Publications by authors named "Suzann Pershing"

53 Publications

Age, Gender, and Laterality of Retinal Vascular Occlusion: A Retrospective Study from the IRIS® Registry.

Ophthalmol Retina 2021 May 12. Epub 2021 May 12.

Schepens Eye Research Institute of Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA 02114, USA. Electronic address:

Purpose: Retinal vascular occlusion is a leading cause of profound irreversible visual loss, but the understanding of the disease is insufficient. We systematically investigated the age, gender, and laterality at the onset of retinal artery occlusion (RAO) and retinal vein occlusion (RVO) in the IRIS® Registry (Intelligent Research in Sight).

Design: A retrospective registry cohort.

Participants: Retinal vascular occlusion cases participating in the IRIS Registry.

Methods: All cases diagnosed as retinal vascular occlusion in the IRIS Registry between 2013 and 2017 were included. Cases with unspecified gender or laterality were excluded when conducting the relevant analyses. Cases were categorized based on diagnosis codes into RAO, with subtypes transient retinal artery occlusion (TRAO), partial retinal artery occlusion (PRAO), branch retinal artery occlusion (BRAO), and central retinal artery occlusion (CRAO), and into RVO, with subtypes venous engorgement (VE), branch retinal vein occlusion (BRVO), and central retinal vein occlusion (CRVO). Age was evaluated as a categorical variable (5-year increments). We investigated the association of age, gender, and laterality with the onset frequency of retinal vascular occlusion subtypes.

Main Outcome Measures: The frequency of onset of RAO and RVO subtypes by age, gender and laterality.

Results: A total of 1,251,476 retinal vascular occlusion cases were included, 23.8% of which were RAO, while 76.2% were RVO. 1,248,656 and 798,089 cases were selected for analysis relevant to gender and laterality, respectively. The onset frequency of all subtypes increased with age. PRAO, BRAO, CRAO, and CRVO presented more frequently in men (53.5%, 51.3%, 52.6%, 50.4%), while TRAO, VE, and BRVO presented more frequently in women (54.9%, 56.0%, 54.5%). BRVO and all RAO subtypes showed a right-eye onset preference (BRVO 51.0%, TRAO 51.7%, PRAO 54.4%, BRAO 53.5%, CRAO 53.4%), while VE and CRVO exhibited a left-eye onset preference (VE 53.3%, CRVO 50.9%).

Conclusions: While retinal vascular occlusion incidence increases with age regardless of subtypes, we found various subtype-specific disease onset differences related to gender and, in particular, ocular laterality. These findings may improve understanding of the specific etiology of retinal vascular occlusions of different subtypes and their relationship with structural and anatomic asymmetries of the vascular system.
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http://dx.doi.org/10.1016/j.oret.2021.05.004DOI Listing
May 2021

Variability and Costs of Low-Value Preoperative Testing for Cataract Surgery Within the Veterans Health Administration.

JAMA Netw Open 2021 May 3;4(5):e217470. Epub 2021 May 3.

Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California.

Importance: The Choosing Wisely guidelines indicate that preoperative testing is often unnecessary and wasteful for patients undergoing cataract operations. However, little is known about the impact of these widely disseminated guidelines within the US Veterans Health Administration (VHA) system.

Objective: To examine the extent, variability, associated factors, and costs of low-value tests (LVTs) prior to cataract operations in the VHA.

Design, Setting, And Participants: This cohort study examined records of all patients receiving cataract operations within the VHA in fiscal year 2017 (October 1, 2016, to September 31, 2017). Records from 135 facilities nationwide supporting both ambulatory and inpatient surgery were included.

Exposures: A laboratory test occurring within 30 days prior to cataract surgery and within 30 days after clinic evaluation.

Main Outcomes And Measures: Overall national and facility-level rates and associated costs of receiving any of 8 common LVTs in the 30 days prior to cataract surgery. The patient characteristics, procedure type, and facility-level factors associated with receiving at least 1 test, the number of tests received, and receipt of a bundle of 4 tests (complete blood count, basic metabolic profile, chest radiograph, and electrocardiogram).

Results: A total of 69 070 cataract procedures were identified among 50 106 patients (66 282 [96.0%] men; mean [SD] age, 71.7 [8.1] years; 53 837 [77.9%] White, 10 292 [14.9%] Black). Most of the patient population had either overweight (23 292 [33.7%] patients) or obesity (27 799 [40.2%] patients). Approximately 49% of surgical procedures (33 424 procedures) were preceded by 1 or more LVT with an overall LVT cost of $2 597 623. Among patients receiving LVTs, electrocardiography (7434 patients [29.9%]) was the most common, with some patients also receiving more costly tests, including chest radiographs (489 patients [8.2%]) and pulmonary function tests (127 patients [3.4%]). For receipt of any LVT, the intraclass correlation coefficient was 0.61 (P < .001) at the facility level and 0.06 (P < .001) at the surgeon level, indicating the substantial contribution of the facility to amount of tests given.

Conclusions And Relevance: Despite existing guidelines, use of LVTs prior to cataract surgery is both common and costly within a large, national integrated health care system. Our results suggest that publishing evidence-based guidelines alone-such as the Choosing Wisely campaign-may not sufficiently influence individual physician behavior, and that system-level efforts to directly deimplement LVTs may therefore necessary to effect sustained change.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.7470DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8103225PMC
May 2021

Need for Retinal Detachment Reoperation Based on Primary Repair Method Among Commercially Insured Patients, 2003-2016.

Am J Ophthalmol 2021 Apr 22;229:71-81. Epub 2021 Apr 22.

From the Department of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, (M.G.R.R., S.P.), Palo Alto; Veterans Affairs Palo Alto Health Care System, (S.P.), Palo Alto, California, USA. Electronic address:

Purpose: To examine associations between primary repair, patient characteristics, and rhegmatogenous retinal detachment (RRD) reoperation.

Design: Retrospective cohort study.

Methods: We used administrative claims to identify enrollees with incident RRD treatment by laser barricade, pneumatic retinopexy (PR), pars plana vitrectomy (PPV), or scleral buckle (SB) between 2003 and 2016. Analysis excluded patients with less than 3 years of continuous enrollment, previous RRD diagnosis, or repair. We determined reoperation frequency (PPV, PR, or SB) within 90 days postrepair and used multivariable logistic regression to identify associations between reoperation and patient and primary repair characteristics.

Results: Of 16,190 patients with documented primary RRD repair, 2,918 (18.0%) required reoperation within 90 days. Reoperation was significantly associated with male sex (odds ratio [OR] 1.24, P < .001), pseudophakia (OR 1.25, P < .001), vitreous hemorrhage (OR 1.22, P = .001), and worse systemic health (OR 1.19-1.25, P < .05, for Charlson Comorbidity Index ≥3). Pseudophakia had higher reoperation odds after all primary procedures except PPV. In addition, 28.7% of primary PR cases required reoperation, vs 19.1% of SB and 17.9% of PPV repairs. Adjusting for other patient characteristics, PR had highest odds of reoperation (OR 1.90, P < .001, vs primary PPV). Primary laser barricade had lowest odds of reoperation (OR 0.49, P < .001). PPV was the most frequent reoperation procedure.

Conclusions: Nearly 1 in 5 patients require reoperation within 90 days after primary RRD repair. Cases requiring only primary laser barricade had lowest reoperation odds, likely representing less severe RRDs. Primary PR had highest reoperation odds; PPV and SB were similar to each other. These findings are important for patient education and surgical decision-making.
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http://dx.doi.org/10.1016/j.ajo.2021.04.007DOI Listing
April 2021

Development of the Elective Outpatient Percutaneous Coronary Intervention Episode-Based Cost Measure.

Circ Cardiovasc Qual Outcomes 2021 Mar 3;14(3):e006461. Epub 2021 Mar 3.

Acumen LLC, Burlingame, CA (A.T.S., R.D., J.L., O.G., X.W., S.P., E.L., T.E.M., J. Bhattacharya, S.N.).

Background: The Merit-Based Incentive Payment System adjusts clinician payments based on a performance score that includes cost measures. With the Centers for Medicare & Medicaid Services, we developed a novel cost measure that compared interventional cardiologists on a targeted set of costs related to elective percutaneous coronary intervention (PCI). We describe the measure and compare it to a hypothetical version including all expenditures post-PCI.

Methods: Measure development was guided by 39 clinician experts. They identified services within 30 days of PCI that could be potentially affected by the interventional cardiologist. Expenditures for these PCI-related services were included as measure costs in a process termed service assignment. We used 1 year of Medicare claims to calculate clinician scores using the final measure that included only PCI-related costs (with service assignment) and a hypothetical version that included all costs post-PCI (without service assignment). We calculated reliability for both measures. This marker of precision breaks measure variance into signal (difference between clinicians) versus noise (difference between PCI episodes for a clinician). We also determined the change in clinician performance quintile between measures.

Results: We identified 100 992 elective outpatient PCI episodes from May 2, 2016, to May 1, 2017. Total Medicare expenditures within 30 days of PCI averaged $13 234. After excluding costs unrelated to PCI, average cost was $10 966. For individual clinicians, mean reliability for the hypothetical measure without service assignment was 0.36. After service assignment, final measure reliability increased to 0.53. When evaluated as clinician groups, reliability increased from 0.43 to 0.73 following service assignment. Approximately 66% (2340 of 3527) of clinicians were reclassified into a different performance quintile after excluding unrelated costs.

Conclusions: The elective outpatient PCI cost measure had increased precision and reclassified clinician performance relative to a hypothetical version that included total expenditures.
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http://dx.doi.org/10.1161/CIRCOUTCOMES.119.006461DOI Listing
March 2021

Bidirectional Association between Visual Impairment and Dementia Among Older Adults in the United States Over Time.

Ophthalmology 2021 Feb 27. Epub 2021 Feb 27.

Byers Eye Institute, Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, California; Veterans Affairs Palo Alto Health Care System, Palo Alto, California. Electronic address:

Purpose: Although visual impairment (VI) has been associated with worse cognitive performance among older adults, the temporal relationship between the 2 remains subject to debate. Our objective was to investigate the longitudinal impact of VI on cognitive function and vice versa.

Design: Retrospective, time-to-event study.

Participants: National Health and Aging Trends Study (NHATS) participants from 2011 to 2018 cycles.

Methods: A total of 10 676 participants aged 65 years and older were included. Cox proportional hazards regression models evaluated the impact of baseline VI on subsequent dementia and impact of baseline dementia on subsequent VI. Models were adjusted for potential confounding variables, including demographics, clinical comorbidities, and hearing and physical function limitations.

Main Outcome Measures: Hazard ratio (HR) for incident dementia among participants with baseline self-reported VI and HR for incident VI among participants with baseline dementia.

Results: Of the 10 676 participants included in the analysis, approximately 40% were aged 65-74 years, 40% were aged 75-84 years, and the remaining 20% were aged 85 years and older. The majority were female (59%), and 68% self-identified as non-Hispanic White. Among participants with normal cognitive status at baseline, subsequent dementia was observed in 1753 (16%), and among participants with normal self-reported vision at baseline, subsequent VI was reported in 2371 (22%). In adjusted regression models, participants with baseline VI had higher likelihood of developing dementia over subsequent follow-up (HR, 2.3; 95% confidence interval [CI], 2.0-2.6; P < 0.001). Likewise, participants with baseline dementia had a higher likelihood of developing self-reported VI over time (HR, 2.5; 95% CI, 2.2-2.8; P < 0.001).

Conclusions: Self-reported VI in the US Medicare population is associated with greater dementia likelihood over time, and dementia is similarly associated with greater VI likelihood over time. Associations are likely multifactorial and bidirectional and could be explained by intervening variables in the path from VI to dementia, or vice versa, or by common risk factors for pathological processes in both eyes and brain. These findings suggest the need for early identification of older adults with visual compromise and consideration of visual disability in the cognitively impaired.
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http://dx.doi.org/10.1016/j.ophtha.2021.02.021DOI Listing
February 2021

Smoking Is Associated with Higher Intraocular Pressure Regardless of Glaucoma: A Retrospective Study of 12.5 Million Patients Using the Intelligent Research in Sight (IRIS®) Registry.

Ophthalmol Glaucoma 2020 Jul - Aug;3(4):253-261. Epub 2020 Mar 31.

Department of Ophthalmology, University of Washington, Seattle, Washington; eScience Institute, University of Washington, Seattle, Washington. Electronic address:

Purpose: To compare the average intraocular pressure (IOP) among smokers, past smokers, and never smokers using the American Academy of Ophthalmology Intelligent Research in Sight (IRIS®) Registry.

Design: Retrospective database study of the IRIS® Registry data.

Participants: Intelligent Research in Sight Registry patients who were seen by an eye care provider during 2017.

Methods: Patients were divided into current smoker, past smoker, and never smoker categories. The IOP was based on an average measurement, and separate analyses were performed in patients with and without a glaucoma diagnosis based on International Classification of Diseases (Ninth Edition and Tenth Edition) codes. Stratified, descriptive statistics by glaucoma status were determined, and the relationship between smoking and IOP was assessed with a multivariate linear regression model.

Main Outcome Measures: Mean IOP.

Results: A total of 12 535 013 patients were included. Compared with never smokers, current and past smokers showed a statistically significantly higher IOP by 0.92 mmHg (95% confidence interval [CI], 0.88-0.95 mmHg) and 0.77 mmHg (95% CI, 0.75-0.79 mmHg), respectively, after adjusting for age, gender, glaucoma, age-related macular degeneration, diabetic retinopathy, cataract, glaucoma surgery, cataract surgery, and first-order interactions. In addition, the difference in IOP between current and never smokers was the highest in the fourth decade, regardless of the glaucoma status (glaucoma group, 1.14 mmHg [95% CI, 1.00-1.29 mmHg]; without glaucoma group, 0.68 mmHg [95% CI, 0.65-0.71 mmHg]).

Conclusions: Current smokers and past smokers have higher IOP than patients who never smoked. This difference is higher in patients with an underlying glaucoma diagnosis.
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http://dx.doi.org/10.1016/j.ogla.2020.03.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7532983PMC
March 2020

Artificial intelligence in global ophthalmology: using machine learning to improve cataract surgery outcomes at Ethiopian outreaches.

J Cataract Refract Surg 2021 Jan;47(1):6-10

From the Department of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine (Brant, Hinkle, Shi, Hess, Zubair, Pershing, Tabin), Stanford, and the VA Palo Alto Health Care System (Pershing, Tabin), Palo Alto, California, USA.

Differences between target and implanted intraocular lens (IOL) power in Ethiopian cataract outreach campaigns were evaluated, and machine learning (ML) was applied to optimize the IOL inventory and minimize avoidable refractive error. Patients from Ethiopian cataract campaigns with available target and implanted IOL records were identified, and the diopter difference between the two was measured. Gradient descent (an ML algorithm) was used to generate an optimal IOL inventory, and we measured the models performance across varying surplus levels. Only 45.6% of patients received their target IOL power and 23.6% received underpowered IOLs with current inventory (50% surplus). The ML-generated IOL inventory ensured that more than 99.5% of patients received their target IOL when using only 39% IOL surplus. In Ethiopian cataract campaigns, most patients have avoidable postoperative refractive error secondary to suboptimal IOL inventory. Optimizing the IOL inventory using this ML model might eliminate refractive error from insufficient inventory and reduce costs.
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http://dx.doi.org/10.1097/j.jcrs.0000000000000407DOI Listing
January 2021

Cataract Surgery Complexity and Surgical Complication Rates Among Medicare Beneficiaries With and Without Dementia.

Am J Ophthalmol 2021 01 20;221:27-38. Epub 2020 Aug 20.

Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan, USA; Center for Eye Policy and Innovation, and School of Public Health, University of Michigan, Ann Arbor, Michigan, USA.

Purpose: To evaluate cataract surgery complexity and complications among US Medicare beneficiaries with and without dementia.

Design: Retrospective claims-based cohort study.

Participants: A 20% representative sample of Medicare beneficiaries, 2006-2015.

Methods: Dementia was identified from diagnosis codes on or prior to each beneficiary's first-eye cataract surgery. For each surgery, we identified setting, routine vs complex coding, anesthesia provider type, duration, and any postoperative hospitalization. We evaluated 30- and 90-day complication rates-return to operating room, endophthalmitis, suprachoroidal hemorrhage, retinal detachment, retinal tear, macular edema, glaucoma, or choroidal detachment-and used adjusted regression models to evaluate likelihood of surgical characteristics and complications. Complication analyses were stratified by second-eye cataract surgery within 90 days postoperatively.

Results: We identified 457,128 beneficiaries undergoing first-eye cataract surgery, 23,332 (5.1%) with dementia. None of the evaluated surgical complications were more likely in dementia-diagnosed beneficiaries. There was also no difference in likelihood of nonambulatory surgery center setting, anesthesiologist provider, or postoperative hospitalization. Dementia-diagnosed beneficiaries were more likely to have surgeries coded as complex (15.6% of cases vs 8.8%, P < .0001), and surgeries exceeding 30 minutes (OR = 1.21, 95% CI = 1.17-1.25).

Conclusions: Among US Medicare beneficiaries undergoing cataract surgery, those with dementia are more likely to have "complex" surgery" lasting more than 30 minutes. However, they do not have greater likelihood of surgical complications, higher-acuity setting, advanced anesthesia care, or postoperative hospitalization. This may be influenced by case selection and may suggest missed opportunities to improve vision. Future research is needed to identify dementia patients likely to benefit from cataract surgery.
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http://dx.doi.org/10.1016/j.ajo.2020.08.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7736486PMC
January 2021

Comparing cataract surgery complication rates in veterans receiving VA and community care.

Health Serv Res 2020 10 27;55(5):690-700. Epub 2020 Jul 27.

Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts.

Objectives: To compare 90-day postoperative complication rates between Veterans receiving cataract surgery in VA vs Community Care (CC) during the first year of implementation of the Veterans Choice Act.

Data Sources: Fiscal Year (FY) 2015 VA and CC outpatient data from VA's Corporate Data Warehouse (CDW) 10/01/14-9/30/15). FY14 data were used to obtain baseline clinical information prior to surgery.

Study Design: Retrospective one-year study using secondary data to compare 90-day complication rates following cataract surgery (measured using National Quality Forum (NQF) criteria) in VA vs CC. NQF defines major complications from a specified list of Current Procedural Terminology (CPT) codes. We ran a series of logistic regression models to predict 90-day complication rates, adjusting for Veterans' sociodemographic characteristics, comorbidities, preoperative ocular conditions, eye risk group, and type of cataract surgery (classified as routine vs complex).

Data Collection: We linked VA and CC users through patient identifiers obtained from the CDW files. Our sample included all enrolled Veterans who received outpatient cataract surgery either in the VA or through CC during FY15. Cataract surgeries were identified through CPT codes 66 984 (routine) and 66 982 (complex).

Principal Findings: Of the 83,879 cataract surgeries performed in FY15, 31 percent occurred through CC. Undergoing complex surgery and having a high-risk eye (based on preoperative ocular conditions) were the strongest clinical predictors of 90-day postoperative complications. Overall, we found low complication rates, ranging from 1.1 percent in low-risk eyes to 3.6 percent in high-risk eyes. After adjustment for important confounders (eg, race, rurality, and preoperative ocular conditions), there were no statistically significant differences in 90-day complication rates between Veterans receiving cataract surgery in VA vs CC.

Conclusions: As more Veterans seek care through CC, future studies should continue to monitor quality of care across the two care settings to help inform VA's "make vs buy decisions."
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http://dx.doi.org/10.1111/1475-6773.13320DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7518823PMC
October 2020

Intraocular Pressure Changes after Cataract Surgery in Patients with and without Glaucoma: An Informatics-Based Approach.

Ophthalmol Glaucoma 2020 Sep - Oct;3(5):343-349. Epub 2020 Jun 9.

Byers Eye Institute, Stanford University, Palo Alto, California; Veterans Affairs Palo Alto Health Care System, Palo Alto, California.

Purpose: To evaluate changes in intraocular pressure (IOP) after cataract surgery among patients with or without glaucoma using automated extraction of data from electronic health records (EHRs).

Design: Retrospective cohort study.

Participants: Adults who underwent standalone cataract surgery at a single academic center from 2009-2018.

Methods: Patient information was identified from procedure and billing codes, demographic tables, medication orders, clinical notes, and eye examination fields in the EHR. A previously validated natural language processing pipeline was used to identify laterality of cataract surgery from operative notes and laterality of eye medications from medication orders. Cox proportional hazards modeling evaluated factors associated with the main outcome of sustained postoperative IOP reduction.

Main Outcome Measures: Sustained post-cataract surgery IOP reduction, measured at 14 months or the last follow-up while using equal or fewer glaucoma medications compared with baseline and without additional glaucoma laser or surgery on the operative eye.

Results: The median follow-up for 7574 eyes of 4883 patients who underwent cataract surgery was 244 days. The mean preoperative IOP for all patients was 15.2 mmHg (standard deviation [SD], 3.4 mmHg), which decreased to 14.2 mmHg (SD, 3.0 mmHg) at 12 months after surgery. Patients with IOP of 21.0 mmHg or more showed mean postoperative IOP reduction ranging from -6.2 to -6.9 mmHg. Cataract surgery was more likely to yield sustained IOP reduction for patients with primary open-angle glaucoma (hazard ratio [HR], 1.19; 95% confidence interval, 1.05-1.36) or narrow angles or angle closure (HR, 1.21; 95% confidence interval, 1.08-1.34) compared with patients without glaucoma. Those with a higher baseline IOP were more likely to achieve postoperative IOP reduction (HR, 1.06 per 1-mmHg increase in baseline IOP; 95% confidence interval, 1.05-1.07).

Conclusions: Our results suggest that patients with primary open-angle glaucoma or with narrow angles or chronic angle closure were more likely to achieve sustained IOP reduction after cataract surgery. Patients with higher baseline IOP had increasingly higher odds of achieving reduction in IOP. This evidence demonstrates the potential usefulness of a pipeline for automated extraction of ophthalmic surgical outcomes from EHR to answer key clinical questions on a large scale.
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http://dx.doi.org/10.1016/j.ogla.2020.06.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7529869PMC
June 2020

Big data requirements for artificial intelligence.

Curr Opin Ophthalmol 2020 Sep;31(5):318-323

Department of Ophthalmology, University of Washington, Seattle, Washington, USA.

Purpose Of Review: To summarize how big data and artificial intelligence technologies have evolved, their current state, and next steps to enable future generations of artificial intelligence for ophthalmology.

Recent Findings: Big data in health care is ever increasing in volume and variety, enabled by the widespread adoption of electronic health records (EHRs) and standards for health data information exchange, such as Digital Imaging and Communications in Medicine and Fast Healthcare Interoperability Resources. Simultaneously, the development of powerful cloud-based storage and computing architectures supports a fertile environment for big data and artificial intelligence in health care. The high volume and velocity of imaging and structured data in ophthalmology and is one of the reasons why ophthalmology is at the forefront of artificial intelligence research. Still needed are consensus labeling conventions for performing supervised learning on big data, promotion of data sharing and reuse, standards for sharing artificial intelligence model architectures, and access to artificial intelligence models through open application program interfaces (APIs).

Summary: Future requirements for big data and artificial intelligence include fostering reproducible science, continuing open innovation, and supporting the clinical use of artificial intelligence by promoting standards for data labels, data sharing, artificial intelligence model architecture sharing, and accessible code and APIs.
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http://dx.doi.org/10.1097/ICU.0000000000000676DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8164167PMC
September 2020

Sex Differences in the Repair of Retinal Detachments in the United States.

Am J Ophthalmol 2020 11 5;219:284-294. Epub 2020 Jul 5.

Byers Eye Institute at the Stanford University School of Medicine, Palo Alto, California, USA.

Purpose: To investigate differences between women and men in the repair of rhegmatogenous retinal detachments (RRDs) in the United States.

Design: Retrospective cohort study.

Methods: Setting: A large insurance claims database.

Participants: Subjects with an incident RRD between 2007 and 2015.

Data: Demographic data, comorbid ocular conditions associated with RRD, systemic comorbidities, and surgical intervention (pneumatic retinopexy [PR], pars plana vitrectomy [PPV], laser barricade, or scleral buckle [SB]) were collected.

Main Outcome Measures: Odds of receipt of surgical intervention for incident RRD, time to repair, type of intervention, and the rate of reoperation by sex.

Results: The study period included 133 million eligible records with 61,071 cases of incident RRD among which 43% (n = 26,289) were women. The primary outcome model had 23,933 confirmed RRD cases with a 93% retinal detachment repair rate. Women had 34% reduced odds of receipt of surgical repair of an RRD (odds ratio [OR] 0.66, 95% confidence interval [CI] 0.59, 0.73; P < .001) after adjusting for confounders. This effect persisted in all sensitivity models. Among patients who received repair, women were more often delayed (0.17 days, P = .04). Women were more likely to undergo primary laser barricade (relative risk ratio [RRR] 1.68, P < .001), primary SB (RRR 1.15, P < .001), and PR (RRR 1.07, P < .04) than men. The odds of reoperation were lower in women (OR 0.91, 95% CI 0.85, 0.96; P = .002) after adjustment.

Conclusions: Insured women are less likely than insured men to receive surgical intervention for an RRD. Based on the results of this study, if the odds of repair were equal between women and men in the United States, then 781 more women would receive surgery each year, or 7,029 more during the study period. Women are more likely to have the repair performed with scleral buckle, laser barricade, and pneumatic retinopexy. The reason for these sex differences in RRD repair remains unknown and requires further investigation.
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http://dx.doi.org/10.1016/j.ajo.2020.06.039DOI Listing
November 2020

Systemic Corticosteroid Use after Central Serous Chorioretinopathy Diagnosis.

Ophthalmology 2021 01 30;128(1):121-129. Epub 2020 Jun 30.

Byers Eye Institute, Stanford University, Palo Alto, California; Veterans Affairs Palo Alto Health Care System, Palo Alto, California. Electronic address:

Purpose: To analyze the frequency of systemic corticosteroid prescriptions before and after central serous chorioretinopathy (CSC) diagnosis.

Design: Retrospective claims-based analysis.

Participants: A nationally representative sample of commercial insurance beneficiaries who received care between 2007 and 2015.

Methods: We limited the study population to beneficiaries with incident CSC diagnosed by an eye care provider, excluding those with other major ophthalmologic comorbidities. We developed a non-CSC comparison cohort matched to CSC patients by age, sex, general health (Charlson Comorbidity Index), and geographic region. We compared systemic corticosteroid prescriptions before and after CSC diagnosis and by diagnosing provider (optometrist vs. ophthalmologist) and evaluated likelihood of steroids treatment among CSC versus matched control patients using logistic and Cox proportional hazard regression models.

Main Outcome Measures: Systemic corticosteroid prescription frequency among CSC patients within 12 months pre-diagnosis and at 6, 12, and 24 months post-diagnosis, median time to steroid initiation and discontinuation, and odds of receiving steroids post-diagnosis among CSC and control patients.

Results: We identified 3418 CSC patients. Nearly 39% (n = 1326) were prescribed systemic steroids at some point during the analysis period, versus 23% of controls (4033 of 17 178 patients). Over 12% of CSC patients (n = 430) within 1 year pre-diagnosis, and nearly 12% (n = 404) within 1 year post-diagnosis. Most patients who received steroids after diagnosis were steroid naive (n = 231). Among those receiving steroids, CSC patients demonstrated longer median time to first post-diagnosis steroid prescription (1.82 years vs. 0.50 years for non-CSC patients) and longer time to last steroid prescription (1.62 years vs. 0.35 years for non-CSC patients). Although CSC patients were significantly less likely to receive steroids within 6 months post-diagnosis compared with non-CSC patients (odds ratio, 0.72; 95% confidence interval, 0.59-0.89), they were significantly more likely to receive steroids by 2 years post-diagnosis. Prescribing patterns were similar for patients diagnosed by an ophthalmologist versus optometrist.

Conclusions: Despite evidence showing that steroids contribute to CSC development, many patients continue to be prescribed systemic corticosteroids after CSC diagnosis. Our results suggest a need for greater communication and collaboration among providers to ensure that clinical practice reflects evidence-based recommendations.
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http://dx.doi.org/10.1016/j.ophtha.2020.06.056DOI Listing
January 2021

The New USMLE Step 1 Paradigm: An Opportunity to Cultivate Diversity of Excellence.

Acad Med 2020 09;95(9):1325-1328

L. Katznelson is associate dean of graduate medical education and professor of neurosurgery and medicine (endocrinology and metabolism), Stanford University School of Medicine, Stanford, California.

The February 2020 announcement that United States Medical Licensing Examination (USMLE) Step 1 results will be reported as pass/fail instead of numerical scores has been controversial. Step 1 scores have played a key role in residency selection, including screening for interviews. Although Step 1 scores are viewed as an objective criterion, they have been shown to disadvantage female and underrepresented minority applicants, cause student anxiety and financial burden, and affect student well-being. Furthermore, Step 1 scores incompletely predict applicants' overall residency performance. With this paradigm shift in Step 1 score reporting, residency programs will have fewer objective, standardized metrics for selection decisions, which may lead to greater emphasis on USMLE Step 2 Clinical Knowledge scores or yield unintended consequences, including shifting weight to metrics such as medical school reputation.Yet, greater breadth in residency selection metrics will better serve both applicants and programs. Some students excel in coursework, others in research or leadership. All factors should be recognized, and broader metrics should be implemented to promote and recognize diversity of excellence. Given the need for metrics for residency selection as well as for a more holistic approach to evaluating residency applicants, assessment during medical school should be revisited and made more meaningful. Another opportunity may involve use of situational judgment tests to predict professionalism and performance on other competencies. It will be important to evaluate the impact of the new Step 1 paradigm and related initiatives going forward. Residency application overload must also be addressed.
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http://dx.doi.org/10.1097/ACM.0000000000003512DOI Listing
September 2020

Receipt of Eye Care Services among Medicare Beneficiaries with and without Dementia.

Ophthalmology 2020 08 25;127(8):1000-1011. Epub 2020 Feb 25.

Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan; Center for Eye Policy and Innovation, University of Michigan, Ann Arbor, Michigan.

Purpose: To examine the relationship between dementia status and receipt of eye care among US Medicare beneficiaries.

Design: Retrospective, claims-based analysis.

Participants: A 20% representative sample of Medicare beneficiaries who received care between January 1, 2006, and December 31, 2015.

Methods: Dementia was identified from diagnosis codes documented in a beneficiary's first 3 years of observed Medicare enrollment. Eye care visits were identified from provider specialty codes on each encounter claim. We used multivariable Cox proportional hazards regression models with time-varying covariates to compare the likelihood of receiving eye care between beneficiaries with and without dementia. All models were adjusted for potential confounders, including demographics, urban/rural residence, systemic health (Charlson Index), and ocular comorbidities.

Main Outcome Measures: Hazard ratio (HR) and 95% confidence interval (CI) for (1) being seen by any eye care provider (ophthalmologist or optometrist); (2) being seen by an ophthalmologist specifically; and (3) receiving cataract surgery (among beneficiaries with ophthalmologist encounters).

Results: A total of 4 451 200 beneficiaries met inclusion criteria; 3 805 718 (85.5%) received eye care during the study period, and 391 556 (8.8%) had diagnosed dementia. Some 73.4% of beneficiaries diagnosed with dementia saw an eye care provider during the study period and 55.4% saw an ophthalmologist versus 86.7% and 74.0% of beneficiaries, respectively, without dementia diagnoses. Compared with those without dementia diagnoses, beneficiaries with diagnosed dementia had lower likelihood of seeing any eye care provider (adjusted HR, 0.69; 95% CI, 0.69-0.70) and were less likely to see an ophthalmologist (adjusted HR, 0.55; 95% CI, 0.55-0.55). Among the subset of beneficiaries who did see ophthalmologists, those with diagnosed dementia were also less likely to receive cataract surgery than beneficiaries without diagnosed dementia (HR, 0.62; 95% CI, 0.62-0.63) and less likely to receive a cataract diagnosis (18% vs. 82%).

Conclusions: US Medicare beneficiaries diagnosed with dementia are less likely to receive eye care than those without diagnosed dementia. Depending on visual acuity and functional status, this may have implications for injury prevention, physical and cognitive function, and quality of life. Further work is needed to identify barriers to receiving eye care, determine eye care services and settings that provide greatest value to patients with dementia, and implement measures to improve access to appropriate eye care.
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http://dx.doi.org/10.1016/j.ophtha.2020.02.022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7384939PMC
August 2020

Association of Visual Impairment With Risk of Incident Dementia in a Women's Health Initiative Population.

JAMA Ophthalmol 2020 06;138(6):624-633

Byers Eye Institute at Stanford, Palo Alto, California.

Importance: Dementia affects a large and growing population of older adults. Although past studies suggest an association between vision and cognitive impairment, there are limited data regarding longitudinal associations of vision with dementia.

Objective: To evaluate associations between visual impairment and risk of cognitive impairment.

Design, Setting, And Participants: A secondary analysis of a prospective longitudinal cohort study compared the likelihood of incident dementia or mild cognitive impairment (MCI) among women with and without baseline visual impairment using multivariable Cox proportional hazards regression models adjusting for characteristics of participants enrolled in Women's Health Initiative (WHI) ancillary studies. The participants comprised community-dwelling older women (age, 66-84 years) concurrently enrolled in WHI Sight Examination (enrollment 2000-2002) and WHI Memory Study (enrollment 1996-1998, ongoing). The study was conducted from 2000 to the present.

Exposures: Objectively measured visual impairment at 3 thresholds (visual acuity worse than 20/40, 20/80, or 20/100) and self-reported visual impairment (determined using composite survey responses).

Main Outcomes And Measures: Hazard ratios (HRs) and 95% CIs for incident cognitive impairment after baseline eye examination were determined. Cognitive impairment (probable dementia or MCI) was based on cognitive testing, clinical assessment, and centralized review and adjudication. Models for (1) probable dementia, (2) MCI, and (3) probable dementia or MCI were evaluated.

Results: A total of 1061 women (mean [SD] age, 73.8 [3.7] years) were identified; 206 of these women (19.4%) had self-reported visual impairment and 183 women (17.2%) had objective visual impairment. Forty-two women (4.0%) were ultimately classified with probable dementia and 28 women (2.6%) with MCI that did not progress to dementia. Mean post-eye examination follow-up was 3.8 (1.8) years (range, 0-7 years). Women with vs without baseline objective visual impairment were more likely to develop dementia. Greatest risk for dementia was among women with visual acuity of 20/100 or worse at baseline (HR, 5.66; 95% CI, 1.75-18.37), followed by 20/80 or worse (HR, 5.20; 95% CI, 1.94-13.95), and 20/40 or worse (HR, 2.14; 95% CI, 1.08-4.21). Findings were similar for risk of MCI, with the greatest risk among women with baseline visual acuity of 20/100 or worse (HR, 6.43; 95% CI, 1.66-24.85).

Conclusions And Relevance: In secondary analysis of a prospective longitudinal cohort study of older women with formal vision and cognitive function testing, objective visual impairment appears to be associated with an increased risk of incident dementia. However, incident cases of dementia and the proportion of those with visual impairment were low. Research is needed to evaluate the effect of specific ophthalmic interventions on dementia.
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http://dx.doi.org/10.1001/jamaophthalmol.2020.0959DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7163778PMC
June 2020

Ophthalmology Consultation to Detect Endogenous Endophthalmitis: Clinical Characteristics in Consulted Versus Diagnosed Cases Among At-Risk Inpatients.

Ophthalmic Surg Lasers Imaging Retina 2020 03;51(3):159-A3

Background And Objective: Predisposing factors for ophthalmology consultations and endogenous endophthalmitis were compared among inpatients with systemic infection.

Patients And Methods: This was a retrospective cohort study in a tertiary care hospital between January 1, 2010, and December 31, 2014. Multivariable logistic regression was utilized.

Results: There were 9,527 encounters identified with systemic infection. The 5-year incidence rate was 8.4% (803/9,527) for consultations and 0.3% (25/9,527) for endophthalmitis. Factors most associated with consultations included positive fungal blood cultures and HIV. Factors most associated with endophthalmitis included positive blood fungal cultures and endocarditis. Four of 25 endophthalmitis patients lacked positive blood cultures; six of 20 endophthalmitis patients with adequate mentation were asymptomatic.

Conclusions: Positive blood fungal cultures were strongly associated with both endophthalmitis and consultations. Endocarditis was strongly associated with endophthalmitis but less associated with consultation and may warrant increased attention. Neither presence of symptoms nor positive cultures may be sufficiently accurate to determine need for consultation. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:159-169.].
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http://dx.doi.org/10.3928/23258160-20200228-05DOI Listing
March 2020

Association of Rhegmatogenous Retinal Detachment and Outcomes With the Day of the Week That Patients Undergo a Repair or Receive a Diagnosis.

JAMA Ophthalmol 2020 02;138(2):156-163

Byers Eye Institute, Department of Ophthalmology, Stanford University, Stanford, California.

Importance: Because variation in care on weekends has been reported in many surgical fields, it is of interest if variations were noted for care patterns of rhegmatogenous retinal detachments (RRDs).

Objective: To assess the association between modality of RRD repair and day of the week that patients receive a diagnosis or undergo RRD repair.

Design, Setting, And Participants: A retrospective claims-based cohort analysis was performed of primary RRD surgery for 38 144 commercially insured patients in the United States who received a diagnosis of incident RRD between January 1, 2008, and December 31, 2016, and underwent repair within 14 days of diagnosis. Multinomial regression models were used to assess patients' likelihood of repair with different modalities, logistic regression models were used to assess patients' likelihood of reoperation, and linear regression models were used to assess time from diagnosis to repair. Data analysis was performed from March 9 to September 5, 2019.

Exposures: Day of the week that the patient received a diagnosis of RRD or underwent RRD repair.

Main Outcome And Measures: Modality of repair, time from diagnosis to repair, and 30-day reoperation rate.

Results: Among the 38 144 patients in the study (23 031 men [60.4%]; mean [SD] age at diagnosis, 56.8 [13.4] years), pneumatic retinopexy (PR) was more likely to occur when patients received a diagnosis of RRD on Friday (relative risk ratio [RRR], 1.37; 95% CI, 1.17-1.60), Saturday (RRR, 1.73; 95% CI, 1.36-2.20), or Sunday (RRR, 1.53; 95% CI, 1.08-2.17) compared with Wednesday. Pneumatic retinopexy was more likely to be used for surgical procedures on Friday (RRR, 1.55; 95% CI, 1.33-1.80), Saturday (RRR, 2.03; 95% CI, 1.61-2.56), Sunday (RRR, 2.28; 95% CI, 1.55-3.35), or Monday (RRR, 1.70; 95% CI, 1.46-1.98). Patients undergoing PR on Sundays were more likely to receive another procedure (PR, scleral buckle, or pars plana vitrectomy) within 30 days (odds ratio, 1.62; 95% CI, 1.07-2.45). An association between the need for reoperation for repairs performed via scleral buckle or pars plana vitrectomy and the day of the week of the initial repair was not identified. Patients who received a diagnosis on a Friday waited a mean of 0.28 days (95% CI, 0.20-0.36 days) longer for repair than patients who received a diagnosis on a Wednesday.

Conclusions And Relevance: These findings suggest that management of RRD varies according to the day of the week that diagnosis and repair occurs, with PR disproportionately likely to be used to repair RRDs during the weekend. Ophthalmologists should be aware that these results suggest that patients undergoing PR on Sundays may be more likely to require reoperation within 30 days.
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http://dx.doi.org/10.1001/jamaophthalmol.2019.5253DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6990708PMC
February 2020

Development and validation of a predictive model for American Society of Anesthesiologists Physical Status.

BMC Health Serv Res 2019 Nov 21;19(1):859. Epub 2019 Nov 21.

Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, California, 94025, USA.

Background: The American Society of Anesthesiologists Physical Status (ASA-PS) classification system was developed to categorize the fitness of patients before surgery. Increasingly, the ASA-PS has been applied to other uses including justification of inpatient admission. Our objectives were to develop and cross-validate a statistical model for predicting ASA-PS; and 2) assess the concurrent and predictive validity of the model by assessing associations between model-derived ASA-PS, observed ASA-PS, and a diverse set of 30-day outcomes.

Methods: Using the 2014 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use Data File, we developed and internally cross-validated multinomial regression models to predict ASA-PS using preoperative NSQIP data. Accuracy was assessed with C-Statistics and calibration plots. We assessed both concurrent and predictive validity of model-derived ASA-PS relative to observed ASA-PS and 30-day outcomes. To aid further research and use of the ASA-PS model, we implemented it into an online calculator.

Results: Of the 566,797 elective procedures in the final analytic dataset, 8.9% were ASA-PS 1, 48.9% were ASA-PS 2, 39.1% were ASA-PS 3, and 3.2% were ASA-PS 4. The accuracy of the 21-variable model to predict ASA-PS was C = 0.77 +/- 0.0025. The model-derived ASA-PS had stronger association with key indicators of preoperative status including comorbidities and higher BMI (concurrent validity) compared to observed ASA-PS, but less strong associations with postoperative complications (predictive validity). The online ASA-PS calculator may be accessed at https://s-spire-clintools.shinyapps.io/ASA_PS_Estimator/ CONCLUSIONS: Model-derived ASA-PS better tracked key indicators of preoperative status compared to observed ASA-PS. The ability to have an electronically derived measure of ASA-PS can potentially be useful in research, quality measurement, and clinical applications.
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http://dx.doi.org/10.1186/s12913-019-4640-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6868867PMC
November 2019

Characteristics of Ophthalmology Trials Registered in ClinicalTrials.gov, 2007-2018.

Am J Ophthalmol 2020 03 13;211:132-141. Epub 2019 Nov 13.

Department of Ophthalmology, Byers Eye Institute, Stanford University, Palo Alto, California, USA; Veterans Affairs Palo Alto Health California System, Palo Alto, California, USA. Electronic address:

Purpose: To perform a comprehensive analysis of characteristics of ophthalmology trials registered in ClinicalTrials.gov.

Design: Cross-sectional study.

Methods: All 4,203 ophthalmologic clinical trials registered on ClinicalTrials.gov between October 1, 2007, and April 30, 2018, were identified by using medical subject headings (MeSH). Disease condition terms were verified by manual review. Trial characteristics were assessed through frequency calculations. Hazard ratios and 95% confidence intervals were determined for characteristics associated with early discontinuation.

Results: The majority of trials were multiarmed (73.6%), single-site (69.4%), randomized (64.8%), and had <100 enrollees (66.3%). A total of 33% used a data-monitoring committee (DMC), and 50.6% incorporated blinding. Other groups (51.6%) were funded by industry, whereas 2.6% were funded by the US National Institutes of Health (NIH). NIH trials were significantly more likely to address oncologic (NIH = 15.5%, Other = 3%, Industry = 1.5%; P < 0.001) or pediatric disease (NIH = 20.9%, Other = 5.9%, Industry = 1.4%; P < 0.001). Industry-sponsored trials (69.6% of phase 3 trials) were significantly more likely to be randomized (Industry = 68.7%, NIH = 58.9%, Other = 60.8%; P < 0.001) and blinded (Industry = 57.2%, NIH = 42.7%, Other = 43.5%; P < 0.001). A total of 359 trials (8.5%) were discontinued early, and 530 trials (12.6%) had unknown status. Trials were less likely to be discontinued if funded by sources other than industry (hazard ratio [HR], 0.72; 95% confidence interval [CI], 0.55-0.95; P = 0.021) and/or had a DMC (HR, 0.71; 95% CI, 0.55-0.92; P = 0.010).

Conclusions: Ophthalmology trials in the past decade reveal heterogeneity across study funding sources. NIH trials were more likely to support historically underfunded subspecialties, whereas Industry trials were more likely to face early discontinuation. These trends emphasize the importance of carefully monitored and methodologically sound trials with deliberate funding allocation.
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http://dx.doi.org/10.1016/j.ajo.2019.11.004DOI Listing
March 2020

Automated extraction of ophthalmic surgery outcomes from the electronic health record.

Int J Med Inform 2020 01 17;133:104007. Epub 2019 Oct 17.

Center for Biomedical Informatics Research, Stanford University, 1265 Welch Rd, Stanford, USA.

Objective: Comprehensive analysis of ophthalmic surgical outcomes is often restricted by limited methodologies for efficiently and accurately extracting clinical information from electronic health record (EHR) systems because much is in free-text form. This study aims to utilize advanced methods to automate extraction of clinical concepts from the EHR free text to study visual acuity (VA), intraocular pressure (IOP), and medication outcomes of cataract and glaucoma surgeries.

Methods: Patients who underwent cataract or glaucoma surgery at an academic medical center between 2009 and 2018 were identified by Current Procedural Terminology codes. Rule-based algorithms were developed and used on EHR clinical narrative text to extract intraocular lens (IOL) power and implant type, as well as to create a surgery laterality classifier. MedEx (version 1.3.7) was used on free-text clinical notes to extract information on eye medications and compared to information from medication orders. Random samples of free-text notes were reviewed by two independent masked annotators to assess inter-annotator agreement on outcome variable classification and accuracy of classifiers. VA and IOP were available from semi-structured fields.

Results: This study cohort included 6347 unique patients, with 8550 stand-alone cataract surgeries, 451 combined cataract/glaucoma surgeries, and 961 glaucoma surgeries without concurrent cataract surgery. The rule-based laterality classifier achieved 100% accuracy compared to manual review of a sample of operative notes by independent masked annotators. For cataract surgery alone, glaucoma surgery alone, or combined cataract/glaucoma surgeries, our automated extraction algorithm achieved 99-100% accuracy compared to manual annotation of samples of notes from each group, including IOL model and IOL power for cataract surgeries, and glaucoma implant for glaucoma surgeries. For glaucoma medications, there was 90.7% inter-annotator agreement. After adjudication, 85.0% of medications identified by MedEx determined to be correct. Determination of surgical laterality enabled evaluation of pre- and postoperative VA and IOP for operative eyes.

Conclusion: This text-processing pipeline can accurately capture surgical laterality and implant model usage from free-text operative notes of cataract and glaucoma surgeries, enabling extraction of clinical outcomes including visual acuities, intraocular pressure, and medications from the EHR system. Use of this approach with EHRs to assess ophthalmic surgical outcomes can benefit research groups interested in studying the safety and clinical efficacies of different surgical approaches.
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http://dx.doi.org/10.1016/j.ijmedinf.2019.104007DOI Listing
January 2020

Endophthalmitis after Cataract Surgery in the United States: A Report from the Intelligent Research in Sight Registry, 2013-2017.

Ophthalmology 2020 02 28;127(2):151-158. Epub 2019 Aug 28.

American Academy of Ophthalmology, San Francisco, California.

Purpose: To determine recent incidence and visual outcomes for acute-onset endophthalmitis after cataract surgery performed in the United States.

Design: Retrospective cohort study.

Participants: United States cataract surgery patients, 2013-2017 (5 401 686 patients).

Methods: Cases of acute-onset postoperative endophthalmitis occurring within 30 days after cataract surgery were identified using diagnosis codes in the American Academy of Ophthalmology IRIS (Intelligent Research in Sight) Registry database, drawn from electronic health records in ophthalmology practices across the nation. Annual and aggregate 5-year incidences were determined for all cataract surgeries and specifically for standalone procedures versus those combined with other ophthalmic surgeries. Patient characteristics were compared. Mean and median visual acuity was determined at 1 month preoperative as well as 1 week, 1 month, and 3 months postoperative among patients with and without endophthalmitis.

Main Outcome Measures: Incidence of acute-onset postoperative endophthalmitis after cataract surgery.

Results: A total of 8 542 838 eyes underwent cataract surgery, 3629 of which developed acute-onset endophthalmitis (0.04%; 95% confidence interval, 0.04%-0.04%). Endophthalmitis incidence was highest among patients aged 0 to 17 years (0.37% over 5 years), followed by patients aged 18 to 44 years (0.18% over 5 years; P < 0.0001). Endophthalmitis occurred 4 times more often after combined cases (cataract with other ophthalmic procedures) than after standalone cataract surgeries (0.20% vs. 0.04% of cases), and occurred in 0.35% of patients receiving anterior vitrectomy. Mean 3-month postoperative visual acuity was 20/100 (median, 20/50) among endophthalmitis patients, versus a mean of approximately 20/40 (median, 20/30) among patients without endophthalmitis. However, 4% of endophthalmitis patients still achieved 20/20 or better visual acuity, and 44% achieved 20/40 or better visual acuity at 3 months.

Conclusions: Acute-onset endophthalmitis occurred in 0.04% of 8 542 838 cataract surgeries performed in the United States between 2013 and 2017. Risk factors may include younger age, cataract surgery combined with other ophthalmic surgeries, and anterior vitrectomy. Visual acuity outcomes vary; however, patients can recover excellent vision after surgery. Big data from clinical registries like the IRIS Registry has great potential for evaluating rare conditions such as endophthalmitis, including developing benchmarks, longer-term time trend investigation, and comprehensive analysis of risk factors and prophylaxis.
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http://dx.doi.org/10.1016/j.ophtha.2019.08.026DOI Listing
February 2020

Understanding Patient Attitudes Toward Multifocal Intraocular Lenses in Online Medical Forums Through Sentiment Analysis.

Stud Health Technol Inform 2019 Aug;264:1378-1382

Byers Eye Institute, Stanford University, Palo Alto CA, USA.

Multifocal intraocular lens implants (IOLs) are a premium option for cataract surgery which patients may purchase to achieve improved spectacle-independence for near vision but may have trade-offs with visual quality. We demonstrate the use of sentiment analysis to evaluate multifocal lenses discussed on MedHelp, a leading online health forum. A search for "multifocal IOL" was performed on MedHelp.org on November 1, 2016, yielding relevant patient posts. Sentiment analysis was performed using IBM's Watson, which extracted 30,066 unique keywords and their associated sentiment scores from 7495 posts written by 1474 unique patient users. Keywords associated with monovision, monofocal, and toric lenses had positive mean sentiment, significantly higher than for keywords associated with multifocals, which had negative mean sentiment (p < 0.001, ANOVA). Many keywords represented complaints and were associated with negative sentiment, including glare, halo, and ghosting. Sentiment analysis can provide insights into patient perspectives towards multifocal lenses by interpreting online patient posts.
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http://dx.doi.org/10.3233/SHTI190453DOI Listing
August 2019

Use of Bevacizumab and Ranibizumab for Wet Age-Related Macular Degeneration: Influence of CATT Results and Introduction of Aflibercept.

Am J Ophthalmol 2019 11 15;207:385-394. Epub 2019 May 15.

Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor, Michigan, USA; Center for Eye Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA; Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, Michigan, USA. Electronic address:

Purpose: To assess whether publication of Comparison of Age-related macular degeneration Treatment Trial (CATT) results and introduction of aflibercept to the marketplace affected intravitreal bevacizumab and ranibizumab utilization.

Design: Retrospective analysis of treatment patterns.

Methods: We calculated weekly bevacizumab and ranibizumab utilization during 3 timeframes: (1) before CATT publication, (2) between CATT publication (April 28, 2011) and assignment of a unique aflibercept billing code (January 1, 2013), and (3) afterward for 164,188 Medicare beneficiaries with neovascular macular degeneration receiving ≥1 anti-vascular endothelial growth factor injection(s) from January 1, 2008 to December 31, 2014. We identified ophthalmologists who predominantly (≥80%) administered bevacizumab or ranibizumab and evaluated changes in preferences over the 3 periods. We replicated analyses on 881,381 commercially insured beneficiaries.

Results: Among 317 ophthalmologists administering predominantly ranibizumab to Medicare beneficiaries pre-CATT, 221 (69.7%) reduced ranibizumab use post-CATT, whereas 96 (30.3%) continued using ranibizumab ≥80% of the time. Findings were reversed among 1041 ophthalmologists who predominantly administered bevacizumab pre-CATT-777 (74.6%) continued bevacizumab-predominant use while 264 (25.4%) reduced bevacizumab use post-CATT. Among the 145 ophthalmologists who predominantly administered ranibizumab before aflibercept's availability, 77 (53.1%) reduced ranibizumab utilization and 68 (46.9%) continued using ranibizumab ≥80% of the time after aflibercept became available. Corresponding numbers among the 909 ophthalmologists who predominantly administered bevacizumab pre-aflibercept were 381 (41.9%) reducing and 528 (58.1%) continuing bevacizumab-predominant use. Similar results were observed for commercially insured patients.

Conclusions: Many ophthalmologists who favored ranibizumab switched to bevacizumab after CATT publication, while most who favored bevacizumab before CATT publication continued favoring it afterward. Aflibercept's introduction had little impact on preferences for ranibizumab or bevacizumab.
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http://dx.doi.org/10.1016/j.ajo.2019.05.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6856411PMC
November 2019

The Relative Impact of Patient, Physician, and Geographic Factors on Variation in Primary Rhegmatogenous Retinal Detachment Management.

Ophthalmology 2020 01 12;127(1):97-106. Epub 2019 Apr 12.

Department of Ophthalmology, University of California, San Francisco, San Francisco, California.

Purpose: To evaluate geographic variation and characterize the relative contributions of patient characteristics, physician practice, and geographic region on variation in primary rhegmatogenous retinal detachment (RRD) management.

Design: Retrospective claims-based analysis.

Participants: Commercially insured patients with incident RRD diagnosed between 2008 and 2016 (12 779 patients).

Methods: We determined whether patients underwent primary RRD repair within 60 days of diagnosis and identified repair type. We characterized physicians using physician identifier variables and characterized geography by Combined Statistical Areas or Core-Based Statistical Area. We used multilevel mixed effects logistic regression models to evaluate patient-, physician-, and geographic-level variation in whether patients underwent RRD repair and used multilevel mixed effects multinomial models to characterize variation in repair type. For each model, we evaluated patient fixed effects and physician random effects nested within geographic random effects. We estimated intraclass correlation coefficients and variance partition coefficients, respectively, to compare relative contributions of patient, physician, and geography to overall variation.

Main Outcome Measures: Odds ratios for RRD repair and variation estimates for patient, physician, and geography.

Results: Most incident RRD patients received treatment within 60 days post-diagnosis. Pars plana vitrectomy was most common (49%), followed by laser barricade (23%), scleral buckle and pneumatic retinopexy (both 11%), and cryotherapy (5%). Physician-level variation showed greater impact on receipt of any treatment than geographic-level variation (estimated variance coefficients of 1.09 and 0.32, respectively). Patient-level characteristics represented approximately 82% of overall variation in receipt of any repair, versus 16% from physician-level and 2% from geographic-level factors. Among RRD patients who underwent repair, estimated variance coefficients were 0.07 for geography and 3.37 for physician. Physician-level factors represented approximately 50% of total variation in repair type, followed by patient-level (49%), and geographic-level (1%) factors.

Conclusions: Rhegmatogenous retinal detachment repair decisions are influenced by patient-level and physician-level factors, less so by geographic variation. Patient characteristics account for most of the variation in receipt of repair, and physician practice accounts for most of the variation in choice of procedure. These findings indicate a need for additional studies to understand drivers behind differences in care and clinical outcomes and to identify barriers in access to care.
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http://dx.doi.org/10.1016/j.ophtha.2019.04.019DOI Listing
January 2020

Differences in Cataract Surgery Rates Based on Dementia Status.

J Alzheimers Dis 2019 ;69(2):423-432

Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI, USA.

Background: Cataract surgery substantially improves patient quality of life. Despite the rising prevalence of dementia in the US, little is known about use of cataract surgery among this group.

Objective: To evaluate the relationship between dementia status and cataract surgery.

Methods: Using administrative insurance claims for a representative sample of 1,125,387 US Medicare beneficiaries who received eye care between 2006 and 2015, we compared cataract surgery rates between patients with and without dementia via multivariable regression models to adjust for patient characteristics. Main outcome measures were annual rates of cataract surgery and hazard ratio and 95% confidence interval (CI) for receiving cataract surgery.

Results: Cataract surgery was performed in 457,128 patients, 23,331 with a prior diagnosis of dementia. 16.7% of dementia patients underwent cataract surgery, compared to 43.8% of patients without dementia. 59 cataract surgeries were performed per 1000 dementia patients annually, versus 105 surgeries per 1000 nondementia patients. After adjusting for patient characteristics, dementia patients were approximately half as likely to receive cataract surgery compared to nondementia patients (adjusted HR = 0.53, 95% CI 0.53-0.54). Among the subset of patients who received a first cataract surgery, those with dementia were also less likely to receive second-eye cataract surgery (adjusted HR = 0.87, 95% CI 0.86-0.88).

Conclusion: US Medicare patients with dementia are less likely to undergo cataract surgery than those without dementia. This finding has implications for quality of care and dementia progression. More information is necessary to understand why rates of cataract surgery are lower for these patients, and to identify conditions where benefits of surgery may outweigh risks.
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http://dx.doi.org/10.3233/JAD-181292DOI Listing
September 2020

Risk factors for incident central serous retinopathy: case-control analysis of a US national managed care population.

Br J Ophthalmol 2019 12 14;103(12):1784-1788. Epub 2019 Mar 14.

Stanford University School of Medicine, Stanford, California, USA

Aim: To evaluate clinical comorbidities and steroid use as risk factors for central serous retinopathy (CSR).

Methods: Using national insurance databases, we conducted a case-control study of beneficiaries with an incident diagnosis of CSR between 2007 and 2015 (n=35 492) and randomly selected controls matched on age-based and sex-based propensity scores (n=1 77 460).

Results: The mean age (SD) of cases was 49.1 (12.2) years, and the majority (69.2%) were male. Cases were more likely to have received steroids in the past year (OR 1.14, 95% CI 1.09 to 1.19, p<0.001) and to have comorbid Cushing's syndrome (OR 2.19, 95% CI 1.33 to 3.59, p=0.002), age-related macular degeneration (OR 5.24, 95% CI 5.00 to 5.49, p<0.001), diabetic macular oedema (OR 2.05, 95% CI 1.71 to 2.47, p<0.001) and diabetes mellitus (OR 1.44, 95% CI 1.33 to 1.56, p<0.001). Glaucoma was associated with lower odds of CSR (OR 0.54, 95% CI 0.51 to 0.56, p<0.001). Patients with other previously hypothesised risk factors (including essential hypertension, pregnancy, other autoimmune disease, sleep disorders, infection and gastro-oesophageal reflux disease) had lower odds of CSR.

Conclusions: Male middle-aged patients with recent steroid exposure were significantly more likely to develop CSR. Other risk factors include diabetes mellitus, diabetic macular oedema and age-related macular degeneration. Other previously hypothesised risk factors did not appear to confer increased risk. More research is needed to confirm and examine underlying pathophysiology.
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http://dx.doi.org/10.1136/bjophthalmol-2018-313050DOI Listing
December 2019

Choice of Primary Rhegmatogenous Retinal Detachment Repair Method in US Commercially Insured and Medicare Advantage Patients, 2003-2016.

Am J Ophthalmol 2018 12 23;196:82-90. Epub 2018 Aug 23.

Retina Service, Department of Ophthalmology, University of California, San Francisco, San Francisco, California, USA.

Purpose: To evaluate trends for rhegmatogenous retinal detachment (RRD) repair and the influence of patient characteristics on repair type in a large US population including children and adults, between 2003 and 2016.

Design: Retrospective cohort study.

Methods: Setting: Administrative claims for beneficiaries in a large nationwide managed-care network, including Medicare Advantage, employer-sponsored, and commercial insurance.

Population: Beneficiaries undergoing RRD primary repair procedures.

Main Outcome Measure: RRD repair procedure type.

Results: We identified 31 995 beneficiaries with RRD over the study period, mean age 59.8 years. Ocular comorbidities, including pseudophakia (16.9%), vitreous hemorrhage (14.6%), myopia (2.9%), and lattice degeneration (11.0%), were more common among RRD than non-RRD patients. Pars plana vitrectomy (PPV) was consistently the most common repair procedure, increasing over time. Scleral buckle utilization declined and utilization of other procedures remained relatively constant. After adjustment for age, demographics, and geographic region, PPV was more likely among patients with pseudophakia (OR = 1.81, P < .001) and vitreous hemorrhage (OR = 1.38, P < .001). Lattice degeneration (OR = 1.42, P < .001) and younger age were associated with higher odds of scleral buckle. Pneumatic retinopexy was more likely among patients with better systemic health and less likely among patients with ocular comorbidities including vitreous hemorrhage or lattice degeneration.

Conclusions: PPV is increasingly the most common RRD repair procedure across a broadly representative US population. However, other techniques are still preferred for some patients and, in aggregate, choice of repair procedure seems influenced by patient characteristics in a manner consistent with recommendations in the literature.
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http://dx.doi.org/10.1016/j.ajo.2018.08.024DOI Listing
December 2018