Effectiveness of an ophthalmic hospital-based virtual service during COVID-19

The management of ophthalmic diseases in the virtual hospital can be implemented and is complementary to those of on-site F2F clinics. Virtual clinical service may be a useful model in the post-COVID-19 pandemic “new normal”. The COVID-19 pandemic crisis has posed challenges for healthcare providers1, meanwhile, brought about new opportunities for telehealth services worldwide. Although media publicity for telehealth and virtual consultations has been widespread2, few peer-reviewed studies have been conducted to describe the characteristics and effectiveness of hospital-based telehealth virtual practice in response to the COVID-19 pandemic. In China, the Zhongshan Ophthalmic Center (ZOC) of Sun Yat-sen University established a virtual clinical service utilizing several digital technologies3 (5G telecommunication networks, big data analytics, artificial intelligence (AI)4 and blockchain technology5) to deliver online ophthalmic diagnosis and treatment services. This study analyzed the characteristics and effectiveness of a virtual service run by the tertiary ophthalmic center in China to construct a pragmatic paradigm for telehealth eye care services during and beyond the pandemic. With lockdown regulations for COVID-19 epidemic, during February 1 to 7 2020, ZOC on-site registration was open for emergencies only; Comprehensive and specialist clinics were gradually reopened since February 15, 2020. The ZOC internet hospital was launched on February 1 to provide patients with diagnosis and treatment options. Three inter-linked modules constituted the main body of the ZOC internet hospital: AI prescreening by chatbot and image recognition6, virtual live consultation with ophthalmologists, and online pharmacy for prescription renewals and remote drug delivery (details in Figure S1a, available at www.aaojournal.org). We extracted clinical services records from virtual 2020, Face-to-face (F2F) 2020 and F2F 2019 from Feb 1 to Mar 13 for analysis, including patient age, gender, address, date and hour for consultation, transcript records of online communications, diagnosis of on-site clinic visits, etc. We used the Shapiro-Wilk test to evaluate for normal distribution of each sample. The median and interquartile range (IQR) was used for the description of continuous variables which don’t conform to a normal distribution. The Kruskal-Wallis test (among three groups) and the Wilcoxon-rank sum test (between two groups) were used for comparisons. The frequency and proportion were used for descriptions of categorical variables, and the Chi-square test was used for comparisons between groups. P < 0.05 was considered statistically significant for all tests. This study followed the principles outlined in the Declaration of Helsinki. The study protocol was approved by the ethical board committee of the Zhongshan Ophthalmic Center, Sun Yat-sen University. During the six-week study period, a total of 38,038 visits online (virtual 2020) and offline (F2F 2020) were observed in this study, including 10,641 visits with the AI chatbot, 9,850 virtual live consultations by 127 doctors, and 17,547 on-site F2F clinic visits. Along with the gradual opening of the on-site outpatient and emergency services by the ZOC, the number of on-site patients showed a steep rise. Simultaneously, online service numbers steadily increased because of the increased awareness of the service, optimization of the patient user experience, and the availability of online pharmacy service and delivery (Figure S1b, available at www.aaojournal.org). Thus, we were able to offer an end-to-end solution based on a fully virtual diagnosis and treatment. The median age of virtual 2020 patients was 32 years old, significantly younger than the F2F 2019 (35 years old) and F2F 2020 (45 years old) groups. The proportions of youth (18–34 years old, 35.9%) and middle-aged (35–54 years old, 26.8%) patients increased in Virtual 2020 group after the COVID-19 outbreak compared with F2F 2019 group. Females were more likely to use virtual live consultation (53.3% of 9850 visits) than F2F 2020 (47.7% of 17,547 visits) or F2F 2019 (51.1% of 98,225 visits) (Figure 1a). Retinopathy was one of the most common reasons for the virtual 2020 (22.6%, 1644/7273), F2F 2020 (26.5%, 1203/4532), and F2F 2019 (20.1%, 10740/53308) groups. Nevertheless, there were more visits for ocular surface diseases (24.2%, 1761/7273) and glaucoma (19.4%, 1411/7273) in patients receiving virtual live consultation. Trauma (26.3%, 1194/4532) accounted for the second-largest proportion of F2F 2020. Refraction (26.1%, 13895/53308) problems were the most common reason for F2F 2019 consultations (Figure 1b). Compared with F2F 2019, which represented the normal state before the COVID-19 outbreak, F2F 2020 visits in the corresponding period involved patients more geographically concentrated around ZOC clinics-from Guangdong Province (85.6%, 14,050/16,405 of China) and Guangzhou City (72.9%, 10,112/13,876 of Guangdong Province), due to the travel restrictions during the national lockdown. By contrast, Virtual 2020 visits were significantly more dispersed, with the median geographical distance 340 (64.0-677) kilometers, significantly further than F2F 2020 (2.66 (0.01-128)) and F2F 2019 (2.65 (0.00-219)) (Figure 1c, Table S1, available at www.aaojournal.org). We further analyzed the indications of virtual live consultations 2020. Specific disease consultation was the most commonly cited reason for virtual live consultation and accounted for 67.0% of the total 9,850 visits, followed by symptomatic complaints (56.0%), prescription renewal (54.6%), other consultations (2.2%, including drug usage, procedures for attending clinics during the lockdown period, eye health consultation, etc.), and repeated consultation (1.6%). Among the symptomatic complaints addressed, ocular discomfort or appearance abnormalities constituted the overwhelming majority (87.2%). In terms of specific disease consultations, 38.7% and 26.9% of the total 6,597 visits concerned follow-up and queries about surgery-related information. The top three most referred diseases were ocular surface diseases (26.7%), retinopathy (24.9%), and glaucoma (21.4%) (Figure S2a, available at www.aaojournal.org). When stratified by age, specific disease consultation was the most common reason across all age groups, and the demand increased with age from 64.7% in children (<18 years old, 1339/2069) to 70.7% in seniors (>55 years old, 1131/1599). Youth (18–34 years old) were the most eager to seek virtual consultation for symptom complaints (60.4%, 2036/3539) and other consultations (2.6%, 92/3539). Seniors (>55 years old) were most likely to use virtual consultation for prescription renewal, with up to 10% more seniors requesting prescription renewal than the other age groups. Repeated consultation was the only category that children (or their guardians, 1.8%, 37/2039) were more likely to use (Figure S2b, available at www.aaojournal.org ). The study has several limitations. First, during the six-week study period, the ZOC online/on-site services were running separately and thus were analyzed as independent parts. We could not trace the flow of visits for a patient from online to on-site, or vice versa. Subsequently, the online and on-site healthcare interactions were integrated and incorporated in the ZOC internet hospital design. Second, the direct reproducibility of the virtual clinical services may be limited by the licensing requirements from different countries/regions. Nevertheless, we would offer lessons and collaborate with other ophthalmology services providers during and after this COVID-19 pandemic. Our results indicate that online medical services could be fully utilized for telehealth advantages including time-savings, bridging geographical barriers, and additional functionalities such as remote assessment, in a complementary manner to on-site F2F clinical services. Interestingly, we observed from the spectrum of diseases that ocular surface diseases were most cited in the virtual live consultations in 2020, which differs significantly from the most common reasons in the F2F 2020 (retinopathy) and F2F 2019 (refraction) groups. This finding may reflect that COVID-19 may have ocular surface symptoms, although we did not record COVID-19 positive patients in our service. Alternatively, ocular surface disorders could be related to physical/psychological factors (break from regular life, overuse of digital screens, stress, anxiety during the pandemic)7. Even as countries and systems adapt to the post-COVID-19 “new normal”, many of the virtual systems that were established to meet short-term needs will eventually evolve into long-term trends and solutions. The virtual clinical practice was indicated beneficial especially for patients with ocular surface complaints or in need of follow-up medications. Furthermore, virtual evaluation could provide effective forward triage to specific on-site specialists as a useful complement. The virtual service also offered an alternative for the less time or geography accessible patients. These guidance and lessons from the study would be a reference for other ophthalmology services in different countries during and after this COVID-19 pandemic. YZ, CC, DST, DVG, YZL, TYW, XFL and HTL were responsible for critical revision of the manuscript for important intellectual content. XHW, DYY, and MY were responsible for figures. XFL and HTL had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

• Tipo de recurso: Article of investigation
• Fecha de publicación: 2020
• Institución: Universidad de Bogotá Jorge Tadeo Lozano
• Repositorio: Expeditio: repositorio UTadeo
• Idioma: eng
• OAI Identifier: oai:expeditiorepositorio.utadeo.edu.co:20.500.12010/14570
• Acceso en línea: https://doi.org/10.1016/j.ophtha.2020.10.012; http://hdl.handle.net/20.500.12010/14570
• Palabra clave: Ophthalmic; Virtual service; COVID-19; Síndrome respiratorio agudo grave; COVID-19; SARS-CoV-2; Coronavirus
• License: Abierto (Texto Completo)