Telemedicine use by pediatric rheumatologists during the COVID-19 pandemic

Pediatric rheumatology education: the virtual frontier a review

BACKGROUND

Many children with rheumatic and musculoskeletal diseases are unrecognized. Identifying these children requires health care provider awareness, knowledge, and skills to recognize disease features and how (and when) to refer to specialist care. The aim of this paper is to highlight the need for better access to health care, review the essential role that education and virtual care play to address unmet need in low resource areas and especially to expand workforce capacity. Using collaborative partnerships, virtual platforms, and innovative assessment methods, musculoskeletal care and education can be delivered to reach a greater audience than ever before. Increased awareness through multiple initiatives and readily available resources are imperative to improve global rheumatology care.

CONCLUSION

The needs of children with rheumatic diseases and musculoskeletal conditions are vastly underserved around the world resulting in preventable morbidity and mortality. Expanded implementation of virtual education and e-health care platforms provides an opportunity to increase access to care for children globally.

Impact of the COVID-19 Pandemic on the Management of Juvenile Idiopathic Arthritis: Analysis of United States Commercial Insurance Data

BACKGROUND/OBJECTIVE

Given limited information on health care and treatment utilization for juvenile idiopathic arthritis (JIA) during the pandemic, we studied JIA-related health care and treatment utilization in a commercially insured retrospective US cohort.

METHODS

We studied rates of outpatient visits, new disease-modifying antirheumatic drug (DMARD) initiations, intra-articular glucocorticoid injections (iaGC), dispensed oral glucocorticoids and opioids, DMARD adherence, and DMARD discontinuation by quarter in March 2018-February 2021 (Q1 started in March). Incident rate ratios (IRR, pandemic vs prepandemic) with 95% confidence intervals (CIs) were estimated using multivariable Poisson or Quasi-Poisson models stratified by diagnosis recency (incident JIA, <12 months ago; prevalent JIA, ≥12 months ago).

RESULTS

Among 1294 children diagnosed with JIA, total and in-person outpatient visits for JIA declined during the pandemic (IRR, 0.88-0.90), most markedly in Q1 2020. Telemedicine visits, while higher during the pandemic, declined from 21% (Q1) to 13% (Q4) in 2020 to 2021. During the pandemic, children with prevalent JIA, but not incident JIA, had lower usage of iaGC (IRR, 0.60; 95% CI, 0.34-1.07), oral glucocorticoids (IRR, 0.47; 95% CI, 0.33-0.67), and opioids (IRR, 0.44; 95% CI, 0.26-0.75). Adherence to and discontinuation of DMARDs was similar before and during the pandemic.

CONCLUSIONS

In the first year of the pandemic, visits for JIA dropped by 10% to 12% in commercially insured children in the United States, declines partly mitigated by use of telemedicine. Pandemic-related declines in intra-articular glucocorticoids, oral glucocorticoids, and opioids were observed for children with prevalent, but not incident, JIA. These changes may have important implications for disease control and quality of life.

An Overview of Reviews to Inform Organization-Level Interventions to Address Burnout in Rheumatologists

OBJECTIVE

To identify organization-directed strategies that could be implemented to prevent burnout among rheumatologists.

METHODS

A search of English language articles published 2011 or later was conducted on Cochrane Database of Systematic Reviews, Embase, Medline, and PsycInfo on January 25, 2022. Included reviews had ≥ 1 primary studies with ≥ 10% of participants who were physicians, recorded burnout as an outcome, and described an organization-directed intervention to prevent burnout. Overlap of primary studies across reviews was assessed. The final review inclusion was determined by study quality, minimization of overlap, and maximization of intervention breadth. The A Measurement Tool to Assess Systematic Reviews (AMSTAR) 2 tool was used for quality assessment. Included studies and interventions were assessed by rheumatologists for their applicability to rheumatology.

RESULTS

A total of 17 reviews, including 15 systematic reviews, 1 realist review, and 1 umbrella review were included. AMSTAR 2 quality ratings classified 5 systematic reviews as low quality, 1 as moderate, and 9 as critically low. There was significant heterogeneity between and within reviews. Six conducted a metaanalysis and 11 provided a qualitative summary of findings. The following intervention types were identified as having possible applicability to rheumatology: physician workflow and organizational strategies; peer support and formal communication training; leadership support; and addressing stress, mental health, and mindfulness. Across interventions, mindfulness had the highest quality of evidence to support its effectiveness.

CONCLUSION

Although the quality of evidence for interventions to prevent burnout in physicians is low, promising strategies such as mindfulness have been identified.

Telemedicine in an adolescent and young adult medicine clinic: a mixed methods study

BACKGROUND

Adolescents and young adults are a diverse patient population with unique healthcare needs including sensitive and confidential services. Many clinics serving this population began offering telemedicine during the Covid-19 pandemic. Little is known regarding patient and parent experiences accessing these services via telemedicine.

METHODS

To assess for trends and disparities in telemedicine utilization in the first year of the pandemic, we used the electronic health record to obtain patient demographic data from an adolescent and young adult medicine clinic in a large urban academic institution. Characteristics of patients who had accessed telemedicine were compared to those who were only seen in person. Mean age was compared using t-test, while other demographic variables were compared using chi-squared test or Fisher's exact test. We performed qualitative semi-structured interviews with patients and parents of patients in order to characterize their experiences and preferences related to accessing adolescent medicine services via telemedicine compared to in-person care.

RESULTS

Patients that identified as female, white race, Hispanic/Latinx ethnicity were more likely to have utilized telemedicine. Telemedicine use was also more prevalent among patients who were privately insured and who live farther from the clinic. Although interview participants acknowledged the convenience of telemedicine and its ability to improve access to care for people with geographic or transportation barriers, many expressed preferences for in-person visits. This was based on desire for face-to-face interactions with their providers, and perception of decreased patient and parent engagement in telemedicine visits compared to in-person visits. Participants also expressed concern that telemedicine does not afford as much confidentiality for patients.

CONCLUSIONS

More work is needed to address patient and parent preferences for telemedicine as an adjunct modality to in-person adolescent and young adult medicine services. Optimizing quality and access to telemedicine for this patient population can improve overall healthcare for this patient population.

Satisfaction with telehealth compared to non-telehealth services among pediatric patients and their caregivers: A systematic review of the literature

BACKGROUND

Telehealth is the use of technology to deliver healthcare in a virtual format. The COVID-19 pandemic prompted an increase in the use of telehealth.

OBJECTIVE

To review satisfaction with pediatric care only in studies that have at least one group of pediatric patients and/or their caregivers receiving telehealth during the COVID-19 pandemic and at least one comparison group of those receiving non-telehealth services.

METHODS

We searched for peer-reviewed studies published in English that compared satisfaction with pediatric care between pediatric patients and/or their caregivers receiving telehealth services during the COVID-19 pandemic and those receiving non-telehealth services. Because of stay-at-home orders, studies with comparison groups for non-telehealth services that took place either before or during the pandemic were eligible. We conducted the search on January 5, 2023, in the PubMed, EMBASE, CINAHL, and PsycInfo databases. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Two reviewers independently screened titles and abstracts prior to reviewing the full-text of remaining articles. The following information from each eligible study was extracted: country, participant characteristics by comparison group, study design, telehealth approach, measurement tools to assess satisfaction, and findings by comparison group.

RESULTS

All eligible 14 studies assessed satisfaction among caregivers and/or pediatric patients participating in video and/or telephone visits during the COVID-19 pandemic compared to those having in-person appointments either prior to or during the pandemic. In 5 of the 14 studies, comparison non-telehealth services took place before the pandemic, and in the remaining 9 investigations, non-telehealth services took place during the pandemic. Thirteen studies were observational investigations with different designs and one study was a quasi-experimental intervention with 3 comparison groups for video, in-person, and hybrid visits. In 9 out of the 14 studies, satisfaction with telehealth services was higher compared to that during in-person visits. Reasons caregivers were satisfied with video visits were the ease of use and the reduced need for transportation. Reasons caregivers were not satisfied with remote care included limited personal interaction with the provider and technological challenges. Caregivers participating in telehealth expressed concerns about the lack of a physical examination. Those participating in non-telehealth services expressed that in-person interactions promoted treatment adherence. Only 1 study assessed satisfaction among patients where adolescents completed their own surveys; a higher percentage of adolescents using telehealth reported effective communication with the provider compared to patients using in-person visits.

CONCLUSIONS

Telehealth services tended to receive more favorable or comparable satisfaction ratings than in-person visits in most studies. Needed improvements in telehealth included strategies to address technological challenges and develop better rapport between the patient/caregiver and medical provider. Interventions on the effectiveness of pediatric telehealth compared to pediatric non-telehealth services on improving satisfaction and health outcomes will be valuable.

CLINICALTRIAL

Use of Telemedicine Healthcare Systems in Children and Adolescents with Chronic Disease or in Transition Stages of Life: Consensus Document of the Italian Society of Telemedicine (SIT), of the Italian Society of Preventive and Social Pediatrics (SIPPS), of the Italian Society of Pediatric Primary Care (SICuPP), of the Italian Federation of Pediatric Doctors (FIMP) and of the Syndicate of Family Pediatrician Doctors (SIMPeF)

Telemedicine is considered an excellent tool to support the daily and traditional practice of the health profession, especially when referring to the care and management of chronic patients. In a panorama in which chronic pathologies with childhood onset are constantly increasing and the improvement of treatments has allowed survival for them into adulthood, telemedicine and remote assistance are today considered effective and convenient solutions both for the chronic patient, who thus receives personalized and timely assistance, and for the doctors, who reduce the need for direct intervention, hospitalizations and consequent management costs. This Consensus document, written by the main Italian Scientific Societies involved in the use of telemedicine in pediatrics, has the objectives to propose an organizational model based on the relationships between the actors who participate in the provision of a telemedicine service aimed at minors with chronic pathologies, identifying specific project links between the areas of telemedicine in the developmental age from the first 1000 days of life to the age adult. The future scenario will have to be able to integrate digital innovation in order to offer the best care to patients and citizens. It will have to be able to provide the involvement of patients from the very beginning of the design of any care pathway, increasing where possible the proximity of the health service to citizens.

Privacy and Security Risk Factors Related to Telehealth Services - A Systematic Review

The objective of the study is to identify challenges and associated factors for privacy and security related to telehealth visits during the COVID-19 pandemic. The systematic search strategy used the databases of PubMed, ScienceDirect, ProQuest, Embase, CINAHL, and COCHRANE, with the search terms of telehealth/telemedicine, privacy, security, and confidentiality. Reviews included peer-reviewed empirical studies conducted from January 2020 to February 2022. Studies conducted outside of the US, non-empirical, and non-telehealth related were excluded. Eighteen studies were included in the final analysis. Three risk factors associated with privacy and security in telehealth practice included: environmental factors (lack of private space for vulnerable populations, difficulty sharing sensitive health information remotely), technology factors (data security issues, limited access to the internet, and technology), and operational factors (reimbursement, payer denials, technology accessibility, training, and education). Findings from this study can assist governments, policymakers, and healthcare organizations in developing best practices in telehealth privacy and security strategies.

The concept of telemedicine in pediatric rheumatology in Tunisia: Parents' perceptions

INTRODUCTION

With the COVID-19 pandemic, health care systems are facing challenges in delivering proper patient care. Children and adolescents with juvenile idiopathic arthritis require specialized and comprehensive attention. In this context, telemedicine is an alternative that has the potential to improve access to healthcare in addition to cost savings. The objective of our study was to evaluate parents' willingness for telemedicine and factors helping to adopt this alternative in the era of COVID-19.

METHODS

We undertook a cross-sectional study via structured phone interviews of parents' JIA patients as well as those with no established diagnoses. We evaluated their point of view and willingness to adhere to TM.

RESULTS

The study included 40 parents. The main reasons for favoring TM were avoiding hospitals during the pandemic (32.5%), time saving (27.5%) as well as avoiding school absenteeism (27.5%). The main reasons for preferring a live consultation were the fear of a possible discrepancy between physical and distant evaluation (47.5%) and the fear of the trivialization of the disease (38.5%). There was no association between preference for TM and a family history of COVID-19 (p = 0.704) as well as electronic devices afforded (p = 0.263). However, patients who lived away from hospital, not familiar with the concept of TM and with higher income adhered less to TM.

CONCLUSION

Unlike the literature data, our study showed the low prevalence of parents willing to accept TM as a model of care. This imply an urgent need for parent and patient education to promote TM especially in pediatric rheumatology.

Pediatric rheumatologists' perspectives on diagnosis, treatment, and outcomes of Sjögren disease in children and adolescents

BACKGROUND

Sjögren disease in children and adolescents (pedSD) presents differently than adult disease. Diagnosis and classification are controversial, optimal treatment is unknown and outcomes are poorly understood. Here, we describe the current perspectives of pediatric rheumatologists on diagnosis, treatment, and outcomes of pedSD.

METHODS

A voluntary, 17-question survey was distributed to providers in the Childhood Arthritis and Rheumatology Research Alliance and/or the American College of Rheumatology Childhood Sjögren's Study Group at the 2020 Convergence Virtual Conference. Findings are reported using descriptive statistics and chi-square testing.

RESULTS

Of 465 eligible providers, 157 (34%) responded with 135 (29%) completing the survey. The majority (85%) saw five or fewer patients with pedSD in the past year. Parotitis, dry eye and/or dry mouth, and constitutional symptoms were among the most specific and common clinical features. Most providers (77%) used clinical judgment guided by adult criteria for diagnosis. The vast majority (86-99%) of survey participants indicated routine use of serologic testing, while salivary gland ultrasound, minor salivary gland biopsy and other diagnostic tests were less often used. The most commonly prescribed systemic immunomodulators were hydroxychloroquine, corticosteroids, methotrexate, rituximab, and mycophenolate. Seven providers reported malignancy in a patient with pedSD, including one death.

CONCLUSIONS

Pediatric rheumatologists diagnose and treat pedSD; however, most only see a few patients per year and rely on clinical judgment and laboratory testing for diagnosis. Treatment frequently includes systemic immunomodulators and malignancies are reported. More studies are needed to better understand natural history, risk factors, and the impact of interventions on outcomes.

Burnout in Rheumatologists in Latin America

BACKGROUND

Rheumatology is considered a low-risk specialty, but studies have shown a prevalence of burnout between 42% and 51%.

OBJECTIVES

The aim was to determine the prevalence of burnout in rheumatologists in Latin America and the factors associated with it.

METHODS

Cross-sectional study based on a survey completed through Google Forms platform that was sent by the national rheumatology associations of Latin America. Burnout was assessed with the Maslach Burnout Inventory. Data were analyzed using the statistical program SPSS v.22.

RESULTS

Two hundred ninety-seven rheumatologists from 15 countries were included, mainly Argentina (28.3%), Brazil (26.3%), and Mexico (12.8%). The majority were women 62%, 42.4% worked in public hospitals with an average of 40.1 ± 14.2 hours per week; 31.3% did research, 13.1% clinical trials, 56.6% teaching, and 42.8% administrative work; 36% received an annual income less than $25,000; 56.6% had burnout in at least 1 dimension. Only 20.2% thought they had burnout, 9.1% were currently receiving professional help, and 15.8% had sought help in the past; 72.1% said they were willing to participate in a program to reduce burnout. The rheumatologists with burnout were younger than those without burnout (46.5 vs 49.9 years, p = 0.015).

CONCLUSIONS

Burnout affects near half of rheumatologists in Latin America and was associated with younger age, long working hours, low satisfaction, less happiness, higher Patient Health Questionnaire-9, suicidal thoughts, anxiety, income, presence of comorbidities, and low self-esteem.

The Emerging Telehealth Landscape in Pediatric Rheumatology

This article provides an in-depth review of telemedicine and its use in pediatric rheumatology. Historical barriers to the use of telemedicine in pediatric chronic care are described, and recent policy changes that have supported the use of telemedicine are discussed. Future directions and suggestions for the evaluation of telemedicine in pediatric rheumatology care are provided with a special focus on clinical outcomes, its use in research, patient acceptability, and health equity.

The Telemedicine-Based Pediatric Examination of the Neck and Upper Limbs: A Narrative Review

With the COVID-19 pandemic hastening the adoption of telemedicine into clinical practice, it has also prompted an abundance of new literature highlighting its capabilities and limitations. The purpose of this review is to summarize the current state of the literature on telemedicine applied in the context of a musculoskeletal examination of the neck and upper limbs for children 3 to 18 years old. The PubMed and ScienceDirect databases were searched for relevant articles from January 2015 to August 2021 using a combination of keywords and nested searches. General examination components including inspection, guided self-palpation, range of motion, sensory and motor examination, as well as special testing are described. Although the literature is focused mainly on adult populations, we describe how each component of the exam can be reliably incorporated into a virtual appointment specific to pediatric patients. Caregivers are generally needed for most consultations, but certain maneuvers can be self-performed by older children and adolescents alone. There is general feasibility, validity, and substantial reliability in performing most examination components of the upper limbs remotely, except for the shoulder exam. Compared to those made in person, clinical diagnoses established virtually were found to be either the same or similar in most cases, and management decisions also had high agreement. Despite this, there is evidence that some pediatric providers may not be able to collect all the information needed from a telemedicine visit to make a complete clinical assessment. Lastly, currently available smartphone applications measuring joint range of motion were found to have high reliability and validity. This narrative review not only establishes a foundation for a structured pediatric musculoskeletal examination, but also aims to increase physicians' confidence in incorporating telemedicine into their standard of care.

The Telemedicine-Based Pediatric Examination of the Back and Lower Limbs: A Narrative Review

The COVID-19 pandemic has accelerated the transition to virtual healthcare while also prompting an abundance of new literature highlighting telemedicine's capabilities and limitations for various medical applications, notably musculoskeletal examinations. Telemedicine provides an opportunity to deliver timely patient- and family-centred care while maintaining physical distancing and improving access to remote communities. This review aims to narrate the current state of the literature on telemedicine applied in the context of a musculoskeletal examination for children aged 3 to 18 years. The PubMed and ScienceDirect databases were searched for relevant articles from January 2015 to August 2021 using a combination of keywords and nested searches. The general examination components relevant to the back and lumbosacral spine, hip, knee, ankle/foot, and gait are described. These components include inspection, palpation, range of motion, motor, and sensory examination as well as special testing. There is general feasibility, validity, and substantial reliability in performing most examination components, and primary diagnoses established virtually were found to be either the same or similar in the vast majority of cases. Despite the current literature focusing mainly on adult populations, we describe how each aspect of the exam can be reliably incorporated into a virtual appointment specific to the pediatric population. Currently available smartphone-based applications that measure joint range of motion were generally found to have high reliability and validity. Caregivers are needed for most of the consultation, especially in younger children, but select physical exam maneuvers can be self-performed by older children and adolescents alone. By providing an overview of the available smartphone tools as well as the reliability and validity of remote assessments, this review not only establishes a foundation for a structured pediatric musculoskeletal examination, but also aims to increase providers' confidence in incorporating telemedicine into their practice.