Background: Many patients with rheumatic disease require immunosuppressive medication putting them at high risk of COVID-19 infection. Reduced staffing in rheumatology due to redeployment to COVID-19 work, limited out patient capacity and patient vulnerability have had a major impact on our ability to review our patients to assess their condition and treatment (by face-to-face, video or telephone consultations). Novel strategies are essential to safely and effectively treat patients with rheumatic disease whilst minimising their risk of exposure to COVID-19 infection.
Objectives: The objective was to develop a digital solution to help deliver safe, efficient and effective care for patients with rheumatic diseases. The aim was to produce a system that allowed us to integrate data recorded directly by patients with information held in our electronic health records to provide a virtual review of care.
Methods: An online questionnaire was used to collect clinical information, including validated disease activity measures, to conduct a remote assessment in 175 patients awaiting follow-up appointments. This assessment was integrated within our electronic health records (EHR). The questionnaire contained measures of disease activity (DAS28 or BASDAI); patient reported outcomes; patient preferences regarding the urgency and type of appointment; any recent problems or changes in medication. This information was imported into a database for clinician review, together with previous clinical records and results of relevant investigations, to inform clinical decisions and to decide on the safest and most appropriate timing for follow-up. Report letters were sent to the patient and their primary care providers.
Results: Of the 175 patients (149 with RA and 26 with AS), 108 patients (89/149 [60%] with RA [mean age=64; female=65%] and 19/26 [73%] with AS [mean age=45; female=54%]) submitted responses over a 6-week period based on which clinical decisions were made. The mean questionnaire completion time was 19 minutes for RA responders and 16 minutes for AS responders. Non responders (67/175 [mean age=61; female=63%]) remained on our list of patients awaiting follow-up arrangements to be made. Sixty-nine responders (64%) had stable disease therefore did not require any changes to their treatment and were offered an appointment within the next 6 months, of whom 12 (11%) requested face-to-face follow-up. Of the remaining 39 – with less stable disease – requiring more rapid follow-up assessment, 22 patients (56%) required a face-to-face consultation to consider treatment change. So far 9 of these patients have had follow-up, of whom 6 necessitated treatment escalation (Methotrexate increase n=2; anti-inflammatory increase n=2; intramuscular steroid n=1; anti-TNF escalation n=1). Thirty-nine patients (36%) provided feedback on the process of completing the questionnaire, 85% of whom used a mobile phone and the remainder used a computer or tablet. The majority (70%) found it “extremely easy” or “somewhat easy” to complete; remaining responses: “neutral” 20%, “somewhat difficult” 10%, “extremely difficult” 0%.
Conclusion: We have created and tested a system of remote clinical management for patients with RA and AS. Amongst the 108 responders, just 31% required a face-to-face appointment, with treatment changes made accordingly. With a backlog of 3,800 awaiting allocation to follow-up appointments, remote clinical management will allow us to safely and efficiently prioritise patients requiring urgent follow-up for treatment optimisation. We will integrate this system into our standard care pathway beyond the COVID-19 pandemic to streamline our service, deliver effective care and provide evidence to support the use of costly biologic drugs.1 We plan to investigate the barriers for non-responders.
References: Holroyd CR, Seth R, Bukhari M, et al. The British Society for Rheumatology biologic DMARD safety guidelines in inflammatory arthritis. Rheumatology. 2019; 58 (2): e3–e42.
Disclosure of Interests: Tamir Malley: None declared, John Jackman: None declared, Sarah Manderson: None declared, Larissa Saldana Pena Grant/research support from: Pfizer’s Global Medical Grants program, Ellie Evans: None declared, Joe Barrett Grant/research support from: Pfizer’s Global Medical Grants program, Anushka Soni Grant/research support from: Pfizer’s Global Medical Grants program, Raashid Luqmani Grant/research support from: Pfizer’s Global Medical Grants program
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