Descripción de un servicio de telerreumatología en una institución colombiana / Description of a tele-rheumatology service in a Colombian institution

RESUMEN

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ABSTRACT

ABSTRACT Introduction: Models in health care have been static for a long time, but recently there has been a change in recognising that technology in the area of information and communication could lead to a change in improving health services. Telemedicine has been increasing and its use now extends to the entire process of health care. It is beginning to be implemented in the rheumatology area, in Colombia. The characteristics of a tele-rheumatology service are described, as well as a more detailed observation of a cohort of patients with rheumatoid arthritis (RA), in order to identify strengths and improvements. Methods: A descriptive observational cross-sectional study was conducted on the total population of patients who were treated by the tele-rheumatology service in the synchronous modality for a period of 30 months. As regards the follow-up of patients with RA, all patients were included who were treated exclusively by means of synchronous telemedicine for a minimum period of 6 months with at least three follow-ups, in which it was possible to calculate the clinimetry by Das28 with the use of C reactive protein (CRP). Measures of frequency, central tendency and dispersion according to type of variable will be used for the descriptive analysis. Results: Data was collected from 1905 patients during the period between August 2017 and March 2020. A total of 4864 consultations were made. Non-attendance of 368 (7.85%) consultations was registered. There were 1784 (83%) patients with a definitive diagnosis by the rheumatologist. A total of 284 patients (14.9%) were discharged by the rheumatology service, and 85 (4.46%) were referred for an exclusively face-to-face evaluation. Auxiliary medical care at the place of origin was provided by a general practitioner in 1,749 (91%) cases. There was no security during the care process as regards the physical examination in 46 (2.4%) cases. Of the total number of patients, 184 (9.6%) cases came from rural areas or municipalities far from the place of care. Biological therapies were prescribed in 139 patients, 56 new prescription during the 30 months. Of 479 RA patients, 200 met the criteria for follow-up. Of these, according to the activity measured by DAS28 with the use of ultrasensitive CRP, 54 patients (27%) were found on admission to the program in remission, 23 (11.5%) patients had low activity, 81 (40.5%) patients had moderate activity, and high activity was found in 42 (21%) patients. Regarding the start of follow-up, there was a 47% increase in the number of patients in remission, and low activity to 19.5%, in contrast to a reduction of 25% in patients with moderate activity and in 9% increase high activity in their last measurement, possible during monitoring. In the group of 200 patients from long-term follow-up, biological therapies were used 61 times. Of the 166 patients during follow-up without biological therapies on admission, these were required in 16%. Discussion: A detailed follow-up of the patients was carried out in the telemedicine service in a synchronous way for a period of two and a half years. The low percentage of absences shows a good adherence to the program. Physical examination, the main reason for medical care at the remission site, was not without difficulties, in this minority it was necessary to carry out diagnostic images. It would be important to assess this group of patients where there are doubts regarding the physical examination, those who have a certain number of appointments without a definitive diagnosis, or in whom biological or high-cost therapies would be used should necessarily be referred to face-to-face consultation. In the group of patients with RA, the percentage of biological use is considered high in relation to the expected standards. This may be for several reasons, such as the high number of patients with prior use of biological agents, the majority of patients with long-term disease, and difficulties in accessing follow-up due to rheumatology, as well as the small number of sero-negative patients in the study population, and practices related to non-presential medical practice may overestimate the activity of the disease. In conclusion, telemedicine has great advantages in the care of rheumatology patients, although it requires modifications to improve these services in favour of patients.