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We were interested to read the recent report from Gianfrancesco et al 1 in which they highlight impacts of medication on COVID-19 rates from an international registry. An important public health prevention measure advocated by European League Against Rheumatism (EULAR) and the British Society for Rheumatology has been stringent social isolation ‘shielding’ for patients on current immunomodulatory medication. ‘Shielding’ patients remain isolated in their homes, having minimal contact with even members of their household, for potentially 12 weeks or more.2 To complement Gianfresesco’s1 work, we present data from a large rheumatology cohort in the UK evaluating impact of treatment group and shielding on COVID-19 incidence. We also present data on impact of therapy and shielding on health-related quality of life (HRQoL).
We undertook an audit of our follow-up patient cohort (1 February 2020 to 1 May 2020) and found death rates from swab confirmed COVID-19in that population (12/10387; 0.12%), similar to the local population (4131/7 415 149; 0.12%), compiled from a regional COVID-19 test database. We then audited follow-up patients with a recorded mobile phone number for clinician contact by a linked mobile-phone short message service (SMS) message, previously described.3 This method enables rapid response and provides a feedback rate comparable to conventional techniques. After piloting a questionnaire in patient participation groups, a national charity (Hibbs Lupus Trust) and clinicians, we evaluated patients on 24 April 2020, to assess rheumatoid disease epidemiology, prevalence of COVID-19, effect of stringent social distancing (shielding) and HRQoL by Short Form-12 (SF12), which assesses Physical Component Score (PCS) and Mental Component Score (MCS) on a 0–100 scale (0-lowest score).4 We present the data as mean and SD, with mean differences and 95% CI reported for significant differences in HRQoL scores.
By day 7, 1693/7910 of those with mobile phone numbers recorded (21.4%, mean age 59.4 years; SD 12.3) had responded with complete COVID data, 1605 completed SF-12. Most respondents were female (1175/1693, 69.4%) and Caucasian (1589/1693, 93.9%). The primary diagnosis was inflammatory arthritis: rheumatoid arthritis 846 (50.0%), psoriatic arthritis 267 (15.8%) and ankylosing spondylitis 82 (4.8%). Of 1693, 792 (46.8%) were shielding (table 1).
Of 1693, 61 (3.6%) reported COVID-19 infection (8-confirmatory swab result; 3-clinical diagnoses with ‘false-negative’ swab; 50-clinical diagnosis, not swabbed in line with UK policy at that time)5; 7/61 (11.5%) patients were hospitalised, 2 requiring intensive care. Of this group, 24/61 were shielding, a similar proportion to the non-COVID cohort (24/61 vs 768/1632 (p=0.24). We found no significant effect of treatment on self-reported COVID-19 incidence (table 1).
HRQoL data (SF12) was collected for 1605/1693 survey respondents. There were significantly lower MCS in the COVID-19 infected group (n=60) compared with non-infected (n=1545), (38.9 (8.0) vs 42.2 (8.0); mean difference: −3.3; 95% CI -5.2, to 1.4, p<0.001), but no difference in PCS (−0.4; 95% CI −2.1,1.3) (Table). In patients without COVID-19 the ‘shielding’ group (722/1545) had significantly lower MCS (−2.1; 95% CI −2.9, to 1.4, p<0.001) and PCS (−2.2; 95% CI -3.8, to 2.5; p<0.001) than those not shielding (823/1545) (Table). Patients adhered well to shielding (792/1693 advised), 414 (52.3%) not leaving the house and 365 (46.1%) minimal contact with others. There were no differences in MCS between patients on non-biologic DMARDs (655) and biologic DMARDs (268) (0.6, 95% CI: 0.1,2.4). There were small, but significantly lower, MCS in and Black and Minority Ethnic (BAME, 99) and Caucasian patients (1506) (1.5, 95% CI: 0.1, 3.0, p=0.044). There were no differences in PCS between medication, diagnostic or ethnic groups.
The COVID-19 pandemic presents many problems for clinicians managing patients with rheumatoid disease. Our study suggests that overall strict social isolation had little impact on the incidence of COVID-19 infection. Patients who had suffered from the virus had reduced mental but not physical HRQoL scores. Importantly, however, there was adverse effect on both MCS and PCS reported by patients undergoing shielding when compared with those not, a finding reflecting early work from India.6 Quality-of-life scores were not affected by use of biologic as opposed to non-biological DMARD, suggesting this was not simply a reflection of disease severity. Patients are likely to require increased mental and physical support as a result of the COVID pandemic, and further work on the role of therapy efficacy and impact of shielding is needed to support the important registry work presented by Gianfrancesco et al 1 to guide future policy.
Formal research ethics approval was not deemed to be required by our institution for this service evaluation; this work is compliant with European Union General Data Protection Regulation; no additional consent for sending healthcare SMS messages is required.
The authors would like to thank the local patient participation groups and the Hibbs Lupus Trust for their input into the study and piloting the SMS technology.
Contributors The methodology was developed by JB, TS and NC. The study was conceived by JB and NC and designed by JB, NC and TS: it was internally reviewed and piloted by SR, NB, SV, TA, HS and BS. The manuscript was drafted by NC and JB and reviewed by all authors prior to final submission.
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.
Disclaimer The views expressed are those of the authors and do not necessarily represent the views of the Royal Wolverhampton NHS Trust or NHS England.
Competing interests None declared.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.
Provenance and peer review Not commissioned; internally peer reviewed.
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