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

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