|Ahead of print publication
Virtual consulting in the times of COVID-19
Latika Gupta1, Supriya Sharma2, Rajat Kharbanda1, Shelley Aggarwal3, Durga Prasanna Misra1, Vikas Agarwal1
1 Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
2 Department of Surgical Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
3 Santa Clara County Juvenile Hall, Santa Clara Valley Medical Center, Division of Adolescent Medicine, Stanford Children's Health, Stanford University School of Medicine, California, USA
|Date of Submission||25-Nov-2020|
|Date of Acceptance||13-Jan-2021|
Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow - 226 014, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: Confinement and economic uncertainty, along with disease-specific issues such as pain and suffering may uniquely impact rheumatology patients, putting non-COVID morbidity at par with COVID-related losses.
Methods: We conducted a review of records to explore the clinical profile and interventions in rheumatology patients at a tertiary care center in Northern India to identify the potential problems and propose direction for the future.
Results: In our experience spanning 5 weeks, among 508 rheumatology patients who sought teleconsultations, rheumatoid arthritis was the most common diagnosis (35.2'), and 43' were asked to continue the same treatment over tele consults, whereas investigations were awaited for another 16'. Nearly one-third (29.9') required an intervention, though this largely consisted of dose titrations (104 of 152, 68.4'). Certain diseases such as myositis were under-represented among consults (1.2') but over-represented (33.3') among admissions. Among the 54 patients who were asked to rate their teleconsultation experience, the voice and consultation quality were rated and average of 9.9 each, and 88.9' (48/54) said they would prefer teleconsultations until the pandemic is over.
Conclusion: A sizeable proportion of rheumatology patients can be managed with teleconsultations, with some requiring greater assistance, calling for a triage protocol for the times ahead. With propositions for a deliberate transition into the realm of virtual consulting, chronic caregivers can hope to reach an optimal balance between e-consults and in-person visits.
Keywords: Arthritis, COVID-19, India, myositis, pandemics, remote consultation, rheumatology
| Introduction|| |
The COVID-19 pandemic has precipitated the world's largest global health crisis since the world wars. The travel restrictions and need to socially distance has disrupted the continuity of medical care and has had a disproportionate impact on those with chronic illnesses such as rheumatic diseases (RDs) being the worst affected. Patient struggles range from a perceived heightened vulnerability to COVID-19, canceled medical appointments, trouble in renewing prescriptions, as well as the inability to collect important reports, thus postponing crucial treatment decisions. Moreover, the burden of mental illnesses is higher in those with chronic illnesses in general. Confinement and economic uncertainty, along with disease-specific issues such as pain and suffering may further impact patients, putting nonCOVID morbidity at par with COVID-related losses.
The large estimated global burden is 20 million for rheumatoid arthritis alone. This same burden is much higher for other autoimmune rheumatic disorders combined and carries the potential for overwhelming healthcare resources through a surge in cases in the postdisaster period. This foresight calls for forward triage, which can be guided by type of disease, status of the disease, age, and cardiovascular comorbidities. Rheumatologists around the world appear to have seamlessly transitioned into virtual consulting while embracing the challenge of adapting to novel technological tools.
In a recent survey among rheumatology practitioners in India, one-third had resorted to WhatsApp consultations, to patients with RDs while 16.1' and 12.2' provided email and video consultations in an effort to circumvent disrupted medical services. Only 10' of physicians were continuing their clinics at the time of the survey, which could be attributed to the perceived higher risk of COVID-19 in this population. Virtual consults may offer the best screening portal to identify and delegate physical examination to those who need it the most. The potential to use devices for aiding ancillary care such as nutrition and mindfulness advice is another boon. In line with this, teleconsultations were recently legalized by a national medical advisory body in India.
In a country such as India, a land of diversity with over 400 dialects, and where rural penetration of the Internet is poor, there may be unique challenges to the accessibility, acceptance, and utility of virtual care. Moreover, chronic diseases often affect the elderly, who may require financial and logistics aid from family to seek remote care. In rheumatology, a large proportion of individuals need long term therapy. The burden of mental diseases is also expected to be high in this group of individuals, adding to the challenge of drug and consult compliance and remote care. Thus, tailored therapy delivered with the help of nurse-led care, community health workers, and general practitioners together with specialists may aid a tele-triage system for sustainable health support. Thus, in this pilot study, we sought to determine the clinical profile of patients with RDs seeking teleconsultations using telephonic consults and WhatsApp at a tertiary care center in northern India during the COVID-19 pandemic. We also determined the acceptance of remote consultations among this group of patients and identified the possible means to improve teleconsultations for the future.
| Methods|| |
All registered patients with RDs (1989–2020) at a rheumatology tertiary care center in Northern India were offered the option of teleconsultation using a central telephone number during the COVID-19 pandemic. In view of travel restrictions, patients were intimated to avail teleconsultation facilities through a previously designated helpline number, on their previously allotted appointment dates after the implementation of a nationwide lockdown in India on March 23, 2020. All queries were responded to on 6 days a week, from 9:30 am to 1:30 pm [Figure 1]a.
|Figure 1: Profile of teleconsultation cases at a tertiary care centre in India (a) Methodology, (b) Patient profile, (c) Tele-advice given|
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When dealing with new skin lesions, imaging or laboratory results, the patients were requested to share photographs or documents on the social messaging application, WhatsApp.™ When the issues could not be sorted out through audio calling or messages, the patients were could opt for videocalling on WhatsApp. Data were collected from May 11, 2020 to June 13, 2020.
Exploration of records with regard to primary diagnosis, recent investigations, treatment record was done. Treatment advised to all the patients was noted. Those patients who required injectable drugs to be administered as an intravenous infusion were listed as infusions. Relapse was defined as per physician judgment.
Patients were also asked to rate the consultations with regard to experience with teleconsult, voice quality, and their opinion regard continuation of teleconsultation (on a 1–10 Visual Analog Scale) in this pandemic.
Descriptive statistics were used. Results were expressed as number of patients and ' and for patient satisfaction-based questions mean standard deviation was used. IBM SPSS version 25 (copyright IBM Corporation and its licensors, 2017, Chicago) was used for analysis.
| Results|| |
In our experience spanning 5 weeks managed by the authors, amounting to twenty outpatient days. Five hundred and eight rheumatology patients who sought teleconsultations, rheumatoid arthritis was the most common diagnosis (35.2'), spondyloarthritis (14.8'), and lupus (17.1') being the next most common diagnosis. Nearly half (43') were asked to continue the same treatment over teleconsults, while investigations were awaited for another 16'. 29.9' required an intervention, though this largely consisted of dose titrations (104 of 152, 68.4'). Fifteen (2.9') patients could not be managed through teleconsults, and required admission to the hospital for disease flare and management. Certain diseases such as myositis were under-represented among consults (1.2') but over-represented (33.3') among admissions [Table 1] [Figure 1]b, [Figure 1]c.
Since this study was conducted during the imposed lockdown period in India, travels were completely restricted and the outpatient clinics were closed. All patients were managed on the phone, apart from those who were called for admission due to requirement for urgent care.
Among the 54 patients who were asked to rate their teleconsultation experience, the voice and consultation quality were rated and average of 9.9 each, and 88.9' (48/54) said they would prefer teleconsultations until the pandemic is over. We identified several means for a seamless transition to virtual consulting for better management of chronic RDs [Table 2].
|Table 2: Suggestions to increase permeation of teleconsultation services|
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| Discussion|| |
This is a new method of collaboration with patients for handling chronic care, which was considered a more significant barrier in a developing country until necessity pushed the reality that this can be done in a resource-challenge environment. The situation necessitates a shift to patient-reported outcome measures, which may be facilitated by using the appropriate use of technology. Moreover, syncing data from mobile app-based trackers and wearable devices (as a measure of physical activity) can be a valuable resource while reducing manual data entries and probability of human error. This is of greater importance in this era of litigation and stringent record keeping. It seems logical to use portable attachments on smartphones to complement patient monitoring ranging from mobility, physiology, and drug compliance on a routine basis in the coming decade. In a low-middle income country as ours, tertiary care centers are few and oftentimes patients travel long distances for a consultation. The use of virtual consults for prescription renewals and routine visits for monitoring drug adverse effects can obviate non-essential travel, reducing financial burden significantly. Community health care workers and local general physicians may use teleconsultations to guide management on routine visits. In clinic visits can then be streamlined and limited to annual visits or on the occasion of a flare or other situations necessitating care. Thus, this approach may fall in line with sustainable development goals of most countries in the postendemic economic meltdown.
The impact of a real human interaction in the development of a human (caregiver-patient) connection is vital to trust and wholesome clinical care. Thus, while first visits may preferably be in person, though subsequent follow-ups may be reduced by this technique. Further, poor penetrance of digital technologies in low-middle income countries remains a challenge. The availability of a unified online hospital information system is another requirement before the country can endorse the teleconsultation model on a larger scale. Moreover, a lack of standardized reimbursement protocols and specialists' compensation may be another (optimistically) transient inconvenience. We reiterate the urgent need for laws to safeguard the interest of all stakeholders, which may gain a greater importance in the prevailing psychologically challenging times, with widespread anxiety, anger, fear, and denial, which may possibly increase the litigations against the doctors.
It would be ideal to compare the profile of patients pre-pandemic with teleconsultations to gain greater insights into the intricacies of remote care. Besides, since the centralized contact system for COVID-19 admissions is separate, we could not assess the incidence of COVID-19 in RDs in the current study.
Thus, with propositions for a deliberate transition into the realm of virtual consulting [Table 2], chronic caregivers can hope to soon reach an optimal balance between the mix of e-consults and in-person visits.
| Conclusion|| |
Teleconsultations allow for a new form of doctorpatient interaction, which needs mutual trust and acceptance. Teleconsultations are neither a magic bullet nor a replacement for a physician. Instead, it is a new type of medical cooperation to provide continuity of medical care and improve the outcomes of chronically ill patients. We cautiously conclude that e-consulting seems a feasible alternative to medical specialists' face-to-face follow-up or telephone appointments.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]