Impact of technical factors on remote consultations in rheumatology - lessons from a COVID-19 initiative

Background/Aims Since the COVID-19 pandemic started, there have been changes in clinical practice to limit transmission, such as switching from face-to-face to remote consultations. Although there was some evidence of efficacy for remote consultations before the pandemic, the implications of a more widespread provision are unclear. We aimed to study the influence of technical factors on remote consultations in our experience during the pandemic. Methods Clinicians were asked to complete a data collection form after each remote consultation for information on technology used (video vs phone);technical problems encountered;discharge and subsequent appointment status;and technical aspects of the consultation itself using 11-point numerical rating scales (NRS) including Time Adequate, Relevant History, Physical Exam, Management Plan, and Communication Quality scales. Data were collated in a Microsoft Access 2010 database, and analysed in SPSS version 25. For dichotomous variables, Mann-Whitney U tests were used to compare means, and Chi-square tests to compare proportions. Spearman correlations were used to describe strength of association amongst NRS. Odds ratios were used to describe strengths of association of variables to subsequent appointment status. Results Of 285 forms valid for analysis, 48 (16.8%) had video consultations. 259 forms had technical problems data recorded, with 48 (18.5%) experiencing a technical problem. Video patients were significantly younger (mean 49.3 vs 61.3 years, P < 0.001), had higher scores on Physical Exam scale (mean 4.0 vs 2.6, P < 0.001), but had no significant difference on Management Plan scale (7.3 vs 7.2). Those with technical problems were more common among video than phone consultations (33.3% vs 15.4%, P = 0.005), had lower scores on Time Adequate scale (7.7 vs 8.7, P < 0.001) and Communication Quality scale (7.1 vs 8.4, P < 0.001), but had no significant difference on Management Plan scale (7.3 vs 7.2). The strongest correlations of Management Plan scale were with Communication Quality scale (R = 0.64, P < 0.001), and Relevant History scale (R = 0.63, P < 0.001). Of the NRS, a 1-point reduction in scores on Management Plan scale was the strongest predictor of subsequent face-to-face appointment request (Odds Ratio 1.88, 95% CI 1.58-2.24), and this remained an independent predictor in multivariate analysis (adjusted OR 1.90, 1.57-2.31). Conclusion Video patients were younger suggesting a preference for video over phone amongst younger patients. Although technical problems were more common with video than with phone consultations, having a video consultation or a technical problem had no significant impact on the management plan. However, scoring lower on the Management Plan scale was the strongest predictor of, and independently associated with requesting a subsequent face-to-face appointment. Further studies might help refine the selection of clinical contexts and technologies deployed to improve outcomes with remote consultations. Disclosure S. Vasireddy: None. S. Wig: None. M. Hannides: None.

Technical factors can impact on remote consultations in rheumatology: results from a service evaluation during the COVID-19 pandemic.

Since the COVID-19 pandemic started, there have been changes in clinical practice to limit transmission, such as switching from face-to-face to remote consultations. We aimed to study the influence of technical factors on remote consultations in our experience during the pandemic. 12 clinicians completed data collection forms after consultations, recording the technology used (video vs phone); technical problems encountered; discharge or subsequent appointment status; and technical aspects of the consultation process using 0-10 numerical rating scales (NRS) (Time Adequate; Relevant History; Physical Exam; Management Plan; and Communication Quality). Data were collated on an MS Access 2016 database and transferred to SPSS version 25 for statistics. Of 285 forms valid for analysis, 48 (16.8%) had video consultations. Of 259 forms with technical problems data recorded, 48 (18.5%) had a technical problem. Video patients were significantly younger (mean 49.3 vs 61.3 years, p < 0.001), had higher scores on Physical Exam scale (mean 4.0 vs 2.6, p < 0.001), but had no significant difference on Management Plan scale (7.3 vs 7.2). Those with technical problems were more common among video consultations (33.3% vs 15.4%, p = 0.005), had lower scores on Time Adequate scale (7.7 vs 8.7, p < 0.001) and Communication Quality scale (7.1 vs 8.4, p < 0.001), but had no significant difference on Management Plan scale (7.3 vs 7.2). The strongest correlation of Management Plan scale was with Communication Quality scale (Rho = 0.64). Of the NRS, a 1-point reduction in scores on Management Plan scale was the strongest predictor of subsequent face-to-face appointment (Odds Ratio 1.88, 95% CI 1.58-2.24), and this remained an independent predictor in multivariate analysis (adjusted OR 1.90, 1.57-2.31). Having a technical problem was inversely associated with the outcome of a subsequent face-to-face appointment (OR 0.17, 0.04-0.74), and this remained significant after adjustment for Management Plan in multivariate analysis (adjusted OR 0.09, 0.12-0.54). Video patients were younger suggesting a preference for video amongst younger patients. Although technical problems were more common with video, having a video consultation or a technical problem had no significant impact on management plan. Scoring lower on the Management Plan scale was the strongest predictor of, and independently associated with, requesting a subsequent face-to-face appointment. The inverse relationship of technical problems with subsequent face-to-face appointment request will need validation in further studies.

Incidence of COVID-19 in patients with rheumatic disease: is prior health education more important than shielding advice during the pandemic?

The COVID-19 pandemic has led to major changes in clinical practice on a global scale in order to protect patients. This includes the identification of vulnerable patients who should "shield" in order to reduce the likelihood of contracting SARS-CoV2. We used national specialty guidance and an adapted screening tool to risk stratify patients identified from our prescribing and monitoring databases, and identify those needing to shield (score ≥ 3) using information from departmental letters, online general practice records and recent laboratory investigations. We collated underlying rheumatological conditions and risk factors. Two months into the shielding process, we examined the COVID-19 status of these patients using hospital laboratory records and compared to population level data. Of 887 patients assessed, 248 (28%) scored ≥ 3 and were sent a standard shielding letter. The most common risk factor in the shielding letter group was age ≥ 70 years and/or presence of a listed co-morbidity (199 patients). The most common rheumatology conditions were rheumatoid arthritis (69.4%), polymyalgia rheumatica (8.5%) and giant cell arteritis (8.5%). Coronavirus incidence rates were similar in the shielding letter group (0.403%) and in the UK population (0.397%). However, we found a trend towards lower incidence (0.113%) in our whole cohort (RR 0.28, 95%CI 0.04-2.01 for the whole cohort compared to UK population). The trend towards lower incidence in this cohort could be because of prior education regarding general infection risk and response to public health messages. While risk stratification and shielding could be effective, prior education regarding general infection risk and public health messages to enhance health protection behaviours during a pandemic may have equal or more important roles. Key Points • Patients on treatment for rheumatic disorders showed a trend for lower incidence of COVID-19 transmission irrespective of shielding letter status • This could potentially be because of prior education regarding infection risk received when starting on disease-modifying medication • Health education influencing health protection behaviours may be of equal or more importance than shielding information in reducing transmission of SARS-CoV-2.