John W. Kitchens, MD: Describe how you normally see patients and then how you have modified that during COVID-19.
David Almeida, MD, PhD, MBA: We were lucky that our practice setup was already prepared to handle the COVID-19 crisis. Our practice has two floors. The pre-COVID routine saw patients interacting with physicians on the first floor, where diagnosis, imaging, and a treatment plan occurred. Treatment was administered on the second floor, which had a negative pressure system with multiple lanes. We’re providing the same level of care. Our injection clinic was already set up, and so, other than extending intervals for a few patients, we’re sticking to pre-pandemic treatment regimens. We use the first-floor imaging stations for selected patients, but the injection clinic is running at full tilt.
Dr. Kitchens: Dr. Weng, can you walk me through the hypothetical first visit for a patient with wet age-related macular degeneration (AMD)? Tell me what your protocols were before the pandemic so we have a basis for comparison.
Christina Weng, MD, MBA: Our pre-pandemic check-in process required a technician to gather patient history, assess vision, and administer imaging. All of this was per-formed before the patient and the physician interacted. Before the pandemic, we imaged any referred patients with OCT and occasionally fluorescein angiography to con-firm diagnosis. I asked that a family member join the patient, if possible, so that another listening ear can absorb the information I’m delivering. At that point, I usually had the patient initiate therapy on their next visit because I needed pre-authorization to start injecting in most cases. Now, our policy at Baylor does not allow patients to bring family members to appointments, unless that family member is there to assist with something like translation or a physical handicap. We try to streamline patient intake, too, which minimizes the number of surfaces a patient touches and the number of rooms that need to be turned over between patients. Many of our patients only receive OCT testing; ancillary test-ing such as fluorescein angiography and fundus photography are performed only if it will change clinical management.
I see patients in the same room where they are worked up, and I’m often administering treatment on the same day to eliminate the need for a return visit. I’m not sure how sustainable this is from a financial and insurance perspective, but it’s what we’re doing at Baylor now.
PATIENTS AND BILLING
Dr. Kitchens: If we reserve imaging for only those patients whose disease management may be altered after the results, as Dr. Weng has described, then some patients may feel like we’re not providing a full workup. Is that your experience, Dr. Adam?
Dr. Adam: Not at all. In fact, most of my patients are appreciative of getting in and out so quickly. Injection-only visits take about 30 minutes—a far cry from some of our previous turnaround times. For patients who report visual change, we check visual acuity and perform imaging. I wonder how we’ll transition back after the pandemic’s intensity is reduced.
Dr. Almeida: Have you run into difficulty with billing? Payers sometimes want to see vision checks or pressure checks on an assessment.
Dr. Adam: We don’t bill for visits during injection-only vis-its. We bill only for the injection and, if needed, the OCT
Dr. Kitchens: Drs. Adam and Almeida are in private practice. Does their experience with injection-only visitation mirror your experience at Baylor, Dr. Weng?
Dr. Weng: We check vision and pressure in all of our patients, and the vast majority of our patients receive OCT imaging. Our wet AMD patients are on treat-and-extend regimens, and we use that imaging to guide treatment. Luckily, OCT images are quickly acquired, so they do not disrupt our processing flow as long as they are ordered correctly.
Dr. Kitchens: How have you engaged with patients via telemedicine during the pandemic?
Dr. Adam: The day before a patient is scheduled for an in-person visit, we call them to gather information usually acquired during their in-person intake. History, medications, review of symptoms—all of that is included in their chart. When their visit starts, they get their pressure checked and then I see them immediately. I think we’ll continue with this model even after the pandemic.
Dr. Kitchens: Telecommunication with some of our patients can be challenging.
Dr. Adam: Agreed. Sometimes it’s a matter of getting a family member to help them with technology. Not uncommonly, the patient has trouble hearing you. It’s not a perfect system—I would say it works for 50% to 60% of my patients. Still, it does lend itself to increased efficiency in the clinic.
Dr. Almeida: We use the same system that Dr. Adam just outlined. We gather as much information as possible over the phone before bringing patients in, and then we instruct them to visit our injection clinic for treatment visits. Telehealth, in that way, creates a quick and safe visit for our patients. But we have not done anything like video conferencing. We haven’t had the need yet.
Dr. Weng: We have the ability to videoconference with patients via our EHR system, but I’ve found it challenging. It can be useful for triaging patients, and some patients find it reassuring to know a doctor is listening to their symptoms. But when a patient reports a change in vision, I can’t say, “Oh, I don’t think it’s really anything,” without the aid of an OCT or a dilated examination.
Dr. Kitchens: Are there any technologies that you wish you had?
Dr. Weng: Home OCT is something that would revolutionize retina. If we had that, we could tell patients with accuracy how quickly they need to be seen.
Dr. Kitchens: Agreed. Home OCT would be a game-changer. We have the Amsler grid, obviously, and we also have the ForeseeHome device (Notal Vision). Dr. Almeida, has your practice used the ForeseeHome?
Dr. Almeida: Our practice covers such a huge area that we have chosen to concentrate on efficiency and on supporting our local referral base.Unfortunately, we don’t have the band-width for something like ForeseeHome.
Dr. Adam: My practice also hasn’t embraced ForeseeHome, or any home-based monitoring system for that matter. Has your practice looked into these, Dr. Kitchens?
Dr. Kitchens: We’re believers in it. We were in the HOME study, which evaluated the ForeseeHome device’s efficacy. About 70% of my patients can use it, and they love it; the other 30% have difficulty with it. We have found it an effective monitoring tool for patients.
A RETURN TO IN-PERSON MEETINGS?
In-person education is one of the jewels of retina, and a dynamic of the job that many physicians miss. What concerns do you have about the resump
Dr. Adam: It’s going to take a lot to convince me that in-person meetings should be resumed. I need to see evidence of a nationwide paradigm shift on how travel and business is conducted before I can comfortably attend a convention.
Dr. Almeida: It’s tricky. Obviously, I want to go and see my colleagues and learn about their research. But I also don’t want to acquire the virus while traveling, become an asymptomatic carrier, and then pass it along to my patients.
Dr. Weng: Our facility requires people who visited certain states to quarantine for 14 days. Even if I visit a state that isn’t on the list when I leave, I would be required to quarantine if that state is added to the list while I’m there. I must consider this when traveling to any potential events.
Dr. Kitchens: Has the pandemic affected your choice of drug—say, allowing more steroid use in patients with diabetic eye disease, or using a different anti-VEGF agent for wet AMD patients?
Dr. Adam: Before the pandemic, we had plenty of patients who received bevacizumab (Avastin, Genentech) and were happy to come in every 4 or 5 weeks for an appointment. Now, given that every appointment is a risk of exposure, our practice has shifted our anti-VEGF agents of choice, particularly for patients in long-term care facilities, as they are at the greatest risk for complications should they contract COVID-19.
Dr. Weng: Drug durability was already a hot topic, and now it’s even more important. Longer-duration drugs could allow us to avoid a situ-ation like we had at the beginning of the pandemic, when we had to strictly enforce social distancing and decide which patients we were able to see. Technology that could get us to quarterly intervals or longer would be great. That is part of the reason the Port Delivery System (PDS, Genentech) excites me so much. Regarding steroid use, I am generally a proponent of it, but given that it may also be harder for patients to return to our clinic if there is an IOP spike, it is important to select patients carefully.
Dr. Kitchens: Are you switching anti- VEGF agents?
Dr. Weng: I’ve considered it. Some patients with wet AMD experience longer duration of effect if they receive aflibercept (Eylea, Regeneron), for example. And of course, now there is brolucizumab (Beovu, Novartis). The patients I’ve started on brolucizumab have responded wonderfully, and many have moved to quarterly treatments. Given the safety considerations around brolucizumab, however, I think a lot of doctors are hesitant to start patients on this agent, especially during this time.
Dr. Almeida: With respect to neo-vascular AMD, we have significant experience with longer duration of effect and stable efficacy intervals with aflibercept, although we use all the available anti-VEGF agents. We started using brolucizumab in November 2019. When some safety concerns arose, we revised our con-sent process and monitor those patients closely.
THE FUTURE OF RETINA
Dr. Kitchens: Some of the changes we made will be here for the long term. Others will fade away with time. Does the panel have any ideas about which protocols will stay in place?
Dr. Weng: Cleaning practices and hygiene routines will probably stick around for a while. It’s hard to justify going back to a less-clean workplace. I think that wiping down rooms with bleach and wearing masks will be around for a while. Forever, maybe.
Dr. Adam: Creating a less-clean practice—that’s going to be a hard sell.
Dr. Almeida: As someone who loves staying involved with clinical trials, I look forward to enrolling patients and gathering data. We have a completely separate area for our clinical trials division, which facilitates pandemic preparedness in research patients. I can see this division of clinical roles (eg, imaging, diagnosis, treatment, research, etc.) remaining for the long term.
Dr. Adam: The challenge with recruiting for clinical trials at the moment is that patient volume is down. Patient enthusiasm is still pres-ent, which is key. But, in Colorado, our referrals fell sharply when optometry offices closed.
MURTAZA ADAM, MD, Physician, Colorado Retina Associates, Denver, Colorado
Financial disclosures: Allergan/AbbVie, EyePoint Pharmaceuticals, Genetech, Novartis, Regeneron
DAVID R.P. ALMEIDA, MD, MBA, PHD,Vitreoretinal Surgeon, Erie Retinal Surgery, Erie, Pennsylvania
EMAIL: firstname.lastname@example.org; Twitter: @davidalmeidaMD
Financial disclosures: Allergan/AbbVie, Alcon, Alimera Sciences, Bayer, Genentech, Novartis, Regeneron
CHRISTINA Y. WENG, MD, MBA, Associate Professor of Ophthalmology; Fellowship. Program Director, Vitreoretinal Diseases and Surgery; Baylor College of Medicine-Cullen Eye Institute, Houston. Director, Medical Student Clinical Elective Ben Taub General Hospital, Houston
Financial disclosures: Allergan/AbbVie, Alcon, Alimera Sciences, DORC, Novartis, Regeneron, RegenxBio
INTERVIEW BY JOHN W. KITCHENS, MD
As seen in: RETINA TODAY | SEPTEMBER 2020. Selected excerpts from a recent edition of New Retina Radio.