Dr. Pershing is on the ophthalmology faculty at Stanford University School of Medicine, with an academic career blending clinical practice, teaching, research, and administration. She serves as Program Director for the Stanford University Medical Center ophthalmology residency and Chief of Ophthalmology for the VA Palo Alto Health Care System.
In her role as residency program director, she is excited to innovate and implement novel approaches to residency education—such as establishing the 4-year research track residency program (SOAR), opportunities for resident elective scholarly activity, and efforts to develop a valuable internship program for incoming ophthalmology residents at Stanford.
Her research interests focus on improved utilization of big data, biomedical informatics techniques, and evidence-based medicine to study outcomes, health care utilization, disease progression, and cost-effectiveness of ophthalmic treatment. Dr. Pershing is active in big data initiatives and analysis, including collaborative projects at Stanford and serving as site PI for the American Academy of Ophthalmology (AAO) IRIS Registry analytic group at Stanford. She also serves as the AAO representative to the American Board of Medical Specialties task force on Information and Data Sharing, focusing on collaboration among specialty boards and societies to use data sources such as national clinical registries to facilitate improved quality of care, continuing certification, and practice and outcomes assessments. Dr. Pershing is also is involved in health policy efforts, including helping to develop CMS episode-based cost measures for MIPS, and is interested in health care innovation—technology, quality, and delivery systems.
Dr. Pershing serves on the national board of directors of the Alpha Omega Alpha medical honor society, with focus on resident and faculty development initiatives, and mentors both medical students and undergraduate students.
Ophthalmology Residency Program Director, Stanford University Medical Center (2018 - Present)
Chief, Ophthalmology and Eye Care Services, VA Palo Alto Health Care System (2013 - Present)
Honors & Awards
Stanford Faculty Teaching Award, Stanford Department of Ophthalmology (2014)
Presidents Clinical Science Award, Medical University of South Carolina (2006)
American Medical Womens Association Glasgow-Rubin Certificate of Commendation, Medical University of South Carolina (2006)
Merck Award for Academic Excellence, Medical University of South Carolina (2006)
Elected Member, Alpha Omega Alpha Medical Honor Society (2004)
Boards, Advisory Committees, Professional Organizations
Board of Directors, Alpha Omega Alpha National Medical Honor Society (2009 - Present)
Working Group and Task Force, American Academy of Ophthalmology IRIS Clinical Data Registry (2012 - 2017)
Working Group, Cataract Surgery and Macular Degeneration, International Consortium for Health Outcomes Measurement (2013 - 2016)
Internship:Scripps Mercy Hospital Transitional Internship (2007) CA
Fellowship:Stanford University Ophthalmology ResidencyCA
Residency:Stanford University Ophthalmology Residency (2010) CA
Medical Education:Medical University of South Carolina (2006) SC
Board Certification: Ophthalmology, American Board of Ophthalmology (2012)
Fellowship, Stanford University - Health Policy and Health Services Research and Health Policy, CA (2013)
Independent Studies (7)
- Directed Reading in Health Research and Policy
HRP 299 (Aut, Win, Spr, Sum)
- Directed Reading in Ophthalmology
OPHT 299 (Aut, Win, Spr)
- Early Clinical Experience in Ophthalmology
OPHT 280 (Aut, Win, Spr)
- Graduate Research
HRP 399 (Aut, Win, Spr, Sum)
- Graduate Research
OPHT 399 (Aut, Win, Spr)
- Medical Scholars Research
OPHT 370 (Aut, Win, Spr, Sum)
- Undergraduate Research
OPHT 199 (Aut, Win, Spr)
- Directed Reading in Health Research and Policy
Med Scholar Project Advisor
Graduate and Fellowship Programs
Use of Bevacizumab and Ranibizumab for Wet Age-Related Macular Degeneration: Influence of CATT Results and Introduction of Aflibercept.
American journal of ophthalmology
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
- Differences in Cataract Surgery Rates Based on Dementia Status JOURNAL OF ALZHEIMERS DISEASE 2019; 69 (2): 423–32
Association of Vision Loss With Cognition in Older Adults
2017; 135 (9): 963–70
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
Self-Reported Receipt of Dilated Fundus Exams among Patients with Diabetes: Medicare Expenditure Panel Survey, 2002-2013.
American journal of ophthalmology
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
Cataract Surgery Complications and Revisit Rates Among Three States
AMERICAN JOURNAL OF OPHTHALMOLOGY
2016; 171: 130-138
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.
2016; 123 (9): 2037-2041
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
2016; 168: 1-12
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
2016; 26 (4): 328-337
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
2016; 47 (6): 555-562
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 2016; 134 (5): 537-543
Supply and Perceived Demand for Teleophthalmology in Triage and Consultations in California Emergency Departments.
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 2015; 133 (11): 1247-1252
Risk factors predictive of endogenous endophthalmitis among hospitalized patients with hematogenous infections in the united states.
American journal of ophthalmology
2015; 159 (3): 498-504
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.
2015; 34 (2): 229-238
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 2015; 34 (2): 229-238
Cost-Effectiveness of Treatment of Diabetic Macular Edema
ANNALS OF INTERNAL MEDICINE
2014; 160 (1): 18-?
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.
2013; 88 (12): 1798-1801
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
Phacoemulsification versus extracapsular cataract extraction: where do we stand?
CURRENT OPINION IN OPHTHALMOLOGY
2011; 22 (1): 37-42
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
Risk factors for incident central serous retinopathy: case-control analysis of a US national managed care population.
The British journal of ophthalmology
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
The Relative Impact of Patient, Physician, and Geographic Factors on Variation in Primary Rhegmatogenous Retinal Detachment Management.
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
Understanding Patient Attitudes Toward Multifocal Intraocular Lenses in Online Medical Forums Through Sentiment Analysis.
Studies in health technology and informatics
2019; 264: 1378–82
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
Choice of Primary Rhegmatogenous Retinal Detachment Repair Method in US Commercially-insured and Medicare Advantage Patients, 2003-2016.
American journal of ophthalmology
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
2017; 182: 133–40
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
Trends in Hospitalization and Incidence Rate for Syphilitic Uveitis in the United States from 1998-2009.
American journal of ophthalmology
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
Determining the Value of Home Monitoring of Patients With Age-Related Macular Degeneration.
2017; 135 (5): 459–60
View details for PubMedID 28358963
- Reply: To PMID 25486541. American journal of ophthalmology 2015; 160 (2): 392-?
Clinical-Pathologic Correlation: Vitrectomy With Epiretinal and Internal Limiting Membrane Peel
OPHTHALMIC SURGERY LASERS & IMAGING RETINA
2014; 45 (3): 218-221
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
Ocular hypertension and intraocular pressure asymmetry after intravitreal injection of anti-vascular endothelial growth factor agents.
Ophthalmic surgery, lasers & imaging retina
2013; 44 (5): 460-464
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
MOSBY-ELSEVIER. 2013: 243–47
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
2013; 44 (2): 133-139
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
Cytomegalovirus Infection with MRI Signal Abnormalities Affecting the Optic Nerves, Optic Chiasm, and Optic Tracts
JOURNAL OF NEURO-OPHTHALMOLOGY
2009; 29 (3): 223-226
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
2007; 11 (5): 443-446
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