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Eyecare in a pandemic: counting the cost of missed appointments

The nation’s first comprehensive look at the impact of reduced optometry services due to the COVID-19 lockdown has been provided in new Specsavers data. Australia and New Zealand optometry director Dr BENJAMIN ASHBY delves into the statistics and outlines a plan to manage the patient backlog.

In March, Australia faced unprecedented and immediate disruption to all services as the country battled the unknown effects of COVID-19.

Cancelled elective surgeries and the complete shutdown or reduction of optometry services featured high on a lengthy list of challenges for the eye health sector. As a result, thousands of Australians missed out on vital eyecare.

Benjamin Ashby.

Now, for the first time through Specsavers data gathered during the lockdown spanning 30 March to 31 May, it is possible to quantify the impact on patient services and the subsequent backlog.

According to Dr Benjamin Ashby, optometry director for Specsavers Australia and New Zealand, 2020 was supposed to be the year when vision and eye health came to the fore in public consciousness.

Across its 350 Australian practices alone, the optical chain was anticipating the delivery of eyecare to 3.6 million patients. It had strategies in place to detect and refer 51,000 cases of glaucoma; to register 200,000 Australians living with diabetes to KeepSight, helping to protect their vision from diabetic retinopathy; and to identify and refer 56,000 people with suspected retinal conditions.

Ashby said prior years of strategy, collaboration and implementation had firmly established this trajectory of progressing Specsavers’s long- term goal of transforming eye health to eliminate avoidable vision loss for its patients.

However, this was curtailed with the emergence of COVID-19.

This chart demonstrates the drop off in ophthalmology referrals from February to May.

On 30 March 2020, like many other optometry practices, Specsavers made the difficult decision to close its doors to routine eyecare.

“Cognisant of the escalation and extension of important restrictions to flatten the curve of COVID-19, and wanting to ensure the safety of patients and staff as well as supporting the nation in time of crisis, Specsavers hibernated normal retail services and remained only open for urgent and essential care,” Ashby said.

“‘Open for Care’ meant that we were focussed only on providing eye tests for those requiring urgent care. This included assessment of those patients with symptoms consistent with a high risk of vision loss that may require an emergency referral to a specialist; to those requiring red eye management and treatments; for the renewal of prescription eye drops; and for ongoing care for those with vision threatening eye conditions.”

Ashby said optometrists also assisted patients who had changes in vision that prevented them from functioning normally or caused anxiety, as well as helping those referred from other health professionals.

Dispensing assistance was available for patients with urgent needs. Glasses and contact lenses were posted to customers’ homes, while the company created instructional videos to help patients perform their own temporary repairs. It also deployed extended teams which helped with additional customer support needs and virtual dispensing from its Support Office.

“For the first time ever, our doors were closed to most patients,” Ashby explained. “As experienced by all eye health practitioners, COVID-19 caused a major disruption to the industry.”

The scale of interruption was evidenced in statistics supplied by Specsavers, which demonstrated, nationally, there were 600,000 fewer optometry Medicare patient services from March-April compared with the same months in 2019. Additionally, there were 40,000 fewer visual fields administered in the same period.

In the first week of its ‘Open for Care’ model, Specsavers also saw a 91% patient drop compared with same week-long period last year.

As a result, thousands of Australians missed out on the eyecare they were due.

From 30 March to 31 May, 200,192 patients presented to Specsavers optometrists nationwide. Of those, 3,893 were referred for urgent specialist assistance and 9,298 were given non-urgent referrals.

In April and May more than 25,000 patients that likely required specialist attention did not attend their appointments.

Based on this, in April and May, 25,208 Specsavers patients that likely had eye conditions requiring specialist attention did not attend their appointments.

To further put the potential impact of a protracted COVID-19 shutdown into perspective, if Specsavers provided this level of restricted care for 12 months, more than 150,000 patients with eye conditions would have missed eye tests and their subsequent referrals, leading to them missing out on treatment and putting their vision at risk.

A four-week year-on-year comparison also indicates the post-COVID-19 backlog of patients with diabetes.

In April 2019, Specsavers optometrists saw 13,319 patients with diabetes for their vital diabetes eye checks. The company had just got behind Diabetes Australia’s KeepSight initiative as a co-funder alongside the Federal Government, Novartis and Bayer and, in subsequent months, it saw a steady increase of patients with diabetes.

In line with the projected growth of diabetes eye checks, Specsavers expected to see an average of 22,654 patients with diabetes per month across 2020.

In February this year, it cared for 21,197 patients with diabetes. Then in April, only 1,386 patients with diabetes presented to its optometrists. Of those, only 670 patients were registered to KeepSight from Specsavers over the four-week period compared with 7,632 in February.

Comparison of item number 10915 between 2019 and 2020 for diabetes patients.

This trend was seen nationwide across all optometry professionals, as reflected in the use of Medicare item 10915, which was used 10.7% more year-on-year in February but then 9.2% less than 2019 in March and 75.6% less than 2019 in April.

Simply comparing 10915 for 2019 versus 2020, it has been established that at least 2,190 patients with diabetes missed out on dilated eye examinations in March and 15,714 in April, indicating the backlog of patients with diabetes that are now in need of prioritised care.

Specialist care referrals 

Specsavers data also indicates some interesting findings in the percentages of patients referred for specialist care, demonstrating the urgency of the patients who received eye tests during the lockdown period.

April 2019 saw 6% of patients being referred for urgent eyecare. This rose to 11.9% in April 2020, showing that while patients for general testing significantly decreased, a higher proportion required urgent care.

From an early detection perspective, year-on-year comparison of Medicare item 10910 shows that 166,635 Australians missed out on routine eye tests in March and April 2020 due to the impacts of COVID-19.

Ashby said that not only is prescribing glasses and contact lenses important for the quality of life and long-term eye health, but this patient base is where – through a systematic approach to eyecare – early, initial detections of glaucoma and other degenerative eye conditions are identified.

“Specsavers is now detecting more than 40,000 patients with glaucoma each year, in line with prevalence rates,” he said.

“Half of the patients are newly diagnosed and, according to Glaucoma Australia, where 66% of referrals come from Specsavers, their average age of referral has decreased from 80-89 to 60-69 years old since we’ve introduced measures to detect glaucoma earlier.”

Practices were required to modify their environments to follow health department guidelines

He continued: “Thankfully, the fight against COVID-19 is being won and the necessary closures and restrictions to eyecare set to flatten the curve are (at time of writing 15 June 2020) being lifted by Federal and State Governments. As we know from the data, there is pent-up demand for optometric services and this has put many patients not seen at risk.”

Ashby said Specsavers is focussed on providing a safe environment for patients as routine care resumes. As the company has stood up employees and started to offer services to more members of the public, it is providing patients and staff with a modified practice environment that strictly follows health department guidelines.

Specsavers is also working on a recall model which engages those in Australian communities who need prioritising for care. This involves prioritising recalling patients with risk factors such as diabetes who have missed their original appointment. Similarly, it will manage those with other eye conditions such as glaucoma while also factoring in bookings for day-to-day cases where unusual or previously unknown conditions often present.

“Since reopening for routine eyecare, the data has surprised and given a positive outlook on what we might expect for the rest of 2020,” Ashby said.

“At this stage, Australians seem to be prioritising eyecare and pent-up demand has seen our numbers start to increase again. In the week of writing this, Specsavers national patient volume is uniformly increasing and patients with diabetes make up 6.8%, in line with population prevalence – an important indicator that we are seeing patients present in the right proportions.

“As restrictions continue to lift and as it becomes safer for at-risk patients to confidently leave their homes, we are anticipating further growth of patients.”

Ashby said the company had a long way to go and it’s implementing strategies to best tackle the pent-up demand for optometric services to ensure an increase of positive eye health outcomes.

“As I’m sure many optometrists will relate, COVID-19 has been a tangible reminder as to why we do what we do. Never before has optometry been so important and never before have we seen such proportions of patients in need of urgent care,” he said.

“Given the quantity of Australians in need of eye care at the moment, I believe we should expect a big year ahead. That might just make 2020 the great year for optometry and public eye health that we always hoped it would be.”