Date of Award

January 2021

Document Type

Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Kristen Nwanyanwu

Abstract

The frequency of emergency department (ED) presentations for ophthalmic conditions has continued to rise in the US. Many ocular conditions are self-resolving and do not require specialized care. However, follow-up care is still important for patients due to potential misdiagnoses in the ED, or incorrect treatment regimens. Furthermore, ED encounters represent an opportunity to bring patients with chronic ocular conditions into care for long-term monitoring and management. Therefore, adequate follow-up is an important aspect of care for ophthalmic ED visits. This study included 2,206 patients seen in the ED for an eye-related issue who were subsequently scheduled for ophthalmology follow-up between 2013-2019 at a single tertiary health system in New Haven, CT. The main outcome measures were the frequency of and risk factors for loss to follow-up (LTFU) and ED revisits. In total, 1649 (74.8%) completed follow-up within 2-months of an index ED visit. On multivariable analysis, younger age (p<0.001), a nonurgent ophthalmic condition or non-ophthalmic primary diagnosis (p<0.001), scheduled follow-up >5 days after the ED visit (p<0.001), additional follow-up appointments (<0.001), no prior history of ophthalmology appointments (p=0.045), visual acuity of 20/40 or better (p=0.027), and having Medicaid or being uninsured (p<0.001) were significantly associated with LTFU. The presence of an interpreter significantly increased the likelihood of follow-up among non-English speaking patients (p<0.001). The ED revisit within 4-months of an index visit was significantly higher for patients LTFU versus those who completed follow-up (5.7% vs. 1.1%; p<0.001). A quarter of patients referred for ophthalmic care following an ED presentation were LTFU. We identified multiple factors associated with LTFU that could be used to develop interventions to enhance follow-up. In a follow-up national-level analysis to identify ED revisit rates for ocular conditions, we used a claims-based cohort (IBM MarketScan Research Databases) of patients with commercial insurance who had visited the ED between 2007-2016 for a primary ophthalmic diagnosis in the US. We found that the 3- and 30-day revisit for the overall cohort was 2.5% and 4.1% respectively. Conditions of the cornea and external disease comprised the majority of index diagnosis (65.2%) but were associated with low rates of 30-day revisit (3.1%). Thirty-day revisits rates were highest for conditions related to cataract and lens disorders (28.3%) as well as glaucoma (15.9%). Notably, nearly all (99%) patients revisiting the ED with cataract and lens disorders had a cataract-related procedure within 30 days of the index encounter. In multivariable analysis, younger adults, those with insurance plans lacking out-of-network coverage and cases involving an ophthalmologist were associated with a significantly higher likelihood of a revisit within 3-days of an index visit. ED revisits for ocular conditions may be preventable with timely follow-up care, particularly for patients presenting in the acute post-operative period following cataract surgery.

Comments

This thesis is restricted to Yale network users only. This thesis is permanently embargoed from public release.

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