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.”
About the experts
Aruni Jayatilleke, MD, is an Associate Professor of Medicine and the Director of the Rheumatology Fellowship Program at the Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, USA.
Chris Phillips, MD, is a member of the ACR’s Committee on Rheumatologic Care, where he serves as the Committee chair of the ACR’s Insurance Subcommittee. He is also serving on the ACR’s COVID-19 Practice and Advocacy Task Force.
Mary De Vera
Mary De Vera, PhD, is an Assistant Professor at the University of British Columbia’s Faculty of Pharmaceutical Sciences.