Telehealth Has a Place in Rheumatology, but It Also Has Limits, Study Finds

When a New Zealand health care network switched to telehealth visits, its rheumatology patients had more health care interactions, but they had fewer changes in care and were less likely to be categorized as having active disease.

Telehealth services can be an important link to rheumatology patients and can increase the number of interactions they have with health care providers, but a new report also cautions that a reliance on telehealth will not be sufficient for all patients.

The study is based on the experience of the Hutt Valley District Health Board, which provides care for more than half a million people in the Wellington, New Zealand, region. When the country went on lockdown due to the COVID-19 pandemic, residents were obliged to avoid contact with people outside of their household, and thus health care providers were quickly forced to transition to telephone-based appointments with patients.

Telehealth was not new to the health department’s rheumatology practice, reported corresponding author Rebecca Grainger, PhD, of the University of Otago, but it tended to be limited to a small subset of patients, particularly those in rural areas.

When the pandemic caused the health board to switch its mode of care to telehealth, Grainger and colleagues wanted to understand how patient outcomes in that scenario compared with outcomes from before the pandemic. The researchers looked at the records of rheumatology visits during the first 4 weeks of COVID-19 lockdown (March to April 2020) and compared those records with the same time period in 2019. Their analysis was published in the Internal Medicine Journal.

More patient “visits” were recorded during the lockdown than during the reference period, 340 visits (13.1 per clinic) versus 210 visits (10.5 per clinic), respectively.

Ten percent of patients in the telehealth cohort were unreachable, a proxy for not “attending” medical appointments. In the prepandemic cohort, 7.1% of patients did not attend an appointment.

Fewer patients were listed as having active disease in the telehealth group compared with the reference group (12.6% versus 21.0%). In the telehealth cohort, 83.8% of patients had no reported change in their disease modifying antirheumatic drug (DMARD) management, a higher rate than the 72.4% rate reported in 2019. Likewise, while 37.6% of patients in the reference sample had a medication change during the time frame studied, just 24.7% of patients in the telehealth sample had a change.

Among patients listed as having active disease, nearly half (44.2%) of those in the telehealth group did not see a change in their DMARD or biologic DMARD plan. Yet, back in 2019, all but 22.7% of patients experienced a change. Patients with active disease in the telehealth cohort were less likely to have any intervention at all, compared with those in the 2019 cohort (72.1% versus 90.9%).

Grainger said while the data shows telehealth has a place in rheumatology, it also suggests patient care was less actively managed when patients were only being seen remotely.

“Since intensification of pharmacological treatment is recommended for active inflammatory arthritis, our service may not have achieved this as frequently during lockdown,” Grainger and colleagues wrote.

She said future implementation of telehealth in rheumatology ought to be more selective, focusing on people with rheumatoid arthritis in remission or with low disease activity. Clinicians should also consider which assessments and technologies are most likely to provide meaningful visits.

“It will be critical to identify for which patients telehealth is appropriate and under what circumstances,” the investigators concluded. “Video consultation provides visualization of joints and to improve communication, so [it] is likely to be preferable to phone.”

Reference

Mair J, Woolley M, Grainger R. Abrupt change to telephone follow-up clinics in a regional rheumatology service during COVID-19: analysis of treatment decisions. Intern Med J. 2021;51(6):960-964. doi:10.1111/imj.15336