Patients With Rheumatic Diseases Are More Likely to Avoid Healthcare During COVID-19 Pandemic

Patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), ankylosing spondylitis (AS), and systemic lupus erythematosus (SLE) were more likely to avoid office visits, laboratory testing, and discontinue disease-modifying antirheumatic drugs (DMARDs) without physician indication during the early months of the COVID-19 pandemic, according to a study published in The Journal of Rheumatology.¹

Poorer results were associated with lower socioeconomic status (SES) and not being able to access telehealth, which emphasizes the need for access to healthcare and attention to vulnerable populations, such as those with rheumatic diseases, during the pandemic. Patients who stopped DMARD treatment were also more likely to not have available telehealth measures and avoided office visits.

“Although there are limited data on how immunosuppression affects the risk of severe COVID-19, medication interruptions can risk disease flares and glucocorticoid increases, both associated with infection risk,” stated investigators. “The American College of Rheumatology recommends continuing DMARD unless patients are exposed or infected, but these recommendations may not reach patients or be accepted by them.”

Patients with rheumatic diseases are at an increased risk of developing infections due to their immunosuppression and likelihood of developing comorbidities. The ArthritisPower Patient-Powered Research Network (PPRN) registry conducted this study to dissect patient experiences and discovered high levels of concern about COVID-19, which resulted in disruptions in monitoring, office visits, and DMARD usage.

Participants completed surveys which included questions about concerns and changes in behaviors related to COVID-19 and their personal healthcare routines. These results were compared between different autoimmune conditions, DMARDs usage, and geographical measures of income, education, COVID-19 activity, and urban status. All participants were >18 years and surveys were completed between March 29 and May 26, 2020. The survey included questions about COVID-19 concerns, respiratory illness, COVID-19 testing and diagnosis, DMARD interruption, and general healthcare avoidance. Participants who avoided office visits and testing, had a telehealth visit, or stopped their medications were compared with subgroups using univariate logistic regression.

In total, 1935 patients completed the survey, which subsequently excluded 20 participants who resided outside of the United States and 398 without an autoimmune condition of interest. The mean age of participants was 55.1 years, 88.3% were female, and 89.5% were White. Respiratory illness was self-reported in 243 patients (13.9%) and 11 patients had a physician diagnosis of COVID-19 (0.07%). In regard to the pandemic, 698 (46%) of patients were extremely concerned and 515 (34%) were moderately concerned, with their autoimmune disease diagnosis greatly affecting their answers. There was no geographical or income difference in their answers. Office visits were avoided by 56.5% of participants, laboratory testing was avoided by 42.3%, and other testing was avoided by 36% of patients, with participants receiving biologic treatments, urban counties, and those with greater COVID-19 concerns being more likely to avoid doctor’s office visits. The majority of participants (62.7%) had physicians who offered telehealth. Patients who were more likely to avoid office visits stopped DMARD treatment. The availability of telehealth was not associated with interruption in DMARD usage, but it was more likely in patients who reported that telehealth was not accessible. Interruption of DMARD usage was reported by 48/172 (27.9%) and 7/11 (63.6%) of patients who reported respiratory illness or COVID-19 diagnosis, with 56.4% of these being recommended by their doctor.

In this cohort, 14.9% stopped taking DMARDs without COVID-19 or respiratory illness, and 78.7% of these patients stopped taking the medications without recommendation by a physician. Most patients in this group had lower socioeconomic status, avoided office visits (odds ratio [OR] 1.46, 95% confidence interval [CI] 1.04–2.04), and lacked telehealth availability (OR 2.26 95% CI 1.25–4.08).

Of the remaining 1517 patients, COVID-19 concerns were higher in biologic users. Patients who avoided office visits (56.6%), laboratory testing (42.3%), and used telehealth (29.5%) were more common in urban areas. This may be due to concerns and restrictions around office visits and telehealth availability. Patients with higher socioeconomic status tended to be more likely to use telehealth, however, investigators emphasize assessment of inequities in access to care should be considered as the pandemic continues.

An important limitation of the study was that patients who responded to the survey may have different concerns and behaviors than the general population, as most patients were White and the results may differ from minority populations. Additionally, patients were asked to self-report diagnosis, which may skew results, and it was not clear if medication interruptions impacted disease flares.

“Participants with autoimmune rheumatic disease across the US were highly concerned about COVID-19 and frequently avoided office visits or tests. Participants often stopped medications without the advice of a physician, especially those who had missed office visits and did not have telehealth access,” investigators concluded. “Physicians should ask patients about medication concerns and interruptions, proactively contact patients who have missed visits, and ensure patients are aware of available options for accessing care. Continued assessment of disruptions in care, with a particular focus on vulnerable populations, is of critical importance as the pandemic continues.”

Reference:

George MD, Venkatachalam S, Banerjee S, et al. Concerns, Healthcare Use, and Treatment Interruptions in Patients With Common Autoimmune Rheumatic Diseases During the COVID-19 Pandemic [published online ahead of print, 2020 Nov 15]. J Rheumatol. 2020;jrheum.201017. doi:10.3899/jrheum.201017