It is difficult to comprehend how much has changed over the past 6 months due to COVID-19. As a glaucoma specialist, I have experienced closing my practice to all but urgent cases; reopening with drastic modifications; and coping with complicated financial, staffing, and scheduling challenges. As Chief Medical Officer for Aerie Pharmaceuticals, I wanted to understand how my experience compared with those of other glaucoma practitioners in the hope of learning how industry could best support them.
With this goal in mind, my colleagues initiated a series of three pulse surveys, each including responses from more than 200 eye care professionals from across the United States who treat patients with glaucoma. The results shed light on the different phases of this journey, including the obstacles faced and the solutions implemented in order to best serve patients and protect their vision through this ever-evolving public health crisis (Figure).
Figure. The results of three pulse surveys of US eye care providers shed light on the different phases of the COVID-19 journey, including the obstacles faced and the solutions implemented in order to best serve patients and protect their vision during this time.
PHASE 1: THE LOCKDOWN
The results of the first survey, fielded between March 26 and April 10, illustrated the abrupt and unprecedented impact of COVID-19 on practices across the country. Although 82% of eye care providers reported that their offices remained open, 78% limited in-person visits to only emergent and urgent cases. Temporary office closures were more common in the eastern and central regions of the United States, because these areas experienced high COVID-19 infection rates during this period. Perhaps not surprisingly, these findings closely reflect the early guidance provided by the AAO.1
In conjunction with this dramatic shift, 53% of practices reported limiting their hours of operation, and 66% reduced their office staff. In an effort to provide regular patient care during this time, 41% employed telemedicine with their glaucoma patients, and 45% reported writing 90-day prescriptions more often than before. These strategies were also more common in the harder-hit Eastern states.
Although necessary to flatten the curve, these actions created significant financial challenges for eye care providers across the country from which many are still working to recover today.
PHASE 2: NAVIGATING THE WAY BACK TO PRACTICE
The path to reopening was gradual and required meticulous thought and preparation, as revealed in our second survey, conducted between April 30 and May 11. In this wave, 87% of eye care providers reported that their offices were open in some capacity, 70% with limited hours. The number of eye care providers seeing only urgent and emergent cases declined from 78% in the first survey to 67%.
As part of the effort to safely resume regular care, doctors began to triage glaucoma patients based on a variety of factors, including IOP control, disease progression, adherence to prescribed medical therapy, and risk factors for severe complications from COVID-19. This allowed practices to identify patients who were candidates for telehealth or for whom the length of time between in-person appointments could be extended.
In recognition of the challenges that medical professionals were facing, the CMS temporarily relaxed certain federal privacy regulations and amended payment policies to allow the expanded use of telehealth. Likely influenced by these developments, 55% of survey respondents reported using video or telephone appointments with glaucoma patients during the second phase versus 41% during the first phase.
As practices began to reopen, they implemented a variety of social distancing measures, including the installation of plastic shields on slit lamps, mask requirements, temperature checks, and the transformation or elimination of waiting rooms. Although vital for protecting both staff and patients, these new practices had a significant impact on patient volume. Eighty-five percent of respondents reported that they expected to see fewer patients per day, and many extended office hours to compensate.
PHASE 3: THE NEW NORMAL
Our third survey, conducted between July 7 and 17, painted a picture of a new normal to which eye care providers had begun to adjust. In this third phase, 98% of survey respondents reported that their offices were open, with just 6% seeing only urgent and emergent cases. Forty-five percent of respondents reported returning to “business as usual” compared with a mere 2% of respondents in May.
Although 55% of eye care providers reported using telemedicine for glaucoma care in May, that proportion fell to 19% in July as in-office patient visits resumed. I believe that this reflects the current limitations of this technology as well as patient preferences. In a survey conducted by the Glaucoma Research Foundation (GRF), 87% of patients said, given the choice, they would rather wait 6 weeks for an in-office appointment than see their doctor virtually in 2 weeks.2
PREPARING FOR THE NEXT PHASE AND BEYOND
We have come a long way from the unsettling days of early March, but we have a long way to go. Some regions of the country have steadily eased restrictions, whereas others have been forced to pause or even reverse reopening. Fall will likely bring new challenges. As this article goes to press, my Northern California practice faces the challenge of staff scheduling that accounts for sick time (coronavirus-related or otherwise) as well as parents juggling the demands of remote learning. We must remain flexible and ready to adapt. Doing so is the only way to ensure that we can provide the best possible care to our patients through this crisis and beyond.
1. Recommendations for urgent and nonurgent patient care. American Academy of Ophthalmology. March 18, 2020. Accessed August 1, 2020. www.aao.org/headline/new-recommendations-urgent-nonurgent-patient-care
2. Glaucoma care in the age of COVID-19: the patient perspective. Glaucoma Research Foundation. July 14, 2020. Accessed August 1, 2020. www.glaucoma.org/news/blog/glaucoma-care-in-the-age-of-covid-19-the-patient-perspective.php