番茄社区

VIENNA -- Patients with axial spondyloarthritis (axSpA) who initiated follow-up contacts with their clinicians fared no worse medically than those monitored remotely or, as is normally done, whose follow-up was all done via prescheduled in-person visits, a randomized trial found.

Moreover, letting patients make their own clinic appointments was massively less resource-intensive than having subsequent visits scheduled for them by office staff, reported Inger Jorid Berg, MD, PhD, of Diakonhjemmet Hospital in Oslo, Norway, during a late-breaking abstract session at the European Alliance of Associations for Rheumatology (EULAR) annual meeting.

The recent COVID-19 pandemic awakened both the medical profession and patients to the possibility of having at least some care managed remotely with video conferencing. While hands- and eyes-on care remains indispensable for some conditions and situations, many medical offices around the world (the developed world, anyway) have adopted "telemedicine" capabilities and encouraged patients to use them when possible.

Regular follow-up is essential in axSpA, Berg noted, but whether it must always be conducted face-to-face isn't clear. Use of technology and letting patients take the lead "may allow for more targeted and efficient use of healthcare resources," she told EULAR attendees.

About 18 months into the pandemic, Berg and colleagues began a to compare three approaches to follow-up care for axSpA patients in Norway: usual care, in which patients were told to come into the clinic every 6 months for in-person evaluations; remote monitoring and consultation via video; and letting patients initiate all follow-up contacts, albeit with recommendations to stay in regular touch.

A total of 243 patients were randomized in equal numbers to the three care types, and followed for 18 months. The primary endpoint was probability of achieving an Axial Spondyloarthritis Disease Activity Index (ASDAS) score less than 2.1, indicating low disease activity, when evaluated at months 6, 12, and 18. A 15% margin was set to establish non-inferiority, with usual prescheduled in-person care as the reference. Other outcomes included patient satisfaction and a measure of resource use.

Mean patient age was about 44, and three-quarters were men. A mean of 13 years had elapsed since symptom onset. Baseline ASDAS scores averaged 1.0 and Bath Ankylosing Spondyloarthritis Disease Activity Index (BASDAI) values averaged 1.3.

With remote monitoring, patients were asked to rate their condition via a standard global assessment each month, transmitted to the clinic through a smartphone app. If this suggested a flare might be occurring, patients then proceeded to complete a BASDAI evaluation; a score of 4 or greater would then trigger a nurse phone call and a recommendation to come in for a consultation.

Patients assigned to self-initiated care were encouraged to make contact with clinic staff at least every 3 months, and whenever they had a concern about their condition, but there were no specific requirements.

Five participants lost contact with the study and three withdrew; the remaining 235 were included in the outcomes analysis.

No substantial differences were seen between groups at any of the evaluation points, with 92%-96% of patients showing ASDAS scores below the threshold of 2.1. Differences did not come close to the 15% non-inferiority margin. BASDAI scores at months 6, 12, and 18 were also nearly identical in the three arms.

Patients in each group also expressed high satisfaction with their care, although roughly 5% of those assigned to usual care and remote monitoring said they were dissatisfied. Only about 1% of patients initiating their own care were dissatisfied.

Resource use was measured as a composite of direct and indirect costs associated with healthcare visits and contacts. When looking just at in-person visits, resource use was nearly 10 times greater with usual care than with remote monitoring or patient-initiated care. Moreover, Berg said, all of the excess associated with usual care stemmed from the regularly scheduled in-person visits. Another form of utilization was categorized as "short contacts by phone," and for this outcome, remote monitoring was more intensive by about 50% than either of the other two forms of care.

The ReMonit group has since started a small to compare similar approaches for gout follow-up care.

Comment