evaluate the appropriateness of care. In general, reports of claims data analyses should include clear descriptions of the following methodological elements: the data source, the inclusion and exclusion criteria, the specific billing codes used, and the potential confounding factors incorporated in the multivariable models. CONCLUSIONS The use of claims data for research is expected to increase with the enhanced availability of data from Medicare and other sources. The use of claims data to evaluate resource use and efficiency and to determine the basis for supplementary payment methods for physicians is anticipated. Thus, it will be increasingly important for eye care providers to use accurate and descriptive codes for billing. Adherence to general guidance on the reporting of claims data analyses, as outlined in this article, is important to enhance the credibility and applicability of findings. Guidance on optimal ways to conduct and report ophthalmology-related investigations using claims data will likely continue to evolve as health services researchers refine the metrics to analyze large administrative data sets.

Risk of Musculoskeletal Injuries, Fractures, and Falls in Medicare Beneficiaries With Disorders of Binocular Vision

IMPORTANCE Disorders of binocular vision are increasingly prevalent among fee-for-service Medicare beneficiaries 65 years or older. Visual impairment is a recognized risk factor for fractures. Despite the association of visual impairment and fracture risk, to our knowledge, no study has examined the influence that disorders of binocular vision (strabismus, amblyopia, diplopia, and nystagmus) may have on musculoskeletal injury and fracture risk in the elderly population. OBJECTIVE To evaluate associations between disorders of binocular vision and musculoskeletal injury, fracture, and falls in the elderly. DESIGN, SETTING, AND PARTICIPANTS A retrospective study of 10-year (2002-2011) musculoskeletal injury, fracture, or fall prevalence in a 5% random sample of Medicare Part B fee-for-service claims for beneficiaries with disorders of binocular vision. Participants included Medicare beneficiaries living in the general community who were 65 years or older with at least 1 year of Medicare Part B enrollment. EXPOSURES Diagnosis of a disorder of binocular vision. MAIN OUTCOMES AND MEASURES Ten-year prevalence of musculoskeletal injury, fracture, or fall in individuals with and without disorders of binocular vision. Analyses were adjusted for age, sex, race/ethnicity, region of residence, systemic and ocular comorbidities, and duration of follow-up. RESULTS There were 2,196,881 Medicare beneficiaries identified. Of these, 99,525 (4.5%) had at least 1 reported disorder of binocular vision (strabismus, 2.3%; diplopia, 2.2%; amblyopia, 0.9%; and nystagmus, 0.2%). During the 10-year study period, there were 1,272,948 (57.9%) patients with documented musculoskeletal injury, fracture, or fall. The unadjusted odds ratio (OR) for the association between disorders of binocular vision and any of the 3 injury types was 2.23 (95% CI, 2.20-2.27; P < .001). The adjusted OR was 1.27 (95% CI, 1.25-1.29; P < .001). CONCLUSIONS AND RELEVANCE Medicare beneficiaries with a disorder of binocular vision have significantly higher odds of sustaining a musculoskeletal injury, fracture, or fall. This finding is an important step forward in understanding and developing strategies to prevent these injuries, which are associated with high morbidity in the elderly.

Cataract Surgery and Mortality in the United States Medicare Population

PURPOSE To determine the association between cataract surgery and all-cause mortality in United States Medicare patients with cataract. DESIGN Retrospective cohort study. PARTICIPANTS A 5% random sample of United States Medicare beneficiaries with a diagnosis of cataract from the 2002 through 2012 Denominator and Physician/Supplier Part B files. METHODS The exposure of interest was cataract surgery and the outcome of interest was all-cause mortality. Baseline characteristics that were examined included demographics, systemic comorbidities, and ocular comorbidities. Cox proportional hazards regression modeling was used to assess the association between cataract surgery and mortality. Additional subgroup analyses were performed in propensity score deciles and within strata of age, gender, region, systemic disease burden, and in patients with versus without severe cataract subtypes. MAIN OUTCOME MEASURES All-cause mortality. RESULTS The 5% Medicare sample included 1 501 420 patients with cataract, of whom 544 984 (36.3%) underwent cataract surgery. Patients with cataract surgery were followed up for a mean of 11.4 quarters (standard deviation [SD], 10.8 quarters; range, 0.0-44.0 quarters), whereas patients without cataract surgery were followed up for a mean of 12.9 quarters (SD, 12.2 quarters; range, 0.0-44.0 quarters). Mortality incidence was 2.78 deaths per 100 person-years in patients with cataract surgery and 2.98 deaths per 100 person-years in patients without surgery (P < 0.0001). Overall, patients with cataract surgery had a lower adjusted hazard of mortality compared with patients without surgery (hazard ratio [HR], 0.73; 95% confidence interval [CI], 0.72-0.74). The strongest associations were observed in patients with a high propensity score decile (HR, 0.52; 95% CI, 0.50-0.54), patients 80 to 84 years of age (HR, 0.63; 95% CI, 0.62-0.65), women (HR, 0.69; 95% CI, 0.68-0.70), patients in the western United States (HR, 0.52; 95% CI, 0.32-0.86), patients with a moderate systemic disease burden (HR, 0.71; 95% CI, 0.69-0.72), and patients with severe cataract (HR, 0.68; 95% CI, 0.66-0.70). CONCLUSIONS In a national cohort of United States Medicare beneficiaries with cataract, cataract surgery was associated with decreased all-cause mortality. Further studies are needed to examine mechanisms surrounding the association between cataract surgery and mortality.

The American Academy of Ophthalmology Adopts SNOMED CT as Its Official Clinical Terminology

The road towards broad adoption of electronic health record systems is built upon a foundation of health informatics standards for vocabulary. A terminology is needed not only for an electronic health record but also for clinical decision support, access to clinical information, research, and survey purposes. Dr Chalmers notes, ”Within any field of collective endeavor, the ability of people to communicate accurately and unambiguously with each other is vital to the advancement of knowledge. One of the most fundamental components of scientific communication is a comprehensive vocabulary that encompasses all aspects of the discipline under study.” On May 6, 2004, the departments of Health and Human Services, Defense, and Veterans Affairs announced the adoption of standards to allow for the digital exchange of clinical information across the federal government. Specifically, one of the standards endorsed was the Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) for laboratory result contents, nonlaboratory interventions and procedures, anatomy, diagnosis, and medical problems. President Bush issued an Executive Order on August 22, 2006 that the Department of Health and Human Services and all federal agencies shall ensure that internal programs and external contracts implement relevant interoperability standards. The Department of Health and Human Services is one of 9 charter members of the new International Health Terminology Standards Development Organization for SNOMED CT. Among the organization’s goals are to make SNOMED CT accessible to developing countries, align with international public health standards, and define a role for SNOMED in research and public health surveillance. The National Health Service in the United Kingdom adopted SNOMED CT for its national Care Record, defining it as “a single unified terminology to underpin the development of the integrated electronic patient record by providing an essential building block for a common computerized language for use across the world.” In 2004, the European Commission set forth a comprehensive definition and goals for e-health:

The American Academy of Ophthalmology's IRIS® Registry (Intelligent Research in Sight Clinical Data): A Look Back and a Look to the Future

The seeds for the Academy’s IRIS Registry (Intelligent Research in Sight) were planted more than 3 decades ago with the initiation of the Academy’s Quality of Care Committee in 1985. This blossomed into one of the first medical society practice guidelines for improving care and promoting best practices based on expert consensus and scientific evidence from the peer-reviewed literature, known as the Preferred Practice Patterns. The committee then turned its focus on patient outcomes, with the launch of a National Eyecare Outcomes Network for measuring cataract surgery performance in 1995. At its peak, National Eyecare Outcomes Network collected data on 17 000 patients’ preoperative characteristics, operative parameters, and postoperative outcomes, but subsequently met its demise because the time