While there is much promise for the use of telemedicine in rheumatology, to date, there are scarce data on the efficacy of telemedicine approaches in patients with RA, PsA, or AS. Patients on biological therapies require close monitoring, for which telemedicine has the potential to reduce the number of clinical visits. Thus, telemedicine is very valuable to both clinicians and patients during the present pandemic for several reasons. Overall, our study found no clinically significant differences between PROs before and after a 3-month period of using either telemedicine or in-person visits. During telemedicine visits, a rheumatologist queried the patient directly about their disease, side effects related to therapy, comorbidities, and COVID-19-related symptoms that might require a clinical visit. If any critical issues were identified or telephone management was considered inadequate, an urgent outpatient visit was scheduled. In fact, the exclusive use of telemedicine and the impossibility to deliver drugs could increase the risk of relapses of autoimmune diseases . The use of a flexible approach, the possibility to assess PROs using the iAR Plus app, and the ability to deliver drugs directly to patients allowed for a reduction in the number of clinical visits by 69.9%, while maintaining therapeutic continuity. Moreover, despite this reduction, after the lockdown, there was no clinically significant worsening of PROs in patients receiving immunomodulating therapy.
In the present analysis, all telemedicine visits were made via telephone, which was imposed by the need for a rapid solution for an impending problem. However, it is clear that a telemedicine approach could be improved upon by the use of video calls, allowing for the ability to see a patient’s joints, for example. Cavagna et al. recently carried out a survey of 175 patients with a median age of 63 years attending a rheumatology clinic in Northern Italy . Of these, 80% referred that they owned a device that can make video calls, with 86% saying that they would be able to attend a telemedicine visit using video either alone or with the help of a relative. Moreover, 78% of patients considered telemedicine acceptable and 61% even preferred it. This suggests that telemedicine might be considered as a viable approach in rheumatology patients even after the pandemic. In this regard, Ramão et al. recently published a flowchart for possible reorganization of rheumatology clinics during and after the pandemic  in which it is suggested that telemedicine can be implemented into daily practice. These authors further note that most patients treated with bDMARDs and tsDMARDs can be monitored using telemedicine. To fully achieve the benefits of telemedicine and save patients unnecessary travel to the clinic, better communication between rheumatologists and the general practitioner will be needed, which should include shared access to patient records and improved coordination of routine care such as blood tests . In addition, patients can be given educational additional resources online along with questionnaires for disease severity and functional status, similar to the PROs used herein. Patients appear to be satisfied with these tools and are willing to use them .
For other authors, telemedicine has been proposed as a triage tool during the COVID-19 pandemic, and that its use should depend on the state of diagnosis, disease severity, and treatment administered . In a study of 176 patients seen in a general tele-rheumatology setting, for example, almost 20% of all patients were considered to be inappropriate for such an approach . The best candidates for telemedicine are likely to be those with an established diagnosis and stable disease, and who can undergo a screening visit prior to in-person follow-up. On the other hand, it may not be the most appropriate option for patients with a disease flare, or when the complexity of their disease makes follow-up difficult to carry out remotely . For these reasons, we preferred to adopt a flexible approach, allowing urgent clinical visits whenever, and for whatever reason, a telephone visit was not adequate.
Among the limitations of our study, we report outcomes of patients who were followed for only 3 months via telemedicine, comparing PROs at periods preceding and succeeding that period. Thus, longer term data on the efficacy of a telemedicine approach over time are lacking. In addition, we did not assess clinical outcomes, but only PROs. Notwithstanding, PROs are now considered as an important component to evaluating the impact of the disease and response to therapy . Indeed, PROs are especially important in diseases such as RA and PsA, which can have substantial negative impact on the patient’s quality of life from multiple points of view [26, 27]. PROs are thus important in evaluating the overall success of therapy.
In summary, we found no substantial differences in outcomes when a telemedicine approach was used for a brief period in patients with RA, PsA, or AS. While it is clear that additional data are needed in the long term, and that the approach used can be improved upon, telemedicine has undoubted benefits, especially in light of the present COVID-19 pandemic. It is likely that many patients with these diseases may prefer it, at least for some follow-up visits. Finally, more work is needed to better define the patients for whom telemedicine is most appropriate, such as in those with a definite diagnosis, stable disease, and those living in rural settings. Notwithstanding these challenges, telemedicine appears to have significant benefit for both patients with spondyloarthritis and those treating it.