Suzann Pershing, MD

All Publications

• Development of the Elective Outpatient Percutaneous Coronary Intervention Episode-Based Cost Measure. Circulation. Cardiovascular quality and outcomes Sandhu, A. T., Do, R., Lam, J., Blankenship, J., Van Decker, W., Rich, J., Gonzalez, O., Wu, X., Pershing, S., Lin, E., MaCurdy, T. E., Bhattacharya, J., Nagavarapu, S. 2021: CIRCOUTCOMES119006461

  Abstract

  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.

  View details for DOI 10.1161/CIRCOUTCOMES.119.006461

  View details for PubMedID 33653117

• Bidirectional Association between Visual Impairment and Dementia Among US Older Adults Over Time. Ophthalmology Chen, S. P., Azad, A. D., Pershing, S. 2021

  Abstract

  OBJECTIVE: While visual impairment has been shown to be associated with worse cognitive performance among older adults, the temporal relationship between the two remains subject to debate. Our objective was to investigate the longitudinal impact of visual impairment on cognitive function and vice versa.DESIGN: Retrospective, time-to-event study.SUBJECTS, PARTICIPANTS, AND/OR CONTROLS: National Health and Aging Trends Study (NHATS) participants from 2011-2018 cycles.METHODS, INTERVENTION, OR TESTING: A total of 10,676 participants aged 65 years and older were included. Cox proportional hazards regression models evaluated the impact of baseline visual impairment (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 for incident dementia among participants with baseline self-reported VI and hazard ratio for incident VI among participants with baseline dementia.RESULTS: Of the 10,676 participants included in the analysis, approximately 40% were between the ages of 65-74 years, 40% were between 75-84 years, and the remaining 20% were 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 1,753 (16%), and among participants with normal self-reported vision at baseline, subsequent VI was reported in 2,371 (22%). In adjusted regression models, participants with baseline VI had higher likelihood of developing dementia over subsequent follow-up (HR=2.3, 95% CI: 2.0-2.6 p<0.001). Similarly, participants with baseline dementia had higher likelihood of developing self-reported VI over time (HR=2.5, 95% CI: 2.2-2.8, p<0.001).CONCLUSIONS: Self-reported visual impairment in the US Medicare population is associated with greater likelihood of dementia over time, and dementia is similarly associated with greater likelihood of visual impairment over time. Associations are likely multifactorial and bidirectional, and could be explained by intervening variables in the path from visual impairment to dementia, or vice versa, or by common risk factors for pathological processes in both eyes and brain. These findings suggest need for early identification of older adults with visual compromise, and consideration of visual disability in the cognitively impaired.

  View details for DOI 10.1016/j.ophtha.2021.02.021

  View details for PubMedID 33647283

• Systemic Corticosteroid Use after Central Serous Chorioretinopathy Diagnosis OPHTHALMOLOGY Azad, A. D., Zhou, M., Afshar, A. R., Bakri, S. J., Pershing, S. 2021; 128 (1): 121–29

  View details for DOI 10.1016/j.opatha.2020.06.056

  View details for Web of Science ID 000600748500030

• Comparing cataract surgery complication rates in veterans receiving VA and community care. Health services research Rosen, A. K., Vanneman, M. E., O'Brien, W. J., Pershing, S., Wagner, T. H., Beilstein-Wedel, E., Lo, J., Chen, Q., Cockerham, G. C., Shwartz, M. 2020

  Abstract

  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 66984 (routine) and 66982 (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."

  View details for DOI 10.1111/1475-6773.13320

  View details for PubMedID 32715468

• Big data requirements for artificial intelligence. Current opinion in ophthalmology Wang, S. Y., Pershing, S., Lee, A. Y., AAO Taskforce on AI and AAO Medical Information Technology Committee 2020

  Abstract

  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.

  View details for DOI 10.1097/ICU.0000000000000676

  View details for PubMedID 32657996

• Intraocular Pressure Changes after Cataract Surgery in Patients with and without Glaucoma: An Informatics-Based Approach. Ophthalmology. Glaucoma Wang, S. Y., Azad, A. D., Lin, S. C., Hernandez-Boussard, T., Pershing, S. 2020

  Abstract

  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.

  View details for DOI 10.1016/j.ogla.2020.06.002

  View details for PubMedID 32703703

• Ophthalmology Consultation to Detect Endogenous Endophthalmitis: Clinical Characteristics in Consulted Versus Diagnosed Cases Among At-Risk Inpatients OPHTHALMIC SURGERY LASERS & IMAGING RETINA Wang, K., Krishnan, G., Pershing, S. 2020; 51 (3): 159-+

  Abstract

  Predisposing factors for ophthalmology consultations and endogenous endophthalmitis were compared among inpatients with systemic infection.This was a retrospective cohort study in a tertiary care hospital between January 1, 2010, and December 31, 2014. Multivariable logistic regression was utilized.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.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.].

  View details for DOI 10.3928/23258160-20200228-05

  View details for Web of Science ID 000522489100005

  View details for PubMedID 32211906

• Receipt of Eye Care Services among Medicare Beneficiaries with and without Dementia. Ophthalmology Pershing, S., Goldstein, M. K., Henderson, V. W., Bundorf, M. K., Lu, Y., Rahman, M., Stein, J. D. 2020

  Abstract

  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 4451200 beneficiaries met inclusion criteria; 3805718 (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 thanthose 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 topatients with dementia, and implement measures to improve access to appropriate eye care.

  View details for DOI 10.1016/j.ophtha.2020.02.022

  View details for PubMedID 32317179

• 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. Ophthalmology. Glaucoma Lee, C. S., Owen, J. P., Yanagihara, R. T., Lorch, A. n., Pershing, S. n., Hyman, L. n., Miller, J. W., Haller, J. A., Chiang, M. F., Lum, F. n., Lee, A. Y. 2020; 3 (4): 253–61

  Abstract

  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.Retrospective database study of the IRIS® Registry data.Intelligent Research in Sight Registry patients who were seen by an eye care provider during 2017.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.Mean IOP.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]).Current smokers and past smokers have higher IOP than patients who never smoked. This difference is higher in patients with an underlying glaucoma diagnosis.

  View details for DOI 10.1016/j.ogla.2020.03.008

  View details for PubMedID 33008558

  View details for PubMedCentralID PMC7532983

• The New USMLE Step 1 Paradigm: An Opportunity to Cultivate Diversity of Excellence. Academic medicine : journal of the Association of American Medical Colleges Pershing, S. n., Co, J. P., Katznelson, L. n. 2020

  Abstract

  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 such as 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 judgement 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.

  View details for DOI 10.1097/ACM.0000000000003512

  View details for PubMedID 32433311

• Artificial Intelligence in Global Ophthalmology: Using Machine Learning to Improve Cataract Surgery Outcomes at Ethiopian Outreaches. Journal of cataract and refractive surgery Brant, A. R., Hinkle, J. n., Shi, S. n., Hess, O. n., Zubair, T. n., Pershing, S. n., Tabin, G. C. 2020

  Abstract

  Differences between target and implanted intraocular lens (IOL) power in Ethiopian cataract outreach campaigns were evaluated and machine learning (ML) applied to optimize 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 measured. A gradient descent (an ML algorithm) was used to generate an optimal IOL inventory and measured the model's 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 >99.5% of patients received their target IOL when using only 39% IOL surplus.In Ethiopian cataract campaigns, the majority of patients have avoidable postoperative refractive error secondary to suboptimal IOL inventory. Optimizing IOL inventory using our ML model might eliminate refractive error from insufficient inventory and reduce costs.

  View details for DOI 10.1097/j.jcrs.0000000000000407

  View details for PubMedID 32932371

• Cataract Surgery Complexity and Surgical Complication Rates among Medicare Beneficiaries with and without Dementia. American journal of ophthalmology Pershing, S. n., Henderson, V. W., Goldstein, M. K., Lu, Y. n., Bundorf, M. K., Rahman, M. n., Stein, J. D. 2020

  Abstract

  To evaluate cataract surgery complexity and complications among US Medicare beneficiaries with and without dementia.Retrospective claims-based cohort study PARTICIPANTS: A 20% representative sample of Medicare beneficiaries, 2006-2015.Dementia was identified from diagnosis codes on or prior to each beneficiary's first-eye cataract surgery. For each surgery, we identified setting, routine versus 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. Complications analyses were stratified by second-eye cataract surgery within 90 days postoperatively.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 non-ambulatory surgery center setting, anesthesiologist provider, or postoperative hospitalization. Dementia-diagnosed beneficiaries were more likely to have surgeries coded as complex (15.6% of cases versus 8.8%, p<0.0001), and surgeries exceeding 30 minutes (OR=1.21, 95%CI=1.17-1.25).Among US Medicare beneficiaries undergoing cataract surgery, those with dementia are more likely to have "complex" surgery" lasting over 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.

  View details for DOI 10.1016/j.ajo.2020.08.025

  View details for PubMedID 32828874

• Association of Visual Impairment With Risk of Incident Dementia in a Women's Health Initiative Population. JAMA ophthalmology Tran, E. M., Stefanick, M. L., Henderson, V. W., Rapp, S. R., Chen, J. C., Armstrong, N. M., Espeland, M. A., Gower, E. W., Shadyab, A. H., Li, W. n., Stone, K. L., Pershing, S. n. 2020

  Abstract

  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.To evaluate associations between visual impairment and risk of cognitive impairment.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.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).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.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).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.

  View details for DOI 10.1001/jamaophthalmol.2020.0959

  View details for PubMedID 32297918

• Systemic Corticosteroid Use after Central Serous Chorioretinopathy Diagnosis. Ophthalmology Azad, A. D., Zhou, M. n., Afshar, A. R., Bakri, S. J., Pershing, S. n. 2020

  Abstract

  To analyze frequency of systemic corticosteroid prescriptions before and after central serous chorioretinopathy (CSC) diagnosis.Retrospective claims-based analysis.A nationally-representative sample of commercial insurance beneficiaries who received care between 2007-2015.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 on age, sex, general health (Charlson Comorbidity Index), and geographic region. We compared systemic corticosteroid prescriptions before and after CSC diagnosis and by diagnosing provider type (optometrist versus ophthalmologist), and evaluated likelihood of receiving steroids among CSC patients versus matched controls using logistic and Cox proportional hazard regression models.Frequency of systemic corticosteroid prescriptions 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 post-diagnosis steroids among CSC patients and controls.We identified 3418 CSC patients. Nearly 39% (n=1326) were prescribed systemic steroids at some point during the analysis period, compared to 23% of matched controls (4033 of 17,178 patients). Over 12% of CSC patients (n=430) received steroids within a year pre-diagnosis, and nearly 12% (n=404) received steroids within 1 year post-diagnosis. Most patients who received post-diagnosis steroids were steroid-naïve (n=231). The most common steroid prescribed was oral prednisone (an approximately 1-month supply). Among those receiving steroids, CSC patients had longer median time to first post-diagnosis steroid prescription (1.82 years versus 0.50 years for controls) and longer time to last steroid prescription (1.62 years versus 0.35 years for non-CSC patients). Although CSC patients were significantly less likely to receive steroids at 6 months post-diagnosis compared to matched non-CSC patients (OR=0.72, 95%CI=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.Despite evidence showing 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 clinical practice reflects evidence-based recommendations.

  View details for DOI 10.1016/j.ophtha.2020.06.056

  View details for PubMedID 32619546

• Sex Differences in the Repair of Retinal Detachments in the United States. American journal of ophthalmology Callaway, N. F., Vail, D. n., Al-Moujahed, A. n., Ludwig, C. n., Ji, M. H., Mahajan, V. B., Pershing, S. n., Moshfeghi, D. M. 2020

  Abstract

  To determine differences between women and men in the repair of rhegmatogenous retinal detachments (RRD) in the United States.Retrospective cohort study.SETTING: A large insurance claims database.Subjects with an incident RRD between 2007-2015.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.Odds of receipt of surgical intervention for incident RRD, time to repair, type of intervention, and the rate of reoperation by sex.The study period included 133 million eligible records with 61,071 cases of incident RRD meeting inclusion criteria among which 43% (n = 26,289) were women. Women had 34% reduced odds of receipt of surgical repairof an RRD (OR 0.66, 95% CI 0.59 - 0.73, p<0.001) after adjusting for confounders. This effect persisted in all sensitivity models. Among patients that received repair, women were more often delayed (0.17 days, p = 0.04). Women were more likely to undergo primary laser barricade (RRR 1.68, p < 0.001), primary SB (RRR 1.15, p < 0.001), and PR (RRR 1.07, p < 0.04) than men. The odds of reoperation were lower in women (OR 0.91, 95% CI 0.85 - 0.96, p=0.002) after adjustment.Insured women are less likely than insured men to receive surgical intervention for an RRD. If the odds of repair were equal between women and men in the U.S. 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 and laser barricade. The reason for thesesex differences in RRD repair remains unknown and requires further investigation.

  View details for DOI 10.1016/j.ajo.2020.06.039

  View details for PubMedID 32640255

• Association of Rhegmatogenous Retinal Detachment and Outcomes With the Day of the Week That Patients Undergo a Repair or Receive a Diagnosis. JAMA ophthalmology Vail, D., Pan, C., Pershing, S., Mruthyunjaya, P. 2019

  Abstract

  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.

  View details for DOI 10.1001/jamaophthalmol.2019.5253

  View details for PubMedID 31855233

• Risk factors for incident central serous retinopathy: case-control analysis of a US national managed care population BRITISH JOURNAL OF OPHTHALMOLOGY Zhou, M., Bakri, S. J., Pershing, S. 2019; 103 (12): 1784–88

  View details for DOI 10.1136/bjophthalmol-2018-313050

  View details for Web of Science ID 000501150600017

• Automated extraction of ophthalmic surgery outcomes from the electronic health record. International journal of medical informatics Wang, S. Y., Pershing, S., Tran, E., Hernandez-Boussard, T. 2019; 133: 104007

  Abstract

  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.

  View details for DOI 10.1016/j.ijmedinf.2019.104007

  View details for PubMedID 31706228

• Endophthalmitis after Cataract Surgery in the United States: A Report from the Intelligent Research in Sight Registry, 2013-2017. Ophthalmology Pershing, S., Lum, F., Hsu, S., Kelly, S., Chiang, M. F., Rich, W. L., Parke, D. W. 2019

  Abstract

  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 andspecifically for standalone procedures versus those combined with other ophthalmic surgeries. Patientcharacteristics were compared. Mean and median visual acuity was determined at 1 month preoperative aswell 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 8542838 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.

  View details for DOI 10.1016/j.ophtha.2019.08.026

  View details for PubMedID 31611015

• Gender Differences in Surgical Intervention Rate and Timing for Rhegmatogenous Retinal Detachments Among US Commercially Insured Patients From 2007-2015 Callaway, N. F., Vail, D., Pershing, S., Ludwig, C. A., Moshfeghi, D. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2019

  View details for Web of Science ID 000488800707285

• Refining Metrics for Assessing the Quality of Care of Patients Undergoing Cataract Surgery for Use in Big Data Analyses Weinlander, E., Talwar, N., Weizer, J., Saleem, S., Pershing, S., Stagg, B., Mwanza, J., Lynch, A., Sugar, A., Lee, P. P., Stein, J. D. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2019

  View details for Web of Science ID 000488628105034

• Characterizing Geographic Variation in Surgical Management of Rhegmatogenous Retinal Detachment Vail, D., Pershing, S. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2019

  View details for Web of Science ID 000488800705031

• Differences in Receiving Eye Care Based on Dementia Status Pershing, S., Goldstein, M. K., Henderson, V. W., Lu, Y., Bundorf, M., Rahman, M., Andrews, C., Stein, J. D. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2019

  View details for Web of Science ID 000488800705001

• Risk factors for incident central serous retinopathy: case-control analysis of a US national managed care population. The British journal of ophthalmology Zhou, M., Bakri, S. J., Pershing, S. 2019

  Abstract

  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=35492) and randomly selected controls matched on age-based and sex-based propensity scores (n=177460).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, Helicobacter pylori 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.

  View details for PubMedID 30872284

• Development and validation of a predictive model for American Society of Anesthesiologists Physical Status. BMC health services research Mudumbai, S. C., Pershing, S. n., Bowe, T. n., Kamal, R. N., Sears, E. D., Finlay, A. K., Eisenberg, D. n., Hawn, M. T., Weng, Y. n., Trickey, A. W., Mariano, E. R., Harris, A. H. 2019; 19 (1): 859

  Abstract

  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.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.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.

  View details for DOI 10.1186/s12913-019-4640-x

  View details for PubMedID 31752856

• Understanding Patient Attitudes Toward Multifocal Intraocular Lenses in Online Medical Forums Through Sentiment Analysis Wang, S. Y., Hernandez-Boussard, T., Chang, R. T., Pershing, S., OhnoMachado, L., Seroussi, B. IOS PRESS. 2019: 1378–82

  View details for DOI 10.3233/SHT1190453

  View details for Web of Science ID 000569653400278

• Understanding Patient Attitudes Toward Multifocal Intraocular Lenses in Online Medical Forums Through Sentiment Analysis. Studies in health technology and informatics Wang, S. Y., Hernandez-Boussard, T. n., Chang, R. T., Pershing, S. n. 2019; 264: 1378–82

  Abstract

  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.

  View details for DOI 10.3233/SHTI190453

  View details for PubMedID 31438152

• Characteristics of Ophthalmology Trials Registered in ClinicalTrials.gov, 2007-2018. American journal of ophthalmology Turner, B. n., Rajeshuni, N. n., Tran, E. M., Ludwig, C. A., Tauqeer, Z. n., Weeks, B. n., Kinde, B. n., Pershing, S. n. 2019

  Abstract

  To perform a comprehensive analysis of characteristics of ophthalmology trials registered in ClinicalTrials.gov.Cross-sectional study METHODS: All 4,203 ophthalmologic clinical trials registered on ClinicalTrials.gov between October 1, 2007, and April 30, 2018 were identified using Medical Subject Heading (MeSH) terms. Disease condition terms were verified by manual review. Trial characteristics were assessed through frequency calculations. Hazard ratio and 95% confidence intervals were determined for characteristics associated with early discontinuation.The majority of trials were multi-armed (73.6%), single-site (69.4%), randomized (64.8%), and had <100 enrollees (66.3%). Thirty-three percent utilized a data monitoring committee (DMC), and 50.6% incorporated blinding. 51.6% were funded by industry, while 2.6% by the National Institute 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) and 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). 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 (HR 0.72; 95% 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).Ophthalmology trials in the past decade reveal heterogeneity across study funding sources. NIH trials were more likely to support historically underfunded subspecialties, while 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.

  View details for DOI 10.1016/j.ajo.2019.11.004

  View details for PubMedID 31730839

• Differences in Cataract Surgery Rates Based on Dementia Status JOURNAL OF ALZHEIMERS DISEASE Pershing, S., Henderson, V. W., Bundorf, M., Lu, Y., Rahman, M., Andrews, C. A., Goldstein, M., Stein, J. D. 2019; 69 (2): 423–32

  View details for DOI 10.3233/JAD-181292

  View details for Web of Science ID 000470879800009

• The Relative Impact of Patient, Physician, and Geographic Factors on Variation in Primary Rhegmatogenous Retinal Detachment Management. Ophthalmology Vail, D. n., Pershing, S. n., Reeves, M. G., Afshar, A. R. 2019

  Abstract

  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.Retrospective claims-based analysis.Commercially insured patients with incident RRD diagnosed between 2008 and 2016 (12 779 patients).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.Odds ratios for RRD repair and variation estimates for patient, physician, and geography.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.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.

  View details for DOI 10.1016/j.ophtha.2019.04.019

  View details for PubMedID 30981916

• Use of Bevacizumab and Ranibizumab for Wet Age-Related Macular Degeneration: Influence of CATT Results and Introduction of Aflibercept. American journal of ophthalmology Pershing, S. n., Talwar, N. n., Armenti, S. T., Grubbs, J. n., Rosenthal, J. M., Dedania, V. S., Stein, J. D. 2019

  Abstract

  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.Retrospective analysis of treatment patterns.We calculated weekly bevacizumab and ranibizumab utilization during 3 timeframes: (1) before CATT publication, (2) between CATT publication (4/28/2011) and assignment of a unique aflibercept billing code (1/1/2013), and (3) afterwards for 164188 Medicare beneficiaries with neovascular macular degeneration receiving ≥1 anti-Vascular Endothelial Growth Factor injections from 1/1/2008 to 12/31/2014. We identified ophthalmologists who predominantly (≥80%) administered bevacizumab or ranibizumab, and evaluated changes in preferences over the 3 periods. We replicated analyses on 881381 commercially-insured beneficiaries.Among 317 ophthalmologists administering predominantly ranibizumab to Medicare beneficiaries pre-CATT, 221 (69.7%) reduced ranibizumab utilization 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 utilization 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.Many ophthalmologists who favored ranibizumab switched to bevacizumab after CATT publication while most who favored bevacizumab prior to CATT publication continued favoring it afterwards. Aflibercept's introduction had little impact on preferences for ranibizumab or bevacizumab.

  View details for DOI 10.1016/j.ajo.2019.05.011

  View details for PubMedID 31100217

• Choice of Primary Rhegmatogenous Retinal Detachment Repair Method in US Commercially-insured and Medicare Advantage Patients, 2003-2016. American journal of ophthalmology Reeves, M., Pershing, S., Afshar, A. R. 2018

  Abstract

  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 2003-2016.DESIGN: Retrospective cohort study.SETTING: Administrative claims for beneficiaries in a large nationwide managed-care network, including Medicare Advantage, employer-sponsored, or 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 adjusting for age, demographics, and geographic region, PPV was more likely among patients with pseudophakia (OR=1.81, p<0.001) and vitreous hemorrhage (OR=1.38, p<0.001). Lattice degeneration (OR=1.42, p<0.001) 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 appears influenced by patient characteristics in a manner consistent with recommendations in the literature.

  View details for PubMedID 30144442

• An Analysis of Medicare Reimbursement to Ophthalmologists: Years 2012 to 2013 AMERICAN JOURNAL OF OPHTHALMOLOGY Han, E., Baisiwala, S., Jain, A., Bundorf, M., Pershing, S. 2017; 182: 133–40

  Abstract

  To analyze trends in utilization and payment of ophthalmic services in the Medicare population for years 2012 and 2013.Retrospective, cross-sectional study.A retrospective cross-sectional observational analysis was performed using publicly available Medicare Physician and Other Supplier aggregate file and the Physician and Other Supplier Public Use File. Variables analyzed included aggregate beneficiary demographics, Medicare payments to ophthalmologists, ophthalmic medical services provided, and the most common Medicare-reimbursed ophthalmic services.In 2013, total Medicare Part B reimbursement for ophthalmology was $5.8 billion, an increase of 3.6% from the previous year. From 2012 to 2013, the total number of ophthalmology services rendered increased by 2.2%, while average dollar amount reimbursed per ophthalmic service decreased by 5.4%. The top 5 highest reimbursed services accounted for 85% of total ophthalmic Medicare payments in 2013, an 11% increase from 2012. During 2013, drug reimbursement represented 32.8% of the total Medicare payments to ophthalmologists. Ranibizumab and aflibercept alone accounted for 95% of the entire $1.9 billion in drug reimbursements ophthalmologists in 2013.Medicare Part B reimbursement for ophthalmologists was primarily driven by use of anti-vascular endothelial growth factor (anti-VEGF) injections from 2012 to 2013. Of the total drug payments to ophthalmologists, biologic anti-VEGF agents ranibizumab and aflibercept accounted for 95% of all drug reimbursement. This is in contrast to other specialties, in which drug reimbursement represented only a small portion of Medicare reimbursement.

  View details for PubMedID 28784553

• Association of Vision Loss With Cognition in Older Adults JAMA OPHTHALMOLOGY Chen, S. P., Bhattacharya, J., Pershing, S. 2017; 135 (9): 963–70

  Abstract

  Visual dysfunction and poor cognition are highly prevalent among older adults; however, the relationship is not well defined.To evaluate the association of measured and self-reported visual impairment (VI) with cognition in older US adults.Cross-sectional analysis of 2 national data sets: the National Health and Nutrition Examination Survey (NHANES), 1999-2002, and the National Health and Aging Trends Study (NHATS), 2011-2015. The NHANES was composed of a civilian, noninstitutionalized community, and the NHATS comprised Medicare beneficiaries in the contiguous United States. Vision was measured at distance, near, and by self-report in the NHANES and by self-report alone in the NHATS. Sample weights were used to ensure result generalizability.The NHANES measured Digit Symbol Substitution Test (DSST) score and relative DSST impairment (DSST score ≤28, lowest quartile in study cohort), and the NHATS measured probable or possible dementia, classified per NHATS protocol.The NHANES comprised 2975 respondents aged 60 years and older who completed the DSST measuring cognitive performance. Mean (SD) age was 72 (8) years, 52% of participants were women (n = 1527), and 61% were non-Hispanic white (n = 1818). The NHATS included 30 202 respondents aged 65 years and older with dementia status assessment. The largest proportion (40%; n = 12 212) were between 75 and 84 years of age. Fifty-eight percent were women (n = 17 659), and 69% were non-Hispanic white (n = 20 842). In the NHANES, distance VI (β = -5.1; 95% CI, -8.6 to -1.6; odds ratio [OR], 2.8; 95% CI, 1.1-6.7) and subjective VI (β = -5.3; 95% CI, -8.0 to -2.6; OR, 2.7; 95% CI, 1.6-4.8) were both associated with lower DSST scores and higher odds of DSST impairment after full adjustment with covariates. Near VI was associated with lower DSST scores but not higher odds of DSST impairment. The NHATS data corroborated these results, with all vision variables associated with higher odds of dementia after full adjustment (distance VI: OR, 1.9; 95% CI, 1.6-2.2; near VI: OR, 2.6; 95% CI, 2.2-3.1; either distance or near VI: OR, 2.1; 95% CI, 1.8-2.4).In a nationally representative sample of older US adults, vision dysfunction at distance and based on self-reports was associated with poor cognitive function. This was substantiated by a representative sample of US Medicare beneficiaries using self-reported visual function, reinforcing the value of identifying patients with visual compromise. Further study of longitudinal interactions between vision and cognition is warranted.

  View details for PubMedID 28817745

  View details for PubMedCentralID PMC5710542

• Trends in Hospitalization and Incidence Rate for Syphilitic Uveitis in the United States from 1998-2009. American journal of ophthalmology Albini, T., Callaway, N. F., Pershing, S., Wang, S. K., Moshfeghi, A. A., Moshfeghi, D. M. 2017

  Abstract

  This study evaluates the annual incidence of syphilitic uveitis in the US and trends in hospital admissions over time.Retrospective, longitudinal incidence rate analysis of the National Inpatient Sample (NIS) data from 1998 to 2009.The NIS is a de-identified, random sample dataset of inpatient hospitalizations from 46 states. The number of cases of syphilitic uveitis was defined by (1) International Classification of Diseases, 9th Revision (ICD-9) code for syphilis and uveitis or (2) ICD-9 code for syphilitic uveitis. Annual case count, incidence rate, and trend over time were calculated. Multivariate logistic regression was used to evaluate associated factors for a syphilitic uveitis diagnosis.The study included 455 310 286 hospitalizations during a 12-year study period with a mean of 37 942 524 patients annually. Syphilis and uveitis was recorded for 1861 patients (155 annually) and syphilitic uveitis was diagnosed in 204 subjects (average of 17 cases annually). There was no change in the incidence of syphilitic uveitis, using either definition, over the study period (P for trend = .46). The mean annual incidence of syphilis and uveitis was 0.0004%, or 4 per million. Syphilitic uveitis had an annual incidence of 0.000045%, or 0.45 per million. The odds of syphilitic uveitis were lower among women (odds ratio [OR] 0.40, CI 0.28-0.57) and increased with comorbid acquired immunodeficiency syndrome (OR 4.52, CI 3.01-6.79).We report the first incidence of syphilitic uveitis in the United States. Fortunately, this remains a rare condition. The results demonstrate no change in the number of inpatient admissions for syphilitic uveitis during the study period.

  View details for DOI 10.1016/j.ajo.2017.05.013

  View details for PubMedID 28549847

• Self-Reported Receipt of Dilated Fundus Exams among Patients with Diabetes: Medicare Expenditure Panel Survey, 2002-2013. American journal of ophthalmology Tien Tran, E. M., Bhattacharya, J., Pershing, S. 2017

  Abstract

  To evaluate self-reported adherence to diabetic retinopathy screening examinations among diabetic subjects.Retrospective, population-based cross-sectional study.Medical Expenditure Panel Survey (MEPS) consolidated full-year and prescribed drugs data from 2002-2013 were reviewed; multivariable logistic regression was used to identify patient characteristics as potential barriers to receiving examinations.Of 13 299 persons in the MEPS sample, only 39.62% (95% confidence interval [CI] 38.56%-40.67%) reported receiving annual dilated eye examinations, and 90.31% (CI 89.70%-90.91%) reported ever having received an eye examination. Significant factors related to ever receiving an eye examination included completed high school (odds ratio [OR] = 1.53; CI, 1.33-1.75), bachelor's degree or higher (OR = 1.94; CI, 1.56-2.41), private health insurance (OR = 2.07; CI, 1.70-2.52), public insurance (OR = 1.90; CI, 1.56-2.31), household income >400% of the poverty threshold (OR = 1.75; CI, 1.36-2.25), prescribed diabetes medication (OR = 1.45; CI, 1.27-1.65), diabetic kidney disease (OR = 1.31; CI, 1.08-1.59), prior foot examination (OR = 1.49; CI, 1.28-1.74), prior hemoglobin A1c test (OR = 1.45; CI, 1.28-1.64), and having a usual care provider (OR = 1.50; CI, 1.25-1.80). Self-reported Asian ethnicity (OR = 0.51; CI, 0.39-0.65), needing assistance for at least 3 months (OR = 0.79; CI, 0.62-1.00), and proxy needed to fill out the survey (OR = 0.72; CI, 0.61-0.85) were associated with lower odds of reporting ever having received a dilated eye examination.In this national-representative sample, 90.31% of patients with diabetes reported ever having a dilated eye examination; only 39.62% reported receiving one annually as recommended. These low rates appear associated with possibly modifiable factors, including having a regular care provider, increasing access to care, enrollment in health insurance, and higher education.

  View details for DOI 10.1016/j.ajo.2017.04.009

  View details for PubMedID 28455116

• Determining the Value of Home Monitoring of Patients With Age-Related Macular Degeneration. JAMA ophthalmology Pershing, S. n., Stein, J. D. 2017; 135 (5): 459–60

  View details for PubMedID 28358963

• Cataract Surgery Complications and Revisit Rates Among Three States AMERICAN JOURNAL OF OPHTHALMOLOGY Pershing, S., Morrison, D. E., Hernandez-Boussard, T. 2016; 171: 130-138

  Abstract

  To characterize population-based 30-day procedure-related readmissions (revisits) following cataract surgery.Ambulatory cataract surgery performed in California, Florida, or New York DESIGN: Retrospective cohort study.This study used all-capture state administrative datasets. Cataract procedures from CA, FL, and NY state ambulatory surgery settings were identified using ICD-9-CM and CPT codes. Thirty-day readmissions (revisits) were identified in inpatient, ambulatory, and emergency department settings across each state RESULTS: Across the three states, the all-cause 30-day readmission rate was 6.0% and the procedure-related readmission (revisit) rate was 1.0%. Procedure-related revisits were highest for patients aged 20-29 (2.9%) and 30-39 (2.3%) and lowest for patients aged 70-79 (0.9%). Multivariate associations between clinical characteristics and 30-day procedure-related revisits included age 20-29 (Odds Ratio [OR]: 3.13; 95% Confidence Intervals [CI]: 2.33-4.20) and age 30-39 (OR: 2.35; CI: 1.91-2.89) compared to age 70-79, male gender (OR: 1.29; CI: 1.24-1.34), races black (OR: 1.37; CI: 1.27-1.48) and Hispanic (OR: 1.16; CI: 1.08-1.24) compared to white, and Medicaid insurance (OR: 1.18, CI: 1.07-1.30) compared to Medicare. Diabetes was also associated with increased 30-day procedure-related revisits (OR: 1.093, CI: 1.024-1.168).Cataract surgery is a common and, in aggregate, expensive procedure. Complication-related revisits follow a similar trend as surgical complications in large-scale population data, and may be useful as a preliminary, screening, outcome measure. Our results highlight the importance of age as a risk factor for cataract surgery readmissions, and suggest a relationship between black or Hispanic race, Medicaid insurance, and diabetes associated with higher risk for cataract surgery complications.

  View details for DOI 10.1016/j.ajo.2016.08.036

  View details for Web of Science ID 000388545800018

  View details for PubMedID 27615607

• Integrating the Internship into Ophthalmology Residency Programs: Association of University Professors of Ophthalmology American Academy of Ophthalmology White Paper. Ophthalmology Oetting, T. A., Alfonso, E. C., Arnold, A., Cantor, L. B., Carter, K., Cruz, O. A., Feldon, S., Mondino, B., Parke, D. W., Pershing, S., Uhler, T., Volpe, N. J. 2016; 123 (9): 2037-2041

  Abstract

  Future ophthalmologists will need to have broad skills to thrive in complex health care organizations. However, training for ophthalmologists does not take advantage of all of the postgraduate years (PGYs). Although the traditional residency years seem to have little excess capacity, enhancing the internship year does offer an opportunity to expand the time for ophthalmology training in the same 4 PGYs. Integrating the internship year into residency would allow control of all of the PGYs, allowing our profession to optimize training for ophthalmology. In this white paper, we propose that we could capture an additional 6 months of training time by integrating basic ophthalmology training into the intern year. This would allow 6 additional months to expand training in areas such as quality improvement or time for "mini-fellowships" to allow graduates to develop a deeper set of skills.

  View details for DOI 10.1016/j.ophtha.2016.06.021

  View details for PubMedID 27423312

• Defining a Minimum Set of Standardized Patient-centered Outcome Measures for Macular Degeneration. American journal of ophthalmology Rodrigues, I. A., Sprinkhuizen, S. M., Barthelmes, D., Blumenkranz, M., Cheung, G., Haller, J., Johnston, R., Kim, R., Klaver, C., McKibbin, M., Ngah, N. F., Pershing, S., Shankar, D., Tamura, H., Tufail, A., Weng, C. Y., Westborg, I., Yelf, C., Yoshimura, N., Gillies, M. C. 2016; 168: 1-12

  Abstract

  To define a minimum set of outcome measures for tracking, comparing, and improving macular degeneration care.Recommendations from working-group of international experts in macular degeneration outcomes registry development and patient advocates, facilitated by the International Consortium for Health Outcomes Measurement (ICHOM).Modified Delphi technique, supported by structured teleconferences, followed by online-surveys to drive consensus decisions. Potential outcomes were identified through literature review of outcomes collected in existing registries and reported in major clinical trials. Outcomes were refined by the working-group and selected based upon impact on patients, relationship to good clinical care and feasibility of measurement in routine clinical practice.Standardized measurement of the following outcomes is recommended: visual functioning and quality of life (distance visual acuity, mobility and independence, emotional well-being, reading and accessing information); number of treatments; complications of treatment; and disease-control. Proposed data-collection sources include administrative, clinical data during routine clinical visits and patient-reported sources annually. Recording the following clinical characteristics is recommended to enable risk-adjustment: age; gender; ethnicity; smoking status; baseline visual acuity in both eyes; type of macular degeneration; presence of geographic atrophy, subretinal fibrosis or pigment epithelial detachment; previous macular degeneration treatment; ocular co-morbidities.The recommended minimum outcomes and pragmatic reporting standards should enable standardized, meaningful assessments and comparisons of macular degeneration treatment outcomes. Adoption could accelerate global improvements in standardized data-gathering and reporting of patient-centered outcomes. This can facilitate informed decisions by patients and health care providers, plus allow long-term monitoring of aggregate data, ultimately improving understanding of disease progression and treatment responses.

  View details for DOI 10.1016/j.ajo.2016.04.012

  View details for PubMedID 27131774

• Predictive modeling of risk factors and complications of cataract surgery. European journal of ophthalmology Gaskin, G. L., Pershing, S., Cole, T. S., Shah, N. H. 2016; 26 (4): 328-337

  Abstract

  Cataract surgery is generally safe; however, severe complications exist. Preexisting conditions are known to predispose patients to intraoperative and postoperative complications. This study quantifies the relationship between aggregated preoperative risk factors and cataract surgery complications, and builds a model predicting outcomes on an individual level, given a constellation of patient characteristics.This study utilized a retrospective cohort of patients age 40 years or older who received cataract surgery. Risk factors, complications, and demographic information were extracted from the Electronic Health Record based on International Classification of Diseases, 9th edition codes, Current Procedural Terminology codes, drug prescription information, and text data mining. We used a bootstrapped least absolute shrinkage and selection operator model to identify highly associated variables. We built random forest classifiers for each complication to create predictive models.Our data corroborated existing literature, including the association of intraoperative complications, complex cataract surgery, black race, and/or prior eye surgery with increased risk of any postoperative complications. We also found other, less well-described risk factors, including diabetes mellitus, young age (<60 years), and hyperopia, as risk factors for complex cataract surgery and intraoperative and postoperative complications. Our predictive models outperformed existing published models.The aggregated risk factors and complications described here can guide new avenues of research and provide specific, personalized risk assessment for a patient considering cataract surgery. Furthermore, the predictive capacity of our models can enable risk stratification of patients, which has utility as a teaching tool as well as informing quality/value-based reimbursements.

  View details for DOI 10.5301/ejo.5000706

  View details for PubMedID 26692059

  View details for PubMedCentralID PMC4930873

• Physician Utilization Patterns for VEGF-Inhibitor Drugs in the 2012 United States Medicare Population: Bevacizumab, Ranibizumab, and Aflibercept OPHTHALMIC SURGERY LASERS & IMAGING RETINA Baisiwala, S., Bundorf, M. K., Pershing, S. 2016; 47 (6): 555-562

  Abstract

  To evaluate variation in physician use of vascular endothelial growth factor (VEGF) inhibitors.Population-based analysis of comprehensive, publicly available 2012 Medicare claims, aggregated by physician specialty and service type - including intravitreal injections of bevacizumab (Avastin; Genentech, South San Francisco, CA), ranibizumab (Lucentis; Genetech, South San Francisco, CA), and aflibercept (Eylea; Regeneron, Tarrytown, NY). Physicians were characterized by total patients treated, proportion treated with each drug, total intravitreal injection payments, and proportion of total payments for each drug.The authors identified 2,869 ophthalmologists. On average, each treated 203 patients with VEGF-inhibitors, 75.9% of which were treated with bevacizumab. Using all three agents was the most common practice (1,121 physicians), closely followed by using bevacizumab only (1,061 physicians). Ranibizumab accounted for most payments, but bevacizumab was the largest payment source for a sizeable proportion of physicians who used only/mostly bevacizumab.Most ophthalmologists use multiple VEGF inhibitors, but vary in their relative use. A subset of ophthalmologists predominantly use ranibizumab, but ophthalmologists overall use more bevacizumab despite financial incentives favoring ranibizumab. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:555-562.].

  View details for DOI 10.3928/23258160-20160601-07

  View details for Web of Science ID 000393095900008

  View details for PubMedID 27327285

• Supply and Perceived Demand for Teleophthalmology in Triage and Consultations in California Emergency Departments JAMA OPHTHALMOLOGY Wedekind, L., Sainani, K., Pershing, S. 2016; 134 (5): 537-543

  View details for DOI 10.1001/jamaophthalmol.2016.0316

  View details for Web of Science ID 000375796100016

• Supply and Perceived Demand for Teleophthalmology in Triage and Consultations in California Emergency Departments. JAMA ophthalmology Wedekind, L. n., Sainani, K. n., Pershing, S. n. 2016

  Abstract

  Determining the perceived supply and potential demand for teleophthalmology in emergency departments could help mitigate coverage gaps in emergency ophthalmic care.To evaluate the perceived current need for and availability of ophthalmologist coverage in California emergency departments and the potential effect of telemedicine for ophthalmology triage and consultation.Surveys were remotely administered to 187 of the 254 emergency departments throughout California via the telephone and Internet from June 30 to September 23, 2014. Emergency department nurse managers and physicians from all emergency departments listed in the California Office of Statewide Health Planning and Development database were individually surveyed to assess facility characteristics and resources as well as the perceived usefulness of teleophthalmology consultation. Data analysis was conducted from June 30, 2014, to March 11, 2015.Perceived availability of ophthalmology consultation coverage and perceived effect of telemedicine ophthalmology consultation at each facility.Of the 187 emergency departments surveyed, 18 of 37 rural facilities (48.6%) reported availability of emergency ophthalmology coverage, compared with 112 of 150 nonrural facilities (74.7%). Rural facilities reported a mean (SD) of 23.72 (14.15) miles between the facility and referral location, while nonrural facilities reported a mean of 4.41 (10.23) miles (19.3% difference). On a scale of 1 to 5 (where 1 signifies very low value and 5 signifies very high value), 124 of 187 nurse managers (66.3%) and 80 of 121 physicians (66.1%) rated teleophthalmology as having high or very high value for triage purposes. The most frequently cited potential advantage of emergency teleophthalmology was assistance in patient triage and immediate real-time electronic communication, and the most frequently cited potential disadvantages were unknown cost of contracting and maintenance and concern that eye trauma might make photographs or videos less conclusive.Availability of ophthalmology coverage for emergency eye care is limited, particularly among rural emergency departments in California. Surveyed emergency department nurse managers and physicians indicated moderately high interest and perceived value for a teleophthalmology solution for remote triage and consultation. Overall, the study suggests that teleophthalmology could play a role in mitigating coverage gaps in emergency ophthalmic care and could be further investigated through similar studies in other regions.

  View details for PubMedID 27010537

• A Proposed Minimum Standard Set of Outcome Measures for Cataract Surgery. JAMA ophthalmology Mahmud, I., Kelley, T., Stowell, C., Haripriya, A., Boman, A., Kossler, I., Morlet, N., Pershing, S., Pesudovs, K., Goh, P. P., Sparrow, J. M., Lundström, M. 2015; 133 (11): 1247-1252

  View details for DOI 10.1001/jamaophthalmol.2015.2810

  View details for PubMedID 26291752

• Reply: To PMID 25486541. American journal of ophthalmology Pershing, S., Vaziri, K., Albini, T. A., Moshfeghi, D. M., Moshfeghi, A. A. 2015; 160 (2): 392-?

  View details for DOI 10.1016/j.ajo.2015.04.037

  View details for PubMedID 26187878

• Risk factors predictive of endogenous endophthalmitis among hospitalized patients with hematogenous infections in the united states. American journal of ophthalmology Vaziri, K., Pershing, S., Albini, T. A., Moshfeghi, D. M., Moshfeghi, A. A. 2015; 159 (3): 498-504

  Abstract

  To identify potential risk factors associated with endogenous endophthalmitis among hospitalized patients with hematogenous infections.Retrospective cross-sectional study.MarketScan Commercial Claims and Encounters, and Medicare Supplemental and Coordination of Benefit inpatient databases from the years 2007-2011 were obtained. Utilizing ICD-9 codes, logistic regression was used to identify potential predictors/comorbidities for developing endophthalmitis in patients with hematogenous infections.Among inpatients with hematogenous infections, the overall incidence rate of presumed endogenous endophthalmitis was 0.05%-0.4% among patients with fungemia and 0.04% among patients with bacteremia. Comorbid human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS) (OR = 4.27; CI, 1.55-11.8; P = .005), tuberculosis (OR = 8.5; CI, 1.2-61.5; P = .03), endocarditis (OR = 8.3; CI, 4.9-13.9; P < .0001), bacterial meningitis (OR = 3.8; CI, 1.2-12.0; P = .023), fungal meningitis (OR = 59.1; CI, 14.1-247.8; P < .0001), internal organ abscess (OR = 2.9; CI, 1.2-6.4; P = .02), lymphoma/leukemia (OR = 2.9; CI, 1.6-5.3; P < .0001), skin abscess/cellulitis (OR = 1.75; CI, 1.1-2.8; P = .02), pyogenic arthritis (OR = 4.2; CI, 1.8-9.6; P = .001), diabetes with ophthalmic manifestations (OR = 7.0; CI, 1.7-28.3; P = .006), and urinary tract infection (OR = 0.04; CI, 0.3-0.9; P = .023) were each significantly associated with a diagnosis of endogenous endophthalmitis. Patients aged 0-17 years (OR = 2.61; CI, 1.2-5.7; P = .02), 45-54 years (OR = 3.4; CI, 2.0-5.4; P < .0001), and 55-64 years (OR = 2.9; CI, 1.8-4.8; P < .0001); those having length of stay of 3-10 days (OR = 1.9; CI, 1.1-3.3; P = .01), 11-30 days (OR = 3.1; CI, 1.8-5.5; P < .0001), and 31+ days (OR = 5.3; CI, 2.7-10.4; P < .0001); and those with intensive care unit/neonatal intensive care unit (ICU/NICU) admissions (OR = 1.5; CI, 1.4-1.6; P < .0001) were all more likely to be diagnosed with endogenous endophthalmitis.Endogenous endophthalmitis is rare among hospitalized patients in the United States. Among patients with hematogenous infections, odds of endogenous endophthalmitis were higher for children and middle-aged patients, and for patients with endocarditis, bacterial meningitis, lymphoma/leukemia, HIV/AIDS, internal organ abscess, diabetes with ophthalmic manifestations, skin cellulitis/abscess, pyogenic arthritis, tuberculosis, longer hospital stays, and/or ICU/NICU admission.

  View details for DOI 10.1016/j.ajo.2014.11.032

  View details for PubMedID 25486541

• Treating age-related macular degeneration: comparing the use of two drugs among medicare and veterans affairs populations. Health affairs Pershing, S., Pal Chee, C., Asch, S. M., Baker, L. C., Boothroyd, D., Wagner, T. H., Bundorf, M. K. 2015; 34 (2): 229-238

  Abstract

  While new biologics have revolutionized the treatment of age-related macular degeneration-the leading cause of severe vision loss among older adults-these new drugs have also raised concerns over the economic impact of medical innovation. The two leading agents are similar in effectiveness but vary greatly in price-up to $2,000 per injection for ranibizumab compared to $50 for bevacizumab. We examined the diffusion of these drugs in fee-for-service Medicare and Veterans Affairs (VA) systems during 2005-11, in part to assess the impact that differing financial incentives had on prescribing. Physicians treating Medicare patients have a direct financial incentive to prescribe the more expensive agent (ranibizumab), while VA physicians do not. Medicare injections of the more expensive ranibizumab peaked in 2007 at 47 percent. Beginning in 2009 the less expensive bevacizumab became the predominant therapy for Medicare patients, accounting for more than 60 percent of injections. For VA patients, the distribution of injections across the two drugs was relatively equal, particularly from 2009 to 2011. Our analysis indicates that there are opportunities in both the VA and Medicare to adopt more value-conscious treatment patterns and that multiple mechanisms exist to influence utilization.

  View details for DOI 10.1377/hlthaff.2014.1032

  View details for PubMedID 25646102

• Treating age-related macular degeneration: comparing the use of two drugs among medicare and veterans affairs populations. Health affairs Pershing, S., Pal Chee, C., Asch, S. M., Baker, L. C., Boothroyd, D., Wagner, T. H., Bundorf, M. K. 2015; 34 (2): 229-238

  View details for DOI 10.1377/hlthaff.2014.1032

  View details for PubMedID 25646102

• Clinical-Pathologic Correlation: Vitrectomy With Epiretinal and Internal Limiting Membrane Peel OPHTHALMIC SURGERY LASERS & IMAGING RETINA Demarchis, E. H., Pershing, S., Moshfeghi, D. M. 2014; 45 (3): 218-221

  Abstract

  To correlate clinical and pathologic findings in vitreoretinal surgeries with epiretinal membrane (ERM) and internal limiting membrane (ILM) peels.A retrospective review of the clinical and pathologic reports for 698 vitrectomy specimens involving ERM and/or ILM peels from 2008 to 2012.Labeling with clear operative clinical diagnoses - ERM, ILM or both - was available for 520 of 698 cases; 492 cases had a corresponding pathology result. Combined ERM-ILM specimens were the dominant clinical and pathologic diagnosis. Over 43% had differing operative and pathologic diagnoses, with 79.6% of cases labeled as ERMs, 75.0% of cases labeled as ILMs, and 22.1% cases labeled as ERM-ILM demonstrating incongruous specimens on pathology.It can be difficult to determine the nature of membranes pre- or intraoperatively. Combined ERM-ILM specimens may be more common than previously recognized, implying that the two membranes are not always distinct and surgically separable. [Ophthalmic Surg Lasers Imaging Retina. 2014;45:218-221.].

  View details for DOI 10.3928/23258160-20140411-01

  View details for Web of Science ID 000338322300006

• Cost-Effectiveness of Treatment of Diabetic Macular Edema ANNALS OF INTERNAL MEDICINE Pershing, S., Enns, E. A., Matesic, B., Owens, D. K., Goldhaber-Fiebert, J. D. 2014; 160 (1): 18-?

  Abstract

  Macular edema is the most common cause of vision loss among patients with diabetes.To determine the cost-effectiveness of different treatments of diabetic macular edema (DME).Markov model.Published literature and expert opinion.Patients with clinically significant DME.Lifetime.Societal.Laser treatment, intraocular injections of triamcinolone or a vascular endothelial growth factor (VEGF) inhibitor, or a combination of both.Discounted costs, gains in quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs).All treatments except laser monotherapy substantially reduced costs, and all treatments except triamcinolone monotherapy increased QALYs. Laser treatment plus a VEGF inhibitor achieved the greatest benefit, gaining 0.56 QALYs at a cost of $6975 for an ICER of $12 410 per QALY compared with laser treatment plus triamcinolone. Monotherapy with a VEGF inhibitor achieved similar outcomes to combination therapy with laser treatment plus a VEGF inhibitor. Laser monotherapy and triamcinolone monotherapy were less effective and more costly than combination therapy.VEGF inhibitor monotherapy was sometimes preferred over laser treatment plus a VEGF inhibitor, depending on the reduction in quality of life with loss of visual acuity. When the VEGF inhibitor bevacizumab was as effective as ranibizumab, it was preferable because of its lower cost.Long-term outcome data for treated and untreated diseases are limited.The most effective treatment of DME is VEGF inhibitor injections with or without laser treatment. This therapy compares favorably with cost-effective interventions for other conditions.Agency for Healthcare Research and Quality.

  View details for Web of Science ID 000330249700003

  View details for PubMedCentralID PMC4020006

• Restructuring medical education to meet current and future health care needs. Academic medicine Pershing, S., Fuchs, V. R. 2013; 88 (12): 1798-1801

  Abstract

  U.S. health care is changing, and it will continue to change across multiple dimensions: a different mix of patients; more ambulatory, chronic care and less acute, inpatient care; an older population; expanded insurance coverage; a team approach to care; rapid growth of subspecialty care; growing emphasis on cost-effective care; and rapid technological change. These changes demand a corresponding evolution in physician roles and training. However, despite innovation in content and teaching methods, there has been little alteration to the basic structure of medical education since the Flexner Report sparked widespread reform in 1910. Looking to the future, medical education might evolve to include preparation for a team approach to care via practical training for multispecialty collaborative practice and preparing physicians to be leaders of primary care teams that include nonphysician providers; shorter training for some physicians via flexible pathways and "fast tracks" at each phase of training; cost-effective care in clinical practice; increased training in geriatrics; and "on ramps" and "off ramps" along the physician career path for flexible training over a lifetime. Although the challenges facing the health care system are great, meeting changing health care needs must begin at the foundation, in medical education.

  View details for DOI 10.1097/ACM.0000000000000020

  View details for PubMedID 24128642

• Ocular hypertension and intraocular pressure asymmetry after intravitreal injection of anti-vascular endothelial growth factor agents. Ophthalmic surgery, lasers & imaging retina Pershing, S., Bakri, S. J., Moshfeghi, D. M. 2013; 44 (5): 460-464

  Abstract

  To evaluate elevated intraocular pressure (IOP) after intravitreal injections of vascular endothelial growth factor (VEGF) inhibitors and contribute toward the recognition and understanding of its mechanisms, pattern, and treatment.Retrospective case series of VEGF-inhibitor injections at two academic centers (Stanford University and Mayo Clinic) over 4 years. Cases were evaluated for IOP elevation (≥ 24 mm Hg) or asymmetry (≥ 3 mm Hg IOP difference between eyes on three visits).Twenty-one eyes were identified with pathologically elevated IOP after treatment. Most had delayed-onset (average: 15 months after treatment, after 10 injections) elevation. IOP-lowering therapy was required in 81%. More consecutive visits with IOP asymmetry occurred in patients developing ocular hypertension (11.1% pre-diagnosis vs 66.7% post-diagnosis; OR = 9.00, P = .003).Elevated IOP may occur after ranibizumab or bevacizumab injections, often exhibiting a delayed and perhaps cumulative effect. The authors found significant bilateral IOP asymmetry in patients developing unilateral glaucoma after VEGF-inhibitor injections, a potential early indicator or proxy for pathologic IOP elevation. [Ophthalmic Surg Lasers Imaging Retina. 2013;44:460-464.].

  View details for DOI 10.3928/23258160-20130909-07

  View details for PubMedID 24044708

• Trends in ophthalmic manifestations of methicillin-resistant Staphylococcus aureus (MRSA) in a northern California pediatric population 40th Annual Fall Meeting of the American-Society-of-Ophthalmic-Plastic-and-Reconstructive-Surgery Amato, M., Pershing, S., Walvick, M., Tanaka, S. MOSBY-ELSEVIER. 2013: 243–47

  Abstract

  To determine pediatric clinical trends of ocular and periocular methicillin-resistant Staphylococcus aureus (MRSA) in a large northern California healthcare system.This study was a retrospective cross-sectional review of all pediatric cases (aged 0-18) with culture-positive ophthalmic MRSA isolates identified between January 2002 and December 2009. Medical record review included history, presentation, infection site, acquisition (community or nosocomial), antibiotic sensitivity/resistance, treatment, and clinical outcome. Incidence was classified by year, sex, and age. Parameters were analyzed for statistical significance by trend and χ(2) analysis.A total of 399 ocular and periocular MRSA cases were included. Cases trended upward from 2002 to 2009, peaking in 2006. Of the 137 pediatric cases (0-18 years), 58% were community acquired. Conjunctivitis was the predominant presentation (40%), followed by stye/chalazion (25%), orbital cellulitis/abscess (19%), dacryocystitis (11%) and brow abscess (3%). Significant predictors for ocular infection with MRSA included male sex (61%), neonates (38%), and multiple infection sites on the body (38%). Resistance was high to bacitracin (80.9%) and ofloxacin (48.3%) but remained low for trimethoprim/sulfamethoxazole (8.7%). Topical therapy was effective in 29% of cases; oral antibiotics, in 47%. Intravenous therapy was required in 12% of cases and incision/drainage or surgery in 19%. Initial oral antibiotic treatment, primarily cephalosporins (24%), was ineffective in 37% of patients. There was a significant increase in resistance to antibiotic therapy (P < 0.001) during the study period. No patients developed permanent visual impairment.Pediatric ocular and periocular MRSA is increasing in incidence and resistance in our patient population. Outcomes can be improved by early recognition, proper antibiotic selection, and obtaining cultures and sensitivities when resistant or severe ocular infections are present.

  View details for DOI 10.1016/j.jaapos.2012.12.151

  View details for Web of Science ID 000321224900004

  View details for PubMedID 23623773

• The importance of keeping a broad differential in retina clinic: the spectrum of ophthalmic disease seen by retina specialists in a tertiary outpatient clinic setting. Ophthalmic surgery, lasers & imaging retina Fijalkowski, N., Pershing, S., Moshfeghi, D. M. 2013; 44 (2): 133-139

  Abstract

  To describe the new patient population referred to retina specialists at tertiary ophthalmic academic centers in the United States.Retrospective chart review of all new patients seen by retina specialists at Stanford University from 2008 to 2011.Retina specialists saw 7,197 new patients during the study period, with a mean age of 52.2 ± 25.6 years (range: 0 to 108 years). Younger patients (0 to 10 years) were more likely male (P < .001) while older patients were more likely female (P < .01 for 61 to 70, 81+ years). The most common diagnoses were diabetic eye disease (17.0%), retinopathy of prematurity (9.9%) and age-related macular degeneration (9.5%).Retina specialists treat patients of all ages, and the most common diagnoses vary with age and gender. Patients present to retinal clinic with a vast spectrum of disease from various ophthalmic and systemic etiologies; therefore, it is important to maintain a broad differential diagnosis.

  View details for DOI 10.3928/23258160-20130313-06

  View details for PubMedID 23510039

• Phacoemulsification versus extracapsular cataract extraction: where do we stand? CURRENT OPINION IN OPHTHALMOLOGY Pershing, S., Kumar, A. 2011; 22 (1): 37-42

  Abstract

  Cataract surgery at present is divisible into two general techniques: manual extracapsular cataract extraction and phacoemulsification--with ECCE further separated into the traditional form and small-incision cataract surgery. This review will discuss updates in surgical techniques, outcome comparisons, cost analysis, and the continued role of extracapsular cataract extraction in Western countries.Surgical techniques for manual extracapsular cataract extraction have undergone much refinement, with numerous descriptions of techniques in a recent literature. Studies that have emerged in the last several years allow us to compare surgical results between different techniques and suggest that there is little difference in final outcome when each surgery is done well. Overall cost-effectiveness and suitability of each technique vary based on location and facilities.Manual extracapsular cataract extraction (especially small-incision versions) occupies an important place in modern cataract surgery, and, while not a replacement for phacoemulsification in Western countries, should be part of a cataract surgeon's overall skill set.

  View details for DOI 10.1097/ICU.0b013e3283414fb3

  View details for Web of Science ID 000285135500009

  View details for PubMedID 21088578

• Cytomegalovirus Infection with MRI Signal Abnormalities Affecting the Optic Nerves, Optic Chiasm, and Optic Tracts JOURNAL OF NEURO-OPHTHALMOLOGY Pershing, S., Dunn, J., Khan, A., Liao, Y. J. 2009; 29 (3): 223-226

  Abstract

  A 49-year-old woman who had been immunosuppressed after a renal transplant developed bilateral severe visual loss. Visual acuities were finger counting and hand movements in the two eyes. Both optic nerves were pale. There were no other ophthalmic abnormalities. Brain MRI disclosed marked signal abnormalities involving the optic nerves, optic chiasm, and optic tracts. Cerebrospinal fluid polymerase chain reaction (PCR) was positive for cytomegalovirus. Treatment did not restore vision. Such extensive clinical and imaging involvement of the anterior visual pathway, which has been previously reported with other herpes viruses, illustrates the propensity for this family of viruses to track along axons.

  View details for Web of Science ID 000270048700011

  View details for PubMedID 19726946

• Comparison of anterior vitrectorhexis and continuous curvilinear capsulorhexis in pediatric cataract and intraocular lens implantation. surgery: A 10-year analysis JOURNAL OF AAPOS Wilson, M. E., Trivedi, R. H., Bartholomew, L. R., Pershing, S. 2007; 11 (5): 443-446

  Abstract

  To analyze the rate of inadvertent anterior lens capsular tears with vitrectorhexis or continuous curvilinear capsulorhexis (CCC) in pediatric cataract and intraocular lens (IOL) implantation surgery between January 1, 1997, and December 31, 2006.Retrospective chart review, collecting for each eye: age at cataract surgery, type of anterior capsulotomy, any tearing of the capsule, and if yes, details of the tear.A total of 737 eyes were reviewed. Cases with a ruptured lens capsule that occurred prior to surgery were excluded. Eyes that received an anterior capsulotomy by any other method (n = 27) or eyes that did not receive an IOL (n = 100) were reviewed but excluded from final comparative analysis. Of the remaining 339 eyes, 19 eyes (5.6%) were noted to develop an anterior capsule tear (vitrectorhexis, 12 of 226 eyes, 5.3%; CCC, 7 of 113, 6.2%). These tears occurred during anterior capsulotomy in seven eyes, hydrodissection in one, cataract removal in three, and IOL insertion/manipulation in eight. In eyes operated for cataract at or before 72 months of age, the manual CCC technique was more likely to develop a tear (relative risk, 3.09) compared with eyes of older children (>72 months of age), where the vitrectorhexis technique was more likely to develop a tear (relative risk, 3.14).Vitrectorhexis is well suited for use in children less than 6 years of age due to their highly elastic anterior lens capsule. For children aged 6 years and older, manual CCC is the best technique because, by that age, capsule control and ease of capsulotomy completion has improved.

  View details for DOI 10.1016/j.jaapos.2007.03.012

  View details for Web of Science ID 000250386400006

  View details for PubMedID 17532240