• epidemiology
• outcome and process assessment, health care
• autoimmune diseases

We read with interest the letter by Bozzalla Cassione et al 1 about the role of telemedicine in their clinic during COVID-19 time. Telemedicine represents a useful tool not only in regions with limited access to healthcare2 but also in different settings like quarantine, when healthcare personnel became essential.

Since the Italian National lockdown decision3 and the WHO announcement of the COVID-19 pandemic,4 enormous demand to handle the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection disease challenged the Italian healthcare system. Indeed, in the Fondazione Policlinico Universitario A. Gemelli (FPG) Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) in Rome, the delegated taskforce (Gemelli against COVID-19) gradually opened 14 COVID-19 dedicated wards, in accordance to the progressive increase of serious cases. Concomitantly, several clinics were remodulated to optimise the staff use and to avoid patient exposure to the hospital environment.

The Division of Rheumatology of the FPG-IRCCS is a high-flux rheumatological centre, with almost 16 000 visits performed in the last year for chronic inflammatory arthritis (38%), connective tissue diseases (CTDs) (34%) and other rheumatic diseases (27%) (ie, osteoarthritis and fibromyalgia) from all Italian regions. Before the spread of COVID-19, our rheumatology service was organised to routinely provide several general (for first and follow-up visits) and dedicated outpatient clinics, that is, an early arthritis clinic, two biological clinics for patients on biological disease modificed anti-rheumatic drugs (bDMARDs) or targeted synthetic DMARDs (tsDMARDs), disease-specific clinics (for psoriatic arthritis, spondyloarthropathies, undifferentiated peripheral inflammatory arthritis, systemic sclerosis, systemic lupus erythematosus, systemic vasculitis, Sjögren syndrome, idiopathic inflammatory myopathies and juvenile idiopathic arthritis), muskuloskeletal ultrasound examination, intra-articular injection and infusion services, osteoporosis service (clinical as well as for dual-energy X-ray absorptiometry scan) and a biopsy unit. The telemedicine approach was limited only to deal with blood testing remote examination or to handle urgent matters.

By the COVID-19 diffusion in Italy, our division was promptly and fully reorganised not only in terms of the active clinic number but also in terms of space logistics to fulfil the new requirements for social distance and patient protection. Therefore, during the first phase, only the infusion clinic for patients with chronic inflammatory arthritis and CTDs was maintained to avoid treatment discontinuation. Moreover, an urgent clinic was activated and an official protocol for telemedicine practice was immediately implemented to screen urgent non-postponable appointments, to conduct a virtual consultation asking not to attend rheumatology service in person and still to reassure patients (figure 1). Each phone clinical interview aimed to investigate patients’ general status and presence of concomitant rheumatological disease-related symptoms, and to assess the presence of any symptoms of infection in the last month, on a possible contact with a suspected/confirmed SARS-CoV-2-infected individual. In the presence of any elements suggesting SARS-CoV-2 infection, the patient was invited to call his/her general practitioner (GP) or the official dedicated number5 and the therapy was modified if required. Furthermore, regardless of SARS-CoV-2 infection, in case of disease-related symptoms, the therapy was adjusted and, if necessary, the patient was invited to attend our urgent clinic.

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Figure 1

Graphical representation of telemedicine protocol approach at the Division of Rheumatology of the Fondazione Policlinico Universitario A. Gemelli IRCCS. (A) During each phone clinical interview, the patient’s general status and the presence of concomitant rheumatological disease-related symptoms were investigated (green box). Then, the presence of any symptoms of infection and a possible contact with a suspected/confirmed SARS-CoV-2-infected individual were explored (yellow box); in the presence of any elements suggesting SARS-CoV-2 infection, the patient was invited to call his/her GP or the official regional dedicated phone number (yellow circles), and the therapy was modified accordingly (green circle). Indeed, in case of disease-related symptoms, the therapy was adjusted and, if necessary, the patient was invited to attend the urgent clinic of our division (red circle). (B) In the period between 9 March and 9 May 2020, by telemedicine approach, we managed a mean of 117 calls/day (63 incoming and 54 outgoing calls/day) and 68 emails/day (green box), recognised 51 critical patients who were invited to attend our urgent clinic (red box) and succeeded to identify three patients with rheumatological diseases with confirmed SARS-CoV-2 infection (yellow box). GP, general practitioner; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.

Furthermore, we activated a unique official mobile number for all our patients to give an answer to any questions, doubts or just to give comfort, and every clinic continued to use its own email address with the same aims. Finally, official mobile number and email addresses were spread on social media through the Italian patients’ associations.

Our experience demonstrated how it is possible to help rheumatological patients by telemedicine despite dramatic fast changes in daily life. Actually, thanks to the reduction of new COVID-19 cases and within national lockdown exit plan, our strategy will be to integrate and implement our active telemedicine protocol within the next clinical practice organisation.