Telemedicine for Management of Rheumatoid Arthritis

Claire Barber, MD, talks about her team's research into the use of telemedicine, including patient outcomes, for patients with rheumatoid arthritis.

Additional Resources:

• Han L, Hazlewood GS, Barnabe C, Barber CEH. Systematic review of outcomes and patient experience with virtual care in rheumatoid arthritis. Arthritis Care Res. Published online March 1, 2021. doi.org/10.1002/acr.24586
• Piga M, Cangemi I, Mathieu A, Cauli A. Telemedicine for patients with rheumatic diseases: Systematic review and proposal for research agenda. Semin Arthritis Rheum. 2017; 47(1):121–128. doi: 10.1016/j.semarthrit.2017.03.014
• McDougall JA, Ferucci ED, Glover J, Fraenkel L. Telerheumatology: A systematic review. Arthritis Care Res. 2017; 69(10):1546–1557. doi:10.1002/acr.23153

Claire Barber, MD, is a rheumatologist from the Cumming School of Medicine at the University of Calgary in Calgary, Alberta, Canada.

TRANSCRIPT:

Rebecca Mashaw:  Hello, and welcome to another podcast from Rheumatology Consultant. I'm your moderator, Rebecca Mashaw. Today, we're joined by Dr. Claire Barber, a rheumatologist with the Cumming School of Medicine at the University of Calgary in Canada.

Thank you for joining us today, Dr. Barber.

Along with some of your colleagues, you conducted a study recently published in Arthritis Care and Research on the outcomes and experience with virtual care or telehealth of patients with rheumatoid arthritis. Of course, the use of virtual care throughout all specialties has skyrocketed since the advent of the pandemic, but the option has been around for a while.

Have other studies been conducted previous to yours about the use of telemedicine in rheumatology?

Dr. Claire Barber:  Thanks so much for that question. There have been certainly a number of other studies, reviews, and even other systematic reviews on this topic. I thought I would maybe just highlight two other fairly recent systematic reviews and then maybe just highlight our systematic review, which is slightly different and contributes to this body of evidence.

The first was a systematic review by Piga and colleagues from 2017. It was published in Seminars in Arthritis and Rheumatism, and they evaluate evaluated telerheumatology to understand its feasibility, its effectiveness, and patient satisfaction with this modality of care.

They searched a number of databases and examined rheumatic diseases in general, whereas our study focused in RA. A meta‑analysis was not done due to the heterogeneity of these interventions and outcomes. They identified a number of studies in RA, scleroderma, fibromyalgia, OA, JIA, and also some more general rheumatic disease cohorts.

Overall, they felt that the feasibility of telerheumatology and patient satisfaction were high, and the effectiveness appeared to be equal or higher than standard face‑to‑face encounters with rheumatologist.

There were some limitations. There were small sample sizes. There was lack of blinding for some of these interventions. They concluded that higher-quality randomized controlled trials were needed for this particular topic.

Also published in 2017 was another systematic review by McDougall and colleagues. This was published in Arthritis Care & Research. This study aimed to summarize the published literature on telemedicine for diagnosis and management of inflammatory and/or autoimmune rheumatic diseases, and they included 20 studies.

Again, these studies vary significantly in quality and publication type. Many demonstrated a high risk of bias. There were some conflicting results reported, including regarding the effectiveness of telemedicine with at least 1 study showing that they felt that in‑person care was more effective.

Our study, in contrast, focused specifically on rheumatoid arthritis as opposed to these other reviews that looked at other different types of rheumatic diseases. We only included studies where the use of virtual care could be used to replace an in‑person visit, which is in contrast to other more general reviews. They might have included studies that were used to augment care, to provide care in between visits, for example, or for patients self‑monitoring a disease to help with care.

We feel that this is a really important and timely question to answer given the explosion of virtual care in the pandemic when virtual care has been used very much by many rheumatologists for at least a short period of time — for some, maybe longer periods of time —to replace in‑person visits.

RM:  In your study, as I understand it, you set out to compare patient outcomes between in‑office care and virtual care for patients with RA. What specific outcomes were you interested in?

Dr. Barber:  Thank you for that question. The main outcomes we were interested in, we were really looking at disease activity to see if again patients over time who were followed remotely or by virtual care had similar disease activity to those that had in‑person visits. We also looked at patient experience or satisfaction with virtual care. Those were our two main outcomes.

Rebecca:  Can you give us a quick overview of the research, the databases that you used, the studies you included just generally, the time periods covered, and any limitations?

Dr. Barber:  We searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from inception until March of 2020. We included observational studies, as well as randomized trials describing the use of RA virtual care that replaced a conventional rheumatologist's visit and reported on our outcomes of interest as we've just described.

We reviewed 352 studies, and 6 were selected for inclusion. Half of these were randomized controlled trials. In total, there were over 1000 RA patients included. All of the studies were published in or after 2016. They represented different studies from around the world.

The studies looked at different types of interventions. Some were video conference. Some were telephone calls. Some were monitoring electronic patient‑reported outcomes asynchronously. To involve patient presenters at remote sites, we're presenting the physical exam. There was a significant heterogeneity in the types of outcomes and the types of modalities that were employed.

Overall from the randomized trials and disease activity was very comparable between the virtual care modalities and conventional care at the final follow‑up. One randomized trial found no difference in observed outcomes between virtual care that was provided by a rheumatology nurse, and they had a separate arm of the study that looked at rheumatologist care and comparing the two.

Overall satisfaction appeared generally equivalent with 1 study showing higher satisfaction with video conferencing compared to telephone. Again, the same study reported that the best experience was still with conventional visits in that particular study.

The observational studies had different methods, and populations were generally harder to compare but still provided some important learnings. One of these studies also demonstrated comparable or improved disease activity when evaluated over time.

Another study, higher disease activity did appear to be associated with lower patient satisfaction, so that might be a consideration for physicians when selecting individuals who are appropriate for virtual care.

A study — I believe it's Alaska Tribal Health System — also revealed that over half of patients who received virtual care still expressed a preference for in‑person care despite feeling the quality of care was comparable.

Certainly, this provides learnings and trying to select individuals and making that a bit of a shared decision with patients as to whom and when is it most appropriate to provide virtual care.

RM:  Could you focus on the key conclusions you reached?

Dr. Barber:  The main key conclusion that I would draw from this is that virtual care strategies do appear to support patients in maintaining stable disease activity over time and deliver a good experience, at least in the short term.

There may be some limited evidence that rheumatology nurses delivering virtual care may offer a similar experience to rheumatologist‑led virtual care. That'll be the key learnings.

RM:  Did you find anything in your results that surprised you?

Dr. Barber:  I think I was generally surprised by the small number of studies that met our eligibility criteria. Still, there was also a lack of data on direct video‑conferencing with patients. This is likely to change because of the explosion of use in video‑conferencing since the pandemic. This is looking at the literature just prior to the pandemic.

There was also a lack of long‑term data, and I found that surprising and represents a challenge in an area for a future direction.

RM:  Which leads to my last question, which is—what needs to be done next?

Dr. Barber:  That's a great question. There's a lot of important research to be done in this area. There's room to better understand patient preferences for virtual care as it may or may not be acceptable for all patients. These preferences may vary based over time and potentially by provider and other factors.

We need a better understanding importantly of the equity considerations for the provision of virtual care. In particular, are we adequately caring for individuals who may not have ready access to a computer or high WiFi, or who may have hearing or visual impairment, or speak a different first language, or have different computer literacy, for example?

These are all really important considerations that need further investigation with an equity lens. We also, as I pointed out before, don't understand the long‑term impacts on patient outcomes using these virtual modalities. How safe is it to not see your stable RA patient? Is it indefinitely? Is it 1 year or 2 years? Should we be interspersing these visits? We just don't know.

Understanding the optimal types of virtual care for different clinical situations, so should we be following people by electronic just asynchronous patient‑reported outcomes versus having telephone follow‑ups and understanding if there's different outcomes if we're using telephone versus direct videoconferencing and so on.

While not the focus of our study, I suspect we also need to understand more about how the ongoing use of virtual care and this explosion of virtual care is affecting health system costs in addition to patient outcomes. Those are some of the off‑the‑top‑of‑my‑head thoughts about this area.

I think it's emerging. It's important that we should be investing the time to make sure that we're doing this right, to deliver the best care to our patients living with rheumatic diseases.

RM:  Thank you so much for your time today. This is very interesting, and we look forward to talking to you again in the future when more of this research gets done. Thanks very much, Dr. Barber.

Dr. Barber:  Thank you.