Purpose
To assess trends in prevalence of diagnosed ocular disease and use of eye care services in the Veterans Affairs (VA) health care system.
Design
Prevalence study.
Methods
We performed a retrospective study of all eligible veterans in the VA Capitol Health Care Network from 2007 to 2011. The VA database was used to abstract demographic and socioeconomic variables, including age, race, sex, marital status, service connection, prescription copay, homelessness, and VA facility. Primary outcome measures were the prevalence of diagnosed ocular disease and use of eye care. Ocular diagnoses were determined by International Classification of Diseases, 9th revision codes and use by prescription medication fills, visits to eye care clinics, and cataract surgery frequency.
Results
The average age of veterans ranged from 59.8–60.9, most veterans were male (88.1–89.8%), and there was a high proportion of African Americans (29.5–30%). The prevalence of all ocular diagnoses increased from 20.5% in 2007 to 23.3% in 2011 ( P < .01), a 13.7% increase. Similarly, the prevalence of diagnosed cataract increased by 35.7% ( P = .02) from 7.1% in 2007 to 9.6% in 2011. Diagnosed glaucoma prevalence increased by 9.4% ( P = .03) from 6.7 to 7.4%. The percent of patients seen in eye clinics increased 11.6%% in the 5-year study period to 24.0% in fiscal year 2011 ( P = .05). The use of ophthalmic medications increased 20% ( P < .01). The rate of cataract surgery did not change significantly during the study period.
Conclusions
The prevalence of diagnosed eye conditions among American Veterans is increasing, as is the use of eye care services. Cataract surgery rates did not increase, which may indicate a need to increase availability of these services.
As the US veteran population ages, ensuring that this population has access to routine eye care and surveillance and treatment for ocular diseases will require increased resources for the Department of Veterans Affairs (VA) health care system. The Veterans Health Administration is the largest integrated health care system in the United States, with >1700 sites of care, serving 8.76 million veterans each year, nearly half of whom are >65 years of age. Given the higher prevalence of age-related eye diseases that come with an aging population, there is a growing need for eye care services in the VA system. Indeed, from 2006–2010 there was a 19.4% increase in number of veterans seen in VA optometry or ophthalmology clinics nationally, with some regions seeing a >50% increase in eye clinic use. Regular eye care is necessary to prevent potentially blinding conditions that come at a high cost in terms of individual disability and cost to the VA system.
Information about the characteristics of veterans with eye conditions and prevalence trends for specific eye conditions is currently lacking. Few studies have assessed the prevalence of ocular disease in the veteran population, and none to our knowledge have focused on the overall diagnosed prevalence of ocular disease in veterans at multiple sites. Determination of the diagnosed prevalence of ocular disease in veterans is of particular importance so that the VA can appropriately allocate resources to treat and prevent potentially blinding conditions. In addition, recent legislation allowing veterans to seek care privately means that the prevalence of ocular disease in this population is more relevant to the general medical community. To our knowledge, this is the first study to assess comprehensively the prevalence of ocular disease among patients in multiple VA sites over multiple years.
Methods
We conducted a retrospective review of veterans in the VA Capitol Health Care Network (VISN 5) from 2007–2011. Data for this study were obtained from the VA pharmacy and health care use databases for patients seen from fiscal year (FY) 2007 to FY 2011 in VISN 5, the service region that encompasses Maryland, Washington, DC, Northern Virginia, Northeastern West Virginia, and portions of Pennsylvania. This area is served by 4 VA hospitals and by a network of freestanding VA hospital–affiliated outpatient medical clinics. This study was approved by the Institutional Review Board of the University of Maryland, Baltimore, and the VA Research Committee of the VA Maryland Health Care System. Data used for this study included administrative encounter records of inpatient and outpatient health services provided within VA facilities and medications dispense by VA pharmacies. Records include information on patient demographic characteristics, International Classification of Diseases, 9th revision (ICD-9) diagnostic codes, types and locations of inpatient and outpatient health services, and medications dispensed.
The sample included all veterans in the VA Capitol Health Care Networks who had ≥2 contacts (ie, inpatient or outpatient) with the VA system in each year from FY 2007 to FY 2011. Demographic and VA health care characteristics recorded included age, race, sex, marital status, service connection, prescription copay, homelessness, VA facility location, diabetes diagnosis, and psychotic disorder diagnosis. Race was assigned based on designation at any point in the study period. Patients were classified as diabetic if they had ≥2 inpatient or outpatient records with diagnostic codes of 250.0–250.9, 357.2, 362.0, or 366.41, a method previously validated for VA data. Ophthalmic diagnoses were abstracted from ICD-9 codes assigned at each visit.
Ophthalmic diagnoses of interest included glaucoma, ophthalmic complications of diabetes, and cataract. ICD-9 codes used for these diagnoses were derived from a previous paper on the prevalence of eye disease among diabetics in the VA system and are listed in Appendix 1 . Eye care services use was assessed by frequency of clinic visits to ophthalmology or optometry (ie, VA clinic stop codes 407 and 408), prescription fills, and cataract surgery use. The cataract surgery use rate was calculated as the rate of cataract surgeries performed per diagnosed cataract. Ocular medications were categorized using the VA pharmacy classification system, and we specifically assessed if a veteran had been prescribed ≥1 prescription fill of glaucoma medications (ie, VA pharmacy code OP109), eye lubricants for dry eye (ie, OP500), and overall ocular medication use (ie, OPXXX). Frequency of cataract surgeries were recorded using both Current Procedural Terminology codes (66850–66984) and ICD-9 procedure codes (13.2x–13.5x). Service connection in the VA system indicates that the diagnosis being treated is connected to the veterans’ service and care related to that illness is covered by the VA insurance system. Veterans with >50% service connection do not pay a prescription copay. The frequency of each variable, including demographics, prevalence, and use, was determined in each individual year. Select ocular diagnoses were stratified by race and age for each FY. The prevalence of diabetic retinopathy was calculated both overall and among diabetics. The change of frequency in each variable as a percentage was determined from FY 2007 to FY 2011 for each variable using regression analysis. Statistical significance of trends was determined and represented on Tables 1–3 . SPSS software (IBM, Chicago, IL) was used for statistical analysis.
| Variable | Fiscal Year | β | P Value | ||||
|---|---|---|---|---|---|---|---|
| 2007 (N = 130,709) | 2007 (N = 130,709) | 2007 (N = 130,709) | 2007 (N = 130,709) | 2007 (N = 130,709) | |||
| Age, y (±SD) | 60.9 ± 16.4 | 60.6 ± 16.6 | 60.2 ± 16.5 | 59.9 ± 16.8 | 59.8 ± 16.9 | ||
| Sex, n (%) | |||||||
| Male | 117,380 (89.8) | 116,368 (89.0) | 121,300 (88.5) | 124,998 (88.3) | 127,247 (88.1) | −0.41 | .01 |
| Female | 13,329 (10.2) | 14,411 (11.0) | 15,758 (11.5) | 16,557 (11.7) | 17,148 (11.9) | ||
| Race | |||||||
| White | 58,737 (44.9) | 58,791 (45.0) | 61,913 (45.2) | 64,069 (45.3) | 65,549 (45.4) | 0.13 | .01 |
| African American | 38,908 (30.0) | 39,042 (29.9) | 40,918 (29.9) | 42,201 (29.8) | 42,545 (29.5) | −0.11 | .04 |
| Other | 33,064 (25.3) | 32,946 (25.2) | 34,227 (25.0) | 35,285 (24.9) | 36,301 (25.1) | −0.07 | .19 |
| Married | 62,455 (47.8) | 63,102 (48.3) | 65,155 (47.5) | 66,664 (47.1) | 68,039 (47.1) | −0.26 | .10 |
| Service connection | 89,586 (68.5%) | 87,565 (66.9) | 93,146 (70.0) | 96,849 (68.4) | 98,928 (68.5) | 0.15 | .73 |
| Prescription copay | 20,858 (16.0%) | 21,900 (16.7) | 25,384 (18.5) | 27,816 (19.7) | 30,155 (20.9) | 1.28 | <.01 |
| Homeless | 3655 (2.8) | 3861 (3.0) | 4429 (3.2) | 5048 (3.6) | 5781 (4.0) | 0.30 | <.01 |
| VISN 5 facility | |||||||
| Maryland | 47,387 (36.3) | 48,867 (37.4) | 47,972 (35.0) | 48,186 (34.0) | 48,295 (33.4) | −0.92 | .05 |
| Washington, DC, Virginia, and West Virginia | 83,322 (63.7) | 81,932 (62.6) | 89,086 (65.0) | 93,369 (66.0) | 96,100 (66.6) | ||
| Diabetes | 25,471 (19.4) | 25,465 (19.5) | 26,005 (19.0) | 27,002 (19.1) | 27,664 (19.9) | 0.06 | .67 |
Variable | Fiscal Year | β | P Value | ||||
|---|---|---|---|---|---|---|---|
| 2007 (N = 130,709) | 2007 (N = 130,709) | 2007 (N = 130,709) | 2007 (N = 130,709) | 2007 (N = 130,709) | |||
| Disease category, n (%) | |||||||
| Disorders of refraction and accommodation | 11,067 (8.5) | 12,046 (9.2) | 14,150 (10.3) | 16,078 (11.4) | 18,854 (13.1) | 1.13 | <.01 |
| Glaucoma | 8815 (6.7) | 9003 (6.9) | 9494 (6.9) | 9921 (7.0) | 10,431 (7.4) | 0.14 | .03 |
| Ophthalmic complications of diabetes | 2896 (2.2) | 3180 (2.4) | 3065 (2.2) | 2952 (2.1) | 2908 (2.0) | −0.07 | .148 |
| Cataract | 9215 (7.1) | 8827 (6.7) | 11,292 (8.2) | 12,050 (8.5) | 13,529 (9.6) | 0.68 | .02 |
| Any ophthalmic diagnosis | 26,804 (20.5) | 27,552 (21.1) | 29,677 (21.5) | 31,460 (22.2) | 33,611 (23.3) | 0.67 | <.01 |
| Variable | Fiscal Year | β | P Value | ||||
|---|---|---|---|---|---|---|---|
| 2007 (N = 130,709) | 2008 (N = 130,779) | 2009 (N = 137,958) | 2010 (N = 141,555) | 2011 (N = 144,395) | |||
| Clinic use, n (%) | |||||||
| Seen in ophthalmology or optometry during FY | 28,187 (21.5) | 28,560 (21.8) | 30,053 (21.8) | 31,746 (22.4) | 33,974 (24.0) | 0.56 | .05 |
| Medication use, n (%) | |||||||
| Glaucoma medications | 7319 (5.6) | 7765 (5.9) | 7604 (5.5) | 6271 (4.4) | 9662 (6.6) | 0.07 | .83 |
| Eye lubricants (ie, artificial tears) | 4508 (3.5) | 4796 (3.7) | 5557 (4.1) | 6419 (4.5) | 7380 (5.1) | 0.42 | <.01 |
| Any ophthalmic medication | 11,056 (8.5) | 11,468 (8.8) | 12,414 (9.0) | 13,388 (9.5) | 14,727 (10.2) | 0.42 | <.01 |
| Procedure use, n (%) | |||||||
| Cataract extraction | 811 (0.6) | 831 (0.6) | 862 (0.6) | 965 (0.7) | 989 (0.7) | 0.03 | .06 |
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