Rheumatologists Altered Prescribing, CME Practices During COVID-19 Pandemic

Dr. Pedro M. Machado

The COVID-19 pandemic greatly altered management of and prescribing strategies for patients with rheumatic disease across Europe, according to new survey data.

In findings from an international assessment of rheumatologists, clinicians and prescribers described a shifted landscape similar to that observed in other medical specialties—in which telemedicine practice has been greatly pronounced, advanced therapy initiation has stalled and patient management has greatly entailed assuaging their fears of COVID-19 infection and disease risk.

Led by Dr. Pedro M. Machado, of the Center for Rheumatology and Department of Neuromuscular Diseases at the University College London, investigators sought to interpret European rheumatologists’ perspective on the impact of the COVID-19 pandemic on their management of patients with rheumatoid arthritis, as well its effect on continuing medical education (CME) opportunities for physicians.

The pandemic caused well-documented issues in chronic disease management for patients beyond just rheumatoid arthritis; however, this group has been doubly impacted by regional rheumatologist shortages and a previously slow uptake of telemedicine and remote care options.

“Understanding how telemedicine negatively affects patient care will inform for whom and when telemedicine might be most suitable,” they wrote. “This will allow rheumatologists to plan a better response in future pandemics, while informing future studies into telemedicine uptake and efficacy. Considering the global shortage of rheumatologists it is vital that we learn how COVID-19 has impacted access to ongoing physician education and how this might influence future training.”

Machado and colleagues conducted telephone surveys with rheumatologists participating in the Adelphi RA Disease Specific Programme across 6 European countries in August and September 2020. Clinicians were gauged on 7 attitudinal questions pertaining to changes in patient management, prescription behavior and CME due to COVID-19, with investigators summarizing findings by descriptive statistics.

The final assessment included survey results from 284 rheumatologists across Belgium, France, Germany, Italy, Spain and the UK. All but 2 respondents (99.3%) reported COVID-19 had impacted their management of patients, with the following changes being the most common:

• Shift to video and telephone consultation, and remote completion of patient questionnaires (66.5%)
• Fewer visits by individual patients and a reduced visiting schedule (58.5%)
• Limited physical contact during consultations (58.1%)
• Postponements by patients (56.7%)

Investigators noted 29.6% (n = 84) of rheumatologists said they changed their strategy behind selecting and prescribing medication during the pandemic. Of them, two-thirds (67.9%) reported shifting prescriptions to patient self-administered care. Another 60.7% said they did not start new patients on advanced therapies; a notable rate additionally reported switching patients off advanced treatments to another drug class during the pandemic.

A majority of all rheumatologists (57.6%) believed changes to patient management and prescribing behavior would continue through the end of public health policy responses to the pandemic, at risk of future outbreaks. Per the respondents, approximately one-third (38.0%) of patients with rheumatoid arthritis had expressed concerns over their treatment regimen due to COVID-19 response.

Regarding CME, 142 (50.0%) respondents reported increased webinar attendance, 139 (48.9%) reported online scheduled training and 131 (56.1%) reported attendance of virtual rather than in-person meetings and congresses.

Regarding the revert to telemedicine and remote care, Machado and colleagues stressed there is still “inadequate empirical evidence to guide clinical practice via telemedicine” in rheumatology.

“Telemedicine might be a mechanism for addressing the global shortage and maldistribution of rheumatologists, and it has already been shown to improve access to rheumatologists for more remote patients in Australia and rural New England,” they wrote. “Although it is clear that there is a patient-led demand for telemedicine, studies indicate that telemedicine is underutilized by ethnic minorities and patients with lower socioeconomic status, with issues such as literacy, access to new technologies and willingness to embrace them leading to disparities in patient outcome and access to health care.”

Investigators acknowledged the early pandemic-stage concern of rheumatic patient susceptibility to SARS-CoV-2 infection due to their immunosuppressant medications. The physician survey indicated the fear was at the prescriber level as well.

“Given that it has been found that delays between symptom onset and initiating DMARDs lead to lower remission rates and worse outcomes in patients, ensuring that patients are on the most appropriate rheumatoid arthritis drug/drugs to begin with and prioritizing access to treatments based on patient needs are important to prevent treatment disruption in future. Diversification of treatment options and working with health authorities to improve supply lines could also be key to maintaining treatment in future pandemics.”

The team concluded that alterations to rheumatology prescribing behavior and patient management reflected an effort to accommodate the pandemic public health response. There were additionally trends in prescribing strategy that spoke to the particular fear surrounding patients with rheumatoid arthritis and their clinicians at the time.

While Machado and colleagues noted that remote CME uptake has been a net benefit for rheumatologists, they remain in a lesser-manned specialty and with necessary improvements to remote care strategies becoming evident.

“Given the potential benefits of remote consultations, it is vital that guidance on telemedicine is harmonized and that issues with reimbursement and patient education around the risks of treatment and remote treatment devices highlighted above are addressed,” they wrote.

The study, “Impact of COVID-19 pandemic on the management of patients with RA: a survey of rheumatologists in six European countries,” was published online in Rheumatology Advances in Practice.