Telehealth clinic reduces distress among people with graft-versus-host disease
Key takeaways:
- A multidisciplinary telehealth clinic improved access, reduced distress and narrowed gender disparities in GVHD care.
- The researchers advocate for the lifting of restrictions around state telehealth licensure.
A multidisciplinary, virtual platform showed preliminary feasibility for reducing distress and improving access for patients with graft-versus-host disease, according to findings published in Transplantation and Cellular Therapy.
Researchers at Memorial-Sloan Kettering Cancer Center established a multispecialty GVHD clinic team consisting of bone marrow transplantation specialists, nurses, dermatologists, dentists, nutritionists, physiatrists, research personnel and others.
The investigators assessed all GVHD-associated visits — both in-person and telehealth — conducted between January 2022 and December 2022.
Of 93 patients who received a total of 308 visits, one-third had been conducted via telehealth. Roughly half of the in-person group had a minimum of one telehealth visit, and 10 patients only had telehealth visits.
Most of the patients seen at the clinic had advanced, chronic GVHD. Men accounted for most of the patients seen at the clinic, whereas women more often opted for telehealth visits. Racial or ethnic minority individuals accounted for one-third of the clinic visits.
Only 6% of in-person visits were by patients who lived more than 100 miles from the center, whereas 34% of telehealth visits included patients from greater distances, including outside the state.
Fifteen patients responded to a follow-up symptom survey and reported experiencing decreased stress about GVHD (P=.02), although their other symptoms remained unchanged.
“At the beginning of the COVID-19 pandemic, we had to put our clinic on hold because patients who have undergone stem cell transplants are severely immunocompromised and we recommended they not come to the hospital,” Doris M. Ponce, MD, MS, bone marrow transplant specialist at Memorial Sloan Kettering Cancer Center, told Healio. “However, as the weeks went by, we realized that COVID was going to stay around for a longer period of time than we anticipated, so we began our initiative of creating a functional platform through telemedicine.”
Healio spoke with Ponce about the motivation for the clinic, its results in terms of improving access issues, and future plans for the platform.
Healio: What motivated you to conduct a study of outcomes from your virtual clinic?
Ponce: We wanted to share our experience of how we did this so other centers can follow through on what we have done. We also wanted to share what was accomplished, as well as describe the unmet needs we want to work on to further help our patients.
Healio: How does your telehealth GVHD clinic work?
Ponce: When a patient is scheduled for a telemedicine clinic visit, they get a packet with information on what to expect. We ask them to fill out an electronic quality-of-life questionnaire, and we also ask them to take pictures so that we can document their changes more objectively. These patients tend to have skin involvement and musculoskeletal issues with decreased range of motion. In our picture instructions, we tell them how to take the photos to help us assess their range of motion.
On the date of the appointment, they log in virtually and are assessed by my team of nurses or nurse practitioners, who do a dedicated review system. Once that has happened, our nurses will give an update to the providers, and then all the providers from the clinic assess the patient remotely. We also ask the patient to do blood work locally, so we have blood work results as well when we’re seeing the patient. Some also might have done a radiology or pulmonary function test. When we assess the patient, we’re also evaluating these test results.
The patient sees providers from our multispecialty clinic, and we usually see about four or five at the same time. After that, we will provide recommendations. The patient will then return to our nurse, who will provide a final summary with medication changes. If they need social worker input, that could be done at that time as well.
Healio: What results have you seen as far as reducing patient distress and eliminating access barriers?
Ponce: We found that telehealth did increase our bandwidth in seeing patients and expanded the ZIP code range. With the telemedicine platform, we saw a higher proportion of patients coming from distances more than 50 and sometimes more than 100 miles. Our catchment area really did increase.
About 70% of patients who came to the in-person clinic were male. With the telemedicine platform, we saw an improvement in gender parity — the number of female patients was higher through telemedicine. We don’t know why more women were better represented through telemedicine, but we think there are some gender disparities involving limitations to transportation.
Healio: What are the next steps?
Ponce: We will continue to expand our efforts in terms of the number of patients we are seeing. We are also bringing more clinical trials to our clinics. Patients who come here with advanced GVHD and have exhausted their lines of treatment can have additional treatment options available at our center.
Another step we plan to take is to support other initiatives throughout the country for a multispecialty approach. Other centers are interested in providing a similar service, and our next step is to expand our footprint through collaboration with these other centers. We also want to identify additional subspecialties that will add value to our patient assessments.
Our clinic also has a strong footprint and interest in research, so we want to continue to expand our research efforts. We are collecting and building up biobanking that specializes in chronic disease. We want to continue those efforts for future research projects and questions we might have.
Healio: Is there anything else you’d like to mention?
Ponce: I did want to mention the issue of state licensure. When COVID happened, the telehealth restrictions on seeing patients outside of the state were lifted. I have patients from all over the country and I was able to provide care. Now that those restrictions are back in place, though, it does limit patient access, particularly for those with rare diseases. So, we also have an advocacy effort in place to bring awareness of the limitations of licensure. We are advocating to Congress to lift these limitations for the treatment of patients with diseases like GVHD.
Reference:
For more information:
Doris M. Ponce, MD, MS, can be reached at ponced@mskcc.org.
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