Too much telehealth ‘fraught with danger’ for rheumatologists: Prof. Peter Nash

Excessive reliance on telemedicine is dangerous in rheumatology and a return to regular face-to-face care is needed as soon as possible, a local expert is arguing.

In a strongly-worded paper, Professor Peter Nash has also called for an accounting of the “number needed… per adverse event” via telehealth, pointing to the risks of prescribing potentially toxic antirheumatic therapy in the absence of adequate physical examinations.

Published last week, his editorial stressed there was “no doubt” that telehealth had been vital during the COVID-19 pandemic with its real barriers to in-person care.

It was also clear based on recent research that greater than 60% of patients found telemedicine more convenient than coming in for a physical consultation, the Queensland rheumatologist said.

“Preventing delayed diagnosis of time-critical disease from acute vasculitis to septic complications from therapy as well as monitoring and assessing response to already commenced therapy is important and telehealth played an important role,” he wrote in Joint Bone Spine.

His editorial was in response to a small French study showing that smartphone telehealth consultations by rheumatologists were a cost effective way of initiating DMARD treatment for rheumatoid arthritis patients with uncontrolled disease, resulting in similar health outcomes at a lower cost than conventional monitoring.

However, Professor Nash, Director of the Rheumatology Research Unit at Griffith University, Queensland, warned that initiating DMARDs without regular face-to-face monitoring was “fraught with danger”.

“It is straightforward to diagnose and commence appropriate therapy such as methotrexate in a patient with a strongly positive anti-CCP ab who has an acute onset of painful symmetrical polyarthritis.”

“However, if the examination revealed bibasal pulmonary crackles or an enlarged liver with signs of chronic liver disease or a peripheral vasculitic rash, choice of therapy would be significantly impacted indeed dangerous choices could be avoided by physical examination.”

He noted that while clinicians are familiar with concepts like ‘number needed to treat’ (NNT) to achieve remission or low disease activity or ‘number needed to harm’ per serious adverse event, “perhaps number ‘needed to be treated by telehealth’ per missed serious pathology or incorrect assessment in the absence of an adequate examination is just as important”.

“Our patients deserve to be managed by physicians expert in rheumatic diseases aided appropriately by other health care professionals… and not by rheumatoidarthrologists with an iPhone,” he concluded.

It comes amid ongoing debate over the place of telehealth in Australian specialist care, particularly when conducted via phone rather than video, with health officials arguing phone offers “inferior information transfer” compared to other media.

As a result, the Federal Government scaled back Medicare item numbers for specialist telehealth consultations two months ago, limiting consultant physicians to video consults for all but minor attendances.

Official MBS statistics for specialist initial attendances (equivalent to item 110) had previously showed 685,000 had been provided over the phone since the item became available, compared to 189,000 over video.

Some 5.3 million had been provided face-to-face over the same period.

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