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We thank Dr Santos-Moreno et al 1 for their interest in our paper2 and for sharing their experience on telemedicine use in patients with rheumatoid arthritis (RA). We agree on the fact that a preliminary consultation is necessary to assess the willingness of the patients to be evaluated by telemedicine and, possibly, to explain them how the platform works. However, given the different setting in which we applied telemedicine—a connective tissue diseases (CTDs) outpatient clinic—our approach was slightly different. In fact, unlike inflammatory arthritis, in which disease flares are in most cases symptomatic and impacting on patients’ quality of life and functionality, CTDs like systemic lupus erythematosus (SLE) or systemic sclerosis may give rise to more insidious manifestations. In our opinion, this makes these diseases less suitable for an assessment based on patients’ reported outcomes (PROs). This led to two major differences in our telemedicine assessment protocol:
The preliminary phone call was aimed also at identifying symptomatic patients requiring to be addressed to immediate face-to-face evaluation for suspected life-threatening or organ-threatening manifestations.
Patients who did not refer any major symptom were scheduled for telemedicine assessment. The platform at our disposal allows both visual interaction and real-time sharing of test results.3
Following this approach, from 24 February to 17 April, we evaluated in person 47 patients against the 315 visits planned before the severe acute respiratory syndrome coronavirus 2 outbreak (15%). Most of these patients were treated with infusive drugs: prostanoids in 21 patients (44%) for uncontrolled Raynaud’s phenomenon or for ulcer healing, 4 patients with cyclophosphamide (9%) for interstitial lung disease (ILD) (n=1), myocarditis (n=2) and SLE-related enteric vasculitis (n=1), and 2 patients with rituximab for antisynthetase ILD (n=1) and cryoglobulinaemia-related neuropathy (n=1). The remaining patients were evaluated for clinical assessment and treatment modification due to arthritis (n=8, 17%), ILD (n=5, 10%), nephritis (n=2, 4%), and neuropathy, angio-oedema, myositis, haemolytic anaemia and myocarditis (1 case each, 2%).
Unquestionably, telemedicine has proven itself as a valuable tool at these difficult times, and its diffusion will probably move faster than expected before the pandemic. In order to make telemedicine even more reliable, several digital applications for monitoring disease activity are already available for RA,4 and efforts are being made in order to evaluate their impact on disease control and treatment adherence.5 6 However, a treat-to-target strategy exclusively based on PROs is debated also for RA and might be problematic especially for patients in a near-remission status or with established disease.7 8 In conclusion, we believe that the identification of the most suitable subsets of patients and the development of flexible approaches—allowing a prompt switch to inperson evaluation when necessary—are of utmost importance to provide good-quality healthcare assistance.
Handling editor Josef S Smolen
Contributors Study design: LC, VC and CM. Data collection: EBC, GZ, AB and LC. Data analysis: LC, GZ and VC. Manuscript drafting: GZ. Manuscript review: LC, AB, VC and CM. Final approval: all authors.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Commissioned; internally peer reviewed.