The eyecare industry is keenly looking to project the health and economic impacts of COVID-19. In October 2020 Optometry Australia released a summary of Medicare statistics, reporting a 6-7% drop in optometric services in the 2019/20 financial year compared to the previous year. This quantified the immediate impact of COVID restrictions as 630,000 less Medicare billed optometric services nationwide.
Since June 2020, resurgences of the virus have resulted in fluctuating restriction levels, impacting the delivery of eyecare to vastly different degrees depending on region. The inevitable consequence of this is that the road to recovery looks very different across the country, in particular for metropolitan Melbourne where lockdown measures were in place for almost twice as long as other places. Clinical data has become incredibly useful in understanding where reduced access to optometrists has impacted on diagnosis and management of prevalent eye conditions in the primary eye care setting.
For all health sectors another significant consideration is the impact of restrictions on routine care. For optometrists operating in a lockdown situation, urgent and essential services were rightly reserved for emergency presentations, patients with acute or progressed symptoms and those with known at-risk conditions necessitating care. As such, detection of silently progressive eye conditions like glaucoma, which is estimated to affect 3% of the population over the age of 40, has been significantly impacted due to disruption to routine eyecare in 2020.
At Specsavers, the years preceding the outbreak of COVID-19 saw the culmination of several significant clinical initiatives designed to target detection of glaucoma. Consistent use of OCT for all patients, education around clinical indications for visual fields assessments and implementation of the RANZCO Referral Pathways for Glaucoma Management provided a consistent framework enhancing glaucoma diagnosis across the network. After several years of measurement, 2019 was a defining year for glaucoma care as national detection rates across the Specsavers network averaged 1.2% of total patients (approximately 2.4% of patients seen over the age of 40), 50% of these glaucoma referrals relating to new detection of the disease.
Closely measuring glaucoma detection in the pre-COVID setting was specifically in place to check efficacy of the Specsavers’ glaucoma detection strategy however, as it turns out, it became a valuable baseline which can now be used to understand the impact of COVID-19 on glaucoma detection in 2020.
Across Australia, restrictions were in place between March and May 2020. The data below shows a significant decrease in glaucoma referrals over this period driven by a drastic drop in patient attendance due to restrictions. Figures from metropolitan Melbourne are excluded from this and are discussed later in this article.
Using corresponding glaucoma detections for the same period in 2019, 3,635 patients were estimated to have missed a glaucoma-identifying eye test over this time. Despite a significant drop in volume, the glaucoma referral rate remained steady during the essential care model, with 1.5% of patients presenting referred for glaucoma.
This data shows that there was a 16% drop in new detections but referrals for patients with existing glaucoma increased by 8.6%. This is a reflection of optometric services being accessed by patients with known glaucoma, acute glaucomatous symptoms and/or progression of existing glaucomatous signs during this time and less incidental detection of the disease.
As expected, the data shows that increased access to routine eye tests since June has seen detection volumes recover rapidly. This was tracked to the point at which the estimated group of missed detections was recovered at the end of December 2020.
In addition, the data also shows a sustained 0.1% increase in national glaucoma detection rate (1.2% to 1.3%) when restrictions were lifted and routine eyecare resumed. This occurred simultaneous to a higher than normal demand for services and is equivalent to an additional 1800 Specsavers’ glaucoma detections in the recovery period June – December 2020. This promising trend indicates that missed glaucoma detections are recoverable even as optometry practices adjust to new and changing COVID-safe protocols. It also suggests that access to care in the post-restriction period is crucial to timely detection of conditions such as glaucoma that are likely to present at a higher prevalence as patients who are overdue for their review or routine eye test return.
The metropolitan Melbourne lockdown and impact
As the rest of the country experienced a gradual easing of restrictions in the second half of 2020, the state of Victoria bunkered down for one of the longest and strictest COVID-19 lockdowns that has occurred in the world to date. For metropolitan Melbourne significant restrictions were in place from March until October 2020 resulting in the majority of optometry practices limiting services for almost five months.
While it is still very early to understand the impact of this type of disruption to routine care on glaucoma detection, however initial statistics show metropolitan Melbourne is likely to see a rapid return to pre-COVID glaucoma detection volumes occurring in line with what has been experienced in other regions of Australia in 2020.
Specsavers has estimated that more than 2,500 patients with undiagnosed glaucoma were unable to access routine care during the five-month period of heavy restrictions. This is equivalent to 41% of the estimated total glaucoma detections missed nationally, just in the state of Victoria. However, with the easing of restrictions and the return of patients for overdue reviews and routine care, an increase of detections has been seen. In November and December alone, an additional 730 glaucoma diagnoses have been made across Specsavers’ metropolitan Melbourne practices compared to the same period in 2019. While these numbers are encouraging, they still only represent 33% of the estimated patients missed, indicating a longer recovery ahead before equilibrium is achieved.
Looking closely at referrals both nationally and for metropolitan Melbourne has also revealed that glaucoma detection was more severely impacted than referrals for other eye conditions such as retinal disorders, macular degeneration and diabetic retinopathy. This is likely to be explained by the often-asymptomatic nature of glaucoma and highlights the association between routine eye tests and new detection of glaucoma in patients.
In April and May 2020, glaucoma referral volumes decreased by 64% nationally and in the metropolitan Melbourne lockdown by 74%, compared to the year previous. Referrals for retinal pathology including macular degeneration saw a 54% drop nationally (59% in metropolitan Melbourne); and diabetic retinopathy referrals decreased by 60% nationally and 62% in metropolitan Melbourne compared to 2019.
Feedback from ophthalmology remains important to confirm validity of referrals. In 2019, a subset of 784 Australian patient referrals for glaucoma were analysed to determine the false positive rate. Of those within the subset classified as first assessment referrals (previously undiagnosed glaucoma), 83% were confirmed as definite or probable glaucoma, equating to a 17% false positive rate. Feedback loops such as this are an invaluable way to synchronize referral pathways between local optometry-ophthalmology networks ensuring that the right people are referred at the right time for early treatment of glaucoma, particularly in the current climate. This type of practical feedback has been largely remarked upon by the ophthalmology industry as necessary to drive systemic change.
These figures reflect the impact as shown by Specsavers data, but may serve as an indication of what is occurring across Australia in primary optometric practice. It also begins to reveal the scale of impact of the Victorian lockdown, and how data is critical to better understanding and addressing the nuanced challenges that exist in each region – assisting with access to care and prioritisation of high-risk patients.
As we begin 2021, this data evidences the role of routine eye tests in timely detection of progressive eye conditions including glaucoma. There is ongoing work to be done to ensure patients who have delayed or cancelled their recommended review are encouraged and enabled to return safely, and there is good evidence to suggest recovery is possible with a focus on access and consistency of care.