During the COVID-19 pandemic, the use of telehealth has increased in rheumatology practice, in line with many other areas of medicine, to enable healthcare delivery while reducing patients’ and providers’ risk for SARS-CoV-2 infection.
Here we take a look at how telemedicine is used in rheumatology, explore the advantages and disadvantages, and outline what the professional guidance says. We talk to Mary De Vera, a pharmacoepidemiologist from the University of British Columbia in Vancouver, Canada, whose research examines how telemedicine technologies can improve healthcare delivery and patient outcomes. De Vera was the lead author on a study carried out early in the COVID-19 pandemic to investigate patients’ perspectives on virtual rheumatology appointments.
Two authors on the American College of Rheumatology (ACR)’s position statement on telemedicine – Chris Phillips and Aruni Jayatilleke – also share their thoughts on telemedicine and their top tips for offering the best care via remote appointments.
COVID-19 drives increased demand for telemedicine
De Vera says that for people with rheumatic and musculoskeletal diseases (RMDs), “there was a rapid transition in going from face-to-face care to having delivery at the virtual appointment by telephone or using some sort of internet platform” with the emergence of COVID-19.
“In the Canadian context, I think telemedicine really hasn’t been as used as much […] until COVID-19,” she adds.
In De Vera and colleagues’ study, 44.0% of 429 adults with a rheumatic disease who responded to an international online survey between April 23 and June 9, 2020 said they had attended a virtual clinic appointment during the COVID-19 pandemic. The majority of respondents were from North America, and over half had a diagnosis of rheumatoid arthritis.
She says that 71.2% of the 154 respondents who had a virtual appointment in the survey study said they were satisfied with the consultation, which was “very reassuring in terms of our patients [being] happy with the care they receive.”
The ACR also conducted a survey around the same time (June 5–8, 2020), finding that around 66% of 1109 adult rheumatology patients from the USA had attended a telehealth consultation with their rheumatologist within the past year, with COVID-19 given as the most common reason.
De Vera says that their survey respondents reported using a variety of different types of technology, including “telephone, video conference, email, and some texting” to take part in their virtual rheumatology consultations.
What does the guidance say?
A number of professional organizations have issued guidance on the use of telemedicine for rheumatologists. For instance, at the time of writing EULAR recommends that consultations can take place remotely and blood monitoring can be postponed temporarily, provided that the RMD and treatment are stable and there are no signs or symptoms of drug toxicity. For people with active RMDs, treatment that has recently changed or needs adjustment, or signs of drug toxicity, EULAR says that rheumatologists and patients should balance the risks of a clinic visit with the limitations of remote advice, and make a joint decision.
Similarly, the ACR supports telemedicine as a tool to increase access and improve care for RMD patients during COVID-19, but cautions that it should not replace essential face-to-face consultations.
Is telemedicine right for all rheumatic diseases?
Both ACR experts agree that some patients with rheumatic diseases stand to benefit more from remote management than others, and that disease stability is an important factor to consider.
“It seems clear that patients who are and have been stable on their therapies without major flares can be managed for at least several months remotely, including patients with inflammatory arthritis and systemic conditions such as lupus,” says Aruni Jayatilleke.
“However, patients who have active diseases are difficult to manage remotely for prolonged periods due to the potential for flares and progression of their conditions without monitoring.”
She believes that “long-term management of gout can be effectively done remotely, perhaps even more so than in-person, if patients are able to have lab testing done,” and she “would be comfortable remotely managing patients with stable inflammatory arthritis such as rheumatoid arthritis or ankylosing spondylitis and stable systemic conditions such as lupus, polymyalgia rheumatica, and giant cell arteritis.” However, Jayatilleke stresses that “as most rheumatologists have experienced, these conditions can be unpredictable and flare without warning,” and in such cases “I would favor bringing patients [into the clinic] when possible.”
Similarly, Chris Phillips feels that “fibromyalgia, osteoporosis, and stable inflammatory arthritis where the main need is toxicity monitoring” are well suited to remote evaluation. On the other hand, he says that “unstable inflammatory disease where the exam weighs heavily in decision, or patients with both inflammatory and non-inflammatory pain, such that reported symptoms cannot reliably be ascribed to inflammation, as well as active vasculitis, do not lend well to remote evaluation.”
Chris Phillips’ top tips for rheumatologists on using telemedicine
The pros and cons of telerheumatology during COVID-19 and beyond
The main advantage of telemedicine in rheumatology is “to provide protection to patients,” says De Vera, noting that “rheumatic diseases and the medications used to treat them [can result in] patients [being] immunocompromised, which leaves them more vulnerable to infection.”
Physical exams matter
However, she cautions that rheumatology is “a very tactile area of medicine,” and telemedicine “doesn’t [always] capture what you can get in a face-to-face appointment.” For instance, patients can describe the joints that are swollen over the phone and in some situations the rheumatologist can look at them using video technology, but it is not possible for rheumatologists to “feel whether they’re hot and look at the degree of swelling,” which “would be one of the cons of remote management,” she explains.
Phillips agrees, noting that while “it’s an obvious advantage to our patients to keep them out of the healthcare environment,” especially if they are considered at high risk, “we lose […] the physical exam, which in rheumatology we rely upon heavily to evaluate synovitis, etc.” He also points out that it is “more challenging to obtain patient-reported outcome forms such as MDHAQ [multidimensional health assessment questionnaire] or RAPID 3, depending upon how effectively a clinic has been in figuring out how to send and receive patient documents,” and that there may be issues with “quality of video feeds with many patients, especially those in rural areas and/or [with] poor broadband.”
Limited access to technology
Concerns about internet access were also raised by the authors of a survey study of 548 rheumatologists from 64 countries across the world. In the study, which was carried out between April 8 and May 4, 2020, 17% of respondents estimated that around a quarter of their patients did not have access to video calling facilities, especially those living below the poverty line. The majority of participants felt that these vulnerable patients, particularly those from ethnic minority groups, would suffer worse morbidity and mortality during the pandemic than other patients, and the study authors concluded that rheumatologists need to be particularly “vigilant and proactive” about caring for vulnerable patients.
Jayatilleke adds that issues with access to lab monitoring can be a problem with remote rheumatology care, meaning that “the safety of long-term medications is hard to evaluate as well.”
She summarizes: “For patients with some rheumatic diseases, remote management or telemedicine offers a temporary solution but not a permanent replacement for in-person visits.”
Aruni Jayatilleke’s top tips for rheumatologists on using telemedicine
Telerheumatology beyond COVID-19
De Vera believes that telemedicine may have a place in rheumatology clinical practice beyond the COVID-19 pandemic.
“I think people have always talked about telemedicine, but [COVID-19] really pushed the delivery; it really accelerated it,” she remarks.
“Because the system has been able to pivot, I think it will have a role in providing future care.”
She says that for countries like Canada, where “we have these big populations in centers and then we have patients living in remote areas,” remote healthcare delivery “will really have an effect on accessibility.”
“I think we have an opportunity now during this pandemic as we keep using telemedicine to learn how we’re doing it, to really have it so that it is informed by patients, and also […] the clinicians that will be delivering it, because I think that's going to speak to the sustainability.”
How can telemedicine be improved?
With the “quick pivot” to providing virtual rheumatology appointments at the beginning of the COVID-19 pandemic, De Vera says that there are “definitely improvements needed” to optimize the experience for rheumatologists and their patients.
When she and her colleagues conducted their survey study, the majority (68.5%) of respondents said they did not have a choice between an in-person or virtual option for their most recent appointment. While most (73.8%) of these patients said they were not bothered by the lack of choice, she recommends that “as the pandemic progresses, [...] just [asking] the simple question on the preference of the appointment” would improve the experience for people with rheumatic diseases.
Moreover, De Vera says it is important to “ask people about their technology,” to find out whether they have internet access, what type of internet access they have, and what type of devices they have available.
“Is it going to be a telephone? […] Is there a laptop or a tablet? Does it have the capability to be able to do [video] consultations where you see the doctor?”
She notes that asking “these simple questions [will enable] patients to feel that they’re empowered and they’re part of this decision and that they can do these appointments because they have the technology to support it.”
Indeed, De Vera and colleagues are planning to send a follow-up survey to their respondents “to get a little bit more in depth about their experiences,” including questions on whether they were involved in the decision about having remote consultations, how well their devices worked with the appointments, whether communication with their healthcare provider worked effectively, and how useful they found telemedicine.
“This might inform future care because for some appointments, it might actually be more efficient to use telemedicine,” she says.
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