Survey of Vitreoretinal Specialists in the United States Regarding Telemedicine During the COVID-19 Pandemic

Introduction

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, COVID-19) pandemic has had a profound impact on the delivery of medical care in the United States.^1,2 On March 18, 2020, the American Academy of Ophthalmology, in concert with public health guidelines set by the Centers for Disease Control and Prevention (CDC) and the American College of Surgeons, issued a statement recommending that all ophthalmologists temporarily cease providing any treatment other than urgent or emergent care.³

As the initial wave of the pandemic subsided, the decision to resume routine ophthalmologic care in a clinical setting was often left up to the practice and/or individual physician(s), and depended on several factors, including state and city restrictions on nonessential services, updated local/regional case rates, access to COVID-19 testing, and availability of personal protective equipment for physicians, clinical staff, and patients.

Starting in February 2020, the CDC recommended that health care providers and facilities consider offering clinical services through virtual means, such as video or phone appointments.⁴ Roughly 1 month later, Centers for Medicare & Medicaid Services (CMS) increased access to these telehealth services, allowing Medicare to pay for telehealth visits whether the patient is in a health care facility or at home.⁵ Leading telemedicine platforms soon experienced a 250–700% increase in virtual patient visits during the start of the pandemic. Patients, many of whom were unaware of telemedicine options before the pandemic, began actively seeking out virtual care.^6–8

Telemedicine, or delivering health care services using electronic communication technologies without an in-person visit,⁹ has existed for decades in various forms, but has not been implemented widely in ophthalmology. In the field of vitreoretinal medicine and surgery, ancillary, office-based imaging, and detailed fundus examination are crucial for the diagnosis and management of many conditions, adding another layer of complexity to successful telemedicine implementation. However, given the challenges brought forth by the pandemic, many vitreoretinal specialists began to implement telemedicine services.

This article evaluates the attitudes, beliefs, and practice patterns of vitreoretinal physicians and surgeons regarding the utilization of telemedicine services at the start of the COVID-19 pandemic.

Methods

An anonymous survey of 11 questions was developed by the authors using Qualtrics XM software (Provo, UT, USA). In July 2020, this survey was distributed through e-mail to 2,744 vitreoretinal physicians based in the United States. Throughout the month of July, although the survey remained active, two additional e-mail reminders were sent to individuals who had not completed the survey. E-mail addresses of those who completed the survey were entered into a random drawing to receive 1 of 25 $100 Amazon gift cards.

The survey data were downloaded to an Excel (Microsoft, Redmond, WA, USA) spreadsheet and were analyzed with SPSS software version 24 (SPSS, Inc., Chicago, IL, USA). Descriptive statistics were used for analysis and subgroup analysis. McNemar’s test and Mann–Whitney U tests were used to compare subgroups. Selected variables were collapsed to facilitate analysis. Multivariate logistic regression was used to identify predictors of telemedicine use during the pandemic. This study was approved by the Institutional Review Board (IRB) at Wills Eye Hospital (IRB #2020-73).

The survey, in its entirety, is available as a Supplementary Data2 (Supplementary File S1).

Results

The overall response rate of the survey was 13.0% (361/2,774), with all responses completed during July 2020. Most respondents were male (308/361, 86%), aged 40–59 (202/361, 56.0%), and were not part of a private equity-owned medical practice (309/361, 85.6%). There was good representation across all regions of the United States, with the majority of respondents practicing in the Northeast (115/361, 31.9%) or the South (100/361, 27.7%). Most respondents were either part of a retina-only private practice (150/361, 41.6%) or worked in a multispecialty group (99/361, 27.4%). See Table 1 for detailed demographic information.

Before March 2020, 9.7% (35/361) of respondents had performed a telemedicine visit through phone or video, with a majority (32/35; 91.4%) performing between 0 and 5 telemedicine visits weekly. After March 1, 2020, a statistically significant increase occurred in the number of retinal specialists who had performed telemedicine visits (170/361, 47.1%; p < 0.001). These encounters were still uncommon, with a majority of specialists (111/170, 65.3%) performing 0–5 visits per week, 17.1% (29/170) performing between 5 and 10 visits a week, 7.6% (13/170) performing 10–15 visits a week, and 10% (17/170) performing >15 weekly visits.

Telemedicine visits after March 1, 2020 were conducted with several different platforms, including Zoom (48/170, 28.2%; Zoom Video Communications, San Jose, CA, USA), Facetime (46/170, 27.1%; Apple, Inc., Cupertino, CA, USA), electronic medical record-based systems (46/170, 27.1%), and Google (12/170, 7.1%; Alphabet, Inc., Menlo Park, CA, USA). Other telemedicine providers, including Doximity (17/170; 10.0%; Doximity, San Francisco, CA, USA), direct audio phone call (15/170, 8.82%), WhatsApp Messenger (11/170, 6.47%; Facebook, Inc., Mountain View, CA, USA), and direct text messaging (1/170, 0.58%), were also used.

When evaluating patients during these telemedicine visits, 42.4% (72/170) of physicians relied on the telemedicine guidelines set forth by the American Academy of Ophthalmology and/or local institutional policies (73/170; 42.9%), with many (48/170; 28.2%) also using guidelines established by the American Society of Retina Specialist. Some specialists (29/170; 17.1%) reported not using any telemedicine guidelines to help navigate patient encounters, whereas a few (16/170; 9.4%) used other unspecified methods. Most patients (148/170, 87.1%) did not have access to a remote or home-based system for fundus imaging, defined as either color photography or optical coherence tomography (OCT).

The majority of retinal specialists (225/361; 62.3%) felt that telemedicine, in its current form, is not an acceptable way to evaluate patients with vitreoretinal issues, even in an ideal clinical scenario. However, if remote fundus imaging were available, a majority of respondents (214/361; 59.2%) stated that telemedicine visits could be an acceptable replacement for in-person visits, given the right clinical scenario.

The majority of respondents identified six issues as major barriers to implementing telemedicine when evaluating vitreoretinal patients (Fig. 1): concern that pathology or diagnosis would be missed without an in-person examination (332/361, 92.0%); the inability to obtain remote, or home-based, OCT imaging (330/361, 91.4%); the inability to obtain remote, or home-based, fundus imaging (327/361, 90.6%); the level of technological requirements (both access to the technology and comfort level with using the technology) required to carry out these visits (261/361, 72.3%); concern about potential legal liability (229/361, 63.4%); and a low level of reimbursement given the overall amount of time spent conducting these visits (227/361, 62.9%). Overall, a majority of respondents (231/361, 64.0%) did not feel that concerns regarding data security and/or Health Insurance Portability and Accountability Act (HIPAA) violations represented a significant barrier toward telemedicine implementation.

A multivariate logistic regression was performed to evaluate predictive factors for performing telemedicine visits during the pandemic (Table 2). Baseline characteristics of physician age, gender, region of practice, type of practice, and prior telemedicine implementation before March 2020 were entered into the regression model. Of these five variables, age, gender, and prior telemedicine implementation were significant predictors of telemedicine usage.

Table 2. Potential Predictive Factors for Performing Telemedicine Visits During the Pandemic

VARIABLE	OR (95% CI)	p
Age (vs. reference group ≥70)
30–39	5.7 (1.4–23.1)	0.015**
40–49	4.6 (1.2–18.1)	0.028**
50–59	6.2 (1.6–24.4)	0.009**
60–69	4.1 (1.0–16.6)	0.047**
Gender
Female versus male	2.5 (1.2–5.3)	0.02**
Region of practice (vs. Northeast)
West Coast	1.1 (0.5–2.0)	0.97
Midwest	1.0 (0.5–2.0)	0.92
South	0.7 (0.4–1.2)	0.17
Type of practice (vs. solo practice)
Multispecialty private	1.2 (0.5–2.9)	0.70
Retina only private	0.6 (0.2–1.3)	0.20
University based	1.1 (0.4–2.8)	0.88
Other	0.8 (0.1–12.4)	0.85
Prior telemedicine implementation before March 2020	10.5 (3.2–34.5)	<0.001**

Compared with the oldest group of physicians (≥70), all other age groups were more likely to utilize telemedicine (age 30–39, odds ratio [OR] 5.7, 95% confidence interval [CI] [1.4–23.1], p = 0.015; age 40–49, OR 4.6 [1.2–18.1], p = 0.028; age 50–59, OR 6.2 [1.6–24.4], p = 0.009; age 60–69, OR 4.1 [1.0–16.6], p = 0.047). Compared with male retina specialists, female retina specialists were more than twice as likely to utilize telemedicine after March 2020 (OR 2.5 [1.2–5.3], p = 0.02). Those with prior history of telemedicine use were more likely to implement telemedicine after March 2020 (OR 10.5 [3.2–34.5], p < 0.001).

Regarding the future use of telemedicine, 15.2% (55/361) planned to continue using telemedicine during and after the COVID-19 pandemic as part of their future practice, and 23.0% (83/361) planned to continue telemedicine use only as long as in-person visits are considered more difficult/dangerous due to COVID-19. At the time of survey completion, 58.1% (210/361) of respondents either did not use telemedicine, had stopped using it, and/or had no plans to implement it in the future.

The identified barriers to telemedicine usage differed between respondents who planned to use telemedicine in the future and those who did not (Fig. 2). Physicians who did not plan to use telemedicine in the future had a significantly higher level of concern about pathology or diagnoses that would be missed without an in-person examination (p = 0.005), and had a higher level of concern regarding the technological requirements needed for telemedicine implementation (p = 0.047).

Discussion

The promise of telemedicine is to enhance access to care, with little to no compromise in quality. Even before the COVID-19 pandemic, the expansive and immersive role of technology in daily life has pushed the debate about the role of telemedicine to the forefront of medical care. Over the past decade, much research has supported the efficacy of telemedicine in various medical specialties, including psychiatry, cardiology, radiology, dermatology, and ophthalmology.^10,11

Long before the pandemic, several models of ophthalmic telemedicine existed in a number of countries. These range from consultation services, screening for specific eye diseases, remote supervision, triage, and emergency services.¹² Almost all of these systems rely heavily on an infrastructure of in-person acquisition of digital images and subsequent digital transfer of these images to an ophthalmologist for either real-time or delayed assessment.¹³ However, these current systems are neither universal nor widely available.

During the early months of the COVID-19 pandemic, as access to nonurgent health care was restricted, the implementation of telemedicine in the United States grew substantially across all fields of medicine. This held true in the field of vitreoretinal medicine and surgery, as <10% of survey respondents had performed a telemedicine visit before March 1, 2020, but nearly 50% reported having done so by July 2020. Despite this overall increase, these visits remained relatively infrequent, especially when compared with the typical patient volume of vitreoretinal specialists, with the majority of respondents performing 0–5 visits per week.

Throughout the survey, respondents highlighted the lack of an underlying imaging infrastructure, specifically the inability of patients to obtain home, or remote-based, fundus and/or OCT images and have these available to the retina specialist, as a key reason telemedicine remained relatively underutilized. Given the unparalleled impact that ancillary testing, most notably OCT, has had on the diagnosis and management of countless vitreoretinal conditions, this concern is hardly unexpected.¹⁴ A lack of universal guidelines for the use of telemedicine in retina, and the lack of a single preferred or widely used telemedicine platform, may have also contributed to low utilization.

Unsurprisingly, there was also substantial concern that the lack of in-person examination could result in misdiagnosis. Ophthalmology as a specialty relies heavily on in-person examination. No situation exemplifies this more than a scleral depressed examination of the peripheral retina for an acute posterior vitreous detachment. The heavy reliance of our field on in-person examination means that there are many clinical scenarios in which telemedicine, in its current form, cannot replace an in-person examination. Respondents also expressed significant concern about the potential medicolegal liability involved in telemedicine visits, which has been highlighted as a concern and discussed within other subspecialties.¹⁵

At its current level, and given our respondents’ relatively low level of telemedicine utilization, it is not surprising that only a small subgroup was committed to long-term telemedicine use. Our survey identified three characteristics that made people more likely to carry out telemedicine visits—younger age, female gender, and having performed telemedicine in the past. Interestingly, gender was predictive of telemedicine usage independent of age and other variables.

To boost future telemedicine utilization, several issues should be addressed. It is essential for patients to obtain remote, or home-based, imaging that can be easily accessed by physicians. In fact, in a recent publication surveying thousands of patients who experienced tele-ophthalmology visits, patients also identified the lack of ancillary testing as one of the biggest concerns they had about their virtual appointments.¹⁶ In addition, advances in imaging technology, such as wide-field imaging, and ultra-widefield swept source OCT,¹⁷ would potentially allow telemedicine visits to more closely replicate an in-person examination and could reduce the related likelihood of misdiagnoses. Finally, establishing a uniform set of guidelines to follow during these visits and a more unified platform to carry them out may also increase utilization. It will be fascinating to see how future advances in imaging technology that could allow for a more complete ocular examination will impact telemedicine going forward.

This study does have several limitations, including the inherent weakness of a voluntary survey design. Although we did obtain a 13.0% (361/2,774) completion rate, this is still a small sample size compared with the entire community of retinal specialists. The opinions of those who respond to surveys may differ from those who do not, and this may serve to bias our results, as it might not reflect the views of all vitreoretinal specialists.

One key issue not addressed in the survey was the overall patient volumes seen in the clinical setting while telemedicine was being utilized. A large number of patients seen by vitreoretinal specialists require frequent intravitreal injections to maintain their visual acuity in the face of chronic disease activity. It is conceivable that large numbers of these patients still received in-person evaluation and treatment even in the early stages of the pandemic. As a whole, this would result in fewer patients needing a telemedicine evaluation.

In addition, the recommendations for social distancing and for delaying in-person examination were assumed to be temporary. This potential assumption of an eventual return to “normal, routine” care, was not assessed in the survey, and this perspective could have also impacted the willingness of certain physicians to implement telemedicine and/or consider adopting it for the long term.

The COVID-19 pandemic led to adoption of telemedicine by some vitreoretinal specialists, but overall, telemedicine visits were infrequently performed. Although telemedicine may not be appropriate for all clinical scenarios, its rapid uptake by physicians demonstrates its potential to expand access to care. In order for more widespread utilization, a better infrastructure is needed to allow for remote image acquisition and to facilitate transfer of these data to physicians.

Conclusion

The COVID-19 pandemic increased the usage of telemedicine services by vitreoretinal specialists, but this was not a highly utilized resource. Several barriers must be overcome to make this a potentially viable alternative to providing care.

Authors’ Contributions

All authors have contributed to this study and are deserving of authorship.

Disclosure Statement

No competing financial interests exist.

Funding Information

Funding for the gift cards awarded to 25 randomly selected individuals who completed the survey was provided by the McNamara Retina Research Fund at Wills Eye Hospital. There is no specific grant number.

Supplementary Material

Supplementary File S1

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