Pandemic’s impact on US ophthalmology patient care: Real-world insights

Analyses of data collected in the American Academy of Ophthalmology (AAO) Intelligent Research in Sight (IRIS) Registry suggest that US ophthalmologists, and specifically retina subspecialists, responded appropriately to patient-care guidelines issued by AAO leadership at the outset of the COVID-19 pandemic, said Steven D. Schwartz, MD.

“The investigation showed a decrease in patient visit volume following the release of the AAO statement on March 18, 2020, but also suggested that urgent and emergent patients were appropriately prioritized and well cared for,” said Schwartz, Ahmanson Chair in Ophthalmology, Jules Stein Eye Institute, UCLA, Los Angeles. “Data pertaining to anti-VEGF injections for patients with highly active disease suggest they received careful, individualized management without an adverse effect on their visual outcomes.”

Real-world insights

Although individual ophthalmologists may vary in their experiences and perceptions of how the pandemic affected their patients and practices, the analyses of the IRIS Registry data sought to gain broader insight on these issues by analyzing real-world evidence, Schwartz explained.

“Ultimately we all strive to improve patient care in our practice of ophthalmology. We were interested in determining how ophthalmology responded to the pandemic and if the interruption it caused to in-person visits led to patient harm,” he said.

The analyses were conducted by Verana Health, the end-to-end data and technology partner for the AAO IRIS Registry. Schwartz is on the Board of Directors of Verana Health and one of the founding directors. Theodore Leng, MD, MS, Associate Professor of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, led the analysis team for this research at Verana Health, where he is a consulting ophthalmologist.

Response to guidance on patient care

The AAO letter on March 18, 2020, which came from David W. Parke II, MD, AAO Chief Executive Officer, stated it was essential that all ophthalmologists cease providing treatment other than urgent or emergent care. Analyses of daily patient visits from January through June 27, 2020 showed a decrease in the pre-pandemic volume, which averaged 214,000 visits per day, immediately after March 18th. The decline continued, reaching a trough on April 10th at approximately 34,000 visits per day, and then began to rebound as areas of the country began to open up.

“Clearly the letter from AAO leadership was the seminal event modifying our behavior as a specialty,” Schwartz said.

Further analyses showed parallel patterns in the numbers of visits for new and returning patients. Commenting on the similarity, Schwartz said that it showed both groups of patients had their issues prioritized above any perceived COVID-19 exposure risk.

Another analysis investigated changes in patient visits to retina practices versus to non-retina specialists and optometrists. The results indicated that retina subspecialists continued to care for the urgent/emergent patients with vision-threatening conditions as the retina practices accounted for an increased percentage of overall patient visits at the height of the visit slowdown in April. Whereas in January through March, visits to retina subspecialists accounted for approximately 20% of the total visits, their share of the total volume had nearly doubled in April, reaching 38.5%.

Additional analyses considered potential geographic variations in the visit trends and showed no differences between providers in urban, suburban, or rural locations. However, a state-by-state analysis found that the largest decline in patient visit volume during the spring slowdown occurred in the Northeast region of the US. Furthermore, in contrast to the overall rebound in patient visits that began in late April, the decline in the Northeast persisted through late June. An analysis focusing on the five states that had no “stay at home” orders (Arkansas, Iowa, North Dakota, Nebraska, and South Dakota) showed declines in patient visit volume that tracked with that of the overall nationwide behavior.

“It was appropriate to see the largest decline in patient visits in the Northeast, which was hit hardest by the pandemic during the spring,” Schwartz said. “The data for the states with no stay-at-home order suggests that as a field, ophthalmologists trusted our leadership and followed scientific recommendations, including rebounding with caution care and putting patient safety at the fore.”

Anti-VEGF injection activity

Analyses of anti-VEGF injection data showed that in the 12 weeks leading up to March 18th, a total of almost 1.5 million injections were recorded in the IRIS Registry, translating into a weekly average of 122,785 injections. During the 12 weeks after March 18th, the total number of injections received decreased to approximately 1.2 million and averaged just below 100,000 per week.

Recognizing that patients receiving anti-VEGF injections represent a broad range of diagnostic severity across a broad range of treatment strategies and diagnoses, another analysis was undertaken that focused on “the sickest patients”.

“This approach included 39,819 eyes that had received one injection in the same eye monthly during the 5-month period before March 18th and was expected to be more instructive of how practices responded to the pandemic,” Schwartz said.

The results showed that nearly 50% of the group continued to receive monthly injections during April through June, and approximately 40% of the group received at least one injection during the 3-month study period. Overall, vision was stable in all three subgroups, Schwartz noted.

Mean distance visual acuity was 20/50- in the pre-pandemic period, remained at 20/50- among patients who received monthly injections and in the subgroup that received at least one injection. It fell by only approximately 1 line in the group that went untreated.

Steven D. Schwartz, MD

E: sdschwartz@mednet.ucla.edu

Schwartz did not indicate any financial interest in the subject matter.