Background/Purpose: Telemedicine (TM) offers a strategic means of extending limited clinical pediatric rheumatology (PR) workforce capacity to improve access to care for patients in remote locations.  Tele-rheumatology (TR) often depends on a remote site provider to convey physical examination (PE) findings. While adult TR has diagnostic accuracy of 97% compared to in-person consultations, there are no published data for pediatric TR PE or diagnostic accuracy.  This cross-sectional observational study assessed the accuracy of PE findings in 10 new PR TR consultations.  Pragmatically, we envision a service delivery model involving initially inexperienced musculoskeletal examiners at remote locations.  Hence, our aim was to determine the reproducibility of PE findings and diagnostic agreement. The primary outcome was comparison of the physician TR and remote examiner PE findings, and diagnostic concordance.

Methods: The physician conducted the interview within our hospital at a dedicated TM suite, then guided and documented the remote provider’s PE.  This examiner, a developmental pediatrics physical therapist, was physically located with the patient at our institution’s PR clinic.  We deliberately sought an examiner naïve to PR musculoskeletal examination.  Knowing PE skills improve with repetition, we restricted the study to 10 patients to limit this effect.  Patient selection focused on ensuring a variety of presenting complaints and ages.  The initial 30% knew they had TR consultation scheduled; the remainder was unaware.  We sought parental TM satisfaction after each session via on-line survey and/or in-person interviews.  We used a Likert scale to determine the impact revised PE findings had on clinical decision-making.

Results: We identified 26 PE errors in this cohort of broad age range (14 months to 16 years). The table summarizes concordance. PE errors mainly involved biomechanical disorders with or without generalized hypermobility (7, 2) and musculoskeletal abnormalities (5).  Weighted averages for diagnostic concordance varied: overall (37%), biomechanical disorders (31%), inflammatory diseases (83%) and pain amplification (0%).  The practical impact on decision-making (20% none, 30% minimal, 50% moderate, 0% marked) affected 8 patients: physiotherapy orders (5), and one patient each for lab/x-ray, medication options, and additional consultation.  Completed surveys (50%) indicated 100% agreed or strongly agreed with using TR again, with overall satisfaction of 100%.

Conclusion: Pediatric TR requires a remote site examiner trained in musculoskeletal PE with an emphasis on biomechanical abnormalities which are prevalent in PR. Concerns about reliably identifying juvenile arthritis do not appear to be a major risk of TR, although errors did occur in detecting all involved joints. Pediatric TR can provide access to clinical care with high levels of satisfaction.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/pediatric-tele-rheumatology-a-pilot-project-to-assess-accuracy-of-physical-examination-findings-and-diagnostic-concordance-at-a-distance/