Even before I started my rheumatology fellowship, I knew it would be a demanding career, diagnosing complex diseases with only a few management options in seriously ill patients. What I didn’t appreciate as much before is how badly we are needed across the country.
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Explore This IssueMay 2020
According to the 2018 outcomes report from the National Resident Matching Program, rheumatology is becoming one of the most competitive subspecialties, with 1.4 applicants per position, joining the ranks of cardiology, hematology and oncology.1 However, it would be amiss to ignore more ominous projections—a serious mismatch between supply and demand. According to the 2015 ACR/ARHP Workforce Study of Rheumatology Specialists, a 31% decline in clinical supply, from 4,997 to 3,455 rheumatologists, is predicted against the backdrop of a 138% increase in demand from 6,155 to 8,184, equating to an excess demand for 4,729 adult rheumatologists.2
Besides a quantitative gap, a persistent geographic gap persists, with the ACR Committee on Rheumatology Training & Workforce Issues reporting clustering of rheumatologists in largely metropolitan areas and in the Northeast.3 All of this is occurring in the midst of trying to fulfill demands for more frequent follow-ups to achieve treat-to-target goals.
Strategies proposed to combat these gaps have focused primarily on increasing the workforce, essentially training more fellows and scaling up ancillary care providers (e.g., nurse practitioners). Another side of the argument focuses on changing how care is delivered. Utilization of telemedicine as an alternative strategy has particularly garnered interest.
Broadly defined as “medical information that is exchanged from one site to another through electronic communication to improve a patient’s health,” telemedicine exists to connect remote patients without ready access to a rheumatologist.4 Arguably, its greatest strength lies in its potential to increase access, as well as to reduce costs related to time and transportation for the patient and, potentially, increase patient satisfaction in the process.
Currently, telerheumatology is being incorporated into practice across several medical centers, including the University of Pittsburgh Medical Center, Dartmouth-Hitchcock Medical Center, headquartered in Lebanon, N.H., and the Alaska Native Tribal Health Consortium, based in Anchorage. These institutions use video conferencing technology, in which a patient is remotely presented to the rheumatologist by a trained presenter. However, this approach has not been immune to criticisms and concerns, including excessive costs to set up appropriate broadband technology (often falling on the shoulders of the providers themselves), variable reimbursement policies for Medicaid and Medicare across states and the absence of clear regulations protecting both the physician and patient from medical malpractice (see “The Doctor Will See You Now,”).
However, a limited number of published studies suggest encouraging potential.
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.
Based on available evidence, it’s reasonable to argue that by identifying the right subset of patients (e.g., those with low disease activity who could reliably report symptoms based on self-assessment and manage some form of communication on a digital platform [SMS, text]), telerheumatology could succeed as an adjunct tool to help triage established patients.
More rigorous studies are needed to examine the potential impact on the healthcare system, particularly in regard to cost effectiveness. It’s also not clear, in terms of disease subsets, which patients would benefit, because most studies included patients with RA or an unspecified form of inflammatory arthritis. Another contentious question is how to adequately train the presenters (who are not rheumatologists) to present a complex history and verbally convey articular exam findings accurately.
As a rheumatologist, I like to think we are irreplaceable. But it’s also clear we are in need of innovative assistance to meet demands. Perhaps telerheumatology is one solution.
Elizabeth Park, MD, is a second-year rheumatology fellow at Columbia University Irving Medical Center, New York. Her interest in telemedicine stems from working with the Mobile Health Informatics Program, Botswana-UPenn Partnership as a medical student. She is pursuing a career in clinical research studying cardiovascular outcomes in rheumatoid arthritis patients.
Table 1: FLARE-RA Questionnaire7
The patient is asked to indicate whether the following statements are absolutely true, true, fairly true, not really true, untrue or completely untrue.
- You noticed the appearance or worsening of morning stiffness in joints over several consecutive days.
- You noticed the appearance or worsening of pain in one or several joints over several consecutive days.
- You noticed the appearance or worsening of swelling in one or several joints over several consecutive days.
- You noticed the worsening of your sleep because of arthritis pain over several consecutive nights.
- You noticed a marked worsening in your arthritis lasting several consecutive days.
- You increased your doses of pain killers or anti-inflammatory medication over several consecutive days (if you are not taking any pain killer, select ‘completely untrue).
- You increased your daily dose of prednisone for several consecutive days (if you are not taking prednisone, select ‘completely untrue).
- You felt particularly tired for several consecutive days because of your rheumatic disorder.
- You were so restricted that you have decreased your daily activity over several consecutive days.
- You felt more irritable than usual over several consecutive days because of your rheumatic disorder.
- You felt depressed over several consecutive days because of your rheumatic disorder.
- You felt you wanted to withdraw and be alone over several consecutive days because of your rheumatic disorder.
- You felt an increased need for help over several consecutive days because of your rheumatic disorder.
- Charting outcomes in the match. Specialties Matching Service, Appointment Year 2018. National Resident Matching Program.
- Deal C, Bolster MB, Hausmann JS, et al. 2015 ACR/ARHP workforce Study (WFS): Adult rheumatology specialists in the United States: Effect of gender and generation [abstract]. Arthritis Rheumatol. 2016;68(suppl 10).
- American College of Rheumatology Committee on Rheumatology Training and Workforce Issues, FitzGerald JD, Battistone M, et al. Regional distribution of adult rheumatologists. Arthritis Rheum. 2013 Dec;65(12):3017–3025.
- Tuckson RV, Edmunds M, Michael L. Hodgkins ML. Telehealth. N Engl J Med. 2017 Oct 19;377(16):1585–1592.
- McDougall JA, Ferucci ED, Glover J, Fraenkel L. Telerheumatology: A systematic review. Arthritis Care Res (Hoboken). 2017 Oct;69(10):1546–1557.
- De Thurah A, et al. Tele‐health followup strategy for tight control of disease activity in rheumatoid arthritis: Results of a randomized controlled trial. Arthritis Care Res (Hoboken). 2018 Mar;70(3):353–360.
- Berthelot J-M, De Bandt M, Morel J, et al. A tool to identify recent or present rheumatoid arthritis flare from both patient and physician perspectives: The ‘FLARE’ instrument. Ann Rheum Dis. 2012 Jul;71(7):1110–1116.
- Kuusalo L, Sokka-Isler T, Kautiainen H, et al. Automated text message-enhanced monitoring versus routine monitoring in early rheumatoid arthritis: A randomized trial. Arthritis Care Res (Hoboken). 2020 Mar;72(3):319–325.
- Felson DT, Smolen JS, Wells G, et al. American College of Rheumatology/European League Against Rheumatism provisional definition of remission in rheumatoid arthritis for clinical trials. Arthritis Rheum. 2011 Mar;63:573–586.
- Ferucci ED, Holck P, Day GM, et al. Factors associated with use of telemedicine for follow‐up of rheumatoid arthritis. Arthritis Care Res (Hoboken). 2019 Aug 17. [online ahead of print]
Editor’s note: See the ACR’s suggestions for using telemedicine during the pandemic here.