Combining teleophthalmic visits with asynchronous testing feasible for subspecialty-level evaluation: JAMA
Use of telehealth increased during the COVID-19 pandemic to maintain patient access to care while minimizing person-to-person transmission of the SARSCoV-2 virus. Telehealth in ophthalmology has historically followed the store-and-forward model, wherein retinal photography is combined with remote interpretation for screening of ophthalmic diseases, such as diabetic retinopathy and retinopathy of prematurity.
In 2018, the American Academy of Ophthalmology highlighted the increasing importance of telehealth and its potential to enhance existing practices while enabling new care paradigms. Recent work has sought to expand the scope of telehealth in ophthalmology to include outpatient consultation and monitoring of additional diseases, such as glaucoma.
Nevertheless, telehealth use by ophthalmology was modest compared with other specialties at the onset of the COVID-19 pandemic, presenting a unique opportunity to evaluate the feasibility of different models of ophthalmic telehealth implemented at scale. In this study, Arman Mosenia et al compared telehealth trends between different clinical specialties and ophthalmic subspecialties at a major academic institution over 18 months, beginning at the onset of the COVID-19 pandemic. They also evaluated a model of asynchronous testing as an approach to augment telehealth care within ophthalmology.
This quality improvement study evaluated retrospective, longitudinal, observational data from the first 18 months of the COVID-19 pandemic (January 1, 2020, through July 31, 2021) for 881080 patients receiving care from outpatient primary care, cardiology, neurology, gastroenterology, surgery, neurosurgery, urology, orthopedic surgery, otolaryngology, obstetrics/gynecology, and ophthalmology clinics of the University of California, San Francisco. Asynchronous testing was evaluated for teleophthalmology encounters. A hybrid care model wherein ophthalmic testing data were acquired asynchronously and used to augment telehealth encounters.
Telehealth as a percentage of total volume of ambulatory care and use of asynchronous testing for ophthalmic conditions. The volume of in-person outpatient visits dropped by 83.3% (39 488 of 47 390) across the evaluated specialties at the onset of shelter-in-place orders for the COVID-19 pandemic, and the initial use of telehealth increased for these specialties before stabilizing over the 18-month study period.
In ophthalmology, telehealth use peaked at 488 of 1575 encounters (31.0%) early in the pandemic and returned to mostly in-person visits as COVID-19 restrictions lifted. Elective use of telehealth was highest in gastroenterology, urology, neurology, and neurosurgery and lowest in ophthalmology. Asynchronous testing was combined with 126 teleophthalmology encounters, resulting in change of clinical management for 32 patients (25.4%) and no change for 91 (72.2%).
The COVID-19 pandemic has presented a unique opportunity to evaluate ophthalmic telehealth implementation at scale. In this quality improvement study, authors compared telehealth trends among various clinical specialties and ophthalmic subspecialties at a major academic institution and evaluated the feasibility of using asynchronous ophthalmic testing to augment telehealth encounters between patients and eyecare clinicians.
During the shelter-in-place orders, telehealth use surged across all specialties. As the number of outpatient visits recovered to pre–COVID-19 levels, telehealth use decreased but remained a stable proportion of ambulatory encounters in most specialties, suggesting a paradigm shift in remote care delivery after the pandemic. Many specialties, including obstetrics/gynecology and gastroenterology, which were lower users of telehealth compared with other specialties before the pandemic, saw a continued use of telehealth for patient care.
Telehealth use by ophthalmology was modest compared with other specialties, and patient care returned almost entirely to in-person settings by October 2020. These trends during the COVID-19 pandemic validated intrinsic barriers to ophthalmic telehealth while also providing opportunities to evaluate feasibility of alternate ophthalmic telehealth care paradigms.
A well-recognized limiting factor in ophthalmic telehealth is the need for physical examination and difficulty of remote data collection, and a survey of eye care clinicians at UCSF similarly identified the inability to perform adequate examination and testing as the top barrier to adopting telehealth. Most survey responders were able to document and assess external examination and extraocular motility during video encounters.
Consistently, oculoplastics and pediatric ophthalmology, which often rely on external examination of the eye, had the greatest telehealth use during the COVID-19 shelter-in-place orders and, interestingly, maintained some level of telehealth even after the orders were lifted. In contrast, the retina, glaucoma, and cornea subspecialties, which rely more heavily on microscopic examinations and specialized tools to evaluate ocular health and anatomy, were lower users of telehealth services. These results highlight the importance of instrument-dependent eye examination and the subspecialty-level differences in adoption of remote care delivery.
Ophthalmology is a pioneering field for telemedicine, but its use has traditionally focused on preventive disease screening. The COVID-19 pandemic increased the need for telehealth and presented a unique opportunity to test different implementations of ophthalmic telehealth at scale. Within a major academic center, this quality improvement study demonstrated the feasibility of enhancing ophthalmic telehealth with asynchronous testing, which was found to be effective for some subspecialty-level care. Additional work is needed to evaluate asynchronous testing in a subspecialty-controlled fashion and whether implementation outside the same institution may also be an effective approach for expanding the reach of ophthalmic telehealth care into the community.
Source: Arman Mosenia, MD, MSE; Patrick Li, MD; Rick Seefeldt,; JAMA Ophthalmol. doi:10.1001/jamaophthalmol.2022.4984
