Physician Compliance With the HEDS Recommendation of Antiviral Prophylaxis in Patients Diagnosed With Herpetic Stromal Keratitis at KEI Sameen Zaidi M.D. - PGY-4 Amanda Ismail - MS3 Frank Hwang M.D. The authors have no financial interest to disclose

 Infection of the eye by herpes simplex virus (HSV) is a leading cause of corneal blindness in the United States and other countries.  The infection can lead to corneal scarring and neovascularization, permanent endothelial dysfunction, corneal edema, secondary glaucoma, and cataract. Introduction

Acyclovir Prevention Trial: HEDS-APT evaluated the benefit of long-term acyclovir treatment in patients with a recent history of HSV eye disease but no current active disease. To be eligible, a patient must have experienced any kind of ocular herpes simplex infection (blepharitis, conjunctivitis, keratitis, or iridocyclitis) in the preceding year. The infection must have been inactive and untreated for at least the previous 30 days. Patients were randomized to receive either oral acyclovir (400 mg twice a day) or placebo for 1 year  The cumulative probability of a recurrence of any type of ocular HSV disease during the 12- month treatment period was 19 percent in the acyclovir group and 32 percent in the placebo group (P<0.001).  Among the 337 patients with a history of stromal keratitis, the cumulative probability of re- current stromal keratitis was 14 percent in the acyclovir group and 28 percent in the placebo group (P=0.005).  There was no rebound in the rate of HSV disease in the six months after treatment with acyclovir was stopped. Herpetic Eye Disease Study

  To assess physician compliance with the Herpetic Eye Disease Study’s recommendation of antiviral prophylaxis in preventing recurrences of HSV disease at our institution.  Our hypothesis is that there is 100% physician compliance with the Herpetic Eye Disease Study’s antiviral prophylaxis recommendation. Purpose of Study

Inclusion Criteria:  Age >18,  Clinical diagnosis of Herpetic stromal keratitis Exclusion criteria:  Any ocular or systemic medical condition that may, in the opinion of the investigator, preclude safe administration of oral antivirals.  Pediatric age group. Recruiting:  Retrospective chart review ( 2007-present), after IRB approval.  Corneal ulcer, Corneal opacity and Herpes Simplex Keratitis - Billing codes were used to select charts.  2,200 charts were reviewed out of which 76 charts were selected for analysis.  Approximately 25 charts were excluded from the study conforming to our exclusion criteria. Method

Consent:  A consent was not necessary as there was no planned intervention. Confidentiality:  All patients were assigned a numerical code and only PI and associate PI were privy to the code/patient relationship. The information was kept in a password protected file which will be destroyed at the end of chart review and analysis. Data collection:  Age, Gender, Ethnicity, Ocular history, Medical history, Treatment plan of herpetic stromal keratitis and Clinic location (private clinic or resident’s clinic)  The primary outcome was prescription of oral prophylactic anti-viral to patients who were diagnosed with ocular HSV stromal keratitis in the preceding year. Statistical Analysis:  Chi Squared test Method

Results C: Caucasian, AA: African American, ME: Middle Eastern, NS: Not Specified in EMR N = 76

Results: Treatment by Clinic Type  The chart looks at patients by clinic type  Of all the patients who went to Private Clinic, 79.5% were treated appropriately  Of all the patients who went to Resident Clinic, 83.7% were treated appropriately  P-value :  No significant difference was found between the two groups. N = 39N = 37

Results: Treatment in Private Clinic: Cornea Specialist vs. non Cornea Specialist  The chart looks at patients in PC, by K Specialist or non K Specialist  Of all the patients who were seen by a non K Specialist, 69.2 % of them were treated appropriately  Of all the patients who were seen by a K Specialist, 85.7% of them were treated appropriately  P-value:  No significant difference between the two groups was observed. N = 13N = 42

 16 out of 76 (21%) patients with a diagnosis of herpetic stromal keratitis were not prescribed antiviral prophylaxis  Of the 16: 6 (37.5%)were treated in Resident’s clinic and 10 (62.5%) were managed in Private clinic respectively.  Of the 10: 6 (60%) were treated by a cornea specialist and 4 (40%) were treated by a non cornea specialist.  Of the 62 patients who were prescribed antiviral prophylaxis, 31 (50%) were seen in private clinic while 31 (50%) were seen in resident’s clinic. Results

 There is 81.6% physician compliance with the HEDS – Acyclovir Prevention Trial at our institution.   Cornea specialists had higher rates of compliance compared to non- cornea specialists.  We did not observe any  We did not observe any statistical significance in rates of compliance in private compared to resident clinics or cornea specialists compared to non-cornea specialists.  Next steps include:  Increase the sample size by including more related CPT codes.  Assessing the reason for non compliance.  Addressing the reason for non compliance.  Gain insight into physician Knowledge, Attitude, and Practice. Conclusion

Positives and Negatives Study Positives:  One of the first studies to survey compliance with Herpetic Eye Disease Study, hoping that it leads to formal standardized protocol formation for physicians to follow to reach 100% compliance. Study Negatives:  No statistical significance in the comparison of clinic type (RC vs. PC) or specialist (K vs. non-K)  Study is underpowered. Data collection will be continued.  Snap-shot analysis of data collected at one facility