ABSTRACT
Background: Since COVID-19 pandemic started, there have been changes in clinical practice to limit transmission, such as switching from face-to-face to remote consultations. Our department switched to delivering remote consultations without suspending service. Patients were offered the preference of either video or telephone consultation. It is unclear what factors including clinician-related factors significantly influence remote consultations in Rheumatology. Objectives: We aimed to study the influence of senior (substantively employed) vs trainee status of clinicians on remote consultations in our experience during the pandemic. Methods: Between 15/10/2020 and 09/11/2020, 12 clinicians in our department completed data collection forms after each remote consultation, recording the 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) (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. Results: Nine senior clinicians (3 consultant rheumatologists, 3 Specialist Nurses, 1 Advanced Rheumatology Practitioner and 2 Senior Rheumatology Pharmacists) and 3 trainee clinicians (2 Specialty Trainee Registrars and 1 Foundation Year 2 doctor) completed forms. 285 forms were validated for analysis. The majority of consultations were completed by senior clinicians (266, 93.3% vs 19, 6.7%). Senior and trainee clinicians had a similar proportion of new patients compared to follow-up patients (18%, n=48 vs 15.8%, n=3;p=0.80);of female patients (68%, n=181 vs 63.2%, n=12;p=0.66);and video consultations (17.3%, n=43 vs 10.5%, n=2;p=0.45);and similar mean age of their patients (59.5 vs 56.7years;p=0.72) respectively. Senior clinicians accounted for all the technical issues reported (20%, n=48 vs 0%, n=0;p=0.03). Senior clinicians had lower mean scores compared to the trainee clinicians on NRS for Relevant History (8.68 vs 9.68;p<0.001), Physical Exam (1.49 vs 2.95;p=0.045), and Communication Quality (8.02 vs 9.37, p=0.002);and had no signifcant differences in scores for Time Adequate (8.46 vs 9.00;p=0.10) and Management Plan (7.17 vs 7.84;p=0.16). Senior and trainee clinicians and a similar proportion requests for subsequent face-to-face appointments (21.9%, n=51 vs 25%, n=4;p=0.77). Conclusion: There were no signifcant differences between senior and trainee clinicians in distributions of patients and proportion of video consultations. While no technical issues were reported by the trainee clinicians, this may in part be a refection of their smaller proportion of overall consultations. Although senior clinicians rated their consultations somewhat lower in some of the NRS, there was no signifcant difference in management plan scores and subsequent face-to-face appointment status compared to trainee clinicians. While the lower scores may partly refect the technical issues reported by the senior clinicians, longer clinical experience and greater knowledge may also be an underlying factor for this. Further studies with larger numbers may clarify these issues.
ABSTRACT
Background/Aims The COVID19 pandemic significantly altered healthcare provision. Our department switched immediately to remote consultations without suspending service, including telephone and video consultations. In this analysis we aimed to explore the role of patient-related factors in influencing the process and outcome of remote consultations with a view to improving the quality of service provision. Methods A data collection form was developed and offered to all clinicians to complete after each remote consultation. Information on age, gender, new or follow up status and interpreter use were collected. Clinicians were asked to rate the effectiveness of specific components of the consultation process (time adequate, relevant history, physical examination, management plan and communication quality) as compared to the usual face to face appointments on Numerical Rating Scales (NRS, 00). Data were collated in a Microsoft Access database. Statistical analysis was performed using SPSS version 25. Results In total, 285 valid forms were evaluated. 193 (67.7%) were women. Patients registered for new appointments (n=51, 18%) were significantly younger (mean±SD 52.9 ± 19.7 vs 60.6 ± 17.2 years, P=0.012). There were no significant correlations with age or any significant differences with gender in mean scores of NRS. New patients scored lower on NRS for relevant history (8.0 ± 1.1 vs 8.9 ± 1.2, P<0.001), management plan (4.8 ± 2.5 vs 7.8 ± 2.0, P<0.001) and communication quality (6.6 ± 2.0 vs 8.4 ± 1.6, P<0.001). Interpreter usage (n=9, 3.4%) had lower scores for relevant history (7.1 ± 2.4 vs 8.8 ± 1.1, P=0.012) and communication quality (5.4 ± 2.6 vs 8.1 ± 1.8, P=0.002). There was no significant association of age or gender with subsequent follow up appointment requested as face-to-face or remote. New patients were significantly more likely than follow-up patients to be offered a face-to-face follow up appointment (univariate regression, odds ratio (OR) 5.49, 95% CI 2.7-11.1, P<0.001). However, once adjusted for management plan in multivariate regression, new patients were no longer significantly associated with subsequent follow up face-to-face appointment (adjusted OR 1.19, 0.48-2.92, P=0.71). Conclusion Our study is one of the first in the UK to explore patient-specific factors influencing remote consultations in rheumatology. In our cohort, patient age or gender was not a limiting factor in utilising remote consultation. New consultations and interpreter use pose challenges for remote consultations, and further studies are needed to address these to see if any measures such as appropriate selection at triaging new appointments may be possible, to improve outcomes.
ABSTRACT
Background/Aims The COVID-19 pandemic has disrupted healthcare delivery and provision of medical education and training worldwide. We assessed the impact of the COVID-19 pandemic on rheumatology training experience in the Northwest and Merseyside deaneries of England. Methods Rheumatology trainees from the Northwest and Merseyside deaneries were issued links to an anonymous web-based survey on their training experience between August 2020 to April 2021, during the 2nd wave of the Covid-19 pandemic. Results 34 of 42 trainees completed the survey. 31 were in clinical training: 13 (42%) in a pure rheumatology post and 18 (58%) in a dual post with general medicine. Most trainees attended 3-4 clinics per week (58%), with 23% attending ≤2 clinics and 19% attending 5 clinics. The proportion of face-to-face clinics ranged from 20% to 100% (median 60%). The reduced face-to-face clinical experience was not due to trainees' needs to shield. The range of proportion of phone consultations was 0% to 80% (median 40%). Remote consultations were conducted by telephone only for 26 (84%) trainees and by video or phone for 3 (10%). The durations for both face-to-face and virtual consultations were ranged similarly at 15 to 45 minutes (median 30minutes) for new cases and 15 to 30 minutes (median 20 minutes) for follow-ups. Only 5 (16%) trainees felt confident with assessing new patients by remote consultation. 8 (26%) trainees had some form of formal training in a virtual consultation. However, only 4 (13%) reported being 'aware' of how to guide a patient through self-examination of the joints, 17 (55%) trainees were 'somewhat aware', and 10 (32%) were 'not aware'. 20 (65%) trainees reported reliance on radiological and serological investigations rather than clinical skills during remote consultations. Development of skills for patient communication, joint injections, time management, and prescribing immune-suppressive medications were mainly hampered. The majority of trainees agreed that virtual educational programs had improved opportunities for attendance at structured deanery teaching sessions. Conclusion The impact of the COVID-19 pandemic on rheumatology training has been significant both in terms of current rheumatology education programme delivery and training requirements. Our regional survey shows less than a third of trainees had formal training in conducting remote consultations resulting in low levels of confidence in assessing patients remotely. Less face-to-face patient contact negatively impacted clinical and procedural skills development. Restructuring the rheumatology curricula to include training in rheumatology-specific remote consultations and ensuring clinical and procedural competencies by including novel support modalities like simulation sessions may be options for consideration going forwards. Delivery of some structured teaching sessions through the virtual platform is here to stay.
ABSTRACT
Background/AimsIn 2017 an audit and survey of giant-cell arteritis (GCA) services wereconducted across northwest England (reported previously). This resurvey in 2020, following publication of revised BSR guidance, soughtto identify what changes were made in the intervening period, andprovided the opportunity to assess the impact of COVID-19.MethodsRheumatologists from 16 hospitals in northwest England were invitedto complete a survey in July 2020. Questions focused on serviceprovision for GCA, including pathways, diagnostics and steroidprescription.ResultsResponses were received from 14/16 sites in 2017, and 15/16 in 2020.9/15 (60%) sites reported that the 2017 audit and survey promptedchanges to GCA services, with two (13%) stating that it clarified theneed for implementation of existing plans. Two sites had a GCApathway in 2017. Four of the seven sites who committed to introducingone have now done so, bringing the total in 2020 to six. Eight of thenine remaining sites plan to implement one, six with a specific datewithin six months. Six (40%) have completed additional local audit/QIsince 2017. Temporal artery (TA) ultrasound (US) is now available in anadditional four sites, bringing the total to 6/15 (40%) in 2020. Two sitesreported improvement in both time between first rheumatologyconsultation and TA biopsy, and time to receive results (now <7days for each task in 6/15 (40%)). Six additional sites reportedproviding leaflets on steroids routinely, bringing the total in 2020 to 12/15 (80%), versus 6/14 (43%) previously. Four sites (27%) now have adatabase of GCA patients (one in 2017). There was no major change insites having a standard protocol for steroid taper (n = 8 2017;n = 72020, 89% and 100% of whom respectively use BSR guidance), nor inthe number of patients routinely provided steroid cards (six in 2017;five in 2020). The three sites who do not report giving leaflets onsteroids routinely, all had a pathway. 8/15 (53%) reported COVID-19having an adverse effect upon services, including: reduced access todiagnostics (n = 7: TA US, biopsy, and PET-CT);delayed appointments(n = 4);delayed referrals (n = 3). The tertiary referral centre reported animprovement because access to tocilizumab was facilitated by arelaxation of rules by NHS England.ConclusionThe original audit and survey of current GCA practice in 2017highlighted areas for improvement for each site, and regionally. Sitescontributing to this re-survey report that the exercise stimulated themto improve their current care. The 2017 exercise showed a strongcorrelation between reported practice (survey) and actual practice(audit), leading us to have confidence that responses provided a truepicture of care. This work demonstrates the power of audit to driveimprovement, at a regional level.