ABSTRACT
Background: The ongoing coronavirus disease 2019 (COVID-19) pandemic and subsequent waves still represent a healthcare issue. Their impact on the treat-to-target (T2T) strategy in rheumatoid arthritis (RA) patients has been seldom investigated. Difficult access to rheumatology outpatient clinic, laboratory and imaging investigations as well as nationwide containment measures could potentially affect disease activity and tight-control strategy. Recently, we reported how a telephone-based tight control strategy ensured satisfactory management of RA treated with targeted therapies during the frst wave of the pandemic [1]. However, the performance of our different patterns of healthcare delivery across different pandemic waves has not been studied yet. Objectives: To analyze the impact of different patterns of healthcare delivery on remission of RA patients treated with targeted therapies during the frst wave (2020) and second/third waves (2021) of pandemic compared to the pre-pan-demic period (2019). Methods: In this observational real-life study, data of our cohort of RA patients treated with biologic or targeted synthetic drugs were extracted from a longitudinal registry. Clinical Disease Activity Index (CDAI) was analyzed in the same period from 22nd of February to 18th of May for three consecutive years: before the pandemic (2019), during the frst wave (2020), and during the second/third waves (2021). During the frst wave, patients could choose whether to receive home drug delivery or to maintain their face-to-face visits, in the other periods only in-person visits were delivered. A generalized linear model with the binomial error was ftted to evaluate the difference in the proportion of patients in CDAI remission. Quantile regression was used to compare the median of CDAI in difficult-to-treat (D2T) patients [2]. In both models, the correlation of different measurements on the same patient was considered. Results: In the pre-pandemic period (2019), 407 RA patients were included in this study. During the frst wave (2020) we analyzed 450 patients, of whom 359 patients chose in-person visits, while 91 patients home drug delivery and virtual visit. Finally, 540 patients were included in 2021 (second/third wave). The percentages of patients in CDAI remission were similar in the three periods (prevalence ratio 1.07, p-value 0.423 between 2020 and 2019, and 1.01, p-value 0.934 between 2021 and 2019). The CDAI remission rate was 40.55% (N=163), 43.18% (N=155) and 40.82% (N=220) in 2019, 2020 and 2021, respectively. The disease activity profile during the three periods is reported in detail in the Table 1 below. Among our cohort of D2T patients, the median value of CDAI before (2019), during the frst wave (2020), and during the second/third wave (2021) changed signifcantly (p= 0.053 between 2020 and 2019 and p=0.006 between 2021 and 2019). Conclusion: Although the pandemic has imposed changes in our healthcare delivery, these different strategies seem to be effective in ensuring satisfactory management of RA treated with targeted therapies. The approaches modulated in the context of the different periods have been a feasible compensation for ensuring disease control even in D2T patients.
ABSTRACT
Background: Despite significant improvement in the RA management, up to twenty percent of patients with rheumatoid arthritis (RA) have a difficult-to-treat (D2T) disease. The COVID-19 related mitigation policies, for instance quarantine, and consequent difficult access to in-person visits, laboratory and imaging investigations, adversely affected the follow up of rheumatic patients. Although pandemic-imposed limitations could have negatively influenced disease management particularly in D2T patients, to what degree these restrictions affected the treat-to target (T2T) and tight-control strategy in this subgroup of RA patients has not been investigated yet. Objectives: To evaluate whether the switch to telehealth imposed by COVID-19 pandemic was effective in the management of D2T RA patients treated with targeted therapies. Methods: This observational retrospective real-life study was conducted from November 2019 through September 2020. Among RA patients treated with targeted therapies, RA D2T patients according to EULAR definition (1) were identified. Clinical Disease Activity Index (CDAI) of these patients was analysed retrospectively before, during and after lockdown (LD). During LD period, patients could choose whether to receive home drug delivery or to maintain their face-to-face consultations, and in the former rheumatologists provided virtual care. To evaluate the effect of LD on the percentage of patients in remission, logistic mixed effects regression models were fitted, with CDAI remission as response variable. Results: Data were extracted from a longitudinal observational registry, and at baseline, 52 patients treated with targeted therapies were classified as D2T RA. Among them, during pre-LD, LD, and post-LD 11.54% (N=6), 53.49% (N=23), and 46.15% (N=24) had CDAI remission/low disease activity, while 46 (88.46%), 20 (46.51%) and 28 (53.85%) had CDAI moderate/high. All the patients completed the follow-up. Median values of CDAI during pre-LD, LD, and post-LD were 14.5 [IQR 12-21], 9 [IQR 5.5-16], and 11 [IQR 6-19.2] respectively (see Figure 1 below). Conclusion: Telephone-based tight control strategy ensured satisfactory management of D2T RA treated with targeted therapies. This temporary approach has been a feasible compensation for the decline of face-to-face visits also in this challenging group of RA patients, thus reassuring for future months before the end of pandemic.
ABSTRACT
Background: Rheumatic patients' follow-up in terms of treatment adherence, disease control achieved with treat-to-target (T2T) and tight-control strategy have been deeply influenced by nationwide mitigation strategies such as quarantine, travel restrictions, and inadequate access to routine visits, laboratory and imaging investigations. These restrictions could be potentially detrimental for patients' care, but to what extent these measures affected the T2T and tight-control approach in rheumatoid arthritis (RA) is unknown. Objectives: This study investigated whether the adoption of telephone virtual care imposed by COVID-19 pandemic has been effective in maintaining remission in RA treated with targeted therapies and to identify factors associated with its maintenance. Methods: This observational retrospective real-life study was conducted from November 2019 through September 2020. Clinical Disease Activity Index (CDAI) of RA patients treated with targeted therapies was analysed retrospectively before, during and after the national lockdown (LD). During LD period, rheumatologists provided virtual care by telephone to assess the clinical status to guarantee the absence of current contraindications to therapy. Then, patients could choose whether to receive home drug delivery or to maintain their faceto-face consultations. Logistic mixed effects regression models were fitted, with CDAI remission as response variable. A multivariate analysis and a parsimonious model were finally obtained by stepwise selection procedure using AIC. Results: Data were extracted from a longitudinal observational registry, and at baseline, 502 RA patients were eligible for this study. 52 patients failed to complete their follow-up, 450 patients were included in the final analysis. During LD, 359 patients chose in-person visit, 91 patients home drug delivery and virtual visit. Our cohort did not show a statistically significant decrease in the number of patients fulfilling CDAI remission criteria all along the three periods. Among the 450 patients evaluated, the CDAI remission rate was 40.22% (N=181) and 43.78% (N=197) during pre-LD and post-LD, respectively. As for the 359 patients who choose in-person visits during LD, 43.18% (N=155) were in remission according to CDAI. The final model (step-wise selection) applied to the multivariate analysis of factors that potentially could interfere with disease control in patients with CDAI remission showed that the probability to maintain remission was associated with Caucasian ethnicity, male gender and absence of fibromyalgia (Table 1 below). Conclusion: Telephone-based tight control strategy ensured satisfactory management of RA treated with targeted therapies during the first wave of COVID-19 pandemic. All along the three periods, we observed that the probability to be in CDAI remission was significantly associated with Caucasian ethnicity, male gender, and absence of fibromyalgia. This temporary approach has been a feasible compensation for face-to-face visits, thus reassuring for future months before the end of pandemic.