Pandemic May Significantly Limit Access to Pediatric Ophthalmology Care

Results from a survey conducted by the American Association of Pediatric Ophthalmology and Strabismus (AAPOS) Socioeconomic Committee show the coronavirus disease 2019 (COVID-19) pandemic will leave some pediatric ophthalmology practices strained if not irreparably harmed. Findings are published in the Journal of AAPOS.

There are only about 1000 pediatric ophthalmologists currently serving 75 million children in the United States, according to a joint statement from the American Academy of Ophthalmology (AAO) and AAPOS, while the majority of pediatric ophthalmologists work in private practices.

“Unfortunately, the factors that make the specialty uncommon have also made pediatric ophthalmologists and their patients uncommonly vulnerable to the ravages of the COVID-19 shutdown,” the statement reads. “As a result, children in America may suffer medical outcomes not anticipated in first-world countries.”

In April 2020, during the first peak of COVID-19 cases in the United States, AAPOS conducted a membership survey to assess the pandemic’s effects on pediatric ophthalmology practices, including interim effects on finances and staffing, and the expected effect of government aid and future practice changes.

The 19-question online survey was distributed to all US-based AAPOS full members and candidates-in-training on April 22, 2020. Of the 1047 physicians polled, 416 responded (40% response rate), while 92% of respondents submitted complete data. Practice locations in 46 states and Puerto Rice were classified as suburban (53%), urban (45%), and rural (3%).

Ophthalmologists self-identified as belonging to 1 of the 5 following groups: employed hospital (EH), employed university/academic center (EA), private practice solo (PPS), private practice multispecialty ophthalmology group (PPMOG), and private practice pediatric ophthalmology/strabismus–only group (PPPOG).

For most states surveyed, mid-March was the beginning of the shutdown.

Response data showed that for all practices:

• 93% (377/405) suffered at least a 51% loss of clinical revenue during this period
• For 93% of respondents (378/405), surgery revenue decreased by at least 76%
• 96% (387/405) had a surgical revenue decrease of >51%
• 78% generated 0%-25% of normal revenue during the pandemic shutdown, whereas only 11% were able to generate at least 51% of their normal revenue
• Nearly half (46% [n = 176]) anticipated a slow return to their normal practice productivity; 33% (n = 126) expected a slow return, which could jeopardize their practice viability; 13% (n = 48) expressed pessimism that their practice productivity will return to pre-COVID levels

For private practices, responses were more dire:

• 43% of physicians (122/282) applied for the Economic Injury Disaster Loan (EIDL), and 40% received the loan
• 52% (142/273) reported a staff reduction of >51%
• 35% of the 53 EH or EA respondents reported having had their salary reduced or being furloughed, whereas 90% of the 264 private practice respondents reported having a reduction in salary or furlough
• Bankruptcy was considered an option by 10% of respondents (38/362), and rose to 13% (36/260) when only private practice respondents were analyzed
• Of EH and EA physicians, 7% planned to limit Medicaid, whereas 27% of private practices (72/262) planned to do the same

“This is an alarming, important and pivotal moment in the history of medicine,” said Shira Robbins, MD, a professor of ophthalmology at the Shiley Eye Institute, University of California-San Diego and lead study surveyor. She continued, “we appeal to the legislative bodies to support pediatric ophthalmologists to champion eye health and vision of our most valuable commodity—our children.”

Due to the fact some federal financial assistance programs base assistance on treating elderly Medicare patients, pediatric ophthalmologists often have limited access to these programs.

Compounding the challenges faces by ophthalmologists at this time, guidelines from the American Academy of Pediatrics (AAP) recommended members continue to provide routine pediatric medical examinations, while the AAO recommended ceasing all nonemergent care. These conflicting recommendations made triaging patients more difficult, authors wrote.

Pediatric patients also do not often self-report symptoms, creating a potential for undetected visual damage that may have repercussions later in life.

The frequency of pre-symptomatic carriers actively shedding viral particles combined with the extremely close contact required for ophthalmologic examinations and limitations of personal protective gear also exacerbated the challenges of seeing pediatric patients during the pandemic.

In addition, results suggest “disproportionate consequences for financially disadvantaged children may accelerate, as financial concerns lead both private and academic providers to reduce access of care for Medicaid patients,” researchers stated.

As the survey results only reflect a snapshot 1 month into the shutdown, findings may not represent mid- or long-term effects on pediatric ophthalmology patients.

However, to gauge the extent of economic recovery among practices, AAPOS conducted a follow-up survey in July. According to the joint statement, notable results include:

• 3% of practices are closing permanently
• At least twice as many practices plan to limit Medicaid compared with pre-COVID levels
• 5.4% are considering or have declared bankruptcy
• 42% feel their practice viability remains “day to day” with bankruptcy as a possible outcome
• 52% experienced a salary reduction
• 26% received less than $1,000 from the first round of assistance from HHS
• 51% continue to operate with reduced staff compared to pre-COVID levels
• 91% expect further staff reductions (up to 25%) following completion of PPP loan requirements

“Without continued governmental financial support, many [pediatric ophthalmologists] will not be able to sustain their practices contributing to an even greater access problem for children with eye problems,” said Kathy Lee, MD, PhD, president of AAPOS.

Reference

Robbins SL, Packwood EA, and Siegel LM. Economic impact on pediatric ophthalmologists in the time of COVID-19. J AAPOS. Published online July 27, 2020. doi:10.1016/j.jaapos.2020.06.002