ACR: In-Person Urgent vs. Virtual Non-Urgent Medical Care Save

On April 26, 2020 the American College of Rheumatology (ACR) published a guidance paper to assist rheumatologists and rheumatology health professionals in assessing the need for urgent or face-to-face medical care versus virtual or telehealth patient care.  The driving principals being the need to protect patient safety while providing optimal health care in the current environment of social distancing and home sheltering.

The ACR has provided clinical guidance for the treatment of rheumatology patients; available on the ACR website and summarized below. This includes guidance for the safe management of infusions when necessary.  Key issues are: 

Authority

The ACR holds that rheumatologists and rheumatology health professionals are in the best position to determine what defines routine, urgent, and emergent care for  rheumatology patients. Regulatory bodies, who may not be familiar with the unique needs of rheumatology patients, should defer triage decisions to professional healthcare providers.  Rheumatologists and rheumatology health professionals consider a host of factors related to a patient’s individual circumstance (severity of illness, risk of shortterm complications related to disease or treatment, risk of complications related to COVID-19, prevalence of COVID-19 in the local community, local capacity for ensuring measures to prevent the spread of SARS-CoV-2 in the healthcare setting, etc.), when advising patients on the safest methods for delivering care. But accurate assessment can be hindered in the absence of a face-to-face encounter. Thus, any provider who, in good faith, brings to the clinic a patient when the provider, in collaboration with the patient, believes the need may be urgent should not be subject to post-hoc regulatory audit of urgency.

Urgency

The following scenarios, common in day-to-day rheumatology practices, might reasonably be considered urgent, based on an individual patient’s unique situation. These examples are in no way intended to be comprehensive or proscriptive.

• Infusions and administration of medications in the office.
• The potential risks versus benefits of infusions must be ascertained for each individual patient and will change over time as the COVID-19 pandemic continues. Forced non-medical switching to a different drug or to home infusions, by a payer solely based on cost considerations and without the consent of the patient and the patient’s rheumatologist or rheumatology health professional, is always inappropriate and remains inappropriate during the COVID-19 pandemic.
• Many patients are prescribed powerful subcutaneous and infusible medicines precisely because their rheumatologic disease is active and/or highrisk. For these patients, withholding therapy increases the risk of a flare which in some cases (as in patients with ANCA-associated vasculitis, for example) can be life threatening.
• In certain cases, delaying an infusion or an in-office injection may be reasonable. For instance, when a patient’s disease is well controlled, a drug holiday is deemed low risk, and measures to promote physical distancing in the infusion center are not feasible, it may be in the patient’s best interests to delay therapy. For instance, rheumatologists and rheumatology health professionals may reasonably consider delaying treatments with zoledronic acid.
• In contrast, interruptions in therapy with denosumab have been associated with poor outcomes and therefore extending dosing intervals beyond eight months should be avoided if possible.
• Some clinics may be equipped to offer curbside treatment with injectable medications (such as certolizumab and denosumab) in order to maximize physical distancing and patient safety.
• Acute flare or ongoing disease activity of a known disease, or adverse effect due to a medication, for which the patient and rheumatologist or rheumatology health professional estimate that the benefits of immediate face-to-face evaluation and/or treatment outweigh the risk.
• Joint aspirations and injections. Based on the severity of pain and/or functional limitation or concern for septic arthritis, face-to-face evaluation for aspiration and/or injection of a joint may well be urgent. In contrast, rheumatologists and rheumatology health professionals, in shared decision making with the patient, may consider delaying routine joint injections if the patient’s condition is stable and/or local conditions dictate.
• New patient evaluations when the consulting or referring provider indicates urgency (suspected rheumatoid arthritis, systemic lupus erythematosus, vasculitis, etc.).

Lab Monitoring

Routine lab monitoring, which is the standard of care for patients on a variety of medicines used by rheumatologists and rheumatology health professionals, also requires individualized decision making. Extending the interval between routine lab monitoring tests may be reasonable if local environmental factors (adequacy of physical distancing at the site where labs are drawn, access to alternative sites, access to off-hours testing) preclude safe testing on schedule and patient factors (dose and duration of therapy, prior abnormalities in lab testing results) are favorable (3).

Telehealth

The ACR supports the use of telehealth for appropriate patients during the COVID-19 pandemic. Due to widespread shortages of rheumatologists and rheumatology health professionals, patients routinely travel across state lines to receive rheumatologic care. The use of telehealth technologies in these scenarios is complicated by state and regional regulations around licensing, certification, and malpractice that vary widely in terms of their allowance for medical professionals to provide care across state lines. The ACR applauds efforts at the federal and state levels, as has been done with HIPAA regulations, to clarify and loosen, when necessary, regulations covering licensing, certification, and malpractice coverage to allow rheumatologists and rheumatology health professionals to provide care at a distance during the COVID-19 pandemic in states where they may not hold a license. We urge all states to update regulations immediately to allow appropriate care at a distance in accordance with federal guidance.

Otherwise health professionals are left without a viable telehealth option for their patients who reside out-of-state.

References:

(1) https://www.rheumatology.org/Portals/0/Files/Complexity%20of%20Biologics.pdf

(2) https://www.ncbi.nlm.nih.gov/pubmed/?term=30659428

(3) https://www.ncbi.nlm.nih.gov/pubmed/?term=31012257