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Telemedicine is an evolving and helpful tool in how rheumatologists manage their outpatient cohort. However, careful distinction of who can continue to be managed remotely is crucial.
The COVID-19 outbreak was a huge catalyst for change in medicine. While infection rates ran rampant, physicians had to balance the need to see their most immunosuppressed, and potentially sickest patients, in person against the possibility of exposing these very susceptible individuals to COVID-19 infection.
Those with systemic lupus erythematosus (SLE) are at risk of poor outcomes with nosocomial infections and COVID-19 due to several factors. They have the potential to be severely unwell with multiorgan disease involvement, they can require potent immunosuppression, and may have treatment-related comorbidities, such as steroid-induced diabetes mellitus and hypertension, among others.
Telemedicine either in the form of video or telephone appointments was often utilized in place of face-to-face appointments during the COVID-19 pandemic. This allowed patients to avoid nosocomial infection but to what extent this adversely affected care is unclear. Additionally, it has not been clear to what extent telemedicine generates additional face to face clinic appointments, increasing the workload of the jobbing rheumatologist and/or physician.
Telemedicine has been utilized by a Dutch group in the management of inflammatory bowel disease (IBD) patients to good effect.1 This group demonstrated lower hospital admissions and reduced appointment numbers when patients were evaluated using a patient-centred smartphone application (myIBDcoach) compared to standard care. A similar approach has been carried out by a French group that utilised a smartphone application to monitor rheumatoid arthritis patients.2 This group demonstrated improved quality of life measures and fewer clinic visits in the remote monitoring group.
This recent open-label randomised controlled trial from So et al in Hong Kong aimed to further address this question in SLE.3 Their group randomized 122 patients in a 1:1 ratio to receive either telemedicine or face-to-face follow up for their lupus nephritis. They then collected data on disease outcomes including Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) scores, systemic lupus international collaborating clinics American College of Rheumatology (SLICC/ACR) damage index (SDI) numbers of patients in Lupus Low Disease Activity State (LLDAS), patient-reported outcome measures, and physician global assessment (PGA) at baseline and at 6 months. Telemedicine appointments in this trial were carried out using the widely available Zoom software package. The frequency and modality of follow up were determined by the treating physician, those in the telemedicine group could be booked for face-to-face consultation or further remote follow up.
Patients recruited for this study appeared representative of the broader lupus nephritis population. At baseline, a higher PGA was identified in the telemedicine group compared to the control (mean, 0.67 ± 0.69 vs 0.45 ± 0.60, p = .003).3 This introduces some complexity when interpreting the results. 88.5% of those recruited had biopsy-confirmed nephritis and over 90% were on glucocorticoids. Over 70% were on a concurrent immunosuppressant and 63.9% were in LLDAS but none of those recruited were in disease remission.
In terms of patient satisfaction, the authors found that whilst the mean overall patient satisfaction was higher in the telemedicine group, patients appeared equally happy with how consultations were conducted and how proposed medications were explained to them in both groups.The proportion of patients in LLDAS, patient prednisolone dose and SLEDAI-2K scores were comparable between the groups. No COVID-19 infections were confirmed in either group. Importantly, increasing age was not shown to significantly impact patient satisfaction with remote appointments.
Concerningly a higher proportion of patients were hospitalized in the telemedicine group compared to the face-to-face group(25.0% vs 11.3%, p = .049).3 Investigators did, however, perform an additional logistic regression analysis which suggested that the difference in baseline PGA may account for the increased hospitalization in the telemedicine group. The role of robust clinical examination in assessing patients forms a cornerstone of physician training. Therefore, it seems logical that physicians would want to physically examine patients they identify as possible unwell or at risk of flare at telemedicine appointments. They may also feel less empowered to manage these patients in the community, having only performed 50% of what would normally be considered a comprehensive assessment.
Within this study, the increased patient satisfaction in the telemedicine group is perhaps unsurprising to anyone who has attended a busy outpatient clinic environment. Improved timekeeping and simplified logistics were identified by the authors as logical reasons underpinning this improvement. We should, however, note that this study was conducted during an unprecedented global pandemic where restrictions on travel and appointments were commonplace. Therefore, to what extent patients will accept this form of follow up in the future remains unclear. Additionally, COVID-19 infection rates were comparatively lower in Hong Kong at the time of the study when compared to recent reports. Therefore, a telemedicine approach may be even more desirable in a more hostile environment for immunosuppressed patients with higher circulating infection rates.
In summary, telemedicine is an evolving and helpful tool in how we manage our outpatient cohort. Public uptake of video conferencing has soared in all age groups and, as a result, our collective literacy with these systems is far greater than in the pre-pandemic era. For those with quiescent disease, a well-organized remote appointment where there can be a systematic virtual review of disease activity and the facility for patients to remotely submit blood or urine samples may be appropriate, and indeed desirable for patients. However, remote management of those with brittle disease, multiple comorbidities, or severe organ involvement may be more challenging. Therefore, careful stratification of who can be managed remotely is paramount, as is the ability for these patients to rapidly access face-to-face reviews should their disease flare.
1. de Jong MJ, van der Meulen-de Jong AE, Romberg-Camps MJ, Becx MC, Maljaars JP, Cilissen M, et al. Telemedicine for management of inflammatory bowel disease (myIBDcoach): a pragmatic, multicentre, randomised controlled trial. Lancet (London, England) [Internet]. 2017 Sep 2 [cited 2022 Apr 9];390(10098):959–68. Available from: https://pubmed.ncbi.nlm.nih.gov/28716313/
2. Pers YM, Valsecchi V, Mura T, Aouinti S, Filippi N, Marouen S, et al. A randomized prospective open-label controlled trial comparing the performance of a connected monitoring interface versus physical routine monitoring in patients with rheumatoid arthritis. Rheumatology (Oxford) [Internet]. 2021 Apr 1 [cited 2022 Apr 9];60(4):1659–68. Available from: https://pubmed.ncbi.nlm.nih.gov/33020846/
3. So H, Chow E, Cheng IT, Lau S-L, Li TK, Szeto C-C, et al. Use of telemedicine for follow-up of lupus nephritis in the COVID-19 outbreak: The 6-month results of a randomized controlled trial. Lupus [Internet]. 2022 Apr 7 [cited 2022 Apr 9];31(4):488–94. Available from: https://pubmed.ncbi.nlm.nih.gov/35254169/