Telemedicine in rheumatology: convenience at the cost of accuracy and trust


Telemedicine in rheumatology reduces the accuracy of assessments and impedes the building of trusting medical relationships, according to findings of a comprehensive study into clinical and patient perspectives.

While the results indicate that there is a place for telemedicine for certain patients with rheumatological conditions, there is “a strong overall preference for face-to-face consultations on the part of both clinicians and patients,” according to UK researchers.

Led by Melanie Sloan, from the Department of Public Health and Primary Care at the University of Cambridge, the team sought to shed further light on the suitability, acceptability and safety of telemedicine in rheumatology, against a backdrop of mixed study findings to date.

For the study, reported in Rheumatology, researchers included a total of 1,340 patient and 111 clinician surveys, as well as 60 interviews (31 patients and 29 clinicians). Inflammatory arthritis (32%), lupus (32%), Sjogren’s (9%) and systemic sclerosis (8%) were the four most commonly reported rheumatological diseases, and patient respondents were largely from the UK (96%).

A key finding was that the vast majority of patients (86%) and clinicians (93%) felt telemedicine was worse than face-to-face for accuracy of assessments. According to the researchers, “misdiagnoses and other inaccuracies were frequently reported and often attributed to the absence of examinations and visual cues”.

These issues were further magnified by the cancellation of tests that would have helped accurate diagnoses, with patients reporting having had at least one blood (40%) and/or other tests (48%) cancelled in the 12 month period to March 2021.

Also, symptom severity was underplayed by patients in telemedicine, with around 45% of patients and clinicians reporting less willingness to report symptoms, and clinicians found it more difficult to identify mental health concerns remotely.

With regard to the effect on the patient/clinician relationship, high numbers of clinicians (90%) and patients (69%) felt that telemedicine was worse than face-to-face for building a trusting relationship.

Over 60% of patients and clinicians felt that telemedicine was more convenient than face-to-face, with safety from infection, lack of travel and reduced waiting times, cited as the main advantages. However, the surveys revealed that clinicians significantly over-estimated the convenience for patients, and that remote appointments did not always save clinicians’ time.

Also, the data revealed that access to emergency care was highly variable and with patients experiencing difficulties in getting urgent medical advice; only 48% of patients were confident that a GP would respond within 24 hours, and only 55% believed their rheumatology department would respond within 48 hours.

There was also concern that telemedicine could increase inequalities in access to care. Clinicians and patients reported telemedicine as being a particular disadvantage to patients without English as a first language; with hearing, cognitive or speech difficulties; with strong accents; with more complex and potentially life-threatening illness; in need of urgent care; with mental health difficulties; of older age; socio-economically or educationally disadvantaged; experiencing difficulties with access to/ability related technology.

Preferences

Overall, most participants in the study supported a mix of face-to-face and telemedicine, though a significantly higher number of clinicians (70%) than patients (46%) wanted all emergency appointments to be face-to-face. Clinicians also expressed a strong preference (over twice as many) for telephone appointments over video calls.

Just 3% of clinicians felt that telemedicine was better than face-to-face. Male clinicians and rheumatology registrars were the most negative clinician sub-groups on the relative merits of telemedicine, and rheumatology nurses were the most positive.

Concerns were also raised about the potential over-use of telemedicine as means to cut costs and save time rather than ensure optimal care for patients, and the study found that clinical and patients were rarely consulted on their views and preferences.

The author’s concluded that “training, choice, careful patient selection, and further consultation with clinicians and patients is required to increase telemedicine’s acceptability and safety.”

However, they also noted that while some concerns and risks may lessen as remote consultation systems are improved, “it is unlikely that the serious concerns expressed by our participants regarding assessing complex rheumatological conditions remotely will be fully resolvable”.

“This has implications for the telemedicine ambitions and plans of the UK and other health systems, and highlights the need for ongoing assessment and mitigation of the clinical risks associated with a telemedicine strategy,” they concluded.

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