Tele-rheumatology reaches patients who lack access to care

By the time Christine Peoples, MD, examined the patient, the middle-aged man had been treated inadequately for psoriatic arthritis for years.

Poor mobility made it difficult for him to travel and gaps in his care had exacerbated his condition. But a bidirectional video system at the University of Pittsburgh Medical Center (UPMC) allowed Dr. Peoples to assess the patient, correct his therapeutic regimen, and establish consistent follow up.

Without telemedicine, the patient would have likely continued to deteriorate, said Dr. Peoples, a rheumatologist with the UPMC Teleconsult Centers.

Jennifer Dueweke, RN

“Now, he’s able to go back to work,” Dr. Peoples said. “He’s able to focus on his life, instead of day-to-day pain with no solution in sight. It’s really nice to reach patients who truly need the services of a rheumatologist in a serious way. [Through telemedicine], we are providing academic rheumatology care to patients regardless of where they live.”

Across the country, more rheumatology practices are employing telemedicine to treat patients, particularly physicians at academic medicine centers that have the resources to launch comprehensive units. The technology is a way to bridge the shortage of rheumatologists in rural areas and reach patients who cannot access specialty care for rheumatic conditions, proponents say. A 2013 study in Arthritis & Rheumatism found that many towns and small cities with populations up to 50,000 have no practicing rheumatologists, with some patients having to travel more than 200 miles to get specialty care (2013 Dec;65[12]:3017-25).

Telemedicine is growing by leaps and bounds, and rheumatology is a key specialty in which to use the technology, said Jonathan Linkous, chief executive officer for the American Telemedicine Association.

“Telemedicine is expanding both in terms of the number of consultations and the breadth of services involved,” he said. “Tele-rheumatology was certainly not a big area to be looked at in years past, but it’s one more area that is starting to expand.”

Research is lacking regarding how prevalent tele-rheumatology has become in the United States and whether it’s as effective as face-to-face visits. In a recent analysis of 1,468 potentially eligible tele-rheumatology studies and literature, only 20 addressed direct provider to patient contact that influenced or had the potential to influence clinical care, according to a November 2016 review in Arthritis Care & Research (doi: 10.1002/acr.23153). Of the 20 studies, the majority of articles involved tele-rheumatology use in Europe or Great Britain, said study author John Allen McDougall, MD, a postdoctoral fellow at Yale University, New Haven, Conn. According to the literature, the most common condition treated through telemedicine was rheumatoid arthritis. Little information existed on telemedicine use for gout or the treatment of connective tissue diseases, Dr. McDougall said.

“The first major finding was that there’s really not much out there as far as high quality research that supports or contradicts the use of tele-rheumatology in wide distribution,” Dr. McDougall said. However, “in general, the conclusion of the authors was a qualified, ‘Yes,’ that [tele-rheumatology] has potential and should go forward.”
 

Increasing access, saving time

UPMC has operated a tele-rheumatology program for nearly 3 years that connects rural patients with their specialists. Patients present for video examination at teleconsult centers located in underserved areas within western and central Pennsylvania. On the other end of the screen, Dr. Peoples uses high-level audio and video technology to discuss the patient’s history, direct nurses, make diagnoses, answer questions, and prescribe treatment to patients.

“Patients comment about how much easier it is for them and what a difference this makes in their health care,” Dr. Peoples said. “[Tele-rheumatology also increases] the ability to have regular follow-up care. I see them every few months for their condition and manage it. You can really establish a long relationship with patients just as you would if you saw patients in person.”

Rheumatologists at Dartmouth–Hitchcock Medical Center (DHMC) in Lebanon, N.H., are achieving similar results.

The medical center’s tele-rheumatology unit began in 2011 with the aim of increasing specialty access for patients in northern New Hampshire. Dartmouth also employed a telemedicine clinic from 2012 to 2013 in southern Vermont while seeking to replace a well-established rheumatologist who had retired.

Between October 2011 and December 2014, 176 patients were seen via tele-rheumatology between the two sites over the course of 244 tele-rheumatology patient visits with Dartmouth providers, according to a study published in the June 2016 Seminars in Arthritis & Rheumatism (2016 Dec;46[3]:380-5). Patients lived on average 99 miles from DHMC and 22 miles from the remote clinic site, the study found. The top diagnosis was inflammatory arthritis.

During the study period, Dartmouth tele-rheumatology services saved patients an estimated $26,938 in travel costs and allowed patients to save an average of 200 driving miles per session. Physicians reported being satisfied with the encounters 57% of the time, according to the study. However, they reported that 19% of the patients seen via tele-rheumatology were inappropriate for the visit type, largely because of unclear underlying conditions and cases that were too complex.

For most of doctors and patients involved in the study, tele-rheumatology visits were positive and aided patient access, said Daniel Albert, MD, section chief of rheumatology at DHMC.

“There are some limitations, there’s no question about that,” he said. ... [However], right now there are way too few rheumatologists to care for patients with rheumatic disease. We’ve tried to improve that with [nurse practitioners and physician assistants], but this is another way of addressing that need.”

Pediatric rheumatologists are also using the benefits of telemedicine. Children’s Mercy in Kansas City, Mo., launched a pediatric rheumatology telemedicine clinic in 2014 that links children in Joplin, Mo., with rheumatologists at Children’s Mercy, about 160 miles away. Patients and their parents/guardians treated via telemedicine at the Joplin site missed less work and school and saved money on food, compared with traveling to Kansas City for treatment, according to a 2016 study published in Pediatric Rheumatology (doi: 10.1186/s12969-016-0116-2).

“This is much more convenient for patients,” said Elizabeth A. Kessler, MD, a pediatric rheumatologist at Children’s Mercy and coauthor of the study. “It saves them time and money. With the training of the tele-facilitator, I believe that we’re able to provide them with equivalent care compared with if they were in-person.”