Telehealth Encourages Patients with Diabetes in Racial and Ethnic Minority Groups to Return for in-Person Ophthalmic Care During the COVID-19 Pandemic

Abstract

Purpose: The COVID-19 pandemic had a disproportionate impact on patients from racial and/or ethnic minority groups, causing many to delay healthcare. This study evaluates the role telehealth visits played in helping patients with diabetes mellitus (DM) return for subsequent, in-person eye examinations after the outbreak of COVID-19.

Methods: This retrospective, cross-sectional study analyzed 8147 patients with DM who had completed an outpatient ophthalmology and/or optometry visit in 2019 and who were due for return evaluation after the outbreak of COVID-19 in 2020. Factors associated with return for subsequent, in-person eye examination were assessed.

Results: The mean age of patients was 68.8 (±13.0) years, and 42% were women. 7.4% of patients identified as Asian; 2.9% as Black; 3.4% as Hispanic or Latin American; 0.92%, as more than one race; 1.78%, as other races; and 80.7% as White. Patients from racial and/or ethnic minority groups completed fewer in-person eye examinations after the outbreak of COVID-19 compared with White patients (35.6% versus 44.5%, χ ²=36.172, P<0.001). However, both groups accessed telehealth services at a similar rate during this period (21.1% versus 21.9%, χ ²=0.417, P=0.518). Importantly, patients who received telehealth services returned for subsequent, in-person eye examinations at substantially higher rates, regardless of race (51.0% and 46.6%, respectively, χ ²=1.840, P=0.175). This offset the otherwise lower rate of return experienced by patients from racial and/or ethnic minority groups compared with White patients among the group of patients who did not receive any telehealth services (32.7% versus 42.7%, χ ²=36.582, P<0.001). The impact of telehealth on the likelihood of in-person return remained significant after taking into account age, gender, race, language, residence, severity of diabetic retinopathy (DR), and vision in a multivariate model.

Conclusion: Telehealth initiatives benefited patients from racial and/or ethnic minority groups by reducing disparities in access to eye care experienced during the COVID-19 pandemic.

Keywords: diabetes; diabetic retinopathy; medical care delivery; quality improvement; telehealth.

Figure 1

Total Telehealth and In-person Visits for Patients with Diabetes. Reporting of COVID-19 cases in the Commonwealth of Massachusetts began on March 12, 2020 (13 cases). The seven-day average number of confirmed cases recorded by the Department of Public Health is shown (grey line). In-person weekly visits to the eye clinic (blue bars) dramatically decreased after the recognized outbreak of COVID-19 and declared state-of-emergency on March 15. The first local peak in COVID-19 cases occurred on April 20, 2020 (2299 cases). This coincided with the largest number of weekly telehealth visits (Orange bars). During the month of July, telehealth visits were nearly equal to in-clinic visits (cross hatched bars). Patients began to return for in-person eye examinations during the summer and fall when local case counts were declining and businesses, including eye care practices, were allowed to re-open. A second local peak in COVID-19 cases occurred on December 7, 2020 (4779 cases), prompting additional public health measures to be imposed and total clinic visits to again decrease. Relatively few telehealth visits were conducted during this period. This may reflect an expectation that cases would again decline, permitting in-person care to resume, or relate to the development and approval of vaccines effective for the prevention of COVID-19.