Designing a quality monitoring system for low-resource ophthalmology clinics using Bayesian analysis [Meeting Abstract]
Massa, S; Lu, Y; Misra, P; Anthopolos, R; Elkin, Z
Purpose : Ophthalmology clinics with minimal statistical analytics capabilities may struggle to implement a quality monitoring system to evaluate patient outcomes. We performed a quality improvement study by designing a quality monitoring system for a low-resource ophthalmology clinic that would use small samples to estimate outcomes for larger patient populations. Methods : We evaluated the proportion of primary open-angle glaucoma (POAG) patients who were treated successfully according to American Academy of Ophthalmology Preferred Practice Patterns (PPPs). We analyzed 100 patients seen in the clinic over 3 months in 2019 as the input for our Bayesian analysis. We also created a standardized note template for use by clinicians in the electronic medical record (EMR) for POAG patient visits to facilitate monitoring of treatment successes without requiring clinical expertise. We evaluated adherence to clinician template use in POAG patient notes on the weekly day of glaucoma patient visits over 9 weeks in 2020. Results : Using Bayesian analysis based on our initial data, we created tables that allow for quality monitoring of future 3 month intervals using parameters from smaller samples. Using a small sample of 30 patients, we were able to determine that there was a 100% probability that the clinic as a whole was not achieving the pre-defined target percentage of 80% of POAG patients successfully treated, as defined by the PPPs. Regarding adherence to use of the note template for POAG patients, the median proportion of patients for which the template was used on a single clinic day was 27%, with a maximum of 53% and a minimum of 11%. Conclusions : Based on the input parameters of the number of patients in the sample, the number of treatment successes in that sample, and the target proportion of successfully treated patients, a small sample Bayesian analysis can be used for quality monitoring of patient outcomes for larger patient populations in low-resource clinical settings. Future work includes creation of an open-access database of tables derived from Bayesian analysis for use as a reference by other low-resource clinics in quality monitoring efforts
A virtual COVID-19 ophthalmology rotation
Wendt, Sydney; Abdullah, Zainub; Barrett, Spencer; Daruwalla, Cyrus; Go, Jonathan A; Le, Brandon; Li, Elijah; Livingston, Chelsea; Miller, Matthew; Nakhleh, Lauren; Pecha, Joseph; Pothula, Shravya; Pradhan, Swetak; Sathappan, Varsha; Shah, Alay; Sonuyi, Alan-Michael; Ugoh, Peter; Wang, Qiancheng; Weber, Nicole; Succar, Tony; Blieden, Lauren; Mortensen, Peter; Elkin, Zachary; Sun, Grace; Lee, Andrew G
The coronavirus (COVID-19) pandemic temporarily suspended medical student involvement in clinical rotations, resulting in the need to develop virtual clinical experiences. The cancellation of clinical ophthalmology electives and away rotations reduces opportunities for exposure to the field, to network with faculty, conduct research, and prepare for residency applications. We review the literature and discuss the impact and consequences of COVID-19 on undergraduate medical education with an emphasis on ophthalmic undergraduate medical education. We also discuss innovative learning modalities used from medical schools around the world during the COVID-19 pandemic such as virtual didactics, online cases, and telehealth. Finally, we describe a novel, virtual neuro-ophthalmology elective created to educate medical students on neuro-ophthalmology foundational principles, provide research and presentation opportunities, and build relationships with faculty members. These innovative approaches represent a step forward in further improving medical education in ophthalmology during COVID-19 pandemic and beyond.
Orbital Rosai-Dorfman disease initially diagnosed as IgG4-related disease: a case report
Iyengar, Nishanth S; Golub, Danielle; McQuinn, Michelle W; Hill, Travis; Tang, Karen; Gardner, Sharon L; Harter, David H; Sen, Chandranath; Staffenberg, David A; Thomas, Kristen; Elkin, Zachary; Belinsky, Irina; William, Christopher
Inflammatory orbital lesions include a broad list of diagnoses, many of them with overlapping clinical and radiographic features. They often present a diagnostic conundrum, even to the most experienced orbital specialist, thus placing considerable weight on surgical biopsy and histopathological analysis. However, histopathological diagnosis is also inherently challenging due to the rarity of these lesions and the overlaps in histologic appearance among distinct disease entities. We herein present the case of an adolescent male with a subacutely progressive orbital mass that generated a significant diagnostic dilemma. Early orbital biopsy was consistent with a benign fibro-inflammatory lesion, but corticosteroid therapy was ineffective in halting disease progression. After an initial substantial surgical debulking, histopathological analysis revealed several key features consistent with IgG4-related disease (IgG4-RD), a systemic fibro-inflammatory process typically accompanied by multifocal tumor-like lesions. Surprisingly, within months, there was clear evidence of clinical and radiographic disease progression despite second-line rituximab treatment, prompting a second surgical debulking. This final specimen displayed distinctive features of Rosai-Dorfman disease (RDD), a systemic inflammatory disease characterized by uncontrolled histiocytic proliferation. Interestingly, certain features of this re-excision specimen were still reminiscent of IgG4-RD, which not only reflects the difficulty in differentiating RDD from IgG4-RD in select cases, but also illustrates that these diagnoses may exist along a spectrum that likely reflects a common underlying pathogenetic mechanism. This case emphasizes the importance of surgical biopsy or resection and histopathological analysis in diagnosing-and, ultimately, treating-rare, systemic inflammatory diseases involving the orbit, and, furthermore, highlights the shared histopathological features between RDD and IgG4-RD.
En Face Imaging of Epiretinal Membranes and the Retinal Nerve Fiber Layer Using Swept-Source Optical Coherence Tomography
Greven, Margaret A; Elkin, Zachary; Nelson, Ryan W; Leng, Theodore
BACKGROUND AND OBJECTIVE:To describe en face swept-source optical coherence tomography (SS-OCT) imaging of epiretinal membranes (ERMs) and the underlying retinal nerve fiber layer (RNFL). PATIENTS AND METHODS:SS-OCT images were captured in nine eyes with ERMs. These SS-OCT en face images were qualitatively compared to spectral-domain OCT (SD-OCT) en face images. Using SS-OCT, en face images of the RNFL were obtained, if possible. RESULTS:En face SS-OCT images of ERMs were obtained in all nine eyes of eight individuals with clinically diagnosed ERMs that were superior to SD-OCT images. Clear en face images of the RNFL were acquired in seven of nine eyes (78%) using SS-OCT. CONCLUSIONS:SS-OCT is a novel method for generating en face images of ERMs. Compared with SDOCT en face images, SS-OCT could more clearly identify the plaques and folds of ERMs and underlying defects in the RNFL. Such images could be useful for surgical planning and assessment of the integrity of the underlying RNFL. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:730-734.].
Improving Adherence to National Recommendations for Zoster Vaccination Through Simple Interventions
Elkin, Zachary P; Cohen, Elisabeth J; Goldberg, Judith D; Li, Xiaochun; Castano, Eliana; Gillespie, Colleen; Haberman, Ilyse; Jung, Jesse J; Zabar, Sondra; Park, Lisa; Perskin, Michael H
OBJECTIVE:: In 2011, 15.8% of eligible patients in the United States were vaccinated against herpes zoster (HZ). To increase the usage of the HZ vaccine by studying physicians' knowledge, attitudes, practices, and perceived obstacles after interventions to overcome barriers. METHODS:: General internal medicine physicians were surveyed with a cross-sectional internet survey from October to December 2011 before interventions to increase the use of the HZ vaccine and 1 year later. Interventions included education, increasing availability at the medical center pharmacy, and electronic medical record reminders. Outcome measures included changes in knowledge, attitudes, and practices, and perceived barriers. McNemar chi-square tests were used to compare the changes from the baseline survey for physicians who completed the follow-up survey. RESULTS:: Response rate for the baseline study was 33.5% (89/266) and for the follow-up was 29.8% (75/252). Fifty-five completed both surveys. There was a decrease from 57% at baseline to 40% at follow-up in the proportion of physicians who reported that less than 10% of their patients were vaccinated. They were more likely to know the HZ annual incidence (30% baseline; 70% follow-up; P=0.02), and report having educational information for physicians (7% baseline; 27% follow-up; P=0.003). The top helpful intervention was nursing administration of the vaccine. Average monthly HZ vaccine usage in the affiliated outpatient pharmacy increased in 10 months between surveys by 156% compared with the 3 months before the baseline survey. CONCLUSIONS:: Interventions implemented during the study led to an increase in physicians' basic knowledge of the HZ vaccine and an increase in usage at the affiliated pharmacy.
Studying Physician Knowledge, Attitudes, and Practices Regarding the Herpes Zoster Vaccine to Address Perceived Barriers to Vaccination
Elkin, Zachary; Cohen, Elisabeth J; Goldberg, Judith D; Gillespie, Colleen; Li, Xiaochun; Jung, Jesse; Cohen, Michael; Park, Lisa; Perskin, Michael H
PURPOSE:: To increase usage of the herpes zoster (HZ) vaccine at an academic medical center by studying physicians' knowledge, attitudes, practices, and perceived barriers and analyze the findings by practice setting. METHODS:: A cross-sectional Internet-based survey administered to all 266 general internal medicine physicians in 4 clinical settings at an academic medical center between October 6 and December 12, 2011. Outcomes measures included knowledge questions regarding the disease and vaccine recommendations, Likert-type items about physician attitudes and practices, and questions about barriers and proposed interventions to improve utilization. RESULTS:: Response rate was 33.5% (89 of 266). Responders did not answer all questions. Only 66% (42 of 64) responded that HZ vaccination was an important clinical priority, and 48% (38 of 79) reported that less than 10% of their patients received the HZ vaccine. 95% responded that the influenza (61 of 64) and 92% that the pneumococcal (59 of 64) vaccines were important. Approximately 53% (42 of 79) and 51% (40 of 78) reported that more than 75% of their patients received these vaccines, respectively. Top barrier to vaccination was cost to patients (51 of 66; 77%). Lack of awareness of national recommendations (46 of 65, 71%) varied by setting. Physicians' preferred interventions included nurse-initiated prompting about vaccination (36 of 75, 48%) and chart reminders (34 of 74, 46%). CONCLUSIONS:: Not only increased knowledge but also a change in attitudes and practice are needed to enhance implementation of national recommendations. To improve use of this vaccine, physicians including ophthalmologists need to recommend it more strongly.
Increasing use of the vaccine against zoster through recommendation and administration by ophthalmologists at a city hospital
Jung, Jesse J; Elkin, Zachary P; Li, Xiaochun; Goldberg, Judith D; Edell, Aimee R; Cohen, Michael N; Chen, Kevin C; Perskin, Michael H; Park, Lisa; Cohen, Elisabeth J
PURPOSE: To increase the vaccination rate and identify barriers to administration of the vaccine against herpes zoster by having ophthalmologists screen and provide the vaccine. DESIGN: Prospective interventional cohort study. METHODS: setting: Academic City Hospital, Bellevue Hospital. participants: A total of 100 eligible patients based on recommended Centers for Disease Control (CDC) criteria and ability to speak English and Spanish who received the herpes zoster vaccine were compared with 66 patients who declined the vaccine. interventions: The vaccine was administered after written informed consent was obtained to complete a screening questionnaire evaluating the participants' eligibility and interest in receiving the vaccine. main outcome measures: Barriers to administration of the vaccine were evaluated. RESULTS: A total of 170 consenting patients, including 100 patients who were vaccinated, 66 patients who declined vaccination, and 4 patients who were ineligible, were analyzed. The proportion of subjects who would consider receiving the vaccine if recommended by a doctor among those who received the shingles vaccine, 98.0% (95% CI: 95%-100%), was significantly greater than the proportion in the group that declined, 74.2% (95% CI: 64%-85%) (P = .0001). The most common reason that patients declined the vaccine was wanting to speak with their primary care physician, 46.9% (95% CI: 33%-61%). CONCLUSIONS: Ophthalmologists can screen, educate, and prescribe the vaccine against herpes zoster in order to increase utilization of this vaccine. Nonfinancial or access barriers of this vaccine among underserved eligible patients include absence of recommendation by their primary care doctor.
Smoking cessation knowledge, attitudes, and practice among community health providers in China
Klink, Kathleen; Lin, Susan; Elkin, Zachary; Strigenz, Daniel; Liu, Steven
BACKGROUND:The smoking prevalence is high (32.5%) among male providers in community health centers in Beijing, China. The majority of providers self reported that they advise patients to quit smoking, yet they have low expectations that their counseling is effective in helping patients to quit. Many have not received training on how to advise patients to quit, and half lack knowledge about nicotine replacement. These findings suggest that surveyed providers need more training in tobacco cessation services.
Iritis and iris atrophy after eyebrow epilation with alexandrite laser
Elkin, Zachary; Ranka, Milan P; Kim, Eleanore T; Kahanowicz, Ronit; Whitmore, Wayne G
PURPOSE: To report a case of bilateral iritis and transillumination defects after laser hair removal of the eyebrows with an alexandrite laser. METHODS: A 41-year-old male presented with bilateral eye pain and mild photophobia 2 days after receiving alexandrite (755 nm) laser epilation of both eyebrows. Examination showed visual acuity of 20/20 in both eyes, 2+ conjunctival injection in both eyes, 1+ cells in the anterior chamber of right eye and trace cells in left eye, poor right pupil dilation, and left pupil without movement. Intraocular pressure and fundus examination were normal. He was diagnosed with iritis and iris atrophy, associated with laser epilation. Topical steroids and cycloplegic drops were prescribed for 1 month. RESULTS: After 1 month of treatment, transillumination defects remained in both eyes, but greater in right. In dim light, the right pupil was 4 mm and oval and the left pupil was 6 mm and round. Visual acuity remained 20/20 in both eyes. CONCLUSION: Laser hair removal of the eyebrows can lead to permanent ocular damage even with eye protection, and should be avoided.