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We examined the results of the 2020 skilled nursing facility (SNF) value-based purchasing (SNF VBP) program to identify correlates and potential drivers of SNF performance in this program. The SNF VBP program provides incentive payments to SNFs based on their performance on a risk-adjusted hospital readmission measure (i.e., the rate at which SNF residents are admitted back to the hospital within 30-days of being admitted to the SNF). SNFs are assessed on this measure for both improvement compared to their historical baseline and overall achievement compared to their peers. All SNFs that are covered under Medicare’s prospective payment system are included in the SNF VBP program. We performed analyses to assess the correlation between individual SNFs’ performance in the 2020 SNF VBP (n=15,201), which is based on actual performance in fiscal year 2018, with contemporaneous matched data related to SNF health inspection results, staffing, and performance on quality measures (these data form the basis of the five-star quality rating system on the Nursing Home Compare website). We also examined longitudinal trends in these non-SNF VBP program variables and their association with changes in SNF performance in the SNF VBP program. We controlled for important SNF-specific factors (e.g., for-profit status, connected to a hospital). We found strong contemporaneous and longitudinal associations between SNF VBP program performance and some, but not all, of these factors. Our findings are supported by decades of empirical research in SNF quality and highlight potential policy alternatives that could further incentivize high quality care in SNFs.

The primary objective of this study is to evaluate the impact of various cropping and nutrient management systems on drainage water quality and crop yields. Treatment comparisons evaluate the impact of liquid swine manure application timing, nitrification inhibitor with late fall swine manure application, cereal rye cover crop, and gypsum application. These comparisons will be conducted for multiple years and used to develop appropriate manure and nutrient management practices in order to minimize water contamination potential and enhance the use of swine manure as a nutrient resource.

Background and Objective: A novel computer-guided laser treatment for open-angle glaucoma, called patterned laser trabeculoplasty, and its preliminary clinical evaluation is described. Patients and Methods: Forty-seven eyes of 25 patients with open-angle glaucoma received 532-nm laser treatment with 100-μm spots. Power was titrated for trabecular meshwork blanching at 10 ms and sub-visible treatment was applied with 5-ms pulses. The arc patterns of 66 spots rotated automatically after each laser application so that the new pattern was applied at an untreated position. Results: Approximately 1,100 laser spots were placed per eye in 16 steps, covering 360° of trabecular meshwork. The intraocular pressure decreased from the pretreatment level of 21.9 ± 4.1 to 16.0 ± 2.3 mm Hg at 1 month (n = 41) and remained stable around 15.5 ± 2.7 mm Hg during 6 months of follow-up (n = 30). Conclusion: Patterned laser trabeculoplasty provides rapid, precise, and minimally traumatic (sub-visible) computer-guided treatment with exact abutment of the patterns, exhibiting a 24% reduction in intraocular pressure during 6 months of follow-up ( P < .01).

Poster: "ECR 2009 / C-796 / Main factors influencing the use of testes shields during X-ray examinations in major hospitals in Norway and Denmark" by: "E. Stranden, D. A. Andersen, E. Bergwitz-Larsen, J. A. Eriksen, J. B. Hydal; Drammen/NO"

Purpose To compare 2 optical patient interface designs used for femtosecond laser–assisted cataract surgery. Setting Optimedica Corp., Santa Clara, California, USA, and Centro Laser, Santo Domingo, Dominican Republic. Design Experimental and clinical studies. Methods Laser capsulotomy was performed during cataract surgery with a curved contact lens interface (CCL) or a liquid optical immersion interface (LOI). The presence of corneal folds, incomplete capsulotomy, subconjunctival hemorrhage, and eye movement during laser treatment were analyzed using video and optical coherence tomography. The induced rise of intraocular pressure (IOP) was measured in porcine and cadaver eyes. Results Corneal folds were identified in 70% of the CCL cohort; 63% of these had areas of incomplete capsulotomies beneath the corneal folds. No corneal folds or incomplete capsulotomies were identified in the LOI cohort. The mean eye movement during capsulotomy creation (1.5 sec) was 50 μm with a CCL and 20 μm with an LOI. The LOI cohort had 36% less subconjunctival hemorrhage than the CCL cohort. During suction, the mean IOP rise was 32.4 mm Hg ± 3.4 (SD) in the CCL group and 17.7 ± 2.1 mm Hg in the LOI group. Conclusions Curved contact interfaces create corneal folds that can lead to incomplete capsulotomy during laser cataract surgery. A liquid interface eliminated corneal folds, improved globe stability, reduced subconjunctival hemorrhage, and lowered IOP rise. Financial Disclosure Drs. Talamo, Culbertson, Batlle, Feliz, and Palanker are consultants to and Messrs. Gooding, Angeley, Schuele, Marcellino, and Andersen, and Ms. Essock-Burns are employees of Optimedica Corp., Sunnyvale, California, USA.

About a third of people in the developed world will undergo cataract surgery in their lifetime. Currently, cataract surgery is a manual procedure highly dependent on the surgical skills and complicating factors. We developed and tested an image-guided laser system to improve the precision and reproducibility of cataract surgery. A long-range Optical Coherence Tomography automatically discerns the anterior and posterior surfaces of the lens and cornea, and a co-registered femtosecond laser then performs capsulotomy, lens segmentation and corneal incisions. Capsular strength following laser capsulotomy and mechanical capsulorhexis were compared on cadaveric eyes, and retinal safety was verified on rabbits. 50 patients have undergone cataract surgery using the laser system. Eyes were examined ophthalmoscopically, and extracted capsules were analyzed using histology and SEM.

About one-third of people in the developed world will undergo cataract surgery in their lifetime. Although marked improvements in surgical technique have occurred since the development of the current approach to lens replacement in the late 1960s and early 1970s, some critical steps of the procedure can still only be executed with limited precision. Current practice requires manual formation of an opening in the anterior lens capsule, fragmentation and evacuation of the lens tissue with an ultrasound probe, and implantation of a plastic intraocular lens into the remaining capsular bag. The size, shape, and position of the anterior capsular opening (one of the most critical steps in the procedure) are controlled by freehand pulling and tearing of the capsular tissue. Here, we report a technique that improves the precision and reproducibility of cataract surgery by performing anterior capsulotomy, lens segmentation, and corneal incisions with a femtosecond laser. The placement of the cuts was determined by imaging the anterior segment of the eye with integrated optical coherence tomography. Femtosecond laser produced continuous anterior capsular incisions, which were twice as strong and more than five times as precise in size and shape than manual capsulorhexis. Lens segmentation and softening simplified its emulsification and removal, decreasing the perceived cataract hardness by two grades. Three-dimensional cutting of the cornea guided by diagnostic imaging creates multiplanar self-sealing incisions and allows exact placement of the limbal relaxing incisions, potentially increasing the safety and performance of cataract surgery.

PURPOSE: To evaluate the safety, selectivity, and healing of retinal lesions created using a continuous line scanning laser. METHODS: A 532-nm Nd:YAG laser (PASCAL) with retinal beam diameters of 40 μm and 66 μm was applied to 60 eyes of 30 Dutch-belted rabbits. Retinal exposure duration varied from 15 μs to 60 μs. Lesions were acutely assessed by ophthalmoscopy and fluorescein angiography. Retinal pigment epithelial (RPE) flatmounts were evaluated with live-dead fluorescent assay. Histological analysis was performed at 7 time points from 1 hour to 2 months. RESULTS: The ratios of the threshold of rupture and of ophthalmoscopic visibility to fluorescein angiography visibility (measures of safety and selectivity) increased with decreasing duration and beam diameter. Fluorescein angiography and live-dead fluorescent assay yielded similar thresholds of RPE damage. Above the ophthalmoscopic visibility threshold, histology showed focal RPE damage and photoreceptor loss at 1 day, without inner retinal effects. By 1 week, photoreceptor and RPE continuity was restored. By 1 month, photoreceptors appeared normal. CONCLUSION: : Retinal therapy with a fast scanning continuous laser achieves selective targeting of the RPE and, at higher power, of the photoreceptors without permanent scarring or inner retinal damage. Continuous scanning laser can treat large retinal areas within standard eye fixation time.

Objective: To systematically evaluate the effects of laser beam size, power, and pulse duration of 1 to 100 milliseconds on the characteristics of ophthalmoscopically visible retinal coagulation lesions. Methods: A 532-nm Nd:YAG laser was used to irradiate36retinasinDutchBeltrabbitswithretinalbeamsizes of 66, 132, and 330 µm. Lesions were clinically graded 1 minute after placement, their size measured by digital imaging, and their depth assessed histologically at different time points. Results: Retinal lesion size increased linearly with laser power and logarithmically with pulse duration. The width of the therapeutic window, defined by the ratio of the threshold power for producing a rupture to that of a mild coagulation, decreased with decreasing pulse durations.For132-and330-µmretinalbeamsizes,thetherapeutic window declined from 3.9 to 3.0 and 5.4 to 3.7, respectively, as pulse duration decreased from 100 to 20 ms. At pulse durations of 1 millisecond, the therapeutic window decreased to unity, at which point rupture and a mild lesion were equally likely to occur. Conclusions:At shorter pulse durations, the width and axial extent of the retinal lesions are smaller and less dependent on variations in laser power than at longer durations. The width of the therapeutic window, a measure of relative safety, increases with the beam size. Clinical Relevance: Pulse durations of approximately 20millisecondsrepresentanoptimalcompromisebetween the favorable impact of speed, higher spatial localization, andreducedcollateraldamageononehand,andsufficient width of the therapeutic window (3) on the other.

Pan-retinal photocoagulation in patients with diabetic retinopathy typically involves application of more than 1000 laser spots; often resulting in physician fatigue and patient discomfort. We present a semi-automated patterned scanning laser photocoagulator that rapidly applies predetermined patterns of lesions; thus, greatly improving the comfort, efficiency and precision of the treatment. Patterns selected from a graphical user interface are displayed on the retina with an aiming beam, and treatment can be initiated and interrupted by depressing a foot pedal. To deliver a significant number of burns during the eye's fixation time, each pulse should be considerably shorter than conventional 100ms pulse duration. We measured coagulation thresholds and studied clinical and histological outcomes of the application of laser pulses in the range of 1-200ms in pigmented rabbits. Laser power required for producing ophthalmoscopically visible lesions with a laser spot of 132mm decreased from 360 to 37mW with pulse durations increasing from 1 to 100ms. In the range of 10-100ms clinically and histologically equivalent light burns could be produced. The safe therapeutic range of coagulation (ratio of the laser power required to produce a rupture to that for a light burn) decreased with decreasing pulse duration: from 3.8 at 100ms, to 3.0 at 20ms, to 2.5 at 10ms, and to 1.1 at 1ms. Histology demonstrated increased confinement of the thermal damage with shorter pulses, with coagulation zone limited to the photoreceptor layer at pulses shorter than 10ms. Durations of 10-20ms appear to be a good compromise between the speed and safety of retinal coagulation. Rapid application of multiple lesions greatly improves the speed, precision, and reduces pain in retinal photocoagulation.

It is well known that the use of tightly focused continuous wave lasers can be an effective treatment of common telangiactasia. In general, the technique requires the skills of a highly dexterous surgeon using the aid of optical magnification. Due to the nature of this approach, it has proven to be largely impractical. To overcome this, we have developed an automated system that alleviates the strain on the user associated with the manual tracing method. The device makes use of high contrast illumination, simple monochromatic imaging, and machine vision to determine the location of blood vessels in the area of interest. The vessel coordinates are then used as input to a two-dimensional laser scanner via a near real-time feedback loop to target, track, and treat. Such mechanization should result in increased overall treatment success, and decreased patient morbidity. Additionally, this approach enables the use of laser systems that are considerably smaller than those currently used, and consequently the potential for significant cost savings. Here we present an overview of a proof-of-principle system, and results using examples involving in vivo imaging of human skin.

The skin is a highly organized system composed of resident cells, extracellular matrix, blood vessels, and circulating cells that all work together to maintain cutaneous integrity. Environmental insults, particularly sunlight, act to alter the skin permanently, producing visibly undesirable effects. By wounding the skin or inducing a healing response with minimal wounding, the repair process can be activated to return the skin to a more normal condition. Owing to the complexity of the healing response, even the most well-studied and precise laser system can result in unpredicted results when used to treat photo-damaged skin. Through continued research into the normal functioning of skin, the alterations brought about by chronic photodamage, and the repair process, an integrated approach to treatment of photoaging will evolve. Agents such as alpha-hydroxy acids, retinoids, and growth factors that impact the healing response can be combined with various lasers to optimize improvement of photo-damaged skin, while minimizing the adverse consequences of treatment.