Abstract
Background:
Teleophthalmology programs are expanding, but have not been adapted into many emergency departments (EDs) in the United States.
Introduction:
Determining the potential demand for teleophthalmology services in the United States. EDs could enable development of new strategies to improve access to eye care in resource-limited regions.
Methods:
Telephone surveys were administered to ED physicians and nurses in Florida. Perceptions of ophthalmologist availability, equipment availability, and perceived utility of teleophthalmology services were measured.
Results:
Responses were from 104 of 207 facilities (50.2%); 88/181 (48.6%) designated as nonrural hospitals (NRHs) and 16/26 (61.5%) as rural hospitals (RHs). NRHs reported a median of 1 ophthalmologist available on call compared with a median of 0 at RHs (p < 0.001). NRHs were more likely to have a slit lamp (98.9% NRH, 50.0% RH; p < 0.001) and tonometer (100% NRH, 75.0% RH; p < 0.001). On a scale from 1 (lowest) to 5, most (68/93; 73.1%) perceived the value of teleophthalmology for remote consults as a 4 or 5. The most common perceived benefit of teleophthalmology use was to provide second/expert opinion (26.5% of responses). The most commonly cited perceived disadvantage was the physical unavailability of an ophthalmologist for examination and follow-up care (35.5% of responses).
Discussion:
RHs have less access to ophthalmologists and ophthalmic equipment when managing eye-related complaints in the ED. At both RHs and NRHs, providers face limitations in managing eye complaints and perceived teleophthalmology as a potentially valuable tool for remote expert consultation.
Conclusions:
Results suggest teleophthalmology services may be used to improve access to expert ophthalmic care, particularly in rural communities.
Introduction
Telemedicine has gained rapid adoption in the United States and has been used to deliver expert care to patients in difficult-to-reach areas. 1 The American Heart and American Stroke Associations strongly recommend telehealth for emergency stroke care, 2 and it has been shown to improve emergency care in the rural settings with limited resources and fewer available medical specialists. 3 One such study demonstrated that telemedicine use in rural Arizona improved last-known normal to needle and door-to-needle times for stroke patient. 4 A telemedicine program in Chatham County, a rural emergency department (ED), found that a significant proportion of diagnoses and treatments were changed with the use of telediagnostics and teleradiology programs. 5 Teleophthalmology, which is the delivery of eye care through digital technology and communication, 6 has been increasingly used in nonemergency care in the United States, 7 such as screening for diabetic retinopathy 8 –10 and retinopathy of prematurity. 11 –13
Emergency care teleophthalmology programs have been described internationally 14 ; however, utilization of teleophthalmology in the management of patients in rural and urban ED in the United States has had more limited adoption. A 2018 systematic review of 44 European studies 15 concluded that teleophthalmology was a valid, reliable, and cost-effective tool with comparable outcomes to traditional methods. Only one of these studies 14 specifically examined emergency teleophthalmology and concluded that such a service could reduce the number of emergency transfers between hospitals. 14 In the United States alone, one study reported ∼12 million eye-related ED visits over a 5-year period, with 44.3% deemed nonemergent problems. 16 Emergency eye care availability varies by geographic location 17 and rural areas tend to have lower rates of annual dilated eye examinations. 18
In 2016, Wedekind et al. 19 surveyed California ED providers to evaluate the demand for teleophthalmology services. They concluded teleophthalmology was perceived to have more value in rural EDs than in nonrural EDs in California.
Florida is the third largest state by population, and California is the largest; 22% of Florida adults with incomes below 100% of the federal poverty level are uninsured compared with only 9% in California. 20 (Of note, Texas is the second largest with 39% in this cohort uninsured.) 20 Insurance status and health care costs are known to affect access to eye care. 17,21 To understand the differences in demand for teleophthalmology services across the United States based on these economic factors and geographic variation, we replicated Wedekind et al.'s 19 methodology in the state of Florida. The purpose of our study was to assess the availability of emergency eye care and the perceived value of teleophthalmology services in Florida EDs.
Methods
Study Design and Data Collection
A database of Florida EDs was generated using a publicly available list from the Florida Agency for Health Care Administration. 22 EDs listed in the Florida Department of Health's 2018 rural hospital (RH) directory were designated as rural. 23 The Florida Department of Health defines a hospital as rural if it has “25 beds or less… is reimbursed for 101 percent of the cost of providing services to Medicare patients…” and if it provides “24 h emergency, outpatient, and limited inpatient services, and must meet other requirements to support the services provided.” 24 All remaining locations were designated as nonrural.
ED physicians and nurse managers were contacted at the phone number listed on the organization website, and telephone surveys were administered from March 2017 to May 2018. Each hospital was called up to three times. The survey was divided into 4 parts. Part 1 asked survey responders to address ED demographics, to identify ophthalmologist availability, and to retrospectively quantify emergency eye cases. Part 2 addressed the availability of ophthalmologic clinical equipment in the ED. In part 3, responders were asked about their personal use of teleophthalmology services and perceptions of its value. Participation in part 4 was limited to physicians who were asked to evaluate their level of comfort managing various ocular complaints presenting to the ED. If a survey responder declined to answer an individual question within the survey or indicated he or she did not have an answer, no value was included for that single response. Approval for this study was obtained from the New York University Institutional Review Board.
Statistical Analyses
Basic descriptive statistics, including mean, standard deviation, median, the 25% quartile, and 75% quartile, were calculated to examine each facility's characteristics and were categorized into the following: all facilities, nonrural facilities, and rural facilities. To analyze questionnaire responses at nonrural compared with rural facilities, Wilcoxon rank-sum tests were used for numerical values and chi-squared tests were used for binary or categorical variables. Analyses were carried out using R programming language version 3.4. A p-value of <0.05 was considered statistically significant.
Results
The Florida Agency for Health Care Administration identified 207 EDs on its publicly available website. 22 We received responses to our survey from 104 of 207 facilities (50.2%). There were 181 nonrural (87.4%) facilities and 26 (12.6%) rural facilities. Survey responses were obtained from 88/181 (48.6%) nonrural hospitals (NRHs) and 16/26 (61.5%) RHs. Seventy-one (68.3%) of all survey responders were nurses, while 33 (31.7%) responders were physicians.
ED Characteristics and Services
NRHs were significantly less likely to have ophthalmologists available on call (p < 0.001); the median for nonrural was 1 (Q1, Q3: 0, 1) and 0 (Q1, Q3: 0, 0) for rural (Table 1). There was no significant difference between the number of ophthalmologists available during regular hours at rural and nonrural sites (p = 0.11); the median for nonrural was 0 (Q1, Q3: 0, 1) and 0 (Q1, Q3: 0, 0) for rural. EDs reported an average number of eye-related presenting complaints of 16.11 ± 42.64 per week. Nonrural sites reported a significantly higher number of eye-related presenting complaints (18.44 ± 46.58) compared with rural sites (5.06 ± 4.80; p = 0.003). A dedicated eye ED reported triaging 400 ocular complaints weekly and was an outlier compared with the other emergency settings. After excluding this facility from our analysis, the difference in weekly eye-related issues remained statistically significant between nonrural (13.35 ± 14.34 per week) and rural sites (5.06 ± 4.80 per week; p = 0.003).
Emergency Department Survey Results
Statistically significant as p < 0.05 when comparing nonrural versus rural.
SD, standard deviation.
The average wait time for patients with eye problems was 4.73 ± 7.02 h and the difference between nonrural (4.28 ± 6.62 h) and rural (7.18 ± 8.88 h) sites was not statistically significant (p = 0.28). Across facilities, the average referral rate to outside facilities was 6.12 ± 8.77 per week. There was no significant difference between nonrural and rural site referral rates. The distance to referral sites was shorter for nonrural compared with rural sites (13.03 ± 19.81 miles vs. 37.03 ± 45.53 miles; p = 0.037).
Slit lamps were available at 91.3% (95/104) of facilities, 96.2% (100/104) had handheld tonometers, and 48.1% (50/104) had indirect ophthalmoscopes (Table 1). Nonrural facilities were significantly more likely to have a slit lamp (98.9% nonrural, 50.0% rural; p < 0.001) and tonometer (100% nonrural, 75.0% rural; p < 0.001). There was no significant difference in the availability of indirect ophthalmoscope (51.1% nonrural, 31.3% rural; p = 0.23).
Perspectives on Teleophthalmology
Telemedicine (of any discipline, not specific to ophthalmology) was reportedly used at 71.2% (74/104) of surveyed facilities. More nonrural sites had access to telemedicine than rural sites [nonrural 76.1% (67/88); rural 43.8% (7/16); p = 0.020].
A total of 96.2% (100/104) of providers had never used any formal teleophthalmology service, but 12.5% of providers replied yes when asked if they had ever sent or received digital images via phone or e-mail to discuss a patient with an ophthalmologist.
On a scale of 1 (very low) to 5 (very high), the average perceived value of teleophthalmology services for patient triage was 3.1 (nonrural 3.0; rural 3.1; p = 0.34). By contrast, 73.1% (68/93) of providers perceived the value of teleophthalmology for full remote consults to be high or very high (Table 2). The perceived value for RHs exceeded that for NRHs, although the difference was not statistically significant (nonrural 3.8; rural 4.6; p = 0.13).
Perspectives on Teleophthalmology and Its Utility
Responses range from 1 (very low value) to 5 (very high value) of a possible 5.
Seven survey responders declined to answer this question.
Three survey responders declined to answer this question.
Responders were asked to select up to three perceived advantages and disadvantages of teleophthalmology (Table 3). The most commonly cited perceived benefit of teleophthalmology use was to provide second opinions and expert opinion (26.5% of total responses). The second-most common responses were to improve triage efficiency, enable immediate electronic processing, and improve access to care (14.7% of total responses, respectively). The most commonly cited perceived disadvantage of teleophthalmology was that the ophthalmologist would not be physically present to perform a thorough eye examination when the patient initially presents or for follow-up examinations (35.5% of total responses). The next most common perceived disadvantage was unknown costs (25.8% of total responses), followed by no perceived need (16.1% of total responses).
Perceived Advantages and Disadvantages of Teleophthalmology
Respondents were able to select multiple responses.
Physician Comfort with Ophthalmologic Complaints
Of the 104 surveys administered, 31 were completed by physicians (27 nonrural, 4 rural). The average time each physician had been in practice at the time of the survey was 17.13 ± 11.76 years (Table 4). Time in practice was significantly longer for rural physicians (35.00 ± 3.56 years) compared wiht nonrural physicians (14.48 ± 10.08; p = 0.002). Given the limited sample size, statistical testing could not be used to compare nonrural and rural responses with the remaining questions.
Physician Experience and Comfort with Ophthalmologic Complaints
Statistically significant as p < 0.05 when comparing nonrural versus rural.
Responses range from 1 (very low value) to 5 (very high value) of a possible 5.
NA, not applicable; sample size is too small for any formal statistical testing.
On a scale of 1 (no comfort) to 5 (very comfortable), physicians were most comfortable handling conjunctivitis (96.8% selected 5), corneal abrasions (93.5% selected 5), corneal foreign bodies (87.3% selected 4 or 5), eye pain (77.4% selected 4 or 5), and eye redness (61.5% selected 4 or 5). Physicians were less comfortable managing vision loss (67.8% selected 3 or 4) and lid lacerations (54.8% selected 3 or 4). Although 100% of responders said they were comfortable using a slit lamp, 32.2% rated their comfort examining the anterior segment as 3 or less, and 82.0% rated their comfort examining the posterior segment as 3 or less.
Discussion
The purpose of our study was to assess the perceived value of teleophthalmology in the emergency setting in a region of the country with more challenging access to affordable care. Our study of Florida EDs found that there are fewer ophthalmologists available on call at rural facilities. Rural emergency rooms are less likely to have access to slit lamps and handheld tonometers, and the distance to the nearest referral center is greater than nonrural facilities. Rural providers were less likely to have used telemedicine. Together, these results may suggest that rural compared with nonrural facilities, on average, are not equally equipped to manage eye cases and have less access to support from ophthalmologists.
Across nonrural and rural facilities, only four surveyed providers had ever used teleophthalmology, yet one out of every eight providers had sent or received digital images via phone or e-mail to discuss a patient with an ophthalmologist, and nearly three-quarters of all providers thought teleophthalmology would be valuable as a remote consult tool. Although most physicians surveyed reported feeling fairly comfortable managing conjunctivitis, corneal abrasions, corneal foreign bodies, eye pain, and eye redness, they felt less comfortable addressing vision loss and lid lacerations. About one-third of physicians reported reduced comfort examining the anterior segment, and over 80% reported reduced comfort examining the posterior segment. The most commonly cited perceived advantage of teleophthalmology was the availability of second opinions and expert opinion to emergency room providers.
In Wedekind's California teleophthalmology study, 19 nearly half of surveyed EDs reported telemedicine availability with no significant difference between rural and nonrural sites. Interestingly, 2 years after Wedekind's study, we found a higher overall percentage of telemedicine use in Florida EDs, but use was significantly less frequently available at rural sites. In addition, in our study there were fewer ophthalmologists available during hospital hours at all sites (typically 0–1) compared with the California findings (4 on average). The most important perceived disadvantage of teleophthalmology in Wedekind's study, the unknown associated costs, ranked as highly important to our survey responders as well. These findings are particularly concerning given the higher health care cost-related problems in Florida compared with California. 20 In 2013, the California State Legislature passed an expansion of Medicaid under the Affordable Care Act that would enable coverage of individuals with incomes up to 138% of the federal poverty level. 25 Florida Governor Rick Scott and the state House of Representatives rejected an analogous expansion in 2015, and therefore, the Florida state government declined to expand Medicaid eligibility to adults at or below 138% of the federal poverty level. 20,25
Underserved communities and rural settings have demonstrable gaps in resources, including available ophthalmologists. 19,26 In 2015, Gibson showed that U.S. counties with fewer ophthalmologists per capita were more likely to have lower population densities with more economically disadvantaged residents and more poverty. 27 These counties also contained higher proportions of residents 65 years and older. The Veterans Affairs hospitals have adopted teleophthalmology programs to monitor high-risk diabetic patients and patients in remote rural areas. 9,26,28,29 The Technology-based Eye Care Services program has produced preliminary data regarding the efficacy of teleophthalmology for hospitals and clinics in rural settings and has found lower cost per patient compared with cost per patient in the traditional clinic setting. 26,29,30
Limitations of our study include a response rate of 50.2%, thereby approximately half of respondents did not respond. Although lower than a 73.6% (187/254 EDs) response rate was seen in Wedekind's study, this is still favorable compared with general organizational survey response rates. 31 Another limitation is surveys were administered to both physicians and nurse managers. Differently qualified health care professional respondents could have confounded responses. For example, nurses may have been more likely than doctors to see a benefit in using teleophthalmology services during triage, a pattern that was noted in Wedekind's study. 19
There is a significant lack of access to expert ophthalmic consultation in the emergency setting in both rural and nonrural locations in Florida. The perceived demand and value for teleophthalmology services to address this care gap were perceived as high by most providers and may address disparities in access to care. Although the overall use of telemedicine appeared to be higher than the use noted in a similar California-based 2016 study, there was a greater disparity in telemedicine availability between rural and nonrural facilities. In both studies, those surveyed cited concerns about unknown costs as an important perceived disadvantage associated with teleophthalmology use. Further research is needed to evaluate the emergency teleophthalmology implementation and cost considerations.
Footnotes
Acknowledgments
Concept and design: E.T., J.S.S., and S.R. Acquisition, analysis, or interpretation of data: J.T., S.A., and P.S. Drafting of the article: J.T., S.A., M.W., E.T., and S.R. Critical revision of the article for important intellectual content: All authors. Statistical analysis: J.T. and M.W. Supervision: E.T., J.S.S., and S.R.
Disclosure Statement
J.S.S. receives royalties for intellectual property licensed by the Massachusetts Institute of Technology to Zeiss.
Funding Information
No funding was received for this article.