By Andrew L. Concoff, MD, FACR, CAQSM
The transition to Telerheumatology involves changes to the physical examination from that typically performed at an in-person visit. In Telerheumatology, greater emphasis is placed on inspection to account for the lack of palpation, auscultation, percussion. However, these changes may make the transition to Telerheumatology an anxiety-provoking and uncertain process for clinicians. How can we help increase the certainty of our Telerheumatology-derived diagnostic conclusions and therapeutic decisions? First, it is important to recognize that although preliminary, the best available data suggests that Telerheumatology is an effective approach.1 Second, more aggressive use of laboratory testing is often warranted as a companion to Telerheumatology to add to the data available upon which to make clinical decisions.
In some cases, having laboratory results available at the time of a Telerheumatology visit may significantly affect the approach to patient care. Consider the example of a patient referred for symmetric hand joint pain. Every effort should be made to inspect the hands for suggestions of swelling via Telerheumatology by having the patient hold his/her/their hands up to the camera. We might also describe how our patients can perform a self-squeeze test. Modalities such as x-rays and ultrasound will not likely be available in the current environment. Yet understanding, for instance, that this patient’s anti-citrullinated peptide antibody (ACPA) test is markedly positive virtually assures that the patient has developed, or will soon develop, rheumatoid arthritis. In considering such greater use of laboratory testing, it is reassuring to note that at least one laboratory company has already adopted policies2 to limit the spread of contagion at draw stations, including allowing patients to wait in their cars until notified and holding separate hours for high-risk patients. Further, mobile phlebotomy units are available in some locations to limit the risk of exposure of high-risk patients at laboratory draw sites.
Thus, one way to address the increased uncertainty of Telerheumatology visits is by augmenting them with more aggressive use of laboratory testing than might typically be employed. In order to do so, labs may be ordered as a part of the brief screening visit or telephone call that we have previously recommended. Additionally, a more formal Telerheumatology evaluation can be scheduled for a later date, when the results of the lab draw will be available. This approach may be useful in several circumstances:
- Continued use of routine laboratory follow-up of disease activity and/or surveillance for drug toxicity in RA, SLE, PMR, etc. as might occur under normal circumstances:
- C-reactive protein
- Erythrocyte sedimentation rate
- Complete blood count
- Complete metabolic panel
- Creatine kinase
- Routine urinalysis
- Additional disease-specific, biomarker-based, activity monitoring
- Multi-Biomarker Disease Activity (VECTRA)
- Disease-specific, diagnostic aids among new consultations or to triage the waiting list:
- For ANA positive patients:
- Lupus tests and serologies including ENA, C3, C4, RUA
- AVISE Lupus
- For patients with possible RA:
- Rheumatoid factor, Anti-citrullinated peptide antibodies
- Additional serologies may be useful in identifying patients at increased risk, including:
- Carbamylated proteins (CarP) antibodies
- Peptidylarginine deiminase 4 (PAD4) antibodies
- 14-3-3 eta protein
- For ANA positive patients:
The results of such tests may also augment Telerheumatology visits in several triage and management functions, including determining which patients may safely defer in-person visits versus those that need more urgent in-person visits, as well as decisions regarding the need for changes in medication dose, frequency, or class.
The cost-effectiveness of approaches that use laboratory tests to augment Telerheumatology visits has not been evaluated. Further, insurance coverage for such testing may vary accordingly by the test ordered, as well as by payer, plan and/or location. However, when any additional associated costs are deemed acceptable to patients, the addition of laboratory results during the period of limitation on in-person visits mandated by the COVID-19 pandemic may be considered a reasonable accommodation.
How to Determine the Prevalence of COVID-19 in Your State: Where to Find the Lab Testing Data?
It has become clear that our country’s national COVID-19 screening program has been beset by challenges and limitations that have limited our ability to respond in an optimal and timely manner.3 This has made assessing the risk to your patients, clinic and your staff exceedingly difficult. Ideally, widespread testing at the individual level would be used as it has been in several Asian countries with prior experience with epidemics, such as SARS, early in the course of the disease to impact the spread of the infection at the population level. By identifying early cases, followed quickly by case and contact isolation, the rate of infection can be reduced. As a result of inadequate availability of initial testing, we have been forced to resort to blunt, population-level control efforts including “social distancing”, to reduce the rate of spread.
Recently, some seven weeks after the first U.S. case, testing has begun to accelerate in several areas of the country. However, even now, efforts have been enacted to restrict the indications for the testing to those that have already manifested significant symptoms rather than, for example, to known contacts of those who have tested positive.3 This approach returns to the individual level for purposes of patient care but limits the applicability of test results on the population-level, as the early identification disease and the testing of contacts to determine their need for isolation cannot effectively occur with these limitations. Furthermore, when test results are reported in the media, the data is presented in the form of the number of test-confirmed positive cases. Yet it is now clear that the rate at which various states are testing continues to vary greatly.4 Thus, the incidence and prevalence of COVID-19 in any given state cannot be determined for lack of a denominator, the total number of tests performed. So, how can you determine, what the true degree of risk of COVID-19 disease in your state? Since these data are not being collected or presented by any government agency,3 the best resource I have found is “The COVID Tracking Project,”5 in which volunteer analysts and journalists have assessed these statistics on a state-by-state basis.
Potential Future Incorporation of Rapid COVID-19 Testing to Pre-Clinic Visit Screening
We might take a moment away from the harsh reality of our circumstances to envision the time when rapid COVID-19 testing becomes more widely available, and how it could simplify and improve efforts at pre-clinic triage. We have previously described an aggressive approach to the present-day circumstances of pre-clinic visit patients screening to reduce the risk of transmission. When rapid, point-of-service COVID-19 diagnostic tests of acceptable clinimetrics are widely available, such testing may transform the screening process prior to in-person Rheumatology visits. We might envision, for example, the use of a test recently cleared by the FDA,6 that claims to deliver negative results in as soon as 5 minutes, while positive results are available as quickly as 15 minutes. This timeframe might allow for screening of patients and staff members prior to entry into the clinic. Another innovation is self-administered testing,7 wherein, a patient can obtain a sample with shallower intra-nostril swabbing rather than the traditional, deeper methods. One might envision sending a kit of this type to a patient at home, in time to allow results prior to the planned appointment. With the conclusive evidence provided by such innovative testing determining whether a given clinician, staff member, or patient is infected, the risk of transmission would be dramatically reduced. Of note in this regard, it seems that under pressure from the Federal government, payers agree to waive co-pays for such COVID-19 testing, although the certainty of such an arrangement remains to be verified. It is unclear if financial support for the costs of the equipment required to perform these tests will be extended as part of one of the many bills for C+OVID-19 relief under consideration by Congress. Regardless, until such rapid COVID-19 diagnostic tests are available, the aggressive use of less direct approaches to limit clinic-based spread of infection including limiting in-person visits (a form of medical social distancing), the use of masks or their alternatives for in-person visits, maintaining low patient volume to permit 6-feet of distance between patients and staff, transitioning empty examination room into private infusion suites, and the application of pre-visit symptom and body temperature evaluation measures should continue to be aggressively applied.
The advent of the COVID-19 pandemic has fundamentally changed the practice of Rheumatology. One way that we can face such uncertainty and confront these challenges is band together virtually, by sharing our thoughts and approaches. Please send your concerns, solutions, thoughts, and novel approaches to firstname.lastname@example.org.
Stay safe, stay healthy, stay United.
- McDougall JA, Ferucci ED, et al. Telerheumatology: a systematic review. Arthritis Care Res, 2017: DOI: 10.1002/acr.23153
- LabCorp COVID-19 Patient Letter
- Kelly M, Cahlan S, & Samuels E. “11 to 100,000: What went wrong with coronavirus testing in the U.S.” Washington Post; https://www.washingtonpost.com/politics/2020/03/30/11-100000-what-went-wrong-with-coronavirus-testing-us/?utm_campaign=wp_post_most&utm_medium=email&utm_source=newsletter&wpisrc=nl_most; Accessed 3/30/2020.
- Hickok K. “States aren’t testing uniformly for coronavirus. That’s creating a distorted picture of the outbreak.”, LiveScience. https://www.livescience.com/coronavirus-testing-us-states.html; Accessed 3/29/2020.
- The COVID Tracking Project. https://covidtracking.com/data/, Accessed 3/29/2020.
- Abbott Rapid Point-of-Care COVID-19 test: https://abbott.mediaroom.com/2020-03-27-Abbott-Launches-Molecular-Point-of-Care-Test-to-Detect-Novel-Coronavirus-in-as-Little-as-Five-Minutes
- Japsen B. “Study: patients can do their own coronavirus tests without exposing health workers.” Forbes. https://www.forbes.com/sites/brucejapsen/2020/03/25/unitedhealth-study-patients-can-administer-their-own-coronavirus-tests-without-exposing-health-workers/#1bd4433340dc, Accessed 3/29/2020.