Expanding Access to Care with Telerheumatology in the Military Health System

From the 2021 HVPAA National Conference

Michael Loncharich (Walter Reed), David Desena, Angelique Collamer, Jess Edison

Background

Rheumatic diseases are diagnostically challenging not only due to rarity, but also because symptoms can develop additively.  Access to care poses another hurdle not limited to the military health system (MHS).   By 2025 the majority of the US population will have only 0.5-1 rheumatologist per 100,000 people despite an aging population resulting in an estimated shortage of 3,269 rheumatologists, increasing to 4,133 by 2030.1

A physician shortage during a time of increasing demand is also seen in other subspecialties and primary care, especially in rural areas.2-3 Practice in the MHS adds additional challenges—transitions of care and practice in austere environments. Multiple telehealth modalities have been implemented to mitigate these challenges.

The COVID-19 pandemic prompted unprecedented expansion of TH utilization. In response, the American College of Rheumatology released a position statement advocating to broaden TH to increase access to care. Further, they propose continued use of TH to mitigate the rheumatology workforce shortage into the post-pandemic phase.4

Objective

Compare patterns of rheumatology consultations and outcomes across four different platforms in the MHS: face-to-face, synchronous telehealth, and two asynchronous telehealth platforms.

Methods

We conducted a retrospective review comparing face-to-face rheumatology consults during 2019 with teleconsultations from three virtual systems in the MHS: an asynchronous email-based system from May 2006 to Feb 2018, a web-based platform from 2014 to 2018, and synchronous telehealth consults from March 2020 to March 2021. Consults were reviewed for diagnosis, and if face-to-face follow up or medical evacuation was required. Diagnoses were collected retrospectively based on the primary diagnosis coded. Chi-square analysis with post-hoc testing was performed to assess for differences across consultation modalities.

Results

Leading diagnoses across platforms were inflammatory arthritis, noninflammatory arthritis, and a composite of other diagnoses. Inflammatory arthritis accounted for significantly more consults in the synchronous telehealth (38.4%) and email-based (40.9%) models than in the web-based (23.7%) and face-to-face (32.0%) models. The composite of other diagnoses was the leading diagnosis for the asynchronous web-based model (32.9%), which was significantly more than the synchronous telehealth and face-to-face consults. Synchronous models saw significantly more cases of crystalline arthritis, vasculitis, and fibromyalgia.

Email-based consultations resulted in medical evacuation in 15.7% of cases and prevented 5. Web-based consultations prompted medical evacuation in 20.1% of cases. In the synchronous model, face-to-face follow up was recommended in 15.0% of cases.

Conclusions

Modality of consultation influences the type of cases seen. Both synchronous and asynchronous tele-rheumatology models were able to sufficiently answer the consult question without referral for face-to-face evaluation in 79.9-85.0% of consults, suggesting teleconsultation is a viable method to increase access to high-quality rheumatology care.

Clinical Implications

Our study demonstrated that telerheumatology consults have a long-standing history of effectively answering consult questions remotely. These findings support telerheumatology as a viable solution to expand access to subspecialty care as we enter the post-pandemic phase of medicine and face a growing shortage of rheumatologists.

References

  • Battafarano DF, et al. 2015 American College of Rheumatology Workforce Study: Supply and Demand Projections of Adult Rheumatology Workforce, 2015-2030. Arthritis Care Res. 2018 Apr;70(4):617-626.
  • Zhang X, et al. Physician workforce in the United States of America: forecasting nationwide shortages. Hum Resour Health 2020;18(8).
  • Reed AB, et al. Televascular Consultation Is the Answer to Rural Vascular Surgery Shortage, J of Vasc Surg, 2020;72(3):e306-e307.
  • American College of Rheumatology. Telemedicine [Position Statement]. https://www.rheumatology.org/Portals/0/Files/Telemedicine-Position-Statement.pdf

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