COVID-19 raises profile, utility of digital therapeutic approaches in OA
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The COVID-19 pandemic forced the rheumatology community to adopt a number of telehealth and digital approaches in patient care, according to a speaker at the 2021 OARSI World Congress virtual meeting.
Kim Bennell, PhD, chair of physiotherapy at the University of Melbourne, suggested that osteoarthritis patients may benefit from real-time or asynchronous interventions or a combination of those approaches. Clinicians may also work technology into a package of in-person and out-of-office care. “There is a range of digital approaches,” she said.
Bennell’s talk covered data sets pertaining to telehealth, fully automated web-based interventions and phone-based or wearable technologies. She acknowledged that most of the studies she discussed were conducted pre-pandemic. “COVID-19 obviously dramatically changed the way health care was delivered around the world,” she said. “It provided a good opportunity to look at real world delivery of these telehealth approaches.”
When reviewing data on telehealth, it is important to note whether the study was conducted before or after COVID-19, according to Bennell. Prior to the pandemic, skepticism and lack of acceptance of telehealth were common in the rheumatology community. “Some doctors do not like that they could not use a typical hands-on approach,” she said.
Since the pandemic, however, that thought process has changed across the specialty, even for telehealth visits that are conducted by phone. “It is pleasing to show that the therapeutic relationship does not necessarily suffer as much as some people may think when you are unable to see the person you are interacting with,” Bennell said.
Turning to fully automated web-based interventions, Bennell suggested that a key advantage of these approaches is that a physician is not required at all. The drawback, however, is that adherence can be “problematic” because there is no one to engage the patient.
This has been borne out in some data sets. A study by Bossen and colleagues in the Journal of Medical Internet Research showed that physical activity levels improved in patients who participated in automated exercise programs. However, adherence was “less than optimal,” according to Bennell.
That said, Bennell suggested that automated interventions do not necessarily need to include hard outcomes like activity levels or pain and functioning. They may be used to develop pain coping skills, encourage relaxation or mindfulness, mitigate maladaptive pain strategies or encourage “generally positive user experiences.”
Automated approaches also can be used as standalone treatments or as a first step in a step-managed approach involving a clinician.
To that second point, a study from Allen and colleagues in the Annals of Internal Medicine had patients start with a fully automated program for physical activity. If they showed no improvement, they moved on to phone contact with a health coach. The third step was an in-person visit to a physiotherapist. More self-motivated patients required only the automated program to meet goals, while others benefited from the second or third steps.
Regarding phone-based interventions and wearable devices, Bennell reported that a number of systematic reviews have shown that these strategies can yield improvements in outcomes ranging from daily step counts to weight loss and exercise habits.
However, given that there is a broad range of commercial and clinical devices on the market, clinicians and researchers should carefully consider what technology to use, and how to use it for any given patient. “We need to take into account the e-health literacy of the population being targeted,” Bennell said.
Incorporating specific behavior techniques such as goal setting, monitoring, feedback and instruction is also critical, according to Bennell. “We need to have training of clinicians so they can optimally deliver these interventions,” she said. “We need to have better patient selection to ensure that it is safe or unsafe or suitable.”
While licensing, funding and reimbursement for such programs posed challenges prior to the pandemic, COVID-19 has served to “drive the field forward,” according to Bennell.
To that point, if there is a final component to technology in rheumatology, it pertains to cost. There is speculation that more automated digital services and fewer in-office visits could lower the overall financial burden of osteoarthritis, but this conclusion is far from certain. “More studies need to look at the cost effectiveness of these digital approaches,” Bennell said.
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Bennell K. Digital Health Approaches for the Lifestyle Management of Osteoarthritis. Presented at: OARSI 2021 World Congress on Osteoarthritis; April 29-May 1 (virtual meeting).
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