AT A GLANCE
- Communicating to patients the precautions your practice has taken to ensure their safety can be a critical component in easing patients’ fears.
- Providing guidelines to referring doctors can help clarify which pathologies constitute urgent cases and which can wait 1 to 2 months for treatment.
- Greater reliance on imaging technology can minimize face-to-face interactions and decrease the amount of time patients spend in the clinic.
Retina specialists face the unique challenge of caring almost exclusively for patient populations that are at high risk for severe illness from COVID-19. One such population at risk is our patients with diabetes.1 Kentucky, where I practice, has one of the highest rates of diabetes in the country.2
Although our patient volume was reduced by up to 60% during the early days of the COVID-19 lockdown, when we were seeing only urgent and emergent cases, we have since met and exceeded our pre-COVID volume. This precipitous increase is due not only to the backlog created by delayed or cancelled appointments, but also to an influx of new patients who were unable to see their optometrist or general ophthalmologist during the lockdown and are now being referred for a variety of pathologies, including diabetes-related eye disease.
Pandemic-related concerns can affect our diabetic patients’ diets and lifestyles, and even their ability to access medication and routine medical care. Unfortunately, the impact is greatest on the most marginalized patients. I have had patients present with significantly elevated A1C levels, and consequently exacerbated eye disease, who explained that they did not buy their insulin that month because they could not afford the copay.
Our practice has adopted several key strategies to help ensure that patients in this vulnerable population receive the care they need regardless of the difficult and ever-evolving circumstances of this global pandemic.
COMMUNICATING WITH PATIENTS
Because diabetes puts patients at greater risk for COVID-related complications and mortality, it is understandable that people living with the disease may be hesitant to leave home, whether it be to go to a grocery store or to the doctor’s office. Communicating to patients all the precautions our practice has taken to ensure their safety has been a critical component of our efforts to ease patients’ fears.
As a first step, our practice posted a video to our Facebook page and website in which we explained all of the measures we’d put into place, including social distancing, face mask requirements, and asking patients’ family members to wait in the car. We also posted our complete COVID-19 policies and procedures. The feedback we received for this was extremely positive, as patients were grateful that we made the information easily available.
In addition to this type of mass communication, we reached out by phone to patients who were scheduled for treatments to confirm appointments and explain the new protocols. For those in need of routine follow-up care, we contacted them proactively to schedule it.
COORDINATING WITH REFERRING PHYSICIANS
To ensure that we triage patients appropriately, we are actively coordinating with our referring doctors. This means distributing communications to help clarify which pathologies constitute urgent cases and which can wait 1 to 2 months for treatment. We also encourage referring physicians to capture and share with us ultra-widefield (UWF) images of patients about whom they are concerned (Figure). Reviewing the UWF images helps us determine how urgently these patients need to be seen, or if they can instead be managed by the referring doctor.
Figure. UWF imaging performed by referring physicians helps offices prioritize patients by pathology. UWF imaging depicting a subhyaloid hemorrhage secondary to proliferative diabetic retinopathy (A) and a diabetic vitreous hemorrhage (B) are seen here.
IMPROVING CLINIC EFFICIENCY
It would be impossible to serve our diabetic patients effectively while maintaining the new social distancing and cleaning protocols without increasing patient flow over pre-COVID levels. We have accomplished this in several ways.
First, we identified strategies for expediting appointments. In pre-COVID times, I would meet with and examine a patient prior to ordering imaging or tests. Now, if a patient arrives with a referral for significant diabetic retinopathy, diabetic macular edema (DME), or proliferative disease, our staff immediately captures UWF and OCT imaging, after I have reviewed the referring doctor’s note to confirm that this is indeed the referring doctor’s diagnosis. Having access to these tests before meeting with the patient allows me to assess the situation before I even enter the room. This new process also keeps the patient in the same room throughout the visit, minimizing patient movement throughout the practice.
We have also adopted a new injection protocol, recommending five monthly injections before the next full exam. Although this is more aggressive than our previous routine of performing examination after three treatments, the new protocol is more in line with that of most DME clinical trials, and it decreases overall exam times and patient time spent in the practice. We have always recommended bilateral same-day injections to patients, and we are finding that this, along with performing same-day injections and laser (panretinal photocoagulation), increases our ability to deliver care more efficiently.
Finally, we are relying more on UWF imaging and OCT to assess retinal status. Our practice’s Optos device quickly captures high-resolution Optomap images of virtually the entire retina. These images are useful for identification and documentation of pathology. Under the current circumstances, this technology not only allows us to accurately and reproducibly grade a patient’s retinopathy, it also minimizes face-to-face interactions and decreases the amount of time patients spend in the clinic.
These strategies have played an invaluable role in maintaining our practice volume and patient flow during the past 6 months, and I believe they will continue to do so for the foreseeable future. The new processes have helped us to see and care for many diabetic patients, but we know there are still unserved patients who are taking a pass on potentially vital care due to health or financial concerns. We physicians must continue to do everything we can to expand our capacity and reach out to these patients so that they get the care they need.
1. Coronavirus (COVID-19): People at Increased Risk. Centers for Disease Control and Prevention. Updated August 10, 2020. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/index.html. Accessed August 21, 2020.
2. Diabetes in the United States. State of Childhood Obesity. Updates September 2019. https://stateofchildhoodobesity.org/diabetes/. Accessed August 21, 2020.