Maria Woodward - Academia.edu (original) (raw)
Papers by Maria Woodward
Cornea, 2021
PURPOSE The purpose of this study was to characterize rates of opioid prescription for different ... more PURPOSE The purpose of this study was to characterize rates of opioid prescription for different ulcerative keratitis types. METHODS This cohort study included patients diagnosed with ulcerative keratitis according to the University of Michigan electronic health record data between September 1, 2014 and December 22, 2020. Ulcerative keratitis was categorized by etiologic type (bacterial, fungal, viral, acanthamoeba, inflammatory, polymicrobial, or unspecified) using rule-based data classification that accounted for billing diagnosis code, antimicrobial or antiinflammatory medications prescribed, laboratory results, and manual chart review. Opioid prescriptions were converted to morphine milligram equivalent and summed over 90 days from diagnosis. Opioid prescription rate and amount were compared between ulcerative keratitis types. RESULTS Of 3322 patients with ulcerative keratitis, 173 (5.2%) were prescribed at least 1 opioid for pain management within 90 days of diagnosis. More patients with acanthamoeba (32.4%), fungal (21.1%), and polymicrobial (25.0%) keratitis were treated with opioids compared with bacterial (6.7%), unspecified (2.9%), or viral (1.8%) keratitis (all Bonferroni adjusted P < 0.05). For the 173 patients who were prescribed opioids, a total of 353 prescriptions were given within 90 days of diagnosis, with half given within the first week after diagnosis. The quantity of opioid prescribed within 90 days from diagnosis was not significantly different between ulcerative keratitis types (P = 0.6559). Morphine milligram equivalent units prescribed ranged from 97.5 for acanthamoeba keratitis to 112.5 for fungal keratitis. CONCLUSIONS The type of ulcerative keratitis may influence the opioid prescription rate. Providers can better serve patients needing opioids for pain management through improved characterization of pain and development of more tailored pain management regimens.
Ophthalmology, 2021
This study quantifies the performance of an international cohort of cornea specialists in image-b... more This study quantifies the performance of an international cohort of cornea specialists in image-based differentiation of bacterial and fungal keratitis, identifying significant regional variation and establishing a reference standard for comparison against machine learning models.
Cornea, 2020
PURPOSE To investigate the burden of procedures, visits, and procedure costs in the management of... more PURPOSE To investigate the burden of procedures, visits, and procedure costs in the management of microbial keratitis (MK). METHODS Medical records of patients from an academic hospital outpatient facility between December 2013 and May 2018 were retrospectively reviewed. Patients were included if they were older than the age of 18 years, recruited for study of likely MK, and not concurrently undergoing treatment for other acute eye conditions. For procedural costs, Medicare data for billing were obtained using the Center for Medicare and Medicaid Services Physician Fee Lookup tool. RESULTS A total of 68 patients were included for analysis. Patients were on average 51.3 years (SD = 19.5), 55.9% women (n = 38), and 89.7% White (n = 61). Per person, the average number of procedures was 2.9 (SD = 4.2). The average number of visits was 13.9 (SD = 9.2) over an average of 26.9 weeks (SD = 24.3). Age (P < 0.0001), positive Gram stain (P = 0.03), and mixed Gram stain (P = 0.002) were positively associated with the number of procedures. Age (P = 0.0003), fungal keratitis (P = 0.02), and mixed Gram stain (P = 0.01) were positively associated with the number of visits. Race was inversely associated with the number of procedures (P = 0.045) and visits (0.03). Patients with bacterial keratitis were more likely to have amniotic membrane grafts (P = 0.01) and tarsorrhaphies (P = 0.03) than fungal patients. Across all procedures performed for the management of MK, the mean cost per patient was 1788.7(SD=1788.7 (SD = 1788.7(SD=3324.62). CONCLUSIONS Patients incur many procedural costs and attend many visits during the management of MK. These findings emphasize the importance of patient-provider communication for frequent follow-up care and the potential need to perform procedures for disease management.
Cornea, 2021
PURPOSE To characterize vision-related quality of life after penetrating keratoplasty (PKP), deep... more PURPOSE To characterize vision-related quality of life after penetrating keratoplasty (PKP), deep anterior lamellar keratoplasty (DALK), Descemet stripping automated endothelial keratoplasty (DSAEK), and Descemet membrane endothelial keratoplasty (DMEK) using the National Eye Institute Visual Function Questionnaire (NEI-VFQ 9). METHODS Using the Sight Outcomes Research Collaborative ophthalmology electronic health record repository, questionnaire responses were obtained from 103 PKP patients, 24 DALK patients, 42 DSAEK patients, and 50 DMEK patients undergoing postoperative examination. No exclusions were made based on preoperative diagnosis, age, complications, or comorbidities. Associations between clinical characteristics and vision-related quality of life were analyzed using nonparametric and linear regression methods. RESULTS Patients were surveyed an average of 1.5 years postoperatively (range 24 d to 4.4 yrs). Participants who had undergone DALK, DMEK, DSAEK, and PKP had median composite VFQ scores of 77.8, 84.2, 76.1, and 70.6, respectively (P= 0.002). There were no significant differences in VFQ scores between patients treated with DMEK versus DSAEK (P = 0.440) or between patients treated with PKP versus DALK (P = 1.000). Higher postoperative acuities in the operative and fellow eyes were associated with higher VFQ scores (P < 0.001 and P < 0.001). When controlling for postoperative acuity by regression modeling, surgery type was not associated with patient-reported composite VFQ scores. CONCLUSIONS In this study, patient-reported vision-related quality of life was similar among DMEK and DSAEK participants and also among DALK and PKP participants. When controlling for postoperative acuity, vision-related quality of life was similar among all study participants, irrespective of the keratoplasty technique.
Cornea, 2021
Supplemental Digital Content is Available in the Text. Purpose: Medication nonadherence is a ubiq... more Supplemental Digital Content is Available in the Text. Purpose: Medication nonadherence is a ubiquitous problem. However, the adherence of patients to medications to manage corneal conditions is unknown. A prospective cohort study investigated the patterns of eye drop adherence among patients with corneal conditions. Methods: Patients older than or equal to 18 years taking prescription eye medications were recruited from an academic center's corneal clinic. Data collected included age, sex, total doses of eye medications, and category of primary corneal diagnosis. Participants completed adapted versions of the 12-question Adherence to Refills and Medications Scale (ARMS) and the 3-question Voils' Medication Adherence Scale (VMAS). Survey data were dichotomized as “adherent” and “nonadherent,” and subscales reported for reasons of nonadherence. Logistic regression analyses were used to test associations with adherence. Results: A total of 199 participants were surveyed from February to March 2019 (95% response rate). Participants were aged 19 to 93 years with a mean age of 59 years (SD 17.8). The percent of participants considered nonadherent was 72% by the ARMS and 33% by the VMAS. Older age was associated with higher adherence by the ARMS (odds ratio = 1.48, 95% confidence interval, 1.14–1.93, P = 0.004) and by the VMAS (odds ratio = 1.24, confidence interval, 1.04–1.48, P = 0.012). Adherence was not significantly associated with race, sex, education, total doses of eye medications, or primary cornea diagnosis. Conclusions: Medication adherence was lower than expected, particularly on the ARMS scale that asks more detailed questions. Clinicians should engage in conversations about adherence, especially with younger patients, if they are not seeing an expected clinical response.
Optometry and Vision Science, 2021
Supplemental digital content is available in the text. SIGNIFICANCE Uncorrected refractive error ... more Supplemental digital content is available in the text. SIGNIFICANCE Uncorrected refractive error is the main cause of visual impairment globally. Understanding barriers and facilitators underserved individuals face in obtaining eyeglasses will help address high rates of uncorrected refractive error. PURPOSE The purpose of this study was to understand the barriers and facilitators to obtaining eyeglasses among low-income patients in Michigan. METHODS Participants older than 18 years with hyperopia, myopia, or presbyopia and without active eye disease, severe mental illness, or cognitive impairment at Hope Clinic, Ypsilanti, Michigan, were included in this study. The participants answered a sociodemographic survey and underwent autorefraction and an interview. Interviews were audiorecorded, transcribed, and analyzed by two investigators. RESULTS Interviews were completed by 43 participants, and 30 participants' interviews were analyzed. The mean ± standard deviation age of 30 participants was 55 ± 12 years, 70% were female, 57% were African American, 40% had high school diploma or less, 57% earned less than U.S. $25,000 per year, 93% had worn glasses previously, and 87% had some medical insurance. Uncorrected visual acuity was logMAR 0.73 ± 0.61; best-corrected visual acuity was logMAR 0.16 ± 0.21. Thematic saturation was reached after 25 transcripts. Top barriers to using eyeglasses were cost (312 mentions, 29 participants), negative experiences with eyeglasses (263, 29), and limited access to eye care (175, 27). Top facilitators were positive experiences with glasses (230, 29), easy access to eyeglasses (143, 27), and availability of transportation (65, 27). Most participants (97%, 29) reported being negatively impacted by uncorrected refractive error. Most (97%, 29) were skeptical about obtaining eyeglasses online because of possible prescription problems. CONCLUSIONS Key barriers to correcting uncorrected refractive error in our community span across multiple health domains but are predominately rooted in external factors such as cost and access to vision care. Online eyeglasses may address access issues, but many participants were uncomfortable or unable to obtain glasses online.
Cornea, 2020
PURPOSE The aim of this investigation was to study the patient-reported outcomes of patients with... more PURPOSE The aim of this investigation was to study the patient-reported outcomes of patients with microbial keratitis (MK) using the 9-item National Eye Institute-Visual Function Questionnaire (NEI VFQ-9). METHODS Using the Sight Outcomes Research Collaborative ophthalmology electronic health record repository, patients with MK and control patients who completed the NEI VFQ-9 within 7 days of their appointment were identified. The questionnaire is scored as a mean of the 9 items on a scale from 0 to 100, with higher scores indicating better functioning. Composite and individual item scores were compared between groups using the analysis of variance. RESULTS In total, 916 questionnaires were completed from patients with acute MK (n = 84), nonacute MK (n = 30), MK with a corneal transplant (n = 21), from controls seen in a satellite comprehensive ophthalmology clinic (n = 528), and controls seen at a subspecialty ophthalmology clinic (n = 253). The mean NEI VFQ-9 composite scores per group were 66.6 (SD = 26.8), 78.1 (SD = 17.1), 58.6 (SD =21.6), 88.0 (SD = 10.2), and 83.5 (SD = 13.0), respectively (P < 0.0001). Both patients with acute MK and patients with MK requiring transplant reported significantly worse function than nonacute MK, comprehensive, and specialty patients. Patients with nonacute MK reported significantly worse function than comprehensive control patients (all Tukey-adjusted P < 0.05). DISCUSSION Patients who had or eventually require corneal transplant for management of their MK report worse visual function than patients with nonacute MK. This may be important in helping physicians counsel their patients.
JAMA Ophthalmology, 2019
Importance Opioids, which carry a high risk for addiction and overdose, are commonly prescribed a... more Importance Opioids, which carry a high risk for addiction and overdose, are commonly prescribed after corneal surgery. Data are lacking describing opioid prescribing practices and opioid needs by patients after ophthalmic surgery. Objectives To quantify opioid use and to assess the association of decreasing the number of opioid tablets prescribed after corneal surgery with postsurgical use. Design, Setting, and Participants This prospective cohort study investigated opioid use after corneal surgery using direct interviews of 2 adult patient cohorts separated by an updated opioid prescribing guideline. The first cohort survey assessed the quantity of opioid tablets used after surgery. The cornea division of a tertiary care academic medical center reviewed the use needs and decreased the number of tablets prescribed after routine cases. Simultaneously, a statewide opioid monitoring program began that provided patients with opioid information. A second unique cohort received a more detailed survey to assess use, opioid disposal, and pain control. Data for the first cohort were collected from December 1, 2017, through January 19, 2018; for the second cohort, from June 1 to September 15, 2018. Data were analyzed from October 24, 2018, through September 24, 2019. Exposure Corneal surgery. Main Outcomes and Measures Differences in use of opioid tablets used by both patient cohorts, assessed using the 2-sample t test. Results Of 112 eligible, contacted patients, 82 consented to participate (42 men [51%]; mean [SD] age, 42.5 [17.8] years) and were included in the analysis; 38 of 42 participated in the first cohort and 44 of 70 participated in the second cohort. Of those receiving opioid prescriptions, the first cohort was prescribed significantly more tablets than the second cohort (mean [SD], 18.8 [4.2] vs 6.6 [3.1]; difference, 12.2 [95% CI, 10.4-14.0]; P < .001). The first cohort used significantly more tablets than the second cohort (mean [SD], 8.3 [7.0] vs 4.0 [3.2]; difference, 4.3 [95% CI, 1.4-7.2]; P = .005) and had significantly more leftover tablets (mean [SD], 10.3 [6.9] vs 2.9 [2.7]; difference, 7.5 [95% CI, 4.7-10.2]; P < .001). In the detailed survey for the second cohort, 19 of 27 patients reported pain control as adequate (70% [95% CI, 50%-86%]); 6 of 27, as more than needed (22% [95% CI, 9%-42%]). Twenty of 28 participants (71% [95% CI, 55%-88%]) had leftover tablets; 17 of these (85% [95% CI, 62%-97%]) did not dispose of leftovers, and 3 (15% [95% CI, 3%-38%]) threw away or flushed leftovers. Conclusions and Relevance After an assessment of opioid needs, physicians prescribed fewer opioid pills. However, patients who underwent cornea surgery and received fewer tablets continued to have adequate pain control and used even fewer tablets compared with the initial cohort. Patients with unused opioid tablets did not dispose of them properly.
Cornea, 2019
Purpose: To understand medication use and patient burden for treatment of bacterial keratitis (BK... more Purpose: To understand medication use and patient burden for treatment of bacterial keratitis (BK). Methods: A retrospective study was performed examining medical records of adult patients with BK in an academic cornea practice. Data collected included medications used in the treatment of BK, dosing of medications, and the number and total duration of clinical encounters. Costs of medications were estimated using average wholesale pharmacy price. Linear regression analysis was used to investigate associations of medication use with patient demographics and corneal culture results and reported with beta estimates (β) and 95% confidence intervals (CI). Results: 48 BK patients (56% female) were studied. Patients were treated for a median of 54 days with 10 visits, five unique medications, 587 drops, and seven prescriptions. Estimated median medication cost was $933
JAMA ophthalmology, Jan 12, 2018
Medicare benefits do not include coverage for eyeglasses except after cataract surgery. Understan... more Medicare benefits do not include coverage for eyeglasses except after cataract surgery. Understanding the implications of a change to this policy would require knowing the number of Medicare beneficiaries who use eyeglasses, but no recent estimates are available. To estimate the number of older adults with Medicare who use eyeglasses. This cross-sectional study used data from the 2015 US National Health and Aging Trends Study. Nationally representative data from 7497 respondents were reviewed and sample weights were applied so that the data represented 43.9 million Medicare beneficiaries aged 65 years or older. The estimates were based on the following 4 groupings of beneficiaries: (1) number who used eyeglasses for distance vision correction and had distance vision impairment, (2) number who did not use eyeglasses for distance vision correction and had distance vision impairment, (3) number who used eyeglasses for near vision correction and had near vision impairment, and (4) numbe...
JAMA ophthalmology, 2018
Cataract-related vision impairment is an important public health issue that tends to affect older... more Cataract-related vision impairment is an important public health issue that tends to affect older adults. Little is known about the association between older adults' social support networks and their likelihood of receiving cataract surgery. To determine if older adults with smaller social support networks are less likely to receive cataract surgery. Retrospective cohort study. The National Health and Aging Trends Study, a nationally representative US survey, administered annually from 2011 to 2015 to a cohort of Medicare beneficiaries 65 years and older with no cataract surgery prior to the start of the study. Multivariable logistic regression was performed to evaluate if the number of persons in an individual's social support network influenced whether that individual received cataract surgery during a given year of the study. Overall, 3448 participants were interviewed from 2011 to 2015 for a total of 9760 observations. Of these observations, 3084 (weighted, 38.81%; 95% C...
Cornea, Jan 14, 2017
To assess variability in corneal ulcer measurements between ophthalmologists and reduce clinician... more To assess variability in corneal ulcer measurements between ophthalmologists and reduce clinician-dependent variability using semiautomated segmentation of the ulcer from photographs. Three ophthalmologists measured 50 patients' eyes for epithelial defects (EDs) and the stromal infiltrate (SI) size using slit-lamp (SL) calipers. SL photographs were obtained. An algorithm was developed for semiautomatic segmenting of the ED and SI in the photographs. Semiautomatic segmentation was repeated 3 times by different users (2 ophthalmologists and 1 trainee). Clinically significant variability was assessed with intraclass correlation coefficients (ICCs) and the percentage of pairwise measurements differing by ≥0.5 mm. Semiautomatic segmentation measurements were compared with manual delineation of the image by a corneal specialist (gold standard) using Dice similarity coefficients. Ophthalmologists' reliability in measurements by SL calipers had an ICC from 0.84 to 0.88 between exami...
Journal of Academic Ophthalmology, 2017
Background The Accreditation Council for Graduate Medical Education (ACGME) requires that ophthal... more Background The Accreditation Council for Graduate Medical Education (ACGME) requires that ophthalmology residents participate in scholarly activity during residency. However, residents lack protected time for research. Objective This article aims to determine the impact of a dedicated research rotation on scholarly productivity and research experience during residency. Methods This cohort study compared two groups of ophthalmology residents. Residents who graduated between 2004 and 2009 did not have dedicated research time and served as control residents (CR), while residents who graduated between 2010 and 2015 had a dedicated research rotation and served as the intervention group (research residents, RR). Primary outcomes included publications and presentations recorded over a 4-year period, spanning the 3 years of residency and the first year after graduation. These were analyzed by linear regression and t-tests. Residents also took surveys regarding research experience and chi-sq...
American journal of ophthalmology, Jan 19, 2017
To compare cup to disc ratio (CDR) measurements from images taken with a portable, 45° non-mydria... more To compare cup to disc ratio (CDR) measurements from images taken with a portable, 45° non-mydriatic fundus camera to images from a traditional table-top mydriatic fundus camera. Prospective, cross sectional, comparative instrument validation study. materials-methods SETTING: Clinic-based. 422 eyes of 211 subjects were recruited from the Tilganga Institute of Ophthalmology (Kathmandu, Nepal). Two masked readers measured CDR and noted possible evidence of glaucoma (CDR ≥0.7 or the presence of a notch or disc hemorrhage) from fundus photographs taken with a non-mydriatic portable camera and a mydriatic standard camera. Each image was graded twice. Effect of camera modality on CDR measurement, inter- and intra-observer agreement for each camera for the diagnosis of glaucoma. 196 eyes (46.5%) were diagnosed with glaucoma by chart review. 41.2%-59.0% of eyes were remotely diagnosed with glaucoma over grader, repeat measurement, and camera modality. There was no significant difference in ...
Ophthalmology, Mar 16, 2017
To quantify costs of eye care providers' Medicare Part D prescribing patterns for ophthalmic ... more To quantify costs of eye care providers' Medicare Part D prescribing patterns for ophthalmic medications and to estimate the potential savings of generic or therapeutic drug substitutions and price negotiation. Retrospective cross-sectional study. Eye care providers prescribing medications through Medicare Part D in 2013. Medicare Part D 2013 prescriber public use file and summary file were used to calculate medication costs by physician specialty and drug. Savings from generic or therapeutic drug substitutions were estimated for brand drugs. The potential savings from price negotiation was estimated using drug prices negotiated by the United States Veterans Administration (USVA). Total cost of brand and generic medications prescribed by eye care providers. Eye care providers accounted for $2.4 billion in total Medicare part D prescription drug costs and generated the highest percentage of brand name medication claims compared with all other providers. Brand medications accounte...
Ophthalmology, Jan 31, 2017
To determine the frequency of emergency department (ED) visits for nonurgent and urgent ocular co... more To determine the frequency of emergency department (ED) visits for nonurgent and urgent ocular conditions and risk factors associated with ED use for nonurgent and urgent ocular problems. Retrospective, longitudinal cohort analysis. All enrollees aged 21 years or older in a United States managed care network during 2001-2014. We identified all enrollees visiting an ED for ocular conditions identified by International Classification of Diseases, billing codes. Diagnosis is well-described as urgent, nonurgent, or other. We assessed the frequency of ED visits for urgent and nonurgent ocular conditions and how they changed over time. Next, we performed multivariable Cox regression modeling to determine factors associated with visiting an ED for urgent or nonurgent ocular conditions. Hazard ratios (HRs) with 95% confidence intervals (CIs) of visiting an ED for urgent or nonurgent ocular conditions. Of the 11 160 833 enrollees eligible for this study, 376 680 (3.4%) had 1 or more ED visit...
Retina (Philadelphia, Pa.), Jan 26, 2016
To report the visual acuity outcomes after pars plana vitrectomy for delayed vitreoretinal sequel... more To report the visual acuity outcomes after pars plana vitrectomy for delayed vitreoretinal sequelae of infectious endophthalmitis. All eyes were initially treated with intravitreal antibiotics (Abx). Multicenter, retrospective, consecutive case series. Forty-two eyes met the study criteria. The mean follow-up was 48 weeks (SD ± 61.8). Mean interval from Abx to pars plana vitrectomy was 13 weeks (SD ± 14.3, range 2-70). Indications for pars plana vitrectomy included vitreous opacities (VO) (n = 22), epiretinal membrane (n = 9), and retinal detachment (n = 11). LogMAR visual acuity improved from 1.87 (Snellen equivalent: 20/1,482) preoperatively to 1.35 (Snellen equivalent: 20/447) at final evaluation (P < 0.001). LogMAR visual acuity improved significantly for patients with vitreous opacities (P < 0.01) and retinal detachment (P = 0.02) but not for patients with epiretinal membranes (P = 0.08). Patients with infectious endophthalmitis can gain vision if they have a pars plana v...
Archives of Ophthalmology, 2008
Telemedicine journal and e-health : the official journal of the American Telemedicine Association, Mar 23, 2016
Diabetic retinopathy (DR) is the leading cause of new-onset blindness in adults. Telemedicine is ... more Diabetic retinopathy (DR) is the leading cause of new-onset blindness in adults. Telemedicine is a validated, cost-effective method to improve monitoring. However, little is known of patients' attitudes toward telemedicine for DR. Our study explores factors that influence patients' attitudes toward participating in telemedicine. Ninety seven participants in a university and the Veterans Administration setting completed a survey. Only people with diabetes mellitus (DM) were included. The main outcome was willingness to participate in telemedicine. The other outcomes were perceived convenience and impact on the patient-physician relationship. Participants reported demographic information, comorbidities, and access to healthcare. Analysis was performed with t-tests and multivariable logistic regression. Demographic factors were not associated with the outcomes (all p > 0.05). Patients had decreased odds of willingness if they valued the patient-physician relationship (adjust...
Neurology, 2008
The aim of our study was to evaluate whether wearing sunglasses (the &amp;quot;sunglasses... more The aim of our study was to evaluate whether wearing sunglasses (the &amp;quot;sunglasses sign&amp;quot;) can be used by neuro-ophthalmologists to predict nonorganic visual loss (NOVL) in their patients. We prospectively collected information on all new patients seen by us over 13 months. We included all patients who ultimately received a diagnosis of NOVL, and all patients wearing sunglasses in our clinic. We recorded demographics, iris color, number of positive review of systems, ocular examination, precipitating event or trauma, workers&amp;#39; compensation claims, disability and lawsuit related to the visual loss, and the reason for wearing sunglasses. Among the 1,377 consecutive new patients seen in our clinic during the study, 34 patients wore sunglasses, among whom 7 (20.6%) had organic visual loss. During the study period, 59 patients were diagnosed with NOVL, among whom 27 (45.8%) wore sunglasses. The sensitivity of wearing sunglasses for NOVL was 0.46 (95% CI 0.33 to 0.59). The probability that a patient walking into our clinic had NOVL was 0.043 (95% CI 0.033 to 0.055); it increased to 0.79 (95% CI 0.62 to 0.91) in sunglasses patients. The specificity of sunglasses for the diagnosis of NOVL was 0.995 (95% CI 0.989 to 0.998). At least one of the following characteristics (highly positive review of systems, workers&amp;#39; compensation claim, disability, and lawsuit) was found in 26 of 27 (96.3%) of NOVL patients wearing sunglasses and in none of the sunglasses patients with organic neuro-ophthalmic disorders. All 7 sunglasses patients with organic neuro-ophthalmic disorders had reasonable ophthalmic explanations for wearing sunglasses. The &amp;quot;sunglasses sign&amp;quot; in a patient without an obvious ophthalmic reason to wear sunglasses is highly suggestive of nonorganic visual loss.
Cornea, 2021
PURPOSE The purpose of this study was to characterize rates of opioid prescription for different ... more PURPOSE The purpose of this study was to characterize rates of opioid prescription for different ulcerative keratitis types. METHODS This cohort study included patients diagnosed with ulcerative keratitis according to the University of Michigan electronic health record data between September 1, 2014 and December 22, 2020. Ulcerative keratitis was categorized by etiologic type (bacterial, fungal, viral, acanthamoeba, inflammatory, polymicrobial, or unspecified) using rule-based data classification that accounted for billing diagnosis code, antimicrobial or antiinflammatory medications prescribed, laboratory results, and manual chart review. Opioid prescriptions were converted to morphine milligram equivalent and summed over 90 days from diagnosis. Opioid prescription rate and amount were compared between ulcerative keratitis types. RESULTS Of 3322 patients with ulcerative keratitis, 173 (5.2%) were prescribed at least 1 opioid for pain management within 90 days of diagnosis. More patients with acanthamoeba (32.4%), fungal (21.1%), and polymicrobial (25.0%) keratitis were treated with opioids compared with bacterial (6.7%), unspecified (2.9%), or viral (1.8%) keratitis (all Bonferroni adjusted P < 0.05). For the 173 patients who were prescribed opioids, a total of 353 prescriptions were given within 90 days of diagnosis, with half given within the first week after diagnosis. The quantity of opioid prescribed within 90 days from diagnosis was not significantly different between ulcerative keratitis types (P = 0.6559). Morphine milligram equivalent units prescribed ranged from 97.5 for acanthamoeba keratitis to 112.5 for fungal keratitis. CONCLUSIONS The type of ulcerative keratitis may influence the opioid prescription rate. Providers can better serve patients needing opioids for pain management through improved characterization of pain and development of more tailored pain management regimens.
Ophthalmology, 2021
This study quantifies the performance of an international cohort of cornea specialists in image-b... more This study quantifies the performance of an international cohort of cornea specialists in image-based differentiation of bacterial and fungal keratitis, identifying significant regional variation and establishing a reference standard for comparison against machine learning models.
Cornea, 2020
PURPOSE To investigate the burden of procedures, visits, and procedure costs in the management of... more PURPOSE To investigate the burden of procedures, visits, and procedure costs in the management of microbial keratitis (MK). METHODS Medical records of patients from an academic hospital outpatient facility between December 2013 and May 2018 were retrospectively reviewed. Patients were included if they were older than the age of 18 years, recruited for study of likely MK, and not concurrently undergoing treatment for other acute eye conditions. For procedural costs, Medicare data for billing were obtained using the Center for Medicare and Medicaid Services Physician Fee Lookup tool. RESULTS A total of 68 patients were included for analysis. Patients were on average 51.3 years (SD = 19.5), 55.9% women (n = 38), and 89.7% White (n = 61). Per person, the average number of procedures was 2.9 (SD = 4.2). The average number of visits was 13.9 (SD = 9.2) over an average of 26.9 weeks (SD = 24.3). Age (P < 0.0001), positive Gram stain (P = 0.03), and mixed Gram stain (P = 0.002) were positively associated with the number of procedures. Age (P = 0.0003), fungal keratitis (P = 0.02), and mixed Gram stain (P = 0.01) were positively associated with the number of visits. Race was inversely associated with the number of procedures (P = 0.045) and visits (0.03). Patients with bacterial keratitis were more likely to have amniotic membrane grafts (P = 0.01) and tarsorrhaphies (P = 0.03) than fungal patients. Across all procedures performed for the management of MK, the mean cost per patient was 1788.7(SD=1788.7 (SD = 1788.7(SD=3324.62). CONCLUSIONS Patients incur many procedural costs and attend many visits during the management of MK. These findings emphasize the importance of patient-provider communication for frequent follow-up care and the potential need to perform procedures for disease management.
Cornea, 2021
PURPOSE To characterize vision-related quality of life after penetrating keratoplasty (PKP), deep... more PURPOSE To characterize vision-related quality of life after penetrating keratoplasty (PKP), deep anterior lamellar keratoplasty (DALK), Descemet stripping automated endothelial keratoplasty (DSAEK), and Descemet membrane endothelial keratoplasty (DMEK) using the National Eye Institute Visual Function Questionnaire (NEI-VFQ 9). METHODS Using the Sight Outcomes Research Collaborative ophthalmology electronic health record repository, questionnaire responses were obtained from 103 PKP patients, 24 DALK patients, 42 DSAEK patients, and 50 DMEK patients undergoing postoperative examination. No exclusions were made based on preoperative diagnosis, age, complications, or comorbidities. Associations between clinical characteristics and vision-related quality of life were analyzed using nonparametric and linear regression methods. RESULTS Patients were surveyed an average of 1.5 years postoperatively (range 24 d to 4.4 yrs). Participants who had undergone DALK, DMEK, DSAEK, and PKP had median composite VFQ scores of 77.8, 84.2, 76.1, and 70.6, respectively (P= 0.002). There were no significant differences in VFQ scores between patients treated with DMEK versus DSAEK (P = 0.440) or between patients treated with PKP versus DALK (P = 1.000). Higher postoperative acuities in the operative and fellow eyes were associated with higher VFQ scores (P < 0.001 and P < 0.001). When controlling for postoperative acuity by regression modeling, surgery type was not associated with patient-reported composite VFQ scores. CONCLUSIONS In this study, patient-reported vision-related quality of life was similar among DMEK and DSAEK participants and also among DALK and PKP participants. When controlling for postoperative acuity, vision-related quality of life was similar among all study participants, irrespective of the keratoplasty technique.
Cornea, 2021
Supplemental Digital Content is Available in the Text. Purpose: Medication nonadherence is a ubiq... more Supplemental Digital Content is Available in the Text. Purpose: Medication nonadherence is a ubiquitous problem. However, the adherence of patients to medications to manage corneal conditions is unknown. A prospective cohort study investigated the patterns of eye drop adherence among patients with corneal conditions. Methods: Patients older than or equal to 18 years taking prescription eye medications were recruited from an academic center's corneal clinic. Data collected included age, sex, total doses of eye medications, and category of primary corneal diagnosis. Participants completed adapted versions of the 12-question Adherence to Refills and Medications Scale (ARMS) and the 3-question Voils' Medication Adherence Scale (VMAS). Survey data were dichotomized as “adherent” and “nonadherent,” and subscales reported for reasons of nonadherence. Logistic regression analyses were used to test associations with adherence. Results: A total of 199 participants were surveyed from February to March 2019 (95% response rate). Participants were aged 19 to 93 years with a mean age of 59 years (SD 17.8). The percent of participants considered nonadherent was 72% by the ARMS and 33% by the VMAS. Older age was associated with higher adherence by the ARMS (odds ratio = 1.48, 95% confidence interval, 1.14–1.93, P = 0.004) and by the VMAS (odds ratio = 1.24, confidence interval, 1.04–1.48, P = 0.012). Adherence was not significantly associated with race, sex, education, total doses of eye medications, or primary cornea diagnosis. Conclusions: Medication adherence was lower than expected, particularly on the ARMS scale that asks more detailed questions. Clinicians should engage in conversations about adherence, especially with younger patients, if they are not seeing an expected clinical response.
Optometry and Vision Science, 2021
Supplemental digital content is available in the text. SIGNIFICANCE Uncorrected refractive error ... more Supplemental digital content is available in the text. SIGNIFICANCE Uncorrected refractive error is the main cause of visual impairment globally. Understanding barriers and facilitators underserved individuals face in obtaining eyeglasses will help address high rates of uncorrected refractive error. PURPOSE The purpose of this study was to understand the barriers and facilitators to obtaining eyeglasses among low-income patients in Michigan. METHODS Participants older than 18 years with hyperopia, myopia, or presbyopia and without active eye disease, severe mental illness, or cognitive impairment at Hope Clinic, Ypsilanti, Michigan, were included in this study. The participants answered a sociodemographic survey and underwent autorefraction and an interview. Interviews were audiorecorded, transcribed, and analyzed by two investigators. RESULTS Interviews were completed by 43 participants, and 30 participants' interviews were analyzed. The mean ± standard deviation age of 30 participants was 55 ± 12 years, 70% were female, 57% were African American, 40% had high school diploma or less, 57% earned less than U.S. $25,000 per year, 93% had worn glasses previously, and 87% had some medical insurance. Uncorrected visual acuity was logMAR 0.73 ± 0.61; best-corrected visual acuity was logMAR 0.16 ± 0.21. Thematic saturation was reached after 25 transcripts. Top barriers to using eyeglasses were cost (312 mentions, 29 participants), negative experiences with eyeglasses (263, 29), and limited access to eye care (175, 27). Top facilitators were positive experiences with glasses (230, 29), easy access to eyeglasses (143, 27), and availability of transportation (65, 27). Most participants (97%, 29) reported being negatively impacted by uncorrected refractive error. Most (97%, 29) were skeptical about obtaining eyeglasses online because of possible prescription problems. CONCLUSIONS Key barriers to correcting uncorrected refractive error in our community span across multiple health domains but are predominately rooted in external factors such as cost and access to vision care. Online eyeglasses may address access issues, but many participants were uncomfortable or unable to obtain glasses online.
Cornea, 2020
PURPOSE The aim of this investigation was to study the patient-reported outcomes of patients with... more PURPOSE The aim of this investigation was to study the patient-reported outcomes of patients with microbial keratitis (MK) using the 9-item National Eye Institute-Visual Function Questionnaire (NEI VFQ-9). METHODS Using the Sight Outcomes Research Collaborative ophthalmology electronic health record repository, patients with MK and control patients who completed the NEI VFQ-9 within 7 days of their appointment were identified. The questionnaire is scored as a mean of the 9 items on a scale from 0 to 100, with higher scores indicating better functioning. Composite and individual item scores were compared between groups using the analysis of variance. RESULTS In total, 916 questionnaires were completed from patients with acute MK (n = 84), nonacute MK (n = 30), MK with a corneal transplant (n = 21), from controls seen in a satellite comprehensive ophthalmology clinic (n = 528), and controls seen at a subspecialty ophthalmology clinic (n = 253). The mean NEI VFQ-9 composite scores per group were 66.6 (SD = 26.8), 78.1 (SD = 17.1), 58.6 (SD =21.6), 88.0 (SD = 10.2), and 83.5 (SD = 13.0), respectively (P < 0.0001). Both patients with acute MK and patients with MK requiring transplant reported significantly worse function than nonacute MK, comprehensive, and specialty patients. Patients with nonacute MK reported significantly worse function than comprehensive control patients (all Tukey-adjusted P < 0.05). DISCUSSION Patients who had or eventually require corneal transplant for management of their MK report worse visual function than patients with nonacute MK. This may be important in helping physicians counsel their patients.
JAMA Ophthalmology, 2019
Importance Opioids, which carry a high risk for addiction and overdose, are commonly prescribed a... more Importance Opioids, which carry a high risk for addiction and overdose, are commonly prescribed after corneal surgery. Data are lacking describing opioid prescribing practices and opioid needs by patients after ophthalmic surgery. Objectives To quantify opioid use and to assess the association of decreasing the number of opioid tablets prescribed after corneal surgery with postsurgical use. Design, Setting, and Participants This prospective cohort study investigated opioid use after corneal surgery using direct interviews of 2 adult patient cohorts separated by an updated opioid prescribing guideline. The first cohort survey assessed the quantity of opioid tablets used after surgery. The cornea division of a tertiary care academic medical center reviewed the use needs and decreased the number of tablets prescribed after routine cases. Simultaneously, a statewide opioid monitoring program began that provided patients with opioid information. A second unique cohort received a more detailed survey to assess use, opioid disposal, and pain control. Data for the first cohort were collected from December 1, 2017, through January 19, 2018; for the second cohort, from June 1 to September 15, 2018. Data were analyzed from October 24, 2018, through September 24, 2019. Exposure Corneal surgery. Main Outcomes and Measures Differences in use of opioid tablets used by both patient cohorts, assessed using the 2-sample t test. Results Of 112 eligible, contacted patients, 82 consented to participate (42 men [51%]; mean [SD] age, 42.5 [17.8] years) and were included in the analysis; 38 of 42 participated in the first cohort and 44 of 70 participated in the second cohort. Of those receiving opioid prescriptions, the first cohort was prescribed significantly more tablets than the second cohort (mean [SD], 18.8 [4.2] vs 6.6 [3.1]; difference, 12.2 [95% CI, 10.4-14.0]; P < .001). The first cohort used significantly more tablets than the second cohort (mean [SD], 8.3 [7.0] vs 4.0 [3.2]; difference, 4.3 [95% CI, 1.4-7.2]; P = .005) and had significantly more leftover tablets (mean [SD], 10.3 [6.9] vs 2.9 [2.7]; difference, 7.5 [95% CI, 4.7-10.2]; P < .001). In the detailed survey for the second cohort, 19 of 27 patients reported pain control as adequate (70% [95% CI, 50%-86%]); 6 of 27, as more than needed (22% [95% CI, 9%-42%]). Twenty of 28 participants (71% [95% CI, 55%-88%]) had leftover tablets; 17 of these (85% [95% CI, 62%-97%]) did not dispose of leftovers, and 3 (15% [95% CI, 3%-38%]) threw away or flushed leftovers. Conclusions and Relevance After an assessment of opioid needs, physicians prescribed fewer opioid pills. However, patients who underwent cornea surgery and received fewer tablets continued to have adequate pain control and used even fewer tablets compared with the initial cohort. Patients with unused opioid tablets did not dispose of them properly.
Cornea, 2019
Purpose: To understand medication use and patient burden for treatment of bacterial keratitis (BK... more Purpose: To understand medication use and patient burden for treatment of bacterial keratitis (BK). Methods: A retrospective study was performed examining medical records of adult patients with BK in an academic cornea practice. Data collected included medications used in the treatment of BK, dosing of medications, and the number and total duration of clinical encounters. Costs of medications were estimated using average wholesale pharmacy price. Linear regression analysis was used to investigate associations of medication use with patient demographics and corneal culture results and reported with beta estimates (β) and 95% confidence intervals (CI). Results: 48 BK patients (56% female) were studied. Patients were treated for a median of 54 days with 10 visits, five unique medications, 587 drops, and seven prescriptions. Estimated median medication cost was $933
JAMA ophthalmology, Jan 12, 2018
Medicare benefits do not include coverage for eyeglasses except after cataract surgery. Understan... more Medicare benefits do not include coverage for eyeglasses except after cataract surgery. Understanding the implications of a change to this policy would require knowing the number of Medicare beneficiaries who use eyeglasses, but no recent estimates are available. To estimate the number of older adults with Medicare who use eyeglasses. This cross-sectional study used data from the 2015 US National Health and Aging Trends Study. Nationally representative data from 7497 respondents were reviewed and sample weights were applied so that the data represented 43.9 million Medicare beneficiaries aged 65 years or older. The estimates were based on the following 4 groupings of beneficiaries: (1) number who used eyeglasses for distance vision correction and had distance vision impairment, (2) number who did not use eyeglasses for distance vision correction and had distance vision impairment, (3) number who used eyeglasses for near vision correction and had near vision impairment, and (4) numbe...
JAMA ophthalmology, 2018
Cataract-related vision impairment is an important public health issue that tends to affect older... more Cataract-related vision impairment is an important public health issue that tends to affect older adults. Little is known about the association between older adults' social support networks and their likelihood of receiving cataract surgery. To determine if older adults with smaller social support networks are less likely to receive cataract surgery. Retrospective cohort study. The National Health and Aging Trends Study, a nationally representative US survey, administered annually from 2011 to 2015 to a cohort of Medicare beneficiaries 65 years and older with no cataract surgery prior to the start of the study. Multivariable logistic regression was performed to evaluate if the number of persons in an individual's social support network influenced whether that individual received cataract surgery during a given year of the study. Overall, 3448 participants were interviewed from 2011 to 2015 for a total of 9760 observations. Of these observations, 3084 (weighted, 38.81%; 95% C...
Cornea, Jan 14, 2017
To assess variability in corneal ulcer measurements between ophthalmologists and reduce clinician... more To assess variability in corneal ulcer measurements between ophthalmologists and reduce clinician-dependent variability using semiautomated segmentation of the ulcer from photographs. Three ophthalmologists measured 50 patients' eyes for epithelial defects (EDs) and the stromal infiltrate (SI) size using slit-lamp (SL) calipers. SL photographs were obtained. An algorithm was developed for semiautomatic segmenting of the ED and SI in the photographs. Semiautomatic segmentation was repeated 3 times by different users (2 ophthalmologists and 1 trainee). Clinically significant variability was assessed with intraclass correlation coefficients (ICCs) and the percentage of pairwise measurements differing by ≥0.5 mm. Semiautomatic segmentation measurements were compared with manual delineation of the image by a corneal specialist (gold standard) using Dice similarity coefficients. Ophthalmologists' reliability in measurements by SL calipers had an ICC from 0.84 to 0.88 between exami...
Journal of Academic Ophthalmology, 2017
Background The Accreditation Council for Graduate Medical Education (ACGME) requires that ophthal... more Background The Accreditation Council for Graduate Medical Education (ACGME) requires that ophthalmology residents participate in scholarly activity during residency. However, residents lack protected time for research. Objective This article aims to determine the impact of a dedicated research rotation on scholarly productivity and research experience during residency. Methods This cohort study compared two groups of ophthalmology residents. Residents who graduated between 2004 and 2009 did not have dedicated research time and served as control residents (CR), while residents who graduated between 2010 and 2015 had a dedicated research rotation and served as the intervention group (research residents, RR). Primary outcomes included publications and presentations recorded over a 4-year period, spanning the 3 years of residency and the first year after graduation. These were analyzed by linear regression and t-tests. Residents also took surveys regarding research experience and chi-sq...
American journal of ophthalmology, Jan 19, 2017
To compare cup to disc ratio (CDR) measurements from images taken with a portable, 45° non-mydria... more To compare cup to disc ratio (CDR) measurements from images taken with a portable, 45° non-mydriatic fundus camera to images from a traditional table-top mydriatic fundus camera. Prospective, cross sectional, comparative instrument validation study. materials-methods SETTING: Clinic-based. 422 eyes of 211 subjects were recruited from the Tilganga Institute of Ophthalmology (Kathmandu, Nepal). Two masked readers measured CDR and noted possible evidence of glaucoma (CDR ≥0.7 or the presence of a notch or disc hemorrhage) from fundus photographs taken with a non-mydriatic portable camera and a mydriatic standard camera. Each image was graded twice. Effect of camera modality on CDR measurement, inter- and intra-observer agreement for each camera for the diagnosis of glaucoma. 196 eyes (46.5%) were diagnosed with glaucoma by chart review. 41.2%-59.0% of eyes were remotely diagnosed with glaucoma over grader, repeat measurement, and camera modality. There was no significant difference in ...
Ophthalmology, Mar 16, 2017
To quantify costs of eye care providers' Medicare Part D prescribing patterns for ophthalmic ... more To quantify costs of eye care providers' Medicare Part D prescribing patterns for ophthalmic medications and to estimate the potential savings of generic or therapeutic drug substitutions and price negotiation. Retrospective cross-sectional study. Eye care providers prescribing medications through Medicare Part D in 2013. Medicare Part D 2013 prescriber public use file and summary file were used to calculate medication costs by physician specialty and drug. Savings from generic or therapeutic drug substitutions were estimated for brand drugs. The potential savings from price negotiation was estimated using drug prices negotiated by the United States Veterans Administration (USVA). Total cost of brand and generic medications prescribed by eye care providers. Eye care providers accounted for $2.4 billion in total Medicare part D prescription drug costs and generated the highest percentage of brand name medication claims compared with all other providers. Brand medications accounte...
Ophthalmology, Jan 31, 2017
To determine the frequency of emergency department (ED) visits for nonurgent and urgent ocular co... more To determine the frequency of emergency department (ED) visits for nonurgent and urgent ocular conditions and risk factors associated with ED use for nonurgent and urgent ocular problems. Retrospective, longitudinal cohort analysis. All enrollees aged 21 years or older in a United States managed care network during 2001-2014. We identified all enrollees visiting an ED for ocular conditions identified by International Classification of Diseases, billing codes. Diagnosis is well-described as urgent, nonurgent, or other. We assessed the frequency of ED visits for urgent and nonurgent ocular conditions and how they changed over time. Next, we performed multivariable Cox regression modeling to determine factors associated with visiting an ED for urgent or nonurgent ocular conditions. Hazard ratios (HRs) with 95% confidence intervals (CIs) of visiting an ED for urgent or nonurgent ocular conditions. Of the 11 160 833 enrollees eligible for this study, 376 680 (3.4%) had 1 or more ED visit...
Retina (Philadelphia, Pa.), Jan 26, 2016
To report the visual acuity outcomes after pars plana vitrectomy for delayed vitreoretinal sequel... more To report the visual acuity outcomes after pars plana vitrectomy for delayed vitreoretinal sequelae of infectious endophthalmitis. All eyes were initially treated with intravitreal antibiotics (Abx). Multicenter, retrospective, consecutive case series. Forty-two eyes met the study criteria. The mean follow-up was 48 weeks (SD ± 61.8). Mean interval from Abx to pars plana vitrectomy was 13 weeks (SD ± 14.3, range 2-70). Indications for pars plana vitrectomy included vitreous opacities (VO) (n = 22), epiretinal membrane (n = 9), and retinal detachment (n = 11). LogMAR visual acuity improved from 1.87 (Snellen equivalent: 20/1,482) preoperatively to 1.35 (Snellen equivalent: 20/447) at final evaluation (P < 0.001). LogMAR visual acuity improved significantly for patients with vitreous opacities (P < 0.01) and retinal detachment (P = 0.02) but not for patients with epiretinal membranes (P = 0.08). Patients with infectious endophthalmitis can gain vision if they have a pars plana v...
Archives of Ophthalmology, 2008
Telemedicine journal and e-health : the official journal of the American Telemedicine Association, Mar 23, 2016
Diabetic retinopathy (DR) is the leading cause of new-onset blindness in adults. Telemedicine is ... more Diabetic retinopathy (DR) is the leading cause of new-onset blindness in adults. Telemedicine is a validated, cost-effective method to improve monitoring. However, little is known of patients' attitudes toward telemedicine for DR. Our study explores factors that influence patients' attitudes toward participating in telemedicine. Ninety seven participants in a university and the Veterans Administration setting completed a survey. Only people with diabetes mellitus (DM) were included. The main outcome was willingness to participate in telemedicine. The other outcomes were perceived convenience and impact on the patient-physician relationship. Participants reported demographic information, comorbidities, and access to healthcare. Analysis was performed with t-tests and multivariable logistic regression. Demographic factors were not associated with the outcomes (all p > 0.05). Patients had decreased odds of willingness if they valued the patient-physician relationship (adjust...
Neurology, 2008
The aim of our study was to evaluate whether wearing sunglasses (the &amp;quot;sunglasses... more The aim of our study was to evaluate whether wearing sunglasses (the &amp;quot;sunglasses sign&amp;quot;) can be used by neuro-ophthalmologists to predict nonorganic visual loss (NOVL) in their patients. We prospectively collected information on all new patients seen by us over 13 months. We included all patients who ultimately received a diagnosis of NOVL, and all patients wearing sunglasses in our clinic. We recorded demographics, iris color, number of positive review of systems, ocular examination, precipitating event or trauma, workers&amp;#39; compensation claims, disability and lawsuit related to the visual loss, and the reason for wearing sunglasses. Among the 1,377 consecutive new patients seen in our clinic during the study, 34 patients wore sunglasses, among whom 7 (20.6%) had organic visual loss. During the study period, 59 patients were diagnosed with NOVL, among whom 27 (45.8%) wore sunglasses. The sensitivity of wearing sunglasses for NOVL was 0.46 (95% CI 0.33 to 0.59). The probability that a patient walking into our clinic had NOVL was 0.043 (95% CI 0.033 to 0.055); it increased to 0.79 (95% CI 0.62 to 0.91) in sunglasses patients. The specificity of sunglasses for the diagnosis of NOVL was 0.995 (95% CI 0.989 to 0.998). At least one of the following characteristics (highly positive review of systems, workers&amp;#39; compensation claim, disability, and lawsuit) was found in 26 of 27 (96.3%) of NOVL patients wearing sunglasses and in none of the sunglasses patients with organic neuro-ophthalmic disorders. All 7 sunglasses patients with organic neuro-ophthalmic disorders had reasonable ophthalmic explanations for wearing sunglasses. The &amp;quot;sunglasses sign&amp;quot; in a patient without an obvious ophthalmic reason to wear sunglasses is highly suggestive of nonorganic visual loss.