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September Ophthalmology research highlights

SAN FRANCISCO, CA--- Doctors and medical centers across the United States are debating the use of electronic health records (EHR). This months Ophthalmology, the journal of the American Academy of Ophthalmology, provides a look at Eye M.D.s actions and opinions on the issue. Also highlighted this month are two research studies that will help doctors identify patients who are most vulnerable to advanced age-related macular degeneration (AMD), the leading cause of severe vision loss in the United States and most Western countries.

Academy Sponsors First Study of Electronic Health Records Use by US Ophthalmologists

Health care professionals today need systems that consolidate information and simplify its transmission: research and clinical knowledge are rapidly expanding, treatments are increasingly complex, most patients are seen by multiple caregivers, and the aging United States population will soon need care for chronic illnesses over long time periods. The Institute of Medicine, under the charter of the National Academy of Sciences, considers electronic health records (EHR) key to improving health care, as medication and treatment errors and other adverse events would likely decrease significantly if EHR were in widespread use. EHR are particularly relevant to specialties that rely heavily on diagnostic images and technical data, such as ophthalmology. A recent study by the American Academy of Ophthalmology is the first to assess use of EHR by U.S. ophthalmologists (Eye M.D.s).

The study collected and analyzed the responses of 592 Academy member ophthalmologists who voluntarily completed a standardized survey online or in a telephone interview in March 2006; the full study group was 3,800 randomly selected members. The survey tracked ophthalmologists EHR use (implemented, in process, planned, not planned), importance or value to the user of a variety of EHR features, patient and practice demographics, and system details in practices using EHR.

Of the surveyed practices 12 percent had EHR systems in place, 7 percent were in the implementation process, and 10 percent had plans to do so within 12 months. Among practices with EHR: 69 percent were satisfied or extremely satisfied; 64 percent reported increased or stable productivity; 51 percent reported decreased or stable overall costs; and 76 percent would recommend the use of EHR to fellow ophthalmologists. EHR features rated as most valuable were similar among users and included improved patient care and billing/charge collection. The EHR adoption rate among ophthalmologists is similar to that of other U.S. medical specialties, which is 13 to 15 percent; in contrast, EHR implementation is nearly universal in Europe and the United Kingdom, the researchers noted.

Given these positive findings, why is EHR use still limited among U.S. ophthalmologists? Survey respondents cited high initial investments of money and physician time to select and implement an EHR system as the main barriers. Physicians realize that to be highly beneficial, EHR must be in nearly universal use. New government initiatives could hasten this: the House of Representatives Energy and Commerce Committee recently approved health information technology legislation that would provide incentives for physician adoption of EHR. In addition, the National Health Information Infrastructure initiative of the Department of Health and Human Services is working to build a distributed network of government EHR that would support retrospective research, prospective clinical trials, and early detection of epidemic or bioterrorism disease outbreaks.

CAPT Study Findings on Advanced AMD

The Complications of Age-Related Macular Degeneration Prevention Trial (CAPT) was a multicenter randomized clinical trial (conducted from 1999 to 2005) that investigated whether low-intensity laser treatment could prevent vision loss in patients with early stage age-related macular degeneration (AMD). The advanced stages of AMD destroy the macula in the eyes retina, the area that normally provides the detailed, central vision we rely on for reading, driving and other daily tasks. This clinical trial, sponsored by the National Eye Institute, did not show that the laser treatment was effective in preventing loss of vision, but the results did provide valuable information on factors that predict progression to advanced AMD.

Patients with early AMD whose eyes have many large drusen---abnormal, white-yellow deposits that accumulate under the retina---are known to be at higher risk for developing one or both forms of advanced AMD: choroidal neovascularization (CNV), known as wet AMD, and/or geographic atrophy (GA), known as advanced dry AMD. CAPT is the first study large enough to look separately at risk factors for the development of CNV and of advanced GA in AMD patients with extensive drusen in both eyes. The 1,052 CAPT participants each had 10 or more large drusen and visual acuity of 20/40 or better in each eye at the study outset. Each patient received low-intensity laser treatment in one eye only; the other eye was observed. Follow-up exams took place yearly for five or six years. CAPT concluded that laser treatment did not change the risk of developing CNV, GA, or loss of visual acuity.

Analysis of the CAPT results allowed researchers to identify factors that predicted the risk of progression from early to advanced AMD. They found that some factors were associated with both forms of advanced AMD and others with only one form. Increased age and pigment clumps in the retina were associated with the development of both CNV and GA . Current, but not past, smoking was linked to a higher risk of CNV, indicating that smoking is likely an active stimulus to CNV. The size of the retinal area covered by drusen and the presence of lightly pigmented areas in the retina were associated only with progression to GA. These findings increase the understanding of how CNV and GA develop and aid ophthalmologists in discussing prognosis with patients who have many large drusen, said Maureen G. Maguire, Ph.D., Professor of Ophthalmology, University of Pennsylvania Health System, and, corresponding author on the risk factors study.

AMD and Vision Loss: Low-Luminance Study Yields a New Predictive Tool

Janet S. Sunness, M.D., Director of the Hoover Low Vision Services at the Greater Baltimore Medical Center, and her fellow researchers have discovered a simple and inexpensive way to predict the rapid loss of visual acuity, the ability to see detail, in dry AMD patients. Of patients with GA who have visual acuity of 20/50 or better, about one-quarter become legally blind within four years. Other GA patients never progress to severe vision loss. The ability to identify GA patients at highest risk is important to patient care as well as future AMD research. Dr. Sunness study evaluated GA patients who began the study with 20/50 or better vision; their performance under low luminance, or low-light conditions, strongly predicted whether they would suffer significant loss of visual acuity within two years. This study was the first to quantify predictive values for low luminance visual acuity deficit and describe the importance of this predictive tool for GA patient screening.

It is known that the visual function of GA patients is significantly worse in low-light conditions. In annual exams over the two-year study period, Dr. Sunness team measured the patients standard visual acuity, the ability to read lines on a chart under regular testing conditions, and then repeated this measurement with the patient wearing moderate gray sunglasses (2 log unit neutral density filter). On average, elderly patients without GA were able to see two fewer lines with the filter in place, while GA patients with 20/50 vision or better at baseline saw five fewer lines. The 91 study participants were a cohort of a larger 1992 to 2000 National Institutes of Health-funded study, directed by Dr. Sunness, of the natural history of GA progression at the Wilmer Eye Institute at Johns Hopkins School of Medicine.

The participants with the worst low-luminance deficit (LLD) at baseline were significantly more likely to have lost visual acuity by the end of the study than the better LLD group. Contrast sensitivity and reading speed were also measured for participants; the retinas were photographed; the eyes were examined for AMD progression; and the total area of GA in each eye was determined. Another predictor of visual acuity loss was a significantly reduced reading rate at baseline. Factors that did not predict visual acuity loss in these patients included: age, gender, the GA total area at baseline, or the rate of GA enlargement during the study period.

GA is a public health issue that deserves heightened attention and research, Dr. Sunness says, as the disorder causes more severe vision loss than diabetic macular edema, a well-recognized public health problem, and as treatment or prevention of GA is not currently available. Also, GA affects both eyes for most patients, resulting in vision loss that is more devastating than when eye disorders affect one eye only.


Contact: Mary Wade
American Academy of Ophthalmology

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