Assessing barriers to retinal care during a pandemic

The worldwide challenges of healthcare accessibility have been accentuated by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Social distancing and population lockdowns combined with restrictions, such as the requirement for reduced time during patient visitation and decreased physical proximity within clinical settings, have created additional barriers to patient assessments.

To meet the rapidly evolving needs of patients within a pandemic setting, retinal specialists have had to innovate and look to evolving technologies and practices. It is important to examine and qualitatively assess perceptions of the digital health transformation as well as barriers to adoption and early implementation of digital services. The feedback can be used to improve patient outcomes and, ultimately, provide interventions that are accessible to both patients and clinicians.

Retinal care survey

To meet the need for data on perceptions, a global survey to explore alternative modalities of retinal care utilised during the pandemic was distributed to retinal specialists between 31 March and 12 April 2020. The survey consisted of 44 questions that explored the impact of SARS-CoV-2 across three major domains: digital teleophthalmology, home monitoring and decentralised patient care.

A total of 214 retinal specialists completed the survey. Respondents were predominantly from Western Europe (n = 152, 71%) but also included clinicians from Eastern Europe, United States, North Africa, the Middle East and South America. All participants had medical retinal expertise with a significant majority (56%) having over 15 years of experience in ophthalmology.

Prior to the pandemic, rates of utilisation of teleophthalmology, home monitoring and decentralised patient care were low: 22%, 30% and 19%, respectively (see Table 1). During the SARS-CoV-2 pandemic, healthcare services increased their utilisation of teleophthalmology (49%, P < 0.001) and home monitoring services (42%, P < 0.001).

Minor changes were observed for methods of decentralised patient care, such as intravitreal injections occurring outside of a medical setting and patient screening. This is despite the ongoing need for increased provision of these type of interventions.

Reimbursement was the major factor that influenced the uptake of teleophthalmology services during the Covid-19 pandemic (odds ratio 9.62, 95% confidence interval: 2.42–38.16). However, home monitoring and decentralised care did not demonstrate the same increased uptake with the increased availability of reimbursement infrastructure.

During the pandemic, retinal specialists felt that teleophthalmology would be best utilised for the purposes of triage (75%), consultation (75%) and follow-up (71%), as well as therapy instruction (70%). However, the survey showed that only 50% felt that teleophthalmology would sustainably change the way they deliver retinal care in the future, with 22% saying that it would not change their practice and 27% being unsure (see Figure).

This study found a significant increase in the implementation of home monitoring services during the SARS-CoV-2 pandemic, with 42% (n = 90) of the investigated institutions increasing their efforts for the purpose of home monitoring (P < 0.001). Despite the previously questioned external validity of the Amsler grid,¹ it remained the most commonly-used visual functional test (n = 150, 70%); however, novel alternatives, such as smartphone-based (n = 40, 19%) and hardware-based (n = 16, 8%) assessmentsgained popularity (see Table 2).

Our study was the first to assess attitudes towards the transformative effects of the Covid-19 pandemic on the delivery of retinal care. Attitudes shifted toward acceptance and increased utilisation of teleophthalmology and home monitoring services during the pandemic. This may be the result of increased familiarity with and availability of structures for teleophthalmology and home monitoring that existed prior to the pandemic.

Utilisation of decentralised care did not significantly change. Poor uptake of decentralised care initiatives may be the result of a complex interplay of regulatory and procedural barriers coupled with significant retinal specialist discomfort with decentralised care initiatives: 31% were “not at all comfortable” and 28% were “uncomfortable” with patient care in non-medical settings prior to the pandemic.

Covid-19 has had a significant impact on the way that retinal specialists interact with their patients. Utilisation of teleophthalmology and home monitoring have increased since the onset of the pandemic, as has the positive attitude towards these interventions. However, despite its poor uptake, the response to decentralised care should be critically evaluated as it could still provide an important avenue for increasing retinal healthcare accessibility to marginalised patients at risk of visual deterioration.

Future directions

Further research is needed to analyse these attitudes. Stratifying by generation may be useful to advance our understanding of clinician perspectives and the evolving nature of the field.

In addition, further studies assessing the attitudes of retinal specialists in other geographical locations may provide unique perspectives from healthcare services with different structures and challenges, which may differ from the results of this study, which represented a predominantly European perspective on digital retinal healthcare. Ultimately, long-term prospective studies may be useful in determining the effectiveness of newly implemented digital services on overall patient outcomes.

In conclusion, digital healthcare will continue to provide new avenues for improving patient outcomes. The short-term changes that have been implemented recently will sow the seed for sustainable improvement, and it is up to retinal specialists and policymakers to create the foundations for the digital age of ophthalmology from now on.

Amir Rosenblatt, MD, MPH, MBA

E: amir_rosenblatt@hotmail.com

Livia Faes, MD

E: livia.faes@gmail.com

Anat Loewenstein, MD, MHA

E: anatl@tlvmc.gov.il

Dr Rosenblatt is an ophthalmologist and vitreo-retina surgeon from the Tel-Aviv Medical Center, Tel Aviv, Israel, and currently on his second fellowship at the Royal Victorian eye and ear hospital in Melbourne, Australia. Dr Faes is a Swiss medical retina and uveitis fellow at Moorfields Eye Hospital in London, United Kingdom. Prof. Loewenstein is chair of ophthalmology at Tel-Aviv Medical Center and vice dean of the Faculty of Medicine and Sidney Fox chair of ophthalmology at Tel Aviv University, Tel Aviv, Israel.

The authors have no financial disclosures relevant to the article.

Reference

Faes L, Bodmer NS, Bachmann LM, et al. Diagnostic accuracy of the Amsler grid and the preferential hyperacuity perimetry in the screening of patients with age-related macular degeneration: systematic review and meta-analysis. Eye. 2014;28:788-796.