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Appointment trends in new and established patients in ophthalmology and optometry during a pandemic

Published:March 02, 2021DOI:https://doi.org/10.1016/j.jcjo.2021.02.003
      In response to COVID-19 being formally declared a pandemic, US health care systems implemented protocols aimed at mitigating risk for both patients and providers.
      • Safadi K
      • Kruger JM
      • Chowers I
      • et al.
      Ophthalmology practice during the COVID-19 pandemic.
      The American Academy of Ophthalmology and American Optometric Association recommended delaying all elective ambulatory provider visits and rescheduling routine ophthalmic visits.

      Recommendations for urgent and nonurgent patient care. American Academy of Ophthalmology. https://www.aao.org/headline/new-recommendations-urgent-nonurgent-patient-care. Published March 18, 2020. Accessed July 15, 2020.

      ,

      HPI CoronaVirus Statement 1-30-20.pdf. American Optometric Association. https://www.aoa.org/AOA/Documents/Advocacy/HPI/HPI%20Doctors%20of%20Optometry% 20Essential%20Care%20Guidelines%20During%20COVID %2019.pdf. Published March 24, 2020. Accessed July 15, 2020.

      Although these measures reduced the potential for transmission, little is known about how outpatient ophthalmic care has been affected. The current study evaluated the effect of the COVID-19 lockdown on both new and established patients of different disease acuity scheduled to be seen in optometry, general, and subspecialty clinics.
      A retrospective chart review was performed of all scheduled appointments of adult patients from March 14 through May 4, 2020 (COVID-19 period). A comparable standard operations time was chosen for comparison. Only the first scheduled visit during this period was used so that each visit was associated with 1 unique patient. All patients were stratified by provider subspecialty. To assess the acuity of the disease, established patients were stratified by duration of time between the last visit before the COVID-19 period and the COVID-19 scheduled visit (Group 1 [<6 weeks], Group 2 [6–12 weeks], Group 3 [12–36 weeks], and Group 4 [>36 weeks]). Patients with canceled appointments during the COVID-19 period were also assessed for whether they had a rescheduled and/or completed follow-up visit. Telemedicine and in-person appointments were included. The study was approved by the local ethics committee and adhered to the tenets of the Declaration of Helsinki. No informed consent was needed.
      Compared to standard operations, during the COVID-19 period the overall number of scheduled appointments decreased (62 063 visits versus 44 933 visits) as well as the number of new appointments (14 855 [23%] versus 3243 [7%]) and completed appointments (41 284 [66%] versus 10 791 [24%]) (Supplemental Fig. 1, available online). Younger patients (completed: 66 [interquartile range 44–74] versus not: 68 [77–84]; p < 0.0001) and those with commercial insurance (completed: 30% versus not: 25%; p < 0.0001) were more likely to complete the scheduled appointment (Table 1). Of 28 383 established patients, those who required more frequent follow-up (Group 1: 63%, Group 2: 69%) had fewer cancellations than patients with lower acuity of disease (Group 3: 78%, Group 4: 84%; p < 0.0001) (Table 2). However, the time between the intended follow-up and actual follow-up more than tripled in higher acuity patients (Group 1: from 3.37 to 13.51 weeks; Group 2: from 8.02 to 18.14 weeks; Group 3: from 16.47 to 27.42 weeks; Group 4: from 59.73 to 67.71 weeks). Of the cancelled appointments, 69% and 66% rescheduled the missed appointment in Groups 1 and 2, respectively, which was higher than in patients who had lower acuity of disease (Group 3: 63%, Group 4: 60%; p < 0.0001).
      Table 1Demographics of patients who completed and did not complete (cancelled or no-show) visits within the COVID-19 period
      Completed visitsNot completed visits (canceled + no-shows)P value
      n (% total)6936 (22%)24 683 (78%)
      Age (median [IQR]), y66 [44–74]68 [77–84]< 0.0001
      Mann-Whitney test
      Gender (Female, %)3927 (57%)15 327 (62%)< 0.0001
      χ2 test
      Location (Regional, %)4942 (71%)17 553 (71%)0.9524
      χ2 test
      In state (%)6207 (89%)22 474 (91%)0.1504
      χ2 test
      Insurance type< 0.0001
      χ2 test
      Government4216 (70%)15 829 (75%)
      Commercial/Other1806 (30%)5301 (25%)
      IQR, interquartile range
      low asterisk Mann-Whitney test
      χ2 test
      Table 2Percentage of completed, cancelled, and “no-show” scheduled visits; percentage of cancelled visits that were rescheduled; intended time versus actual time between visits
      Group 1Group 2Group 3Group 4P value
      Total patients52884984475713354< 0.0001
      χ2 test Patients were divided in 4 groups of disease acuity based on the time of their scheduled follow-up visit.
      Completed, n (% total)1715 (32%)1355 (27%)918 (19%)1883 (14%)
      Canceled, n (% total)3339 (63%)3423 (69%)3696 (78%)11 216 (84%)
      No show, n (% total)233 (5%)205 (4%)143 (3%)255 (2%)
      Rescheduled patients, n (% canceled)2292 (69%)2259 (66%)2325 (63%)6740 (60%)<0.0001
      χ2 test Patients were divided in 4 groups of disease acuity based on the time of their scheduled follow-up visit.
      Intended time between visits, weeks (95% CI)3.37 (3.32–3.41)8.02 (7.96–8.07)16.47 (16.37–16.58)59.73 (58.8–60.67)
      Time between visits after rescheduling, weeks (95% CI)13.51 (13.16–13.86)18.14 (17.82–18.46)27.42 (27.12–27.73)67.71 (66.64–68.79)
      low asterisk χ2 testPatients were divided in 4 groups of disease acuity based on the time of their scheduled follow-up visit.
      When analyzed by subspecialty, the highest percentage of completed appointments among all scheduled patients was seen in retina/uveitis (1652 [26%]; Supplemental Table 1, available online), whereas the lowest percentage was seen in glaucoma and oculoplastics (417 [14%] and 133 [13%], respectively). Out of cancelled appointments, 67% of patients with retina/uveitis rescheduled, whereas only 49% of neuro-ophthalmology patients rescheduled (Supplemental Table 2, available online).
      This study describes the profound effects of the COVID-19 lockdown within a multispecialty ophthalmology and optometry practice. The access to care was affected for both new and established patients. Although patients with more acute conditions were seen more frequently and had higher rescheduling rates, the follow-up time was triple that intended. The discrepancy seen between subspecialties is multifactorial and deserves further analysis on multi-institutional level. Although the findings may not be generalizable to all settings, they provide a unique analysis of how a pandemic affects outpatient clinical care, which is the first step in implementing changes that minimize interruptions in care and prepare for transitions back toward a standard practice.
      • Parke DW.
      Ophthalmology after coronavirus disease 2019 (COVID-19): transition back to patient care.

      Footnotes and Disclosure

      The authors have made the following disclosures:
      W.S.: RPB Medical Student Eye Research Fellowship (grant); A.X.C: NIH Institutional Training T32 Award (grant) and RPB Medical Student Eye Research Fellowship (grant); A.R.: Alcon, Novartis, Zeiss, Allergan (all personal fees); R.P.S: Genentech/Roche (personal fees), Alcon/Novartis (personal fees), Apellis (grant), Graybug (grant), Zeiss (personal fees), Bausch + Lomb (personal fees), Regeneron Pharmaceuticals, Inc. (personal fees).

      Appendix. Supplementary materials

      References

        • Safadi K
        • Kruger JM
        • Chowers I
        • et al.
        Ophthalmology practice during the COVID-19 pandemic.
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      2. HPI CoronaVirus Statement 1-30-20.pdf. American Optometric Association. https://www.aoa.org/AOA/Documents/Advocacy/HPI/HPI%20Doctors%20of%20Optometry% 20Essential%20Care%20Guidelines%20During%20COVID %2019.pdf. Published March 24, 2020. Accessed July 15, 2020.

        • Parke DW.
        Ophthalmology after coronavirus disease 2019 (COVID-19): transition back to patient care.
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