With the emergence of COVID-19 came a sudden and dramatic shift in the way rheumatology care was delivered. As the pandemic continues, we speak to Zachary Wallace, rheumatologist and clinical researcher from Massachusetts General Hospital in Boston, USA, about the advantages and drawbacks of some of the changes, and explore what lessons can be taken forward for future clinical practice.
A shift toward hybrid care
The abrupt move to virtual care early in the pandemic presented healthcare providers (HCPs) with many challenges, says Wallace.
“All of a sudden, overnight, we had to figure out how we would deliver the same level of care as best we could, either by phone, or by audiovisual conferencing with patients.”
Following this early phase, he says that as the pandemic continued and society started to re-open, “we entered what I think is probably going to be more of the future,” with HCPs offering a hybrid model of care encompassing some in-person visits and some remote consultations. This “has been something that has had many positives, but also some drawbacks that we’ve learned from,” he notes.
Having the ability to see your provider virtually was a really great benefit.
The pros and cons of remote consultations
For patients, ease of access is one of the main advantages of remote care, particularly for those who live far away from their HCP. Wallace points out that in the USA, “there aren't enough rheumatologists and we aren’t really distributed proportionately across geographic settings,” and so having the ability to see your provider virtually was a really great benefit."
In addition, some rheumatology patients require very specialized care that cannot be delivered by providers close to them, and remote care “really opened up new possibilities” for these people, he says.
From the provider perspective, Wallace says that the benefits of virtual visits were similar, namely being able to connect with patients easily, and a reduction in the proportion of people failing to attend appointments. A study conducted in Ohio, USA, found that the rate of non-attendance at rheumatology clinic appointments was 13.12% during the 10-week period prior to the introduction of virtual clinics. In the 10-week period after the introduction of telemedicine due to COVID-19, the nonattendance rate was 13.91% for in-person appointments, decreasing to 8.48% for virtual appointments.
Wallace says that the main drawback of remote rheumatology care is the lack of physical examination.
“Not being able to examine someone’s joints or listen to their lungs or take a close look at their skin really impacted the level of care that we were able to provide” during the early part of the pandemic “when in-person care really wasn’t a safe option or something that was being offered widely,” he adds.
Lessons learned: Telemedicine represents ‘an important option’
Taking everything into account, “I think that [remote care] is an important option to be able to offer patients,” and “we should figure out ways that we can continue to provide this option to patients,” believes Wallace.
He notes that there are some limitations that need to be addressed in the USA, including geographic limitations based on where HCPs are licensed and restrictions imposed by payers in terms of how HCPs are reimbursed for care.
“Those are two challenges that I think are being addressed, and need to continue to be addressed, to facilitate the use of telemedicine.”
In addition, Wallace highlights that we need to figure out exactly how and when telemedicine should be used.
“How do we identify those patients who are really suitable for this type of visit? And for those that aren’t, how do we make sure that they are able to get in for their visits and get the care that they need?” he asks. As an example, he says that someone experiencing a rheumatoid arthritis (RA) flare “should probably come in for a visit so that we can really understand what joints are affected and the extent of the disease,” while those with flares of severe conditions such as systemic lupus erythematosus or vasculitis “similarly probably need to come in and have a very thorough evaluation done.”
On the other hand, he suggests that a patient who is doing very well on their RA treatment does not necessarily need to attend a clinic visit, and can instead attend a local center for laboratory medicine. In this case, “we can touch base via telehealth visit but a patient may not need to actually come into the office if they’re really feeling well,” he says.
Wallace notes that there are ways in which remote patient assessment can be improved, such as “adapting disease activity measures currently validated for clinician use to be used by patients to determine their disease activity.”
“This may take the form, for instance, of patients performing their own joint counts to assess rheumatoid arthritis disease activity.”
In addition, he suggests that “we can facilitate ways for patients to have vital signs assessed at home as well as disease activity and drug safety [samples for laboratory measurement] drawn at home or in settings in which they feel more safe,” and points to the potential of wearable technology to measure disease activity and wellbeing in people unable to attend the clinic.
“So I think those are kind of the things that we need to think about in terms of how we use this modality moving forward.”
Not being able to examine someone’s joints or listen to their lungs or take a close look at their skin really impacted the level of care that we were able to provide
Medication considerations
Working together to understand the impact of immunosuppressants
In addition to establishing the best way to use telemedicine in future rheumatology practice, “we are also being confronted with [the question of] how to use our medications in a safe way” during the ongoing pandemic, “especially recognizing that many of the medications that we use to treat rheumatic disease are immunosuppressants,” comments Wallace. He says that “we really didn’t know what impact these immunosuppressants would have on patients and on their outcomes” when COVID-19 first emerged, but the rheumatology community quickly worked together to address this.
“One of the things that I think we've learned is that we are a very nimble specialty that’s able to come together very quickly to learn exactly what’s happening to our patients, and that’s exemplified in the COVID-19 Global Rheumatology Alliance,” he says.
Indeed, the COVID-19 Global Rheumatology Alliance was established on March 12, 2020 – the day after the World Health Organization declared the COVID-19 outbreak a pandemic – with the aim of collecting, analyzing, and disseminating information to improve the care of patents with rheumatic diseases. Since its launch, members of the alliance have reported a number of important findings. These include:
- a study showing that rituximab or Janus kinase inhibitor use may be associated with worse COVID-19 severity in RA patients;
- a study suggesting a link between disease activity and COVID-19 mortality risk in people with rheumatic diseases; and
- research on breakthrough infections in vaccinated patients on different treatments.
“It’s great to know that we can come together as a community, and really try and harness our abilities and our specific areas of expertise to share data,” says Wallace.
We are a very nimble specialty that’s able to come together very quickly to learn exactly what’s happening to our patients
Reducing infection risk
In light of study findings from the COVID-19 Global Rheumatology Alliance and other groups, Wallace points out that rheumatologists need to “think about ways to reduce the risk of infection in our patients, whether that’s through vaccination, trying to taper medicines, or avoiding certain medicines.”
He notes: “The best example of this from my own practice and in speaking with others […] is for our patients treated with rituximab,” which gives rise to long-term depletion of B cells.
“I think many of us are starting to wonder what is the right way to use rituximab, knowing that it interferes with our ability to respond to many types of vaccines and may increase our risk of having severe COVID-19 and other severe infections.”
Wallace also suggests that rheumatologists should look more closely at DMARD treatment tapering in day-to-day practice, emphasizing that how to “stratify and identify those patients in whom we can try to limit some of their immunosuppression” remains an important question. Recognizing that COVID-19 “is not going to be the last pandemic,” he recommends that “we need to think about what we can do now to start preparing for the next one.”
Patient awareness and communicating risks
For some patients, the pandemic has increased their awareness of the link between rheumatic diseases, their treatments, and infection risk, and Wallace anticipates that this may affect patient–physician communication going forward.
“These are things that patients are thinking about more than they used to” because COVID-19 is “all around us, every day,” he says, adding that “it’s a very different situation than before the pandemic when people were not talking about immunosuppressed people.”
And this increased awareness “has impacted the way that patients think about their treatment,” believes Wallace.
“I’ve heard more from patients during the pandemic than ever before that they do not want to begin therapy,” and some patients stopped treatment of their own accord early in the pandemic, he says.
Wallace highlights that this has posed a problem for rheumatologists and patients, because many people who stopped treatment experienced flares and increased disease activity.
“We need to think about how to communicate all of these risks to patients,” but “I still think we don’t necessarily do a great job of that,” he says. As an example, Wallace says that although he tells his patients how important it is to contact him if they develop COVID-19, some will still forget to do so and only mention it at a later consultation.
“So, I still think we have more to do in terms of patient education,” he summarizes.
Improving communication with patients
How to communicate effectively with the public about risk is “a very difficult thing to do,” says Wallace. In between consultations, be they in-person or virtual, he feels it is important to “think about the best way to communicate these risks or information to patients,” using methods such as emails, text messages, and printed materials.
He stresses that the preferred method of communication “is going to be different for certain populations, and certain patients have strong preferences about how they receive information.”
With time, “I think we’ll continue to learn what works best, but certainly I’m betting we can all do a better job of communicating during visits a little bit,” he says.
Addressing the challenges faced by rheumatologists
There are also lessons that can be learned from the COVID-19 pandemic in terms of communication and information sharing between rheumatologists.
Wallace says that “all physicians, rheumatologists included, have been inundated with information” during the pandemic, with “so much data coming out [and] the landscape constantly changing.” Therefore, “we need to think about ways that we can keep up,” he says, noting that organizations such as the American College of Rheumatology and EULAR “have done a nice job of setting up taskforces to review the data and break it down in very bite-sized ways for rheumatologists and other providers to process and take in.”
Another way in which rheumatologists themselves have been affected by the pandemic is through physician burnout. Wallace explains that this has occurred “not just because of the information [overload], but also because our patients are maybe sicker because they’ve stopped their medicine [and] avoided care,” and many rheumatologists are experiencing more patient messages and emails than before the pandemic. In addition, he notes that “many of us were pulled from the office to take care of COVID-19 patients during the early phase of the pandemic.”
Taken together, “all of these things [have] put a lot of strain on providers” as they try to deliver really great care, he says.
Nevertheless, Wallace believes that in spite of all the challenges posed by the pandemic, it has also “brought out some incredible strengths [and] attributes of our profession,” and has “brought us together to study this disease and take care of our patients.”
With this in mind, “I think we continue to learn a lot just about how we deliver really ideal care for our patients through the pandemic and that will affect us moving forward,” he predicts.
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