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We read with interest the preliminary German Society of Rheumatology recommendations for the management of patients with autoimmune inflammatory rheumatic diseases during the COVID-19 pandemic, which highlighted the importance of weighing the infection risk of doctor visits against the risk of missing disease controls in individual cases.1 Indeed, the attendance of our lupus nephritis clinic dropped by 14.4% in the 8-week period after the outbreak compared with the same time last year based on the citywide computerised Clinical Management System (So H, 2020). Those unattended patients were at risk of disease flares, which would lead to damage accrual, but at the same time, the rest were exposed to the threat of COVID-19.2 As the other national body suggested, the use of telemedicine (TM), also known as telehealth, to reduce potential exposure to severe acute respiratory syndrome coronavirus 2 might be a reasonable option in these patients.3 Since this is a shared decision-making process between patients and rheumatology healthcare providers, we conducted an online survey to analyse the patient acceptance and perceptions regarding the use of TM for follow-up of lupus nephritis during the COVID-19 outbreak.
Two hundred and three patients currently followed up at the lupus nephritis clinic of the Prince of Wales Hospital (a regional Hospital in Hong Kong) were contacted on the phone for their interest in changing the coming scheduled follow-up to TM-based in the form of a videoconference. Patients or carers needed to possess the technology for conducting a TM consultation: a smartphone, tablet or computer with internet connection; and 21 patients were excluded as a result. The link of this survey was sent to 182 consecutive patients. They were asked to fill in an online questionnaire regarding their ideas of TM follow-up (online supplementary appendix 1). χ2 test and Student t-test were performed to analyse the patient factors associated with the willingness to adopt TM follow-up.
Collectively, 155 out of the 182 eligible patients completed the questionnaire within a 3-week period from 8 May, when there were only isolated local cases confirmed. The mean age of the patient was 45.8 (SD 12.50) years. The great majority of them was female (91%). Out of the 155 patients, 89 (57.4%) were willing to undergo TM follow-up. Patients who refused TM were significantly older (mean age 49.4±12.8 vs 43.2±11.7 years, p=0.002). Overall, 40% of patients agreed or strongly agreed that they were confident in using TM as a mode of follow-up, while 12.3% and 2.6% disagreed or strongly disagreed, respectively, with the rest of the patients showing a neutral response. The responses of the patients to the opinion statements are shown in table 1. The following statements were found to be significantly associated with the acceptance of TM: ‘I am confident about the data privacy and security of TM’, ‘the assessment of disease activity by TM is accurate’, ‘routine clinic visit increases the infection risk during the COVID-19 outbreak’ and ‘TM follow-up reduces the risk of infection during the COVID-19 outbreak’. For those who were not willing to use TM, the top three reasons were ‘worries about the accuracy of disease activity assessment’, ‘worries about data security’ and ‘sick-leave certificates are not provided’ (figure 1). One recurrent practical reason given by patients reluctant for TM follow-up was that they had to come back for blood or urine test and medications anyway.
We found a good acceptance and confidence regarding the use of TM as a mode of follow-up in patients with lupus nephritis. The privacy and security issue, the accuracy of disease activity assessment, as well as the infection risks were important factors considered by the patients. There were also aspects such as the technical or logistic support, which could be modified to potentially improve the patient’s acceptance. However, the results should be interpreted in the context of local stage of epidemic, population and sampling, and mitigation strategies in place. As the usual rheumatology care will likely be disrupted for a prolonged period of time, the use of TM will persist. With the loosening of the antiepidemic measures in many parts of the world, we should start to take into consideration the patient’s preference, as well as perception when choosing the mode of care delivery, as we always do. The efficacy of TM should also be investigated formally in clinical trials.
Contributors HS, C-CS and L-ST equally contributed to the work and approved the article for 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.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.
Provenance and peer review Not commissioned; internally peer reviewed.
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