Telehealth Use in Ophthalmology Modest During COVID-19 Pandemic

Tyson N. Kim, MD, PhD

Telehealth use increased over the first 18 months of the COVID-19 pandemic before stabilizing, with the lowest rate of use observed in ophthalmology, according to new findings from a quality improvement study.

The research suggested that combining teleophthalmic visits with asynchronous testing may be a feasible approach to expand teleophthalmic subspecialty care, whilst additionally noting that further investigation may be needed to evaluate whether asynchronous testing outside a singular institution could provide an effective and lasting approach.

“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,” wrote study author Tyson N. Kim, MD, PhD, Department of Ophthalmology, University of California, San Francisco.

Among Medicare beneficiaries, telehealth use increased by more than 130-fold in the early months of the pandemic, but the adoption was not uniform across specialty. For ophthalmology, telehealth has historically been modeled after the store-and-forward model, with retinal photography combined with remote interpretation for diseases like diabetic retinopathy and retinopathy of prematurity.

More recent work has been performed to broaden the reach of ophthalmic telehealth to include outpatient consultation and disease monitoring, but its use remained modest at the start of the pandemic. Investigators noted the pandemic created a unique chance to evaluate trends between different clinical specialties and ophthalmic subspecialties and assess a model of asynchronous testing as an approach to augment teleophthalmic care.

The team collected the number of ambulatory visits conducted from January 2020 to July 2020 through the UCSF Ambulatory Recovery dashboard. In April 2020, a hybrid model of care was implemented to collect asynchronous data to enhance telehealth consultation with eye care clinicians, or augmented telehealth. The collected data included visual acuity, intraocular pressure (IOP), pachymetry, visual field testing, optical coherence tomography (OCT), retinal photography, specular microscopy, and slit lamp photography.

For the 881,080 patient encounters identified, investigators evaluated the macro-level trends in specialties at UCSF, including primary care, cardiology, neurology, gastroenterology, surgery, neurosurgery, urology, orthopedic surgery, otolaryngology, obstetrics/gynecology, and ophthalmology.

The study data show the volume of in-person outpatient visits among these 11 specialties decreased by 83.3% (39,488 of 47,390) at the onset of shelter-in-place orders for the COVID-19 pandemic. During the period, the use of telehealth rose by 2366.5% (19,524 vs. 825 encounters), representing 71.2% of all 27,426 outpatient encounters by these specialties.

Data from April 2020 show telehealth use peaked across all specialties and ranged from a minimum of 31.0% (488 of 1575 encounters) in ophthalmology to a maximum of 100% (748 encounters) in gastroenterology. Then, in the second quarter of 2020, telehealth use decreased across all specialties and plateaued afterwards, according to the findings.

The following year, in April 2021, telehealth use remained high for several specialties, including gastroenterology (930 of 1072 [86.6%]) and neurology (2657 of 4049 encounters [65.6%]). On the other hand, in ophthalmology, the numbers returned to almost pre pandemic levels and comprised 2.0% (150 of 7459) of all encounters.

Telehealth use was characterized by subspecialty in ophthalmology, as in-person outpatient outcounters dropped by 84.4% in April 2020. The decline was highest in comprehensive ophthalmology and neuro-ophthalmology and lowest in retina and glaucoma services. It additionally saw a peak across all subspecialties, but the peak was more modest for retina and cornea subspecialties.

The data report a total of 126 patients had teleophthalmology encounters that were supplemented with asynchronous examinations and testing from April 2020 to October 2020, with a total of 104 encounters (82.5%) for the evaluation of glaucoma or ocular hypertension.

The examination data was used to ensure the safety of no change in management with or without regular interval follow-up in 91 of 126 encounters (72.2%). However, it resulted in the change of clinical management in 32 patients (25.4%).

“The hybrid model of augmented telehealth in this study increased the depth of remote evaluation across several subspecialties,” Kim wrote. “Hybrid models have been used to study specific conditions or triage emergencies; however, to our knowledge, this is the first report of such hybrid use to deliver routine care across multiple ophthalmic subspecialties at a major academic institution in the US.”

The study, “Longitudinal Use of Telehealth During the COVID-19 Pandemic and Utility of Asynchronous Testing for Subspecialty Level Ophthalmic Care,” was published in JAMA Ophthalmology.