Guess SM, Butt AL, Neely SB, Wild RC, Chou AF, Chodosh J. Dissemination of Knowledge From Randomized Clinical Trials for Herpes Simplex Virus Keratitis. Arch Ophthalmol. 2010;128(12):1624-1625. doi:10.1001/archophthalmol.2010.274
Herpes simplex virus type 1 (HSV), an enveloped virus with double-stranded DNA, is a major source of ocular infections. A 1982 study estimated that 400 000 people in the United States had ocular HSV infection, with 50 000 new and recurrent cases each year.1
Almost 20 years ago, the Herpetic Eye Disease Study Group was organized to elucidate the best treatments for HSV keratitis through the application of controlled, double-masked randomized clinical trials. The Herpetic Eye Disease Study trials demonstrated that topical corticosteroid with a prophylactic antiviral agent shortens the course of HSV stromal keratitis2 and that oral acyclovir prophylaxis significantly reduces recurrences.3 We surveyed eye care providers to examine the degree to which the best evidence-based practices (EBPs) in HSV keratitis have reached community care providers.
A 14-question survey (11 demographic and 3 clinical scenarios) was administered via postal mail or online to eye care providers with permission from their state and subspecialty societies. Questionnaires were distributed to 3 professional categories. Group 1 included optometrists in Arkansas and Texas (n = 3820); group 2 were ophthalmologists without cornea fellowship training in Arkansas, Michigan, Oklahoma, and Texas (n = 1345); and group 3 were ophthalmologists with cornea fellowship training who were contacted through the Ocular Microbiology and Immunology Group and the Cornea Society (n = 1101). Clinicians were asked to identify EBPs for 3 conditions (HSV epithelial keratitis, HSV stromal keratitis, and recurrent HSV stromal keratitis) among 6 treatment options based on their awareness of published randomized clinical trials.4
Returned surveys were entered into a Microsoft Office Access 2003 database (Microsoft Corp, Redmond, Washington), and all respondent categories were merged and deidentified to create an analytic data set. Frequency statistics were computed and bivariate and logistic regression analyses were conducted using SAS version 9.1.2 statistical software (SAS Institute, Inc, Cary, North Carolina). The study was approved by the University of Oklahoma Health Sciences Center Institutional Review Board.
Survey response rates were 6% for group 1, 15% for group 2, and 15% for group 3. Sensitivity analysis determined that respondents and nonrespondents had similar age and sex distributions, suggesting that respondents were representative of the study sample. In response to specific clinical scenarios, more than 95% of respondents from each group selected a topical or oral antiviral agent for treating HSV epithelial keratitis (Table). For HSV stromal keratitis, only 54% from group 1, as compared with 74% and 82% from groups 2 and 3, respectively, chose to combine a topical corticosteroid agent and an antiviral agent as treatment (P < .001). When prompted with a patient with repeated visually significant recurrences of HSV stromal keratitis, 51%, 60%, and 62% of groups 1, 2, and 3, respectively, chose to use an oral antiviral agent to prevent future episodes (P < .001).
Regression analyses showed that clinicians in group 2 were 2.23 (95% confidence interval, 1.34-3.70) times as likely to be aware of EBPs as those in group 1 in treating HSV stromal keratitis. Clinicians in group 3 were 2.92 (95% confidence interval, 1.70-5.01) and 2.27 (95% confidence interval, 1.29-3.98) times as likely to be aware of EBPs as their group 1 counterparts in treating HSV stromal keratitis and preventing recurrent HSV stromal keratitis, respectively. Adjusting for demographic and practice characteristics, training was the single most significant predictor of awareness of EBPs across these 3 common clinical scenarios.
A report by the Institute of Medicine concluded that many Americans are harmed by inappropriate use of health care services.5 McGlynn et al6 found that patients received only 54.9% of recommended care for medical conditions ranging from cataract (78.7%) to alcohol dependence (10.5%). Although the degree to which patients with HSV keratitis may be harmed by failure to follow EBPs is unclear, there appears to be considerable room for improvement in practitioners' knowledge of EBPs to manage HSV keratitis.
Correspondence: Dr Chodosh, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles St, Boston, MA 02114 (firstname.lastname@example.org).
Financial Disclosure: None reported.
Funding/Support: This work was supported by an unrestricted grant to the Department of Ophthalmology, University of Oklahoma Sciences Center from Research to Prevent Blindness.