By Douglas Devries, OD
July 29, 2020
Now is the time to either add or expand point-of-care testing in your practice. We are all struggling with a return to normal patient volumes given the distancing and screening procedures necessary within our practices.
Challenge of Reopening with Social Distancing Requirements
A survey conducted by Jobson Optical Research from July 10-15 had 497 respondents who reported that prior to the pandemic the practices were averaging 26.8 patients a day and during late spring during reopening, were now seeing 21.6 a day as averages.
We are all working diligently to increase the number of patients while attempting to maintain the protocols of screening, distancing and disinfecting. This is inherently difficult within our profession since COVID-19 is spread through respiratory droplets and impossible to maintain the suggested six-foot distance. Medically we are a disadvantage from many other types of healthcare since we are working with slit lamps which put us within a foot of the patient.(1,2)
To emphasize the importance, the American Academy of Ophthalmology has published a list of 14 ophthalmologists worldwide that have succumbed to COVID-19.(3) While we have no idea if it was contracted from their practice, we know we need to be vigilant in providing safeguards. We have adapted to this with additional plastic shields and the utilization of masks by patients and all staff and doctors.
In addition, we are having patients wait in the car to avoid contact in the waiting room with other patients and minimizing talking during the slit lamp exam. While struggling with our patient volume we need to be as efficient as possible with those patients we have in our office. Once we have gone through the screening criteria and get the patient in the office, we should look for efficiencies that will give us as much information as possible to provide the maximum level of care to the patient in a single visit. This serves two purposes in that it could limit the number of return exposures for a patient, and at the same time maximize the visit and thereby the revenue per patient.
Point-of-Care Testing Facilitates Social Distancing & Revenue Generation
This is where point-of-care testing comes in. By screening all of our patients with a validated questionnaire such as Standard Patient Evaluation of Eye Dryness (SPEED) or the Dry Eye Questionnaire 5 (DEQ-5) and setting a protocol number, you will be able to have your staff automatically perform point-of-care testing on your patients prior to you seeing them.
While there is a procedure to go through to be able to perform and bill Clinical Laboratory Improvement Amendment (CLIA) waived tests, in most states it is an easy and straightforward process. There have been eyecare tests in the area of ocular surface disease specified as waived tests by the FDA and they include InflammaDry MMP-9 Test and QuickVue Adenoviral Conjunctivitis Test (formerly AdenoPlus by Quidel).
Once a CLIA Waiver has been obtained, all of these tests can be performed at arm’s length, which is approximately three times the distance of using a slit lamp. Each of these tests are then billable and will have no effect on any evaluation and management code (E&M) or any procedure that is performed. In most cases the tests will also fall under a separate co-pay, which in the case of CMS is zero.
No Capital Investment Required
The MMP-9 test (InflammaDry by Quidel) requires no capital investment and has only the footprint of the tests that you have purchased and the test device is entirely disposed of immediately following the results of the test. The InflammaDry test measures the presence or absence of MMP-9 on the ocular surface and is a non-quantified test that is positive if a pink line appears indicating a concentration of greater than 40ng/ml, and indicating at least a level two dry eye if other conditions of inflammation have been ruled out such as allergic eye disease, epithelial basement membrane dystrophy or corneal infiltrates.
The test takes approximately 30 seconds to perform and yields results in 10 minutes once the reagent solution has reached adequate levels indicated by the blue line in the test window.
Tear osmolarity is a quantified test that is easy to use, and measures the solute concentration of the tears, which has also, like inflammation, and the InflammaDry MMP test, been recognized as a leading indicator of dry eye disease. The results are considered positive when either eye has an osmolarity of greater than 300 mOsm or there is a greater than 8 mOsm difference between the eyes. Once again, the test card that is utilized is disposed off immediately following the results. The instrument has two hand-pieces that dock on a small base.
Initiate Treatment Right Away
The advantage of performing these tests together is to enable you to initiate treatment during the visit and monitor the progress of the treatment in subsequent visits.
In my experience, patients have been satisfied with the point-of-care tests as they validate what the patient has been experiencing in traditional dry eye symptoms. In the case of the non-symptomatic patient, it validates why they often experience a visual fluctuation while reading or driving instead of the traditional dryness complaints. Patients do also like having metrics regarding their condition.
At this time of reopening and of trying to maximize our patient flow–when we also want to provide the highest level of care in our practices–point-of-care testing makes good sense for both our patients and our practices.
1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7176314/. Extra care can be taken when using the slit lamp including asking a patient to properly wear a mask to decrease respiratory droplets
2. https://www.aao.org/clinical-video/infection-control-measures-during-simulated-slit-l, using a breath shield and cleaning the equipment.
Since the MMP-9 InflammaDry test has been shown to correlate with the clinical slit lamp exam findings of presence of punctate epithelial erosions. Use of the InflammaDry can be used as a surrogate (or alternative) to the slit lamp examination for dry eye patients better than any alternative test for dry eye. (https://jamanetwork.com/journals/jamaophthalmology/article-abstract/1556874)