Telemedicine Use by Oculoplastic Surgeons During the COVID-19 Pandemic
Introduction
Telemedicine use expanded dramatically during the COVID-19 pandemic, including to surgical fields with limited prior adoption of telemedicine, such as oculoplastic surgery.1,2 Changes in policies and reimbursement during the COVID-19 public health emergency in the United States supported major growth in telemedicine use for real-time, virtual visits.1 Notably, the surgical specialty of ophthalmology experienced the greatest decline in outpatient visits among all specialties early in the pandemic (more than 70% reduction in April 2020).2 However, despite the increased need for telemedicine use during the pandemic, surgical specialties including ophthalmology had the lowest telemedicine use for outpatient clinic visits by December 2020.2 An improved understanding of telemedicine use patterns, barriers to implementation, and satisfaction with telemedicine could provide valuable insights into methods for sustaining telemedicine use in the long term after the COVID-19 pandemic based on surgeons’ telemedicine experiences during this period.
Oculoplastic surgery may be one of the most significantly underutilized surgical fields for telemedicine, as it is uniquely well suited for real-time, virtual visits. The field focuses on conditions affecting the adnexal structures around the eye, including functional and cosmetic procedures for the eyelid, orbit, and lacrimal system. Commonly treated conditions include ptosis (drooping eyelids), eyelid and orbital tumors, thyroid eye disease, trauma, and cosmetic facial rejuvenation. Oculoplastic surgery is particularly amenable to telemedicine visits due to its emphasis on the external periocular and facial exam, for which high-quality imaging can be obtained by using technology readily available to patients at home. In addition, there is a limited supply of oculoplastic surgeons in the United States, with only ∼30 surgeons graduating from the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) fellowships yearly.3
Although telemedicine in ophthalmology has become well established for store-and-forward teleretinal diabetic retinopathy and retinopathy of prematurity screening, there are a few reports of telemedicine use within other ophthalmic sub-specialties, such as oculoplastic surgery.4,5 The majority of studies consist of single-institution descriptions of telemedicine use by oculoplastic surgeons during the COVID-19 pandemic.6–8 A recent international survey of 70 oculoplastic surgeons from 8 countries reported on telemedicine use, perceived utility, and perceived safety.9 However, the study did not assess for relationships between the frequency of telemedicine use relative to oculoplastic surgeons’ practice characteristics, nor did it include detailed descriptions of visit types, conditions evaluated, or barriers to implementation.
In this study, we sought to obtain a more comprehensive evaluation of oculoplastic surgeons’ experiences with telemedicine use during the COVID-19 pandemic. We surveyed members of the ASOPRS, the largest association of oculoplastic surgeons based in the United States, to assess telemedicine usage patterns, barriers to implementation, as well as both surgeon and perceived patient satisfaction.
Methods
We performed a Web-based, anonymous, cross-sectional survey of ASOPRS members. The survey was open for responses during an ∼2-week period between November 18, 2020 and December 4, 2020. E-mail addresses for all ASOPRS members were obtained from the online member directory. A link to an online survey (Appendix A1) created by using Google Forms (Google, LLC, Menlo Park, CA) was sent to each member’s work e-mail address or to their personal e-mail address if no work e-mail address was listed. Two reminder e-mail notifications were sent during the open survey period. Participants were provided with the option to enter into a raffle for a $100 gift card as a participation incentive. Participants were excluded from analysis if they reported that they were no longer ASOPRS members. If more than one response was received from the same e-mail address, only the last response was included.
The survey asked for information regarding participants’ practice characteristics, telemedicine usage patterns, barriers to telemedicine implementation, as well as both surgeon and perceived patient satisfaction. The survey also asked whether participants used telemedicine for new and/or return patient visits, functional and/or cosmetic visits. “Functional” visits are those in which a problem relating to the function of the eyes and its adnexal structures is assessed (generally considered “medically necessary,” such as eyelids that droop so low as to limit vision). “Cosmetic” visits are those in which a concern relating to personal appearance is assessed.
We compared responses by using Chi-squared tests if the n for the groups compared were each >5 and used Fisher’s exact tests if the n of any groups were ≤5. All statistical analyses were performed by using R Studio version 4.0.0 (RStudio, PBC, Boston, MA).
The University of Wisconsin-Madison Institutional Review Board (IRB) staff determined that this study was exempt from full IRB review due to the activities being consistent with quality improvement. All research activities were conducted in accordance with the Declaration of Helsinki and all federal and state laws.
Results
We received 196 unique survey responses from 963 invited participants (20.5% response rate). Among the 192 ASOPRS members who participated, 88% (n = 169) reported practicing in the United States, 3% (n = 5) in Canada, and 9% (n = 18) in other countries (9%). The majority (84%, n = 162) reported that more than 80% of their clinical practice was providing oculoplastic surgical care (Table 1).
| SURVEY RESPONSES | % |
|---|---|
| Proportion of clinical practice that is oculoplastics | |
| 81–100% | 84.4 |
| 61–80% | 6.3 |
| 41–60% | 6.8 |
| 21–40% | 1.6 |
| 0–20% | 1.0 |
| Years in practice (post-fellowship) | |
| >15 years | 39.1 |
| 11–15 years | 12.0 |
| 6–10 years | 17.2 |
| 0–5 years | 31.8 |
| Practice location—region of the United States | |
| West | 28.1 |
| South | 23.4 |
| Northeast | 20.8 |
| Midwest | 15.6 |
| International | 12.0 |
| Employment type | |
| Self-employed (including partner in private practice) | 38.4 |
| University | 26.0 |
| Private practice (not partner in private practice) | 25.1 |
| Hospital | 7.8 |
| Other | 2.6 |
Telemedicine Usage Patterns
Most participants (79%, n = 152) reported current use of telemedicine at the time of the survey (Fig. 1). Very few who reported currently using telemedicine (14%, n = 21) had used telemedicine before March 15, 2020, the week when the World Health Organization declared the COVID-19 outbreak to be a pandemic. Telemedicine use pre-pandemic was more common among international participants (33%, n = 6) compared with U.S. participants (11%, n = 15, p = 0.02). Telemedicine use was more common among participants with fewer years in practice (89% [n = 54] vs. 69% [n = 52]) for those in practice 0–5 years compared with those in practice >15 years, respectively (p < 0.01). Telemedicine use was most common among participants employed by a university (90%, n = 45) compared with those who were self-employed (70%, n = 52, p < 0.01) and compared with those employed by a private practice (77%, n = 37, p = 0.08). There was no significant difference in telemedicine use by U.S. geographic region (p = 0.91) nor in comparing international versus U.S. participants (p = 0.91). The vast majority reported using telemedicine either very rarely (50%, n = 78) or for less than half of visits (48%, n = 75). International participants who used telemedicine did so more frequently than those in the United States, with the majority (72%, n = 13) reporting using telemedicine for more than half of visits compared with 47% (n = 65) of U.S. participants (p = 0.04).
Fig. 1. Telemedicine use among oculoplastic surgeons (n = 192).
Most participants performed real-time video telemedicine visits (91%, n = 143). Other telemedicine visit modalities included audio-only/telephone visits (61%, n = 95), store-and-forward imaging/video acquired by patients or providers that are shared and reviewed at a later time by the consulting oculoplastic surgeon (17%, n = 26), real-time video visits with telehealth presenters (9%, n = 14), and technician-based in-person visits followed by telemedicine visits with the surgeon (6%, n = 10). International participants were more likely than those in the United States to report using a store-and-forward telemedicine model (33% [n = 6] vs. 14% [n = 20], respectively, p = 0.04) and were less likely to report using audio-only/telephone visits (33% [n = 6] vs. 64% [n = 89], respectively, p = 0.01).
A wide variety of platforms were used due to a relaxation of Health Insurance Portability and Accountability Act regulations during the COVID-19 public health emergency.10 The most commonly reported platforms used were Doximity Dialer (Doximity, Inc., San Francisco, CA) (33%, n = 51), Zoom (Zoom Video Communications, Inc., San Jose, CA) (33%, n = 51), FaceTime (Apple, Inc., Cupertino, CA) (27%, n = 42), and Doxy.Me (Doximity, Inc.) (18%, n = 28). Among the participants who were not self-employed, most participants stated that their video platform was supported by their employer (89%, n = 93), including a wide variety of hospital-specific video platforms. Video telemedicine visits were reported by nearly all participants to be converted to audio-only visits due to technology failure either very rarely (55%, n = 84) or in less than half of visits (41%, n = 63). Similarly, most participants reported that telemedicine visits were converted to an unanticipated in-person visit either very rarely (60%, n = 93) or in less than half of visits (30%, n = 46).
Most participants using telemedicine reported use for both new and returning patients (81%, n = 127), with the minority using telemedicine for only new (1%, n = 1) or for only returning patients (18%, n = 29). The most commonly reported visit categories were postoperative visits (87%, n = 134) and functional non-surgical evaluations (73%, n = 113) (Fig. 2). For functional telemedicine visits, the most common indications were postoperative visits (77%, n = 119) and follow-up discussion visits (77%, n = 119) for patients needing additional counseling after an in-person clinic visit. Additional indications included evaluation of eyelid lesions (68%, n = 106), eyelid malposition (61%, n = 94), droopy eyelid (54%, n = 83), pre-Mohs surgery reconstruction consultation (33%, n = 51), thyroid eye disease (33%, n = 51), blind painful eye (21%, n = 32), orbital mass (14%, n = 22), trichiasis (14%, n = 22), epiphora (15%, n = 24), and orbital or facial fracture (14%, n = 21). For cosmetic telemedicine visits, the most common indications were postoperative visits (57%, n = 83), pre-surgical evaluation (37%, n = 54), injectable evaluation (17%, n = 25), and laser or other skin treatment evaluation (8%, n = 12).
Fig. 2. Categories of telemedicine visits (n = 155).
The most common ocular exam elements evaluated during telemedicine visits were extraocular movements (67%, n = 104), eyelid measurements (54%, n = 84), and conjunctiva/sclera evaluation (47%, n = 73). Evaluation of visual acuity (24%, n = 37), anterior segment exam (17%, n = 26), pupillary exam (8%, n = 12), color vision (7%, n = 11), and visual field (4%, n = 6) were less commonly performed. A significant proportion (21%, n = 33) of participants reported that they did not perform any of the ocular exam elements included in the survey during their telemedicine visits.
Barriers to Telemedicine Implementation
The most commonly cited barriers to telemedicine implementation among all participants were technological issues (35.9%, n = 69), reimbursement concerns (22%, n = 42), and a perceived lack of patient acceptance (20%, n = 39) (Fig. 3). However, a significant proportion of participants (31%, n = 61) reported having no barriers to implementation. Similar results were found among the subset of participants who reported currently using telemedicine (n = 152). In the subset of participants who were not currently using telemedicine (n = 40), the most common barrier to implementation was lack of physician interest (40%, n = 16). However, this subset of participants also reported technological concerns (25%, n = 10), reimbursement concerns (25%, n = 10), and lack of perceived patient acceptance (25%, n = 10) to be barriers at similar rates as endorsed by all participants.
Fig. 3. Barriers to telemedicine implementation (n = 192).
Notably, a significant proportion (36%, n = 55) of participants currently using telemedicine were unsure or did not plan to use telemedicine post-pandemic, assuming no changes to reimbursement or regulatory structures. There were no differences in participant responses regarding plans for telemedicine use post-pandemic when comparing participants in the United States with those located internationally, nor were there differences in response across years in practice or practice types (p > 0.05 for all comparisons).
Surgeon and Perceived Patient Satisfaction with Telemedicine
Nearly half of the participants reported being either satisfied or very satisfied with telemedicine (48%, n = 75), with higher perceived patient satisfaction with telemedicine (satisfied or very satisfied, 74%, n = 116) (Fig. 4). However, there was a sizable proportion reporting being either unsatisfied or very unsatisfied (23%, n = 29). Of note, most participants did not think that telemedicine saves them time (56%, n = 87). The majority of participants were satisfied with current payer reimbursement for telemedicine (53%, n = 79), but a significant proportion were unsatisfied (31%, n = 47). Satisfaction with reimbursement was more common among U.S. participants (54%, n = 72) than among international participants (41%, n = 7), though this difference was not statistically significant (p = 0.27).
Fig. 4. Satisfaction with telemedicine (n = 157). (A) Self-reported satisfaction, (B) Perceived patient satisfaction.
Free Responses
Participants were invited to enter a free response to the question, “Is there anything else about your experience with telemedicine you would like for us to know?” Several participants commented that telemedicine was especially helpful for patients for whom coming into clinic was a challenge, including those with longer travel distances and elderly patients concerned about their increased risks for severe coronavirus infection (Table 2). Participants also reported technology limitations related to the patient’s end of the connection, including poor video quality, lighting, and limited Internet speed, particularly among elderly patients and those living in rural areas.
| THEME | EXAMPLES OF PARTICIPANT RESPONSES |
|---|---|
| Increased accessibility/reduced patient travel | “This is a vital way for us to evaluate people who might otherwise have geographical or socioeconomic constraints.” “Telemedicine is helpful for travel restricted patients, older patients with COVID-19 concerns, and as a baseline evaluation for anything” |
| Patient convenience and satisfaction | “Patients like [telemedicine] because it saves them a huge amount of time. And of course, our patients who live in other states or other countries prefer telemedicine.” “For the patients who are risk-averse regarding COVID, [telemedicine] is a huge satisfier” |
| Patient selection and visit types | “Good for remote patients, screening, and follow-ups.” “Seems ideal for the happy post-operative patient” |
| Technology limitations | “There is potential here, especially for those of us in rural areas. But the technology is cumbersome and internet speeds in rural areas are prohibitive in many situations.” “Technical issues are usually at the patient end—poor quality video, lighting, etc. especially with [the] elderly population” |
| Concerns about quality of care | “I think telemedicine [provides a] sub-standard experience for the patient and physician.” “Telemedicine is not equivalent to an actual in-person exam” |
| Increased time burden for surgeons | “They save the patient time, but not me. Same amount of counseling and talking. Does save staff time in rooming patient but that is offset by staff time needed to set up the call.” “Does not save me time. I can’t provide the same quality of care, and reimbursement is less” |
Discussion
Telemedicine adoption increased significantly among oculoplastic surgeons during the COVID-19 pandemic. However, many current users reported that they were unsure or did not plan to use telemedicine post-pandemic. Telemedicine use was more common among participants with fewer years in practice and those who were university- versus self-employed. Most participants performed real-time video telemedicine visits, and the most commonly reported visit categories were postoperative visits and functional nonsurgical evaluations. The most common barriers to telemedicine use were technological issues, reimbursement concerns, and a perceived lack of patient acceptance. Perceived patient satisfaction was higher than surgeons’ self-reported satisfaction with telemedicine.
As with other surgical fields that had limited prior adoption of telehealth, our study highlights the dramatic increase in telemedicine use among oculoplastic surgeons from 14% pre-pandemic to 79% during the COVID-19 pandemic. Our findings were largely consistent with the limited literature on telemedicine use for oculoplastic surgery that has mostly focused on settings outside the United States and single-institution reports.6–9,11 A descriptive, international survey including a smaller number of oculoplastic surgeons reported similarly high rates of telemedicine use (71%, n = 50) during the COVID-19 pandemic, as well as a similar proportion reporting that they expected to use telemedicine more post-pandemic (57%, n = 40). Our study adds important additional information regarding the frequency of telemedicine use relative to oculoplastic surgeons’ practice characteristics and data on the categories of visit type, as well as specific clinical indications evaluated. We found that telemedicine use was more common among participants with fewer years in practice since younger surgeons may be more comfortable with and more willing to adopt new technology. Surgeons who were university-employed were also more likely to use telemedicine than self-employed, likely because academic institutions often have greater financial, staff, and technical resources to support telemedicine implementation.
Will the COVID-19 pandemic mark a paradigm shift toward increased telemedicine use among oculoplastic surgeons in the long term? Our study evaluated the following factors that may contribute toward answering this question: (1) patient demand, (2) surgeon satisfaction, (3) technology, and (4) reimbursement. Although perceived patient satisfaction with telemedicine was high in our study, concerns about patient acceptance remained one of the top implementation barriers cited by oculoplastic surgeons. Interestingly, surgeons’ self-reported satisfaction with telemedicine was lower than perceived patient satisfaction, signaling a potential divide. Many participants cited limitations due to technology issues, particularly among elderly and rural patients who may benefit the most from telemedicine. Continued advances in camera technology and expanded broadband Internet coverage could further enhance the quality of oculoplastic telemedicine consultations.12 Some studies have also noted that improving clinician confidence with telemedicine may improve utilization.13 For example, the development of validated care models, guidelines, and streamlined workflows for oculoplastic telemedicine could support increased surgeon satisfaction with telemedicine.14,15
It was notable that reimbursement was one of the most commonly cited barriers to telemedicine adoption. A few of the reimbursement and policy changes from the COVID-19 pandemic public health emergency in the United States are currently planned to be continued post-pandemic, which will reduce support for telemedicine use. It is also difficult to measure the possible increases in downstream revenue and cost-savings from decreased clinical overhead associated with telemedicine. Future studies evaluating the return-on-investment and cost-effectiveness of telemedicine models of oculoplastic surgical care could provide evidence that may promote significant and sustained increases in telemedicine adoption to address gaps in access to surgical specialty care.16
Oculoplastic surgery is a unique surgical field in that surgeons manage a diverse array of conditions, and our results have implications for which conditions may be more amenable to telemedicine evaluation than others. We found that real-time video appointments, postoperative visits, and functional non-surgical evaluation were most common. Consistent with other recent reports from single institutions, oculoplastic surgeons in our study reported providing a broad range of telemedicine care during the COVID-19 pandemic, including for new and returning patients, post- and preoperative evaluations, as well as both functional and cosmetic consultations.6–8 One British study suggested that eyelid lesions were among the least well suited for evaluation using telemedicine. However, the majority of our respondents did report using telemedicine to evaluate eyelid lesions (68%). This discrepancy may be due to differences in practice patterns and payment structures—many U.S. insurers do not allow a surgeon to bill for a procedure on the same day the eyelid lesion was evaluated, thereby incentivizing a separate pre-procedure evaluation visit, which could be accomplished via telemedicine. In addition, the findings of our study have broader applicability to other specialties that rely primarily on the patient history, facial, orbital, and oculomotor exam findings, such as facial plastic surgery, pediatric ophthalmology/strabismus surgery, and neuro-ophthalmology.17–21
The strengths of our study included having a survey response rate just more than 20%, which is considered adequate for e-mail-based physician surveys, which typically have response rates of 20% or less.22,23 We also had participants who were well distributed across all years of clinical practice experience, practice types, and geographic regions of the United States. Study limitations include the potential for response bias, as oculoplastic surgeons who use telemedicine may have been more likely to participate in the survey. However, our survey did include a significant number of participants who reported that they were not using telemedicine (21%, n = 40) and we assessed barriers to telemedicine implementation among all participants regardless of their telemedicine use. In addition, the survey was conducted during an ∼2-week period between November 18 and December 4, 2020. It is possible that participant telemedicine use and perceptions regarding telemedicine may have continued to evolve over time relative to the severity of COVID-19 pandemic impacts in their local area. The timing of the survey, however, did allow sufficient time for telemedicine use to be well established by most U.S. clinical practices following the reimbursement and policy changes related to the COVID-19 pandemic public health emergency that took effect in early 2020.
Conclusions
Telemedicine was widely adopted by oculoplastic surgeons during the COVID-19 pandemic and was a feasible method for providing access to a broad range of oculoplastic specialty care. Our study also has significant implications for other surgical fields with prior limited adoption of telehealth with regards to telemedicine usage patterns, implementation barriers, and both surgeon and perceived patient satisfaction with telemedicine. Further research is needed to design sustainable telemedicine programs to enhance patient access to oculoplastic specialty care in the long term.
Authors’ Contributions
Design and conduct of the study (G.J.L., Y.L., and S.W.V.). Collection, management, analysis, and interpretation of the data (G.J.L., S.L., Y.L., and S.W.V.); and preparation, review, or approval of the article (G.J.L., S.L., Y.L., and S.W.V.). S.W.V. accepts full responsibility for the data, analyses, interpretation, conduct of the study, decision to publish, and had full access to all of the data.
Acknowledgments
The authors gratefully acknowledge Mark Banghart, MS for his assistance with the statistical analysis. This study was presented as a poster at the 2021 Virtual Spring Scientific Symposium of the ASOPRS.
Disclosure Statement
No competing financial interests exist.
Funding Information
This work was supported by NIH/NEI K23 EY026518 (Y.L.) and NIH/NEI P30 EY016665. It was also supported, in part, by an institutional grant from Research to Prevent Blindness, New York City, New York, USA to the Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, University of Wisconsin-Madison. The funders had no influence on the design or results of the study.
References
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APPENDIX
Appendix A1. Telemedicine Use in Oculoplastic Surgery
E-mail addresses are used only to ensure that each response is unique and will not be used to identify respondents.
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E-mail address |
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Are you a member of the American Society of Ophthalmic Plastic and Reconstructive Surgery? |
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re you currently using telemedicine in your practice? |
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What have been the primary barriers to implementation in your practice? |
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When did you start using telemedicine? |
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What kind of telemedicine visits do you conduct? |
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What platform do you use? |
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Is this platform supported by your employer? |
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Do you use telemedicine to see new patients, returning patients, or both? |
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What categories of visits do you conduct via telemedicine? |
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What type of cosmetic visits do you conduct via telemedicine? |
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What type of functional visits do you conduct via telemedicine (by diagnosis)? |
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What exam components do you conduct via telemedicine? |
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How often do you conduct visits using telemedicine? |
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How often are planned video telemedicine visits converted to audio-only due to technology failure? |
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How often are planned telemedicine visits converted to an unanticipated in-person visit? (e.g., you are planning to evaluate a lesion via video telemedicine, but video quality is inadequate, and the patient is asked to present for in-person evaluation) |
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Do you plan to continue using telemedicine after the COVID-19 pandemic is over, assuming that there are no changes to the current reimbursement structure, or other regulatory issues? |
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How often would you anticipate conducting using telemedicine after the COVID-19 pandemic is over? |
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| 19. |
What is your level of satisfaction with telemedicine? |
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| 20. |
How do you perceive overall patient satisfaction with telemedicine? |
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| 21. |
Are you satisfied with current payer reimbursement for telemedicine? |
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| 22. |
Do you think telemedicine saves you time? |
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| 23. |
Is there anything else about your experience with telemedicine that you would like us to know? |
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| 24. |
How many years have you been in practice (post-fellowship)? |
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| 25. |
What is your primary practice structure? |
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| 26. |
What proportion of your clinical practice is oculoplastics? |
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| 27. |
What region of the United States do you practice in? |
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| 28. |
Would you like to be enrolled in a raffle to win a $100 Amazon gift card? |
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| 29. |
Would you be willing to be contacted in the future about additional telemedicine-related research projects? |
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