Medicopolitical

Rheumatology teleclinics are here to stay, but can’t replace face-to-face consultations


Teleclinics in rheumatology will remain widespread in clinical practice post pandemic, international experience suggests, but there are divided opinions about their benefits and role in patient care.

A new study by Italian clinicians in Rheumatology has concluded that video consultations with inflammatory rheumatic disease (IRD) patients can accurately assess the need to modify treatment.

Face-to-face visits were found to confirm decisions made via earlier video consultation in 84% of 106 patients, backing the reliability of patient reported outcomes (PROs) via telehealth in IRD patients.

Video consultations had 94.1% sensitivity and 96.7% specificity for detecting the need for treatment adjustment because of inadequate disease activity control, and a comparably high performance (91.9% and 96.7%, respectively) for identifying when treatment adjustment was not needed.

However, the ability to reliably determine the need for treatment tapering dropped to a level of 55.6%, largely because video consultations were not as effective in identifying patients with SLE eligible for tapering the daily dose of prednisone.

“Considering the impact of prednisone on damage accrual, the extent to which video-visiting can be implemented in patients with SLE under tight monitoring will have to be further investigated,” said the study authors, led by rheumatologist Professor Matteo Piga, from University Clinic AOU Cagliari.

The results “provide the so far missing evidence on the valuable role of video-consulting, when applied in support of the standard approach, to increase the number of follow-up rheumatology consultations and favour tight monitoring for patients with IRDs by limiting the number of hospital visits, thus protecting from spreading infections,” they concluded.

Benefits vs drawbacks

Commenting on the findings, UK consultant rheumatologist Dr Antoni Chan, Associate Medical Director at Royal Berkshire NHS Foundation Trust, said he believed that most important decisions can be made, investigations initiated, and vital triage performed at teleconsultation provided guidelines are followed.

“[Teleclinics] are useful for … helping us to decide [which patients are likely] having a joint flare and would benefit most from a face-to-face appointment or a different approach,” he told the limbic.

Dr Chan said that in his experience, teleclinics shortened consultation times as there were often fewer distractions, allowing for more focus.

They also offered key benefits from a patient perspective.

“Teleclinics support patients [seeking] follow up by allowing intermediate discussion encounters, as well as offering opportunities for patients to discuss other concerns they may have if there is a long interval before their next booked face-to-face appointment,” he said.

However the Editor in Chief of Rheumatology, Dr Marwan Bukhari, said there were significant problems with rheumatology teleclinics that he believed outweighed the advantages.

Dr Bukhari, a consultant rheumatologist at the Royal Lancaster Infirmary and Manchester University, said the key issues were that remote consultations did not allow for physical examination of the joints, and made empathic communication  – and holistic management – more difficult.

Remote consulting was not suitable for all patients, he found, particularly for those who need counselling on treatments. The lack of face-to-face contact meant it was difficult  to engage patients in personal discussions such as when trying overcoming hesitation about taking a medication, coping with discomfort and disease activity, or discussing sensitive subjects related to their illness.

Dr Bukhari envisaged a hybrid approach as the way forward, in which patients are seen face-to-face then channelled into appropriate follow-up schemes.

For example, people with diseases like polymyalgia rheumatica, giant cell arteritis, osteoporosis, could be followed up remotely, while those with active inflammatory diseases or connective tissue diseases, or who need a decision about change of treatment or who are under investigation, would have to continue to be seen face-to-face, he suggested.

However, some patients did not seem to take teleconsultations as seriously as those carried out face-to-face, he noted.

“We’ll be phoning patients and they’ll be outdoors gardening, in supermarkets, shopping, even when they know we’re about to call them. So there’s a lack of attention as well as a lack in our ability to pick up on things like body language, or facial expression if it’s by telephone,” he said.

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