Managing a Rheumatology Practice During the COVID-19 Pandemic

By Andrew L. Concoff, MD, FACR, CAQSM

The novel coronavirus (COVID-19) pandemic has altered the landscape of the practice of Rheumatology. United Rheumatology is closely monitoring the situation and has put together this initial communication to summarize several considerations toward coping with the new reality confronted by our members and their patients. It should be emphasized that the nature of this type of pandemic is one of rapid evolution. The thoughts and opinions reflected here are, by nature, valuable for only a limited time. As our understanding evolves, UR will provide frequent updates to these recommendations by carefully monitoring changing events and by sampling the expert opinions of our members.

General Overview

The available statistics regarding the presence of COVID-19 infection in the US, including over 3,000 reported cases of COVID-19 in 49 states with 62 deaths and 12 known recovered patients (as of 3/15/20)1, are almost certainly a significant underestimate of the spread within the population due to under-sampling as a result of the lack of availability of widespread testing. A substantial “jump” in case reporting is expected as more widespread testing becomes available. The presence of a highly contagious and infectious disease that bears significant morbidity and mortality is of great concern to the patients, staff, and doctors in a Rheumatology Practice, as the use of immunosuppressive medication to treat autoimmune disease places patients at greater risk of certain infections. However, the specific impact of such medications or the risk of contracting COVID-19 is unknown. Several factors have complicated the management of the COVID-19 outbreak, including its significant contagiousness, respiratory spread, spread by asymptomatic individuals, and limited testing of the US population to date. These factors have rendered the identification of infected individuals capable of spreading the disease impossible. The CDC has made numerous recommendations for the general public, including the following:

  • “Social distancing,” including:
    • Avoidance of gatherings of over 50 people for the next two months, necessitating the closure of numerous schools and colleges  
      • In areas such as the states of New York and Ohio, and the City of Los Angeles, that have been particularly affected, increased measures have been enacted including mandatory limitation of capacity or even closures of bars, movie theatres, and restaurants (although take-out and delivery services typically continue).
  • Limiting non-essential travel
    • Additional travel restrictions, including those within the US, have been contemplated but not yet enacted (as of 3/15/20).
  • Frequent hand washing
    • Lasting 20 seconds with soap and water or hand sanitizer that is at least 70% alcohol
  • Avoidance of handshaking and contact with “high touch” public surfaces
  • Avoidance of touching one’s face
  • Working from home, if/whenever possible  

High Risk Groups

The CDC has identified certain patient groups as a higher risk for COVID-19.2 These include:

  • Older adults: 
    • Cut-off: 60 years of age
      • Survival among hospitalized Chinese patients age 45-58 has been identified to be markedly better than those aged 63-76 (n=137; p <0.0001)3.
  • People who have serious chronic medical conditions:
    • Heart Disease
    • Diabetes
    • Lung disease

There is currently no direct evidence as to whether contracting COVID-19 infection is more likely among those who suffer from autoimmune diseases in general, or among those who are immunocompromised, including those who are rendered so by taking medications for autoimmune conditions. Thus, it is currently unclear whether patients treated with all, certain, or none of the medications typically used in Rheumatology (notably including various types of DMARDs and Prednisone) are at additional risk of contracting COVID-19.

Office and Staff Management

To limit the risk of transmission of COVID-19 infection in our practices, several precautions that supplement standard, universal precautions have been recommended.

Such standard practices should include disinfecting all surfaces typically contacted by doctor or patient during an office or infusion center encounter between each visit. All medical equipment, including stethoscopes, should also be regularly disinfected. The following are additional steps that have been recommended by the CDC and have been augmented for applicability to the private practice Rheumatology clinic setting through conversation with UR practice leaders:

  1. Avoid unnecessary face-to-face visits
      • Unnecessary patient visits, including routine follow-up care, should be postponed
      • Practices should contact patients with pending visits to discuss whether they have specific needs or questions pertaining to an upcoming visit. If not, such visits may be deferred.   
      • By limiting such visits, the number of patients that pass through the clinic decreases, as does the likelihood of an infected patient exposing those in the clinic, particularly those who are in pre-clinical stages or who are infected but asymptomatic.
      • Patients experiencing symptoms consistent with COVID-19 should be asked to cancel their visits and should be appropriately triaged based upon their symptoms.  
      • Routine pre-visit, reminder phone calls should include mention of the need to cancel visits in the presence of the following, COVID-19 symptoms:
        • Fever
        • Cough
        • Shortness of breath
      • If offices typically charge patients for cancellations, such charges should be avoided.
      • Additionally, automated pre-visit messages should include a contact number for symptomatic patients to allow for a follow-up call that consists of an assessment of symptom severity.  
      • Patients should be triaged to an appropriate level of care depending upon the severity of their current symptoms with explicit descriptions for those with milder symptoms that symptoms may evolve rapidly, with such progression requiring an alternate plan for more aggressive evaluation or intervention. The CDC has summarized the approach to such patients here.
      • Further, telemedicine visits are almost uniquely suited to those who have symptoms but also have additional needs or questions for their Rheumatologist.
      • Posting reminders outside of clinic entrances that refer to the “golden rule” of not wanting to get others sick, just as we would not have others make us sick, may be of value.
      • Each patient should be seen alone in the examination room unless he/she is unable to provide salient history for the visit. Family members, friends, and children should be left at home.
      • Visits with the various vendors, industry representatives, and other non-clinical professionals should be postponed indefinitely.

2. Limit unnecessary contact with patient bodily fluids and contaminated surfaces.

        • Patients should be discouraged from using clinic bathrooms.  
        • Routine urinalysis should be collected outside of the clinic whenever possible.  
        • Follow-up, detailed in-service descriptions of proper sterilization technique(s) should be arranged with each laboratory, equipment, technology, and x-ray company relevant to a given clinic.
        • Waiting and examination rooms should be devoid of shared items typically shared among patients, including magazines and self-service beverages.  
        • Waiting room surfaces should be routinely disinfected.

3. Upon check-in at the clinic, all patients should be queried for the presence of symptoms consistent with COVID-19 or recent infected contacts, particularly those known to have infection with COVID-19.

      • Those with mild symptoms may simply be asked to return home and call back with questions or offered a telemedicine visit, if available.   
      • Those with more severe symptoms deemed unsafe to send home should be sent to the emergency room of a nearby hospital.
      • All clinic personnel who are within six feet of such patients should wear N95 particulate respirators, gloves, and gowns, as available.

4. Office staff should be strongly encouraged to stay home in the event of either the presence of symptoms consistent with COVID-19 infection or any known contact with those suspected of, or determined to have, COVID-19 infection.

      • Having a high index of suspicion is necessary in order to limit the likelihood of bringing such exposures to the office environment and risking in-office spread of COVID-19. 

 5. In the event of a known in-office exposure to a COVID-19 positive patient, staff member, or physician, perform a risk assessment that determines the severity of the exposure and guides appropriate action.  

A critical question in the back of our minds is:
Does the risk of COVID-19 infection, or of serious COVID-19 infection, differ by DMARD drug class, dose, specific DMARD, or with use dual-therapy (e.g., biologic DMARD with Methotrexate) versus monotherapy, or with concomitant use of prednisone?

  • No specific data is yet available with which to answer this question.
  • In order to properly address these issues, UR members are strongly encouraged to register all patients with Rheumatologic conditions that develop infection with COVID-19 on “The COVID-19 Global Rheumatology Registry” website that is currently being developed for this purpose.  This registry is launching sometime between March 20-27, 2020 and can be accessed at www.rheum-covid.org.

References

  1. Johns Hopkins University, Interactive Map. Coronavirus COVID-19 Global Cases by the Center for Systems Science and Engineering (CSSE).  https://coronavirus.jhu.edu/map.html;  Accessed, 3/15/20 
  2. Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19). If you are at a higher risk.  https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/high-risk-complications.html;  Accessed 3/16/2020.
  3. Zhou F, Yu T, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study.  Lancet, 2020; https://doi.org/10.1016/S0140-6736(20)30566-3
  4. Binder-Finnema P, Dzurilla K, et al. A qualitative exploration of shared decision making in rheumatoid arthritis.  Arthritis Care Res, 2018; https://doi.org/10.1002/acr.23801

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