HELSENORGE

Telehealth

Telehealth vs Outpatients clinic Follow up in Rheumatoid Arthritis Patients. A Randomized study. 

Abstract Proposal for ePoster Display at the International Forum on Quality and Safety in Healthcare Gothenburg.


Jannicke S Karlengen (1), Anne C Bull Haaversen (1), Maiju Pesonen (2), Inge C Olsen (2), Andreas P Diamantopoulos (1) 

(1)Dept of Rheumatology, Martina Hansens Hospital, Bærum, Norway; (2) Statistical Unit, University of Oslo

Background​​​​

Rheumatoid arthritis (RA) is a chronic inflammatory joint disease. Outcomes for the individuals living with RA have been improved and the majority of RA patients are now in remission or low disease activity status. Still, RA patients continue to be followed up by pre-scheduled visits. Given competing demands and scarce resources, it is important to minimize nunnecessary follow up care visits at the expense of patients in need of medical attention. As a consequence of the rising health care direct costs, there is a need to optimize and streamline the RA patients’ management.

Self-monitoring and remote patient monitoring are facilitated by electronic health tools. Among RA patients with low disease activity or remission, a Patient-Reported Outcome (PRO)-based telehealth follow-up for tight control of disease activity in RA achieved similar disease control as conventional outpatient follow-up.


Methods

Telehealth - Method.PNG
The study was a randomized study. Patients with RA in remission or low disease activity (RAPID3<6) were recruited at the Department of Rheumatology at Martina Hansens Hospital (MHH), Bærum, Norway, between May and June 2020. RAPID3 stands for Routine Assessment of Patient Index Data 3 and is a pooled index of the three patient-reported American College of Rheumatology rheumatoid arthritis (RA) Core Data Set measures: function (MHAQ), pain, and patient global estimate of status. Rapid3 was used as an outcome measure. Each of the three individual measures is scored 0 to 10, for a total of 30. 

​​​The primary objective was occurrence of flare within 52 weeks, defined as a RAPID3 score of 6 or more at any measurement between randomization and 52 weeks. RAPID3 scores were registered and all patients with a RAPID3 flare were evaluated by a rheumatologist with regard to clinical flare. Data on satisfaction rates was collected at the end of the study. Secondary objective was to compare the clinical flare (as evaluated by a rheumatologist) between the two groups and to compare satisfaction rates with the follow-up procedures among the two patient groups. Visual Analogue Scale (VAS) was used by the patients to score satisfaction with the follow-up procedures. 

The patients were divided in two equal groups, ​one allocated to telehealth (TH) and the other to outpatient clinic (OC) follow-up. All the patients signed an informed consent form prior to recruitment. ​​An electronic app (Dignio), was used to collect data from the Telehealth follow-up group. Digno available both on Apple store and Android play, which the patients  downloaded for free. 

The Go-Treat-It (GTI) program was used to collect data from the conventional follow-up outpatient clinic group. The data collected by the GTI were stored in MHH servers.  According to the treat-to-target strategy, all patients, irrespective of group allocation, had access to extraordinary outpatient visits if needed. The patients contacted the study nurse via the app (TH group) or by phone or by primary care physician referral (OC group). 

Baseline characteristics were compared by Student T test or . Non-inferiority was claimed if the upper limit of the confident interval (CI 95%) of the adjusted risk between the two groups was 0.15. VAS satisfaction with the follow-up” was analysed using a linear regression Model.

Results

Telehealth - Result.PNG

212 patients were recruited, 104 in the OC arm and 108 in the TH arm. Mean age was 60,6 years, with 64,2% being females. 78,8% of the patients had a seropositive RA. All patients fulfilled the EULAR 2012 criteria for RA. An overview of the baseline characteristics is presented in Table 1.

Table1. Baseline characteristics
Telehealth - tabell 1.png

Based on RAPID3 we had following results: 11 (5%) patients flared in the OC group and 27 (13%) patients flared in the TH group, with an adjusted risk difference of 0.14 (95% CI 0.04- 0.23)  meaning that the patients in the TH group had a 14% higher adjusted risk for flare compared to OC group. Thus, the primary endpoint (non-inferiority of the TH group) was not met. However​, no difference was observed in between the two groups regarding the clinical flare, with 10 patients (5%) having a clinical flare in the OC group compared to 15 patients (7%) in the TH group.​ The estimated adjusted risk difference was 0.04 (95% CI -0.05-0.13) meaning that the adjusted risk of flare is 4% higher in the TH group. With regard to clinical flare the TH group was non-inferior to OC group. 
The mean VAS satisfaction scores at 12 months in TH and OC groups were 8.8 and 9.8, respectively. The estimated adjusted mean difference (TH-OC) between the groups was -0.82 (-1.19, -0.47). As the 95% confidence interval of the mean difference does not include zero, the satisfaction with the follow-up at 12 months is significantly lower in the TH group in comparison to the OC group. The main reason for the lower satisfaction rates in the TH group was the log in procedure, which many patients found complicated.

​Conclusion

TH follow up seems to have a significant higher flare rate than traditional follow-up, yet no difference was observed with regard to clinical flare as it was judged by a rheumatologist. One explanation could be the relatively easy and straightforward way for the patients to communicate their problems to outpatient clinic through the app, though not attributed to RA. 

The lower satisfaction rates at the TH group illustrates that technological solutions need to be easy to use by the patients. Feedback from the TH patients , who scored lower than expected, claimed that the reason was technical issues with the app, and was not able to differentiate between the technical issues they had, and then follow-up

At the end of the study, all the Patients was given the choice to continue or change their follow-up from OC tTH or the opposite. Today we have 150 patients in the TH follow-up, only 50 chose to continue with OC follow-ups.

Feedback

Illustrasjon av feedback fra pasienter

Most TH patients were satisfied , those who scored lower than expected, claimed that thereason was technical issues with the app. They were not able to differentiate between the technical issues they had, and the follow-up​.









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