Ophthalmic Virtual Visit Utilization and Patient Satisfaction During the COVID-19 Pandemic

The mean patient satisfaction score from the survey response was 3.67 ± 0.63 (range 1–4). No significant difference in satisfaction scores was found between each specialty (p > 0.05), indicating a high degree of satisfaction across all specialties.

A total of 380 (21%) patients had repeat virtual visits. Mean survey response scores were significantly higher for patients with repeat visits than those without repeat visits (3.82 ± 0.42 vs. 3.62 ± 0.68, p = 0.03). Additionally, survey features based on wait time (p = 0.03), appointment length (p = 0.04), provider thoroughness and skillfulness (p = 0.01), provider courtesy (p = 0.03), respect of visit privacy (p = 0.02), and ability to answer questions virtually (p = 0.03) were rated significantly higher in cases where patients underwent a repeat virtual visit.

Patients undergoing oculoplastic services were more likely to have repeat visits (odds ratio 2.58, 95% confidence interval 2.18–3.06, p < 0.001). On the other hand, specialties such as cornea, comprehensive, glaucoma, and retina services had a lower likelihood of repeat visits (p < 0.001, Table 3). Univariable regression analysis found that repeat visits were related by specialty (oculoplastic, cornea, comprehensive, or glaucoma) (p < 0.001) and to higher scores on all features of the telehealth satisfaction scale (Table 4). Repeat visits were not related to age, sex, or retina specialty (p > 0.05). Multivariate regression analysis found that provider thoroughness and skillfulness were the most predictive features of the patient returning to a telehealth encounter (p = 0.01).

Within each specialty, the top 3 diagnoses are listed below. A full list of the primary diagnoses seen can be found in Table 5.

• Cornea/comprehensive problems: dry eye (153, 31%), meibomian gland dysfunction/blepharitis (111, 22%), and conjunctivitis (69, 14%).

• Oculoplastic problems: chalazion/hordeolum (334, 35%), ptosis (130, 14%), and thyroid eye disease (101, 11%).

• Neuro-ophthalmology problems: cranial nerve palsy/diplopia (93, 26%), visual disturbance (88, 25%), and migraine/headache (29, 8%).

• Glaucoma problems: primary open angle (24, 41%), preglaucoma (12, 20%), and normal tension glaucoma (8, 14%).

• Pediatric problems: strabismus (144, 89%), amblyopia (12, 7%), and genetic disorders (6, 4%).

• Retinal problems: uveitis (20, 36%), macular degeneration (18, 33%), and choroidal pathology (8, 15%).

The final item of the survey prompted patients to respond with any comments or concerns. Two key themes emerged from these free response questions. First, many patients disliked having to wait in front of their device, with no indication as to when their ophthalmologist would sign in. Second, several patients remarked that they would have preferred using a videoconferencing software that they had become accustomed to, such as Zoom or Apple FaceTime, in lieu of an integrated video platform within the Epic electronic medical record. Other patients commented on the ease of use and convenience that telehealth afforded them during the pandemic.

Discussion

Before March 1, 2020, there were no synchronous video visits done in our academic ophthalmology department. Virtual ophthalmology was not heavily utilized in high-volume, tertiary academic eye centers, and 70% of ophthalmologists reported never using telehealth.¹¹ Our results indicate high usage of synchronous ophthalmic video visits over the course of the pandemic. Of 2,330 video visits completed during this time, oculoplastic, neuro-ophthalmology, and cornea services saw the highest volume of patients, while the retina service saw the least. Accounting for the size of the service, utilization of video visits per provider was highest in oculoplastic surgery, followed by pediatrics, then neuro-ophthalmology. Satisfaction was excellent for patients across all subspecialties. Patients who visited oculoplastic services and patients who perceived a high degree of provider thoroughness/skill were more likely to have a recurrent virtual visit. Our study suggests that synchronous videoconferencing for ophthalmology is highly satisfactory and will likely find continued success in select subspecialties as the pandemic fades.

Video visit utilization surged rapidly in the initial months of the pandemic. At the height of the pandemic from March to June of 2020, there were 1,204 video visits completed, representing more than 50% of all video visits completed over the study period. The Kaplan–Meier analysis showed that there were significant differences between specialties in the reduction of video visits as the pandemic progressed. Oculoplastic and pediatric services had the highest sustained utilization and retina service had the lowest. Many patients have returned to in-person ophthalmology visits as of the summer of 2021; however, the oculoplastic service remained one of the highest specialties to continue to utilize video visits.

At our institution, the oculoplastic service performed the highest volume of video visits both overall and on a per provider basis. Videoconferencing is particularly amenable to oculoplastic surgery given the large number of external conditions that can be evaluated, diagnosed, and possibly treated (or counseled on surgical options) with just an external examination. In contrast to other services, there is less reliance on slit-lamp examination and fundoscopy. It is thus unsurprising that the oculoplastic service more commonly had repeat video visits. Additionally, rates of repeat video visits are likely as much a function of provider preference as patient preference. Previous studies have supported the continued use of video visits for eyelid concerns given the increase in efficiency and clinical throughput.^12,13

It is inevitable that there will be issues that cannot be addressed with video visits alone; in these cases, virtual visits function as a triage for conditions that must be seen in person. Within our study, of 88 survey responders who reported a need for in-person visits after their telehealth appointment, 42% of them came from the oculoplastic surgery specialty. These consults would often be for chalazia, and after a discussion with the patient, an in-office procedure could be booked, which was more efficient and safer. The increased patient flow combined with enthusiastic patient/provider support has made live videoconferencing a good match for the needs of oculoplastic surgery services.

Neuro-ophthalmology was the second most utilized service for video visits, and telehealth has the potential to improve access to this specialty. Neuro-ophthalmology relies on detailed patient history, external examination, and previously collected imaging/testing data. Our neuro-ophthalmology service, as well as many around the world, utilized at-home, online visual field testing with tools such as MRF Glaucoma Lite and MRF Neural Lite, which have demonstrated high correlation with Humphrey visual field testing and high reliability and reproducibility.¹⁴ Still, it is unsurprising to see that the majority of visits were for efferent complaints such as diplopia, which can be assessed, in part, by observing eye movements through videoconferencing; migraine aura, which typically requires discussion and reassurance only; and nonspecific visual disturbances. Optic nerve disease was less commonly observed, likely because proper evaluation requires assessment of the optic disc. A survey of telehealth adoption by 208 neuro-ophthalmologists during the COVID-19 pandemic revealed that the most common benefits of video visits perceived by neuro-ophthalmologists included continuity of care for established patients, improved efficiency, and improved access.¹⁵ Moreover, there is high demand for neuro-ophthalmology appointments, and the North American Neuro-Ophthalmology Society estimates an average wait time of 6 weeks up to 3 months.¹⁶ A serendipitous benefit of the widespread adoption of synchronous videoconferencing within academic ophthalmology centers is the possibility of expanded access to care. With high demand and concentration of neuro-ophthalmologists in urban areas, neuro-ophthalmology is well positioned to expand access through virtual visits, offering care to patients in rural areas. For this to happen, loosening of interstate telehealth regulations must continue and should be a principal concern for health care policy officials.

As opposed to oculoplastic and neuro-ophthalmology services, which accounted for more than 50% of all video visits conducted over the pandemic, specialties such as glaucoma and retina only accounted for 5% of all visits. Visualization of the posterior segment of the eye was less feasible with current technologies, making virtual visits difficult for these services. Glaucoma conditions often require in-person testing of intraocular pressure and visual field testing. Based on our results, there were no patients who had a return video visit to the retina service, and patients from the glaucoma service were significantly less likely to return for a video visit.

There are, however, promising technologies that could expand at-home ophthalmological testing. Lens adaptors that can be attached to smartphone cameras can aid in diagnosing cataracts, macular degeneration, and diabetic retinopathy.¹⁷ Use of high-resolution cameras during the videoconferencing itself has also made diagnosis of retinopathy of prematurity possible in the pediatric population.^17,18 Further development of these nascent technologies will be crucial to expanding ophthalmic telehealth care.

Our providers saw a wide variety of conditions through video visits over the past year. The three most common diagnoses were chalazion/hordeolum (15%), dry eye (6%), and ptosis (6%). Compared with the top 3 eye conditions within the National Institute of Health (NIH). All of Us Research Database, the most commonly diagnosed eye conditions included conjunctivitis (10%), dry eye (8%), and injury of eye region (4%).¹⁹ It is no surprise that the overall proportion of dry eye cases diagnosed through video visits was similar to the reported incidence in the NIH database. However, with our telehealth encounters, diagnoses of conjunctivitis (3%) and periorbital trauma (1%) represented a low proportion of total diagnoses. One can speculate that this may be related to the pathology seen during quarantine and certain disease conditions that require in-person examination for adequate diagnosis.

In terms of patient satisfaction, our study attempts to elucidate to what degree ophthalmic patients felt satisfied with their video visits. The satisfaction scores were excellent, and no significant differences were seen between specialties. Survey responders were on average older than nonresponders, likely due to the fact that parents of young children, if they did not respond, would disproportionately lower the average age of nonrespondents. Our questionnaire also demonstrates that patients were specifically satisfied with the video/voice quality of the software—two aspects essential to the end user experience. Previous studies on patient satisfaction in ophthalmic virtual care are somewhat outdated given rapid advancements in videoconferencing software. In general, these satisfaction surveys have been conducted in international rural areas such as West Africa, Australia, and India.^20–22 Systematic reviews of telehealth patient satisfaction have remarked that convenience and decrease in travel heavily influence patients’ approval of telehealth.²³ A recent study at the University of Michigan’s Kellogg Eye Center showed that of 95 patients who had video visits over the course of the COVID-19 pandemic, 92.4% were satisfied with their eye care.²⁴ Our study builds upon this work, providing additional context and demonstrating that patient satisfaction was high across all the major subspecialty services.

Additionally, our analysis found that the factor most predictive of a patient having a recurrent video visit is to what degree they were satisfied with the thoroughness, carefulness, and skillfulness of the ophthalmologist. How the ophthalmologist is perceived over video is a key determinant of patient satisfaction and likelihood of a repeat visit. Of the 1,756 patients examined in this study, 380 (21%) had a recurrent visit. Patients with recurrent visits had predictably higher satisfaction scores overall in all aspects of the survey. This suggests that in the setting of virtual visits, patients value efficiency (low wait times) and proficiency on the part of the provider. Indeed, many patients shared positive experiences, complimenting their providers specifically by name. The rapport shared between the patient and ophthalmologist is likely one of the most important factors affecting the overall virtual visit experience.

In terms of dissatisfaction, many patients disliked the fact that the software offered no indication as to when their ophthalmologist would sign in at the other end. A quick remedy to this would be to include a comment on the waiting screen giving an estimated time at which the ophthalmologist would log on. The other main complaint was that the software lacked the same familiarity that patients had with everyday applications such as Zoom or Apple FaceTime. Improving the user interface for video systems within electronic medical records will likely be a continual process moving forward.

Several limitations exist within this study. This is a single, urban, tertiary care center; thus, the patient population may not be generalizable to the rest of the country. The 14% response rate for the satisfaction questionnaires is low, but expected for e-mail-based patient surveys, which have historically resulted in 5–30% response rates.²⁵ The results of the survey are thus limited by the inherent response rate and bias of nonrespondents. The free response section also lends itself to being answered by patients who had a particularly positive or negative experience with their video visit.

Conclusions

As the pandemic wanes, there is a promising outlook for virtual ophthalmic care. This global event has led to rapid improvements and optimization of telehealth, improving access to eye care. Two key factors that led to widespread adoption and optimization of telehealth were lifting of restrictions for interstate video visits and increasing reimbursements by Medicare and private insurers.²⁶ Sustained usage of virtual ophthalmology will not only likely hinge on continuation of these policies but it will also depend on patient and provider satisfaction and comfort with the telehealth platform. As we have shown, patient satisfaction with video visits is high, and patients are likely to come back for video visits. The future of ophthalmic telehealth can be improved by utilization of video visit platforms that patients are familiar with and technological advances in online vision testing and funduscopic assessment that could theoretically allow for greater applicability across subspecialties.

Authors’ Contributions

Each author listed contributed in the following ways: D.A.C. participated in data collection, statistical analysis, and manuscript writing; A.Q.T. participated in statistical analysis and manuscript writing; and M.J.D. and G.J.L. participated in manuscript writing.

Disclosure Statement

The authors declare no conflicts of interest or financial disclosures.

Funding Information

This research was supported by an unrestricted departmental grant from Research to Prevent Blindness (RPB).