Background/Purpose: The global COVID19 pandemic has had a major impact on healthcare. The effect on rheumatology patients and providers is unclear, as is the role of telemedicine service to meet unique challenges posed by the pandemic.

Methods: Using the Columbus data warehouse of the AARA rheumatologist network, we examined calendar trends in the frequency of kept vs. missed/cancelled office visits and intravenous (IV) infusions of immunomodulatory medications (e.g. abatacept, golimumab, infliximab, tocilizumab) from January to May, 2020. We compared results by primary diagnosis, driving distance from physician office, and socieoeconomic status(SES), proxied by the Area Deprivation Index (ADI). Descriptive statistics and multivariable logistic regression were used to identify factors associated with missed/cancelled visits, controlling for clustering (visits within patients), with results as odds ratios (OR) with 95% confidence intervals(95%CI).

Results: Before March 15^th (i.e. Pre-COVID), mean weekly visit volume overall was 17,203 visits/week among 121,843 unique rheumatology patients, which decreased minimally (3.1%) Post-COVID. Among return patient visits (mean 10,678/week, dropping 9.1% Post-COVID), 100% pre-COVID were in-person visits, but dropped to 70.3%, and were supplemented by 29.7% telemedicine visits. In addition to the decline in office visit volume and the transition to telemedicine visits, the frequency of missed/cancelled in-person appointments Post-COVID also increased. It peaked during week 12 (March 23-28) in which 15.2% of all appointments were missed/cancelled overall, 17.9% for in-person visits vs. 5.1% for infusions (p< 0.0001).

Univariate characteristics of patients keeping vs. missing visits and infusions is shown (Table). After adjustment, and referent to week 1 (Jan 5-11), the OR (95% CI) for cancellations associated with the pandemic at its peak was 1.30 (1.27, 1.34). Compared to follow-up visits for rheumatoid arthritis, new patient visits and return patient visits for osteoarthritis and osteoporosis were associated with a greater likelihood of missed/cancelled office visits, with corresponding OR (95% CI) of 1.59 (1.51, 1.67), 1.34 (1.31, 1.37) and 1.75 (1.71, 1.80), respectively. Patients with lower SES had a 5-20% higher likelihood to miss/cancel office visits compared to those in the highest SES quintile.  Multivariable-adjusted factors also associated with missing/cancelled office visits included greater driving distance to the rheumatologist office, female sex, smoking, comorbidities (e.g. anxiety, asthma, back pain, diabetes, fibromyalgia, GERD, sleep disorder); and region.

Conclusion: The impact of COVID19 on both rheumatology practice visit volume and immunomodulatory treatments has been substantial. Telemedicine and other technology-focused tools for remote digital patient data capture and monitoring are essential to optimize rheumatology care and outcomes. 

Table: Partial List of Factors Associated with Missed/Cancelled vs. Kept Office Visits and Infusions Associated with the Temporal Evolution of the COVID19 Outbreak

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