Ophthalmology and COVID-19: The Impact of the Pandemic on Patient Care and Outcomes: An IRIS® Registry Study
2021; Elsevier BV; Volume: 128; Issue: 12 Linguagem: Inglês
10.1016/j.ophtha.2021.06.011
ISSN1549-4713
AutoresTheodore Leng, Mark Gallivan, Ashley Kras, Flora Lum, Matthew T. Roe, Charles Li, David W. Parke, Steven D. Schwartz,
Tópico(s)Retinal Imaging and Analysis
ResumoIn response to the coronavirus disease 2019 (COVID-19) pandemic, a direct e-mail to American Academy of Ophthalmology membership urged "that all ophthalmologists cease providing any treatment other than urgent or emergent care immediately."1American Academy of OphthalmologyRecommendations for urgent and nonurgent patient care. ONE Network.https://www.aao.org/headline/new-recommendations-urgent-nonurgent-patient-careDate accessed: November 1, 2020Google Scholar In the United States, the Academy's Intelligent Research in Sight (IRIS®) Registry represents one of the largest and most advanced registry databases: more than 70% of United States ophthalmologists contribute to the IRIS Registry database.2Chiang M.F. Sommer A. Rich W.L. et al.The 2016 American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight) database.Ophthalmology. 2018; 125: 1143-1148Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar We used the IRIS Registry to study the treatment of common ophthalmic conditions before and after the Academy's letter, specifically for those receiving intravitreal injections of anti–vascular endothelial growth factor (VEGF) agents to stabilize and improve vision. Intravitreal injections of anti-VEGF agents are the most common surgical procedure in the United States (6 million per year)3Petri A.-S. Boysen K. Cehofski L.J. et al.Intravitreal injections with vascular endothelial growth factor inhibitors: a practical approach.Ophthalmol Ther. 2020; 9: 191-203Crossref PubMed Scopus (19) Google Scholar and are used to treat serious conditions, such as neovascular age-related macular degeneration, diabetic macular edema, and macular edema secondary to retinal vein occlusion. Individuals with active forms of these diseases typically receive monthly intravitreal injections of anti-VEGF agents to protect against precipitous, and often irreversible, visual loss, and delays in care have been shown to result in vision loss.4Song W. Singh R.P. Rachitskaya A.V. The effect of delay in care among patients requiring intravitreal injections.Ophthalmol Retina. 2021; 5: 975-980Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar We included deidentified electronic health record data on patient visits from October 1, 2019, through August 31, 2020, from the Academy's IRIS Registry. As of January 2021, 367 million patient visits of more than 65 million unique patients exist in the database. We included patient visits and procedures associated with practices that were contributing data each month of the study period. We defined new and returning patients by querying the Current Procedural Terminology codes and International Classification of Diseases codes of ocular conditions and defined a patient as having received an anti-VEGF injection by querying for the concurrent presence of both Current Procedural Terminology code 67028, indicating an intravitreal injection, and an Healthcare Common Procedure Code System code (J3490, J3590, or J7999) indicating that an anti-VEGF agent was injected on the same date. We compared the mean number of visits per day over 1-month periods from March 18 through August 17, 2020, with the mean number of patient visits from a baseline of February 1, 2020, through March 17, 2020. We performed a t test at the 95% confidence level for the 2 weeks before and 2 weeks after the Academy recommendation (March 18, 2020) and the state-issued orders and evaluated the impact of the stay-at-home order at the state level. We calculated the total number of anti-VEGF injections by month and stratified by disease type for eyes with known injection and disease laterality. We also created an anti-VEGF cohort of patients with neovascular age-related macular degeneration, diabetic macular edema, and retinal vein occlusion and included eyes that received 1 injection (aflibercept, bevacizumab, or ranibizumab every 28 ± 7 days) in the same eye each month between October 1, 2019, and the end of February 2020; we followed the cohort through July 2020 for continued monthly injections and visual acuity outcomes. Best recorded corrected visual acuity readings were converted to logarithm of the minimum angle of resolution units and were used to assess visual acuity change before and after the period in question. If both eyes qualified, the worst-seeing eye was selected. We computed a t test at the 95% confidence level to compare mean visual acuity readings between the February 1 to March 17, 2020 and the July 1 to 31, 2020 time periods. Analyses were performed with PySpark software (Apache Software Foundation) version 2.4.0 and R software version 3.6.1 (R Foundation for Statistical Computing). From February 1, 2020, through March 17, 2020, an average of 143 000 patient visits per day occurred (including holidays and weekends). From March 18 through April 17, 2020, patient visits dropped to 39 000 visits per day, approximately 27% of baseline (Table S1, available at www.aaojournal.org). The weekday patient visit count nadir occurred on April 10, 2020, with 34 000 patient visits. Patient visits also declined slightly in late July before stabilizing and rebounding slightly in August. Trends in weekly visits also differed for retina subspecialists versus nonretina subspecialists, with retina subspecialists experiencing a greater percentage of overall visits relative to nonspecialists (Fig 1). For states, the mean reduction in patient visit volume 2 weeks after (vs. 2 weeks before) the Academy announcement was not significantly different for those with stay-at-home orders versus those without (Fig S1, available at www.aaojournal.org). The average state-level reduction in patient visit volume was 75% in the 2 weeks after the Academy recommendation (March 18, 2020; Fig S2, available at www.aaojournal.org), which was significantly greater (P < 0.05) compared with the mean reduction after state-issued orders (55.5%). Total patient visits decreased by 62% (from 2.9 million to 1.1 million) from March through April, whereas the number of monthly anti-VEGF injections decreased only approximately 8% (from 330 000 to 304 000). Of the 7455 patients who met our inclusion criteria for the anti-VEGF cohort, 90%, 82%, and 64% received at least 1, 2, and 3 anti-VEGF injections, respectively, in the study eye from March 18 through June 2020. Mean vision was stable across the cohort. Overall, among the 4485 patients who underwent a visual acuity measurement in the baseline period and in July 2020, a statistically significant difference was found in mean visual acuity from baseline (P < 0.05). However, the mean visual acuity from February 1 through March 17, 2020 (0.361 logarithm of the minimum angle of resolution) and July 2020 (0.405 logarithm of the minimum angle of resolution) both approximate to a Snellen categorization of 20/50; thus, the difference is unlikely clinically significant. Similar results were observed after stratifying by disease status, both in terms of statistical and clinical significance (Table S1). The average number of patient visits per day dropped from an average of 143 000 before the Academy notification letter to a weekday trough of 34 000 by April 10th, a drop off of more than 75% in volume. At the state level, even in states with no stay-at-home orders, ophthalmologists followed Academy recommendations with commensurate drops in visits. We found that anti-VEGF injection treatment patterns declined slightly but rebounded, and most patients received at least 1 injection, suggesting careful, individualized management of patients with highly active disease. Across the population, we found little clinical difference in mean visual acuity between February 1 and March 17, 2020, and July 1 to 31, 2020 among patients receiving monthly anti-VEGF injections and did not find evidence of vision loss among those who continued receiving anti-VEGF injections compared with those who did not. Although this is the legal medical record, omissions or errors may occur at the point of care, physician documentation and codification may vary, and measures of visual acuity are not available at consistent time points for all patients in the electronic health record. In conclusion, although it is difficult to draw conclusions about individualized management of patients in this large registry-based data set, patients' vision remained stable and anti-VEGF injections continued to be administered in most patients who had been receiving active treatment. The significant decrease in ophthalmology-related patient visit volume as a result of the COVID-19 pandemic did not greatly impact patients receiving intravitreal injections of anti-VEGF agents to stabilize and improve vision, and therefore did not greatly impact the visual acuity of these more vulnerable patients, suggesting, at least in part, that ophthalmologists continued to provide careful, individualized management of patients requiring treatment, while decreasing the management of the less urgent patients. Download .pdf (.28 MB) Help with pdf files Fig S1 Download .pdf (.03 MB) Help with pdf files Table S1 Download .pdf (.13 MB) Help with pdf files Fig S2
Referência(s)