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    JAMA Ophthalmology

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    Telemedicine for Diabetic Retinopathy

    May JAMA Ophthalmology

    Mansberger et al. compared the long-term effectiveness of telemedicine and traditional eye examinations in providing screening examinations for diabetic retinopathy.

    From Aug. 1, 2006, through Sept. 31, 2009, 567 participants with diabetes were randomized and followed for up to five years (last patient follow-up date was Aug. 6, 2012) as part of a multicenter randomized clinical trial with an intent-to-treat analysis. Participants were assigned to one of two groups: telemedicine (n = 296), in which images were taken with a nonmydriatic camera in a primary care medical clinic and reviewed off site; or traditional surveillance with an eye care professional (n = 271). Two years after enrollment, telemedicine was offered to all participants.

    The main outcomes were percentage of participants receiving annual diabetic retinopathy screening examinations; percentage of eyes with worsening diabetic retinopathy during the follow-up period on a scale from stage 0 (none) to stage 4 (proliferative diabetic retinopathy); and percentage of telemedicine participants who required referral to an eye care professional for follow-up care by the criteria of moderate diabetic retinopathy or worse, the presence of macular edema, or an “unable-to-determine” result for retinopathy or macular edema.

    The telemedicine group was more likely to receive a diabetic retinopathy screening examination when compared with the traditional surveillance group during the time periods of six months or less (94.6 percent vs. 43.9 percent; p < .001) and greater than six months through 18 months (53.0 percent vs. 33.2 percent; p < .001). Diabetic retinopathy worsened by two stages or more in 35 of 409 participants (8.6 percent; 95 percent CI, 5.8-11.2 percent) and improved by two stages or more in five of 409 participants (1.2 percent; 95 percent CI, 0.1-2.3 percent) during the four-year period. The percent of telemedicine participants requiring referral ranged from 19.2 percent (52 of 271) to 27.9 percent (58 of 208).

    The authors concluded that telemedicine increased the percentage of diabetic retinopathy screening examinations, that most participants did not require referral to an eye care professional, and that diabetic retinopathy levels were generally stable during the study period. These findings suggest that primary care clinics can use telemedicine to screen for diabetic retinopathy and monitor for disease worsening over a long period.

    Outcomes of an Inner-City Vision Outreach Program

    May JAMA Ophthalmology

    Recognizing that urban children of low socioeconomic status often do not have access to ophthalmic care, Dotan et al. studied the demographic characteristics and ophthalmic conditions in children attending Give Kids Sight Day (GKSD). This event is an outreach ophthalmic care program held annually in Philadelphia to provide vision screening and immediate treatment if needed.

    In this retrospective case-series study, the registration forms and records of all children who attended GKSD at Wills Eye Hospital in 2012 were reviewed. Demographic characteristics, insurance status, spoken languages, reasons for attending, prior failure of vision screening, and attendance patterns at previous events were analyzed. The ophthalmological findings of these children were examined, including refractive errors, need for optical correction, and diagnoses for which continuous ophthalmic care was necessary. For children who needed ophthalmic follow-up, the rate of return to clinic and barriers to continuous care were analyzed.

    At GKSD 2012, there were 924 children (mean age, 9 years; range, 0-18 years; 51 percent female; 25 percent speaking a non-English language) from 584 families. Of these, 27 percent were uninsured and 10 percent were not aware of their insurance status. Although 42 percent of participants had public insurance that covered vision care and glasses, 35 percent of them did not know their benefits and did not realize vision care was covered. Forty-nine percent of children attended because they had failed community vision screening. Provision of free glasses and failure of previous vision screening were the most common reasons families elected to attend GKSD (64 percent and 49 percent, respectively). Eighty-five percent of children attended GKSD for the first time in 2012, whereas 15 percent had attended prior events.

    Glasses were provided to 61 percent of attendees. Ten percent of the attendees needed continuous ophthalmic care, most commonly for amblyopia. Ten children needed ocular surgery for cataract, strabismus, nystagmus, ptosis, or nasolacrimal duct obstruction. With the assistance of a social worker, 59 percent of children who needed continuous treatment returned to the clinic, compared with 2 percent in prior years before social worker intervention.

    The authors concluded that programs such as GKSD can bridge the gap between vision screening and ophthalmic treatment, a gap that often occurs in low-socioeconomic urban populations. Social worker intervention appears to be useful in overcoming common barriers to follow-up care.

    Cost-effectiveness of Tube vs. Trabeculectomy

    May JAMA Ophthalmology

    The Tube vs. Trabeculectomy Trial (TVT) found that the 350-mm2 Baerveldt implant (tube) and trabeculectomy with mitomycin may be similarly effective in lowering intraocular pressure in primary open-angle glaucoma. Kaplan et al. assessed the cost-effectiveness of these procedures compared with maximal medical treatment. Using the Markov cohort model with a five-year time horizon in a hypothetical cohort of 100,000 patients who required glaucoma surgery, the researchers assessed quality-adjusted life-years (QALYs) gained, costs from the societal perspective, and the incremental cost-effectiveness ratio of medical treatment, trabeculectomy, and tube insertion.

    Costs were identified from Medicare Current Procedural Terminology and Ambulatory Payment Classification reimbursement codes and Red Book medication costs. QALYs were based on visual field and visual acuity outcomes. The hypothetical societal limit to resources was included using a willingness-to-pay threshold of $50,000 per QALY. Costs and utilities were discounted at 3 percent per year.

    The mean costs for medical treatment, trabeculectomy, and tube insertion were $6,172, $7,872 and $10,075, respectively. The mean five-year probability of blindness was 4 percent for both surgical procedures and 15 percent for medical treatment. The utility gained after medical treatment, trabeculectomy, and tube insertion was 3.10, 3.30, and 3.38 QALYs, respectively. The incremental cost-effectiveness ratio was $8,289 per QALY for trabeculectomy vs. medical treatment, $13,896 per QALY for tube insertion vs. medical treatment, and $29,055 per QALY for tube insertion vs. trabeculectomy.

    The cost-effectiveness of each surgical procedure was most sensitive to early and late surgical failure rates and was minimally affected by adverse events, rates of visual field progression, or medication costs. Assuming a willingness to pay $50,000 per QALY, trabeculectomy and tube insertion are cost-effective compared with medical treatment alone. Trabeculectomy, however, is cost-effective at a substantially lower cost per QALY compared with tube insertion. More research is necessary to reliably account for patient preferences between the two operations.

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    JAMA Ophthalmology summaries are based on authors’ abstracts as edited by senior editor(s).

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