The Studies
McDougall et al. published an informative literature review in 2017.5 The authors reviewed 20 studies, 10 of which were abstracts. The majority of the studies were based in Canada and Europe. Most were observational, using telephone or VCT (video telecommunications). Eighteen of the 20 found incorporation of telemedicine to be effective, albeit assessed on various outcomes—mostly satisfaction at the level of provider and the patient, and only a few examining diagnostic concordance and subsequent change in management. Also of note: Ten of those studies remain unpublished as abstracts.
In one of few randomized trials, De Thurah et al. randomized rheumatoid arthritis (RA) patients to telehealth follow-up carried out by a nurse or a rheumatologist vs. conventional outpatient follow-up.6 The study met its primary outcome of non-inferiority of changes in Disease Activity Score in 28 joints (DAS28) after week 52.
What’s more informative is the study’s utilization of a patient-reported outcome (PRO) based decision algorithm—Flare Assessment in Rheumatoid Arthritis (FLARE-RA).7 FLARE-RA is a 13-item questionnaire (five items for joint symptoms and eight items for general symptoms) used to determine the need for a face-to-face outpatient visit. This approach subsequently led to a greater than 50% reduction in the total number of visits to an outpatient clinic in the telehealth intervention group. The one caveat was that the study included mostly those with low disease activity (DAS28: 2.03–2.1), with the majority managed on one medication (methotrexate).
Kuusalo et al. conducted another randomized controlled trial, assigning early, disease-modifying anti-rheumatic drug-naive RA patients to SMS (short messaging service) enhanced follow-up (patients receiving a total of 13 messages with questions regarding medication problems and a patient global assessment scale) or to routine follow-up.8 Although the study did not meet its primary outcome of six-month Boolean remission (based on a 28-joint count: a swollen joint count of 1 or less, a tender joint count of 1 or less, a C-reactive protein of 1 mg/dL or less, and a patient global assessment of disease activity of 1 or less), no statistically significant increase occurred in any unscheduled visits or physician-initiated telephone contacts in the intervention group (although the number of phone calls increased).9 Again, the caveat is that the study included patients with milder disease, the vast majority of whom had sustained DAS28-defined remission.
Ferucci et al. performed a cross-sectional analysis of individuals in the Alaska Tribal Health System with a diagnosis of RA, recruited either when seeing a rheumatologist in person or by video telemedicine.10 On a multi-variable analysis, a higher number of visits in the past year, higher RAPID3 (Routine Assessment of Patient Index Data 3), higher telemedicine survey scores (i.e., more positive views) and a higher mean rheumatologist telemedicine rate (i.e., the proportion of visits conducted by a rheumatologist that are telemedicine based) were all significantly associated with the telemedicine visit, and more traditional risk factors, such as disease duration, seropositivity, erosions and comorbidities, were not.
