key: cord-0778105-ukrnjeoj
authors: Portney, David S.; Zhu, Ziwei; Chen, Evan M.; Steppe, Emma; Chilakamarri, Priyanka; Woodward, Maria A.; Ellimoottil, Chad; Parikh, Ravi
title: COVID-19 and Utilization of Teleophthalmology: Trends and Diagnoses (CUT Group)
date: 2021-02-10
journal: Ophthalmology
DOI: 10.1016/j.ophtha.2021.02.010
sha: c5e82240eebc3831c4ecd0b5009ae8a0e2d0fca4
doc_id: 778105
cord_uid: ukrnjeoj

Telehealth usage peaked at 17% of encounters (4/5-4/11/20) and then declined, accounting for 1.6% (2,031) of the 127,028 ophthalmic visits from 3/15/2020-9/1/2020. Telehealth was disproportionately used for visits related to cornea and external disease diagnoses.

Online only: This article contains additional online-only material. The following should appear 36 online-only: Supplemental Figure 1 , Supplemental Table 1, Supplemental Table 2 , and 37

Supplemental Table 3 . 38

The coronavirus disease 2019 (COVID-19) pandemic altered how clinicians care for patients. 45

Ophthalmologists saw an estimated 81% drop in volume, the most of any specialty during the 46 initial pandemic and public health restrictions. 1 Concurrently, the Centers for Medicare and 47

Medicaid Services (CMS) removed many of the regulatory restrictions (i.e., rural designation 48 zones) on telehealth and began to reimburse for professional telehealth services at the same rates 49 as in-person visits, with the goal of increasing patient access to care via synchronous methods of 50 telehealth such as virtual visits. 2 Ophthalmologists may have difficulty with telehealth visits as 51 much of the evaluation requires a slit lamp, tonometer, dilation, and advanced imaging such as 52 optical coherence tomography (OCT). 53

There lacks evidence of the proportion of actual ophthalmic telehealth use volume beyond a 55 single institution. Potential trends, such as the reduction in the use of telehealth following an 56 initial surge, or the use of telehealth more prominently by certain subspecialties within 57 ophthalmology, are not confirmed with primary data. Our study is the first to demonstrate the 58 characteristics of telehealth utilization in ophthalmology on a large scale with primary data 59 before and during the COVID-19 pandemic. 60 61 62 using a local specialty code, including all outpatient and professional fee claims from 9/1/2019 66 through 9/1/2020. A synchronous telehealth encounter was defined by the presence of specific 67 procedure modifier codes (25 or GT). Store-and-forward retinal imaging claims (Current 68

Procedural Terminology-CPT codes 92227 and 92228) were added to the analysis separately. A total of 362,355 ophthalmology visits occurred from 9/1/2019 to 9/1/2020. Telehealth visits 88 accounted for 91 (0.04%) of the 235,327 ophthalmic visits from 9/1/2019-3/14/2020 and 2,031 89

(1.6%) of the 127,028 ophthalmic visits from 3/15/2020-9/1/2020 (p < 0.001). The proportion of 90 telehealth visits peaked at 17.0% of ophthalmic visits (4/5/20-4/11/20; Figure 1) 

Our study identified the rapid increase and subsequent decrease in the use of telehealth by 112 ophthalmologists during the initial phases of the COVID-19 pandemic, and low levels of 113 teleophthalmology utilization overall. Ophthalmology has been reported as the lowest utilizer of 114 telehealth. 3,4 Cornea and External Diseases accounted for a significantly greater proportion of 115 telehealth visits than they did for total visits, while Retina and Vitreous Conditions, Glaucoma, 116 and Cataract and Other Lens Disorders comprised fewer telehealth evaluations. 117

Currently, conditions associated with corneal and external pathology are best assessed via 119 telehealth, and use for these conditions may reduce in-person visits. Expansion of technology 120 such as home tonometry, home OCT (which have already been developed) and further home-121 based innovation may allow for increased adoption of virtual visits for glaucoma and retina care, 122 especially for established patients. 5,6 Ophthalmology has previously focused on asynchronous 123

forms of telehealth, such as "store-and-forward" imaging to address workforce shortages, not 124 reduce in-person visits. 7 Our study found that ophthalmologists were not well-equipped to shift 125 care from clinics to patients' homes. A key limitation was the inclusion of data from only one 126 payer (Blue Cross Blue Shield of Michigan) in only one state (Michigan). 127

The increase in telehealth adoption coincided with both the pandemic and new federal rules on 129 telehealth. Each factor confounds the other as far as causality for the increase in ophthalmic 130 higher-level office visits are typically not feasible, creating a financial disincentive to continue 134 telehealth visits along with the ethical, patient safety, and legal ramifications of an incomplete or 135 inadequate evaluation. These challenges must also be balanced with patient perceptions of 136 efficacy and convenience. Existing technology such as a home tonometer or home OCT could 137 allow for more effective and frequent use of virtual visits. Until such technology is further 138 reimbursed and utilized, patients with complaints indicative of chalazia, blepharitis, conjunctival 139 hemorrhage, and dry eye may benefit from an initial telehealth evaluation to reduce in-person 140 visits. 141 Figure 1 : Weekly ophthalmology visits by total visits and telehealth visits from 9/1/2019 165 through 9/1/2020. Over the course of the full period, telehealth accounted for 0.58% of total 166 ophthalmic visits; 0.04% from 9/1/2019-3/15/2020 and 1.6% from 3/24/20-9/1/2020. Total 167 telehealth usage peaked from 3/29/20-5/23/20. The minimum number of total ophthalmology 168 visits occurred from 3/29/20-4/11/20. At its peak, telehealth accounted for 17.0% of total 169 ophthalmology visits. 170 J o u r n a l P r e -p r o o f

Analysis: Ophthalmology Lost More Patient Volume Due to 143 COVID-19 Than Any Other Specialty

Medicare Telemedicine Health Care Provider Fact Sheet

148 health-care-provider-fact-sheet

Teleophthalmology in the Era of COVID-19: 150 Characteristics of Early Adopters at a Large Academic Institution

Impact COVID 153 Outpatient Care: Visits Prepandemic Levels but Not All

Icare Home Tonometer: A Review of 157 Characteristics and Clinical Utility

The Importance of Telemedicine during COVID-159 19 Pandemic: A Focus on Diabetic Retinopathy

The Current State of Teleophthalmology 161 in the United States