EULAR: Telehealth useful for disease monitoring; barriers to access exist
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Although telehealth can be useful in treating patients with rheumatic diseases, diagnoses should be established in face-to-face visits, according to new EULAR points to consider.
“These points to consider indicate how telehealth should be developed and implemented in routine clinical care of people with rheumatic and musculoskeletal diseases (RMD),” Annette de Thurah, PhD, of the Aarhus University Hospital in Denmark, and co-authors wrote in the Annals of the Rheumatic Diseases. “They cover several aspects including screening for RMD, preassessment in the referral process, disease monitoring and modification of medication dosages and non-pharmacological interventions.”
To draft new overarching principles and points to consider for the management of patients with RMD through telehealth, de Thurah and colleagues formed a EULAR task force consisting of representatives from 14 European countries, including methodologists, rheumatologists, epidemiologists, physiotherapists, health professionals in the rheumatology specialty and four patients with RMD. Before receiving approval, the authors conducted a scoping review to catalogue knowledge gaps and determine what research was necessary to be completed.
Based on this review, a literature review was designed to focus on the efficacy and safety of remote management of patients with RMD, user perception and adherence as compared with standard care, and barriers to the wider implementation of remote care.
Task force members gathered for two virtual task force meetings. The first meeting, held in November 2020, focused on the definitions of remote care and telehealth, and discussed key questions the research review would answer. The second virtual meeting, held during April 2021, formulated the overarching principles and points to consider using the literature review and expert opinion. Consensus was achieved if the statements reached more than 75% agreement. All statements were accepted during the first round of voting.
According to the overarching principles approved by the task force, tailored care combining remote and face-to-face attendance should be based on shared decision-making, as well as the needs and preferences of people with RMD. In addition, remote care for people with RMD can be delivered by all members of the health care team using a variety of telehealth techniques, the authors wrote.
They added that telehealth interventions should be developed in collaboration with all stakeholders, including the health care team, caregivers and people with RMD, and that members of the health care team involved in remote care interventions should have adequate equipment and training as well as telecommunication skills.
In addition to the four overarching principles, there are nine points to consider for using remote care in the context of RMD. The points to consider are:
Preassessment by telehealth may be considered to improve the referral process to rheumatology and assist in the prioritization of people with suspected RMD.
Telehealth may assist prediagnostic processes for RMD, but diagnosis should be established in a face-to-face visit.
The decision to start disease-modifying antirheumatic drugs should be made in a face-to-face visit, while telehealth may be used for drug education, monitoring and facilitating adherence.
Dose modifications or suspension of DMARDs, as well as the addition of analgesics, NSAIDs or glucocorticoids, can be discussed with people with RMD via telehealth.
Telehealth can be used to monitor symptoms, disease activity and other outcomes.
Telehealth may be used to discuss the need for a face-to-face consultation or other interventions.
Telehealth should be considered for non-pharmacological interventions, including but not limited to disease education, advice regarding physical exercise, self-management strategies and psychological intervention.
Barriers to telehealth services should be assessed and resolved wherever possible.
People with RMD using remote care should be offered training in using telehealth.
“These [points to consider] identified several areas where telehealth may potentially improve quality of care and increase healthcare access within rheumatology,” Thurah and colleagues wrote. “Although our [systematic literature review] did not reveal any evidence on how to implement telehealth solutions, we identified barriers and facilitators that may potentially play a role for the implementation of telehealth interventions into clinical practice.”
Perspective
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David E. Bacha, MD, FACP, FACR
During the pandemic, telehealth played a valuable role in the remote care of rheumatology patients. As rheumatologists try to determine how best to use telehealth moving forward, the 2022 EULAR article provides some timely points to consider for remote care in rheumatic and musculoskeletal diseases. The EULAR points emphasize areas where telehealth could improve rheumatology care and health care access, as well as potential stumbling blocks.
A variety of circumstances lend themselves to telemedicine visits, including stable patient visits that only require nonpharmacologic interventions, basic dose modifications, monitoring or discussions of laboratory and imaging findings. However, rheumatology is a “contact sport.” Rheumatology patients often require more extensive clinical and physical examinations. Thus, face-to-face visits remain essential in clinical rheumatology practices. Rheumatologists will continue to integrate telehealth into their practice patterns but will not be closing their offices anytime soon.
Telehealth is not a one-size-fits-all solution — they need to be tailored to the patient as well as the practice. Several patients have difficulty adapting to the technology required for telehealth visits, and some are limited to audio visits because they have not mastered, or do not have access to, the required technology. For many rheumatology patients, telehealth is not ready for prime time.
The telerheumatology landscape is evolving. Both patients and rheumatologists will need to learn and adapt as technology advances. Although telehealth has its limitations, it provides an option that can complement face-to-face visits. Ultimately, the extent of telehealth use in the United States may depend upon the continuation of adequate insurance reimbursements for these services. Further guidance as to when and where to use telehealth is needed and hopefully forthcoming. Stay tuned.
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