key: cord-0723378-21zzu1jz authors: Leng, Theodore; Gallivan, Mark D.; Kras, Ashley; Lum, Flora; Roe, Matthew T.; Li, Charles; Parke, David W.; Schwartz, Steven D. title: Ophthalmology and COVID-19: The Impact of the Pandemic on Patient Care and Outcomes—an IRIS Registry Study date: 2021-06-16 journal: Ophthalmology DOI: 10.1016/j.ophtha.2021.06.011 sha: 7bbd12a3346625c72480ccdeebebe0f33f8eba4b doc_id: 723378 cord_uid: 21zzu1jz nan Outcomes-an IRIS Registry Study 2 3 Theodore Leng, MD, MS, 1 In response to the COVID-19 pandemic, a direct email to American Academy of Ophthalmology 59 (Academy) membership urged "that all ophthalmologists cease providing any treatment other 60 than urgent or emergent care immediately." 1 In the US, the Academy's IRIS® Registry 61 (Intelligent Research in Sight) represents one of the largest and most advanced registry 62 databases: over 70%of US ophthalmologists contribute to the database." 2 We used the IRIS 63 Registry to study the treatment of common ophthalmic conditions before and after the 64 Academy's letter, specifically for those receiving intravitreal injections (IVIs) of anti-vascular 65 endothelial growth factor (anti-VEGF) to stabilize and improve vision. IVIs of anti-VEGFs are the 66 most common surgical procedure in the United States (6 million per year) 3 and are used to treat 67 serious conditions, such as neovascular age-related macular degeneration (nAMD), diabetic 68 macular edema (DME), and macular edema secondary to retinal vein occlusion (RVO). 69 Individuals with active forms of these diseases typically receive monthly IVIs of anti-VEGF to 70 protect against precipitous, and often irreversible, visual loss, and delays in care have been 71 shown to result in vision loss. 4 72 73 Data 75 We included deidentified electronic health record (EHR) data on patient visits from October 1, 76 2019 through August 31, 2020 from the Academy's IRIS Registry. As of January 2021, 367 77 million patient visits from over 65 million unique patients exist in the database. We included 78 patient visits and procedures associated with practices that were contributing data each month 79 of the study period. 80 We defined new and returning patients by querying the CPT codes and ICD codes of ocular 82 conditions and defined a patient as having received an anti-VEGF injection by querying for the 83 concurrent presence of both a CPT code 67028, indicating an intravitreal injection, and a 84 HCPCS code (J3490, J3590, J7999), indicating that an anti-VEGF agent was injected on the 85 same date. 86 87 Ophthalmology response 88 89 We compared the mean number of visits per day over one-month periods from March 18 90 through August 17, 2020 with the mean number of patient visits from a baseline of February 1, 91 2020 -March 17, 2020. We performed a t-test at the 95% confidence level for the two weeks 92 before and two weeks after from the Academy recommendation (March 18, 2020) and the state-93 issued orders, and evaluated the impact of the stay-at-home order at the state level. 94 J o u r n a l P r e -p r o o f Impact on access to acute care and outcomes 95 We calculated the total number of anti-VEGF injections by month and stratified by disease type 96 for eyes with known injection and disease laterality. We also created an anti-VEGF cohort of 97 patients with nAMD, DME, and RVO and included eyes that received one injection (aflibercept, 98 bevacizumab, or ranibizumab every 28 days +/-7 days) in the same eye each month between 99 October 1, 2019 through the end of February 2020; we followed the cohort through July 2020 for 100 continued monthly injections and visual acuity outcomes. Best recorded corrected visual acuity 101 readings were converted to logMAR units and used to assess pre-post visual acuity change. If 102 both eyes qualified, the worst-seeing eye was selected. We computed a t-test at the 95% 103 confidence level to compare mean visual acuity readings from February 1 through March 17 and 104 July 2020. The weekday patient visit count nadir occurred on April 10, 2020, with 34K patient visits. Patient 113 visits also declined slightly in late July before stabilizing and rebounding slightly in August. 114 115 Trends in weekly visits also differed for retina subspecialists versus non-retina subspecialists, 116 with retina subspecialists experiencing a greater percentage of overall visits, relative to non-117 specialists ( Figure 1 ). 118 119 For states, the mean reduction in patient visit volume two weeks after (versus two weeks prior) 120 the Academy announcement was not significantly different for those with stay-at-home orders 121 versus those without (Supplemental Figure 1) . The average state level reduction in patient visit 122 volume was 75% in the two weeks after the Academy recommendation (March 18, 2020; see 123 Supplemental Figure 2) The average number of patient visits per day dropped from a pre-Academy notification letter 143 average of 143 thousand to a weekday trough of 34 thousand by April 10th-a drop off of over 144 75% in volume. At the state level, even in states with no stay-at-home orders, ophthalmologists 145 followed Academy recommendations with commensurate drops in visits. 146 147 We found that anti-VEGF injection treatment patterns declined slightly but rebounded, and most 148 patients received at least one injection, suggesting careful, individualized management of highly 149 active patients. Across the population, we found little clinical difference in mean visual acuity 150 between February 1 -March 17, 2020 and July 2020 among patients receiving monthly anti-151 VEGF injections and did not find evidence of vision loss among those that continued receiving 152 anti-VEGF injections compared to those that did not. interpretation of the data, preparation, review or approval of the manuscript. The Northeast and the East coast, denoted in red blocks, were affected the most by COVID-19 215 over the months studied and observed the largest decline in patient volume by week 35. The 216 seven states with no "stay-at-home" orders (as of April 14, 2020), denoted in blue blocks, also 217 had the largest decreases in patient volume that tracked with national behavior (i.e., there was 218 no significant difference in reduction in those with and without stay-at-home orders. Note that 219 Wyoming and Utah did have stay-at-home orders for a few counties (e.g., Salt Lake City). 220 Quartile rank is the % difference between week 2 versus week 35, divided into quartiles. Recommendations for urgent and nonurgent patient 186 care Growth Factor Inhibitors: A Practical Approach The Effect of Delay in Care Among Patients 195 (Academy) The journal adheres to the Uniform Requirements set by the International Committee of Medical Journal Editors (http://www.icmje.org/) for authorship. To qualify for authorship, authors must make substantial contributions to the intellectual content of the paper in each of the four following categories:1. Substantial contributions to conception and design of the work; or the acquisition, analysis, or interpretation of data for the work; AND 2. Drafting the work or revising it critically for important intellectual content; AND 3. Final approval of the version to be published; AND 4. 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