The COVID-19 pandemic has disrupted all aspects of life, including the delivery of health services. People living with chronic conditions have found it more difficult to access care from their providers for nonemergency outpatient visits because of precautions put in place to facilitate social distancing, reduce the risk for viral transmission, and increase resources with regard to COVID-19-related care. Although this was initially frustrating for patients and providers, health care systems quickly adapted and began to offer telemedicine services for patients with chronic conditions, including autoimmune rheumatic diseases.
Supported by the American College of Rheumatology, the uptick in telemedicine in the first few months of the pandemic saw many community rheumatology practices migrating to a fully virtual platform. Despite the availability of these services, there was a significant increase in missed or cancelled appointments that telemedicine appointments could not overcome, leading to patients’ making decisions about reducing their use of medications without the advice of their physicians.
However, as the pandemic advanced, through the spring and summer of 2020, we found that participants in urban vs rural zip codes more frequently avoided office visits and testing for their autoimmune condition and also had the most use of telemedicine services.1 Perhaps people in urban areas were more anxious about venturing out into their high-density community where they’d be more likely to come in contact with an infected person in the early days of the pandemic. Restrictions around in-person office visits and greater availability of telemedicine appointments in metropolitan areas may have also led to this difference.
Whether this idea persists still remains a question, as well as whether providers and patients will be able to seek reimbursement for telemedicine visits in the future, which will drive access.
Finding Value in Telemedicine
Telemedicine is particularly valuable for people living with rheumatic conditions because these patients are at potentially elevated risk for worse COVID-19 outcomes due to comorbidities and the use of immunosuppressive drugs such as glucocorticoids and biologics that heighten risk for infections and require close monitoring for side effects.2
It is not enough to offer telemedicine across a variety of communication technologies without some assurance that it provides quality care to all patients. Specifically, to support a patient-centered approach to care, modifications need to be identified and implemented for socially vulnerable populations (defined by housing status, income, education, race, rural residence, computer literacy, and internet access) who may face barriers to accessing effective telemedicine. We also need to understand patients’ preference in their receipt of health care services, what kind of appointments may most benefit from telemedicine, and which services are most appropriate for this approach.
In June 2020, as part of the Autoimmune COVID-19 Project of the Autoimmune Research Collaborative, which is led by Global Healthy Living Foundation’s ArthritisPower® Research Registry, we launched an online survey focused on telemedicine to members of patient communities who have an autoimmune or inflammatory condition, including autoimmune rheumatic disease. The goal of this study was to gain insight on use of telemedicine among a medically vulnerable patient population and to better understand patients’ perceptions and attitudes about telemedicine visits and the factors that influence these perceptions.
Clinical Context Drives Preferences for Telemedicine
We invited people living with rheumatologic disease to participate in a study, recently published in Arthritis Care & Research, to assess their satisfaction with telemedicine and their preferences for the scenarios where telemedicine was provided.3
Using the validated Agency for Healthcare Research and Quality Consumer Assessment of Healthcare Providers and Systems (CAHPS)® survey and a modified version of the validated Telemedicine Perception Questionnaire (TMPQ), this study showed that a majority of survey respondents preferred a telemedicine visit for routine visits (60.4%) and for review of test results (59.8%). On the other hand, only a few respondents also preferred telemedicine visits for evaluation of a new symptom (21.5%), during a disease flare (18.3%), and when starting a new injectable medication (16.1%). Results were similar among respondents who engaged in video vs phone telemedicine visits.3
These data suggest that routine nonemergency visits via telemedicine work well for patients who have no new concerns and for regular information exchanges with their providers.
With regard to patient satisfaction with telemedicine, the mean TMPQ score was 62.8±10.7 on a 0 to 100 scale, supporting a favorable attitude toward telemedicine among patients who participated in a video visit. For example, a higher percentage of participants who had a video visit agreed with the statement that telemedicine was a convenient form of health care delivery (78.2%) vs participants who had a phone visit (69.9%; P =.05); they also agreed that telemedicine saved time (90.4% vs 82.9%; P =.02). In addition, approximately half of study participants (42.5%) noted that telemedicine was at least as good as an in-office visit. Notably, patients’ diagnosis, place of residence, age, and sex were not associated with preference for telemedicine.3
These results demonstrated that people living with autoimmune rheumatic diseases were in support of telemedicine and were satisfied with this approach for routine visits during the COVID-19 pandemic.
Addressing Barriers in Telemedicine to Improve Patient Outcomes
However, questions remain about the barriers to telemedicine in reaching socially vulnerable populations, particularly regarding how to match these communities with existing technologies. Something as seemingly simple in theory (but complicated by economics and regulations in practice), such as improving broadband access, could help in bringing improved access to health services to many different patient populations. In addition, insurance coverage could help facilitate access to care that includes both video and audio-only visits, which may be the only option in geographic areas with low broadband access. Notably, telemedicine could help curtail costs involved in traveling to doctors’ offices and time spent away from work.
Looking ahead, we need to explore how to make telemedicine more useful across additional clinical scenarios. For example, a program that the ArthritisPower Research Registry is exploring in the longer-term, via an ongoing study, is how well patients’ joint self-assessment compares in accuracy with the gold standard, an in-person clinician joint exam. If patients feel confident in their ability to convey this kind of information to their rheumatologists, it could increase their satisfaction with and the convenience of telemedicine appointments.
The COVID-19 pandemic has been burdensome for several reasons and people living with chronic diseases remain on alert with the added concerns of being mindful about the risks associated with infection, despite the availability of vaccines. As telemedicine improves and its optimal uses come into clearer view, we can expect that people living with rheumatic disease will have more options for maintaining contact with their rheumatology team, which is vital for better outcomes.
Benjamin Nowell, PhD, MSW, is the director of patient-centered research at Global Healthy Living Foundation (GHLF) and CreakyJoints® and the principal investigator of ArthritisPower™ Patient-Powered Research Network. Shilpa Venkatachalam, PhD, MPH, is the associate director of patient-centered research at CreakyJoints® and co-principal investigator of ArthritisPower.
- George MD, Venkatachalam S, Banerjee S, et al. Concerns, healthcare use, and treatment interruptions in patients with common autoimmune rheumatic diseases during the COVID-19 pandemic. J Rheum. 2021;48 (4): 603-607. doi:10.3899/jrheum.201017
- Grainger R, Kim AHJ, Conway R, Yazdany J, Robinson PC. COVID-19 in people with rheumatic diseases: risks, outcomes, treatment considerations. Nat Rev Rheumatol. Published online February 25, 2022. doi:10.1038/s41584-022-00755-x
- Danila MI, Gavigan K, Rivera E, et al. Patient perceptions and preferences regarding telemedicine for rheumatologic care during the COVID-19 pandemic. Arth Care Res. Published online January 18. 2022. doi:10.1002/acr.24860