Establishing a hybrid remote clinic for patients on biological and targeted synthetic DMARDs in Rheumatology
Current guidelines recommend 6-monthly reviews of all patients on biological DMARD (bDMARD) and targeted synthetic DMARD (tsDMARD) therapies.
The purpose of these reviews is to monitor safety and efficacy to justify continued prescription of these high-cost drugs.
Since the licensing of the first bDMARDs over 20 years ago, the number of patients taking these medications has grown dramatically; and with the recent change in NICE guidelines to allow commencement of bDMARDs and tsDMARDs in rheumatoid arthritis patients with moderate disease activity (i.e. earlier in the disease trajectory), this population of patients is set to increase further.
This cohort of patients represents a significant proportion of outpatient follow-up activity, and due to the efficacy of these treatments, many of these patients are in remission and would not otherwise require 6-monthly reviews.
The team at North Bristol Trust started this work prior to the COVID-19 pandemic in 2018 and identified that there was an opportunity to use remote reporting of patient outcomes via a smartphone application to reduce unnecessary face-to-face (F2F) appointments for patients who were in remission. However, their service redesign was expedited with the onset of the pandemic when there was a clinical urgency to maintain a safe and robust bDMARD service, whilst also avoiding face-to-face interactions wherever possible.
Current guidelines require 6-monthly reviews, so the clinical team were previously required to see all patients F2F 6-monthly to assess tolerance to and efficacy of treatment. Before using the app, there was no efficient way to remotely collect outcome data on the patients before they came to clinic.
Due to the effectiveness of bDMARDs and tsDMARDs, patients on these treatments often have the lowest disease activity, and many of these F2F appointments were unnecessary.
An audit before implementation of the service change showed that, in 80% of the F2F appointments, no change was made to medication or treatment plan, suggesting many F2F appointments could be avoided by transferring these to remote (virtual, telephone or video) appointments.
To develop and deliver, in partnership with patients, a bDMARD and tsDMARD service that uses a hybrid clinic model (virtual, telephone, video or escalation to F2F) and remotely completed patient reported outcome measures using a smartphone app to guide practice and minimise unnecessary appointments.
Solution and impact
The team worked together with pharmacists, specialist nurses and doctors, wider rheumatology team and patient representatives group to redesign their b/tsDMARD follow up pathway moving from default F2F clinic appointments to incorporate hybrid clinics. This involved integrating non-F2F modalities (telephone/video/virtual) with traditional F2F clinic appointments.
In addition to remote appointments, the team also rolled out a smartphone app (provided by Living With Ltd.) for patients to allow them to regularly report their disease activity using validated patient reported outcome measures (PROMs; RAPID3/HAQ/self-assessed DAS28/BASDAI).
Electronic Patient Reported Outcomes (ePROM) data were shared with the clinical team via a secure cloud-based platform. This provided longitudinal data to improve F2F and non-F2F consultations.
For patients who regularly reported being in remission and had up-to-date satisfactory blood monitoring, the clinical team were able to complete a virtual b/tsDMARD review without needing to call or see the patient.
With all modalities, patients received a letter summarising the outcome of their biologics review. Patients were invited to call the rheumatology advice line if they needed additional support or advice. The pathway redesign made the default review modality as non-F2F every six months.
However, safety nets included either clinician or patient could request a sooner appointment (expedited review) or F2F apt (escalated review) at any point and a F2F review was mandatory every 3 years.
Over 14 months since implementation of the RTC pathway, a total of 1723 clinical reviews have been undertaken, of which:
- 157 (9%) were F2F
- 1051 (61%) were telephone
- 175 (10%) were video
- 340 (20%) were virtual
Because the local NHS Trust has been under block contract with the commissioners since the start of COVID, cost saving calculations are hypothetical.
Prior to block contract, F2F/video review tariff was £120 and the telephone tariff was £60. Virtual reviews do not currently have a formal tariff as the mode of review has only been in existence during the block contract period. However, assuming a virtual tariff is the same or better than a telephone tariff, the data from the clinic suggest the switch to the hybrid model clinic would have saved a minimum of £73,380 over the 14 months of operation (including smartphone app cost of £0.7 per patient per month).
Non-F2F clinics do not require outpatient staff to coordinate clinics representing additional cost saving to the organisation. Non-F2F clinics also offer the opportunity for clinical staff to work remotely allowing additional flexibility and service resilience.
Clinic letters have been templated, meaning less administrative time is needed for typing and checking letters. Irrespective of the current financial contractual agreement, these savings demonstrate overall efficiencies in cost and time to the integrated care system (ICS).
This shift in working practice has improved efficiency as a virtual review takes approximately 15 minutes to complete including administration time while F2F reviews takes 40 minutes. This represents a saving of 142 hours of specialist nurse and specialist pharmacist clinical time over 14 months compared with if all virtual reviews had been undertaken as F2F consultations. This time saving has been reinvested in the service to improve quality.
The clinical team are now able to run a weekly ad hoc RTC, addressing the needs of patients who may be running out of medication before their next scheduled review (e.g. due to a previously cancelled appointment). These ad hoc reviews can now be completed virtually, using outcome data from the ePROM platform where available, or via telephone (if no ePROM data is available). This approach has ensured safe prescribing for patients who would have previously been supplied additional medication without appropriately checking safety and efficacy. This approach has reduced the number of missed doses, prevented overprescribing of medication, and reduced potential patient harm due to inappropriate prescribing.
Over 1000 patients have downloaded the app and over 34,000 PROMs have been submitted to date. This means that the team now have greater granular disease activity data on their patient disease activity than ever before. The additional benefits of implementing a remote PROMs app in the service is that the team have been able to learn from their RTC pathway developments and adopt similar hybrid clinic models in their routine rheumatology reviews, leading to improved quality and efficiency in their wider service.
- The app has been designed with patient input and is quick and easy to use.
- Patients can use both clinically validated ePROMS (RAPID3/HAQ/self-assessed DAS28/BASDAI) as well as optional symptom tracking for any additional symptoms they may wish to track (anxiety, pain, mood etc).
- There are self-management tools (e.g. fatigue dairies), medication tracking, patient information and secure two-way messaging with the clinical team.
- Patients can record flares and contact the nurse-led advice line from within the app.
- Patients can view their historical data and track changes over time.
- The data entered in the app is stored in a secure cloud-based server which can be accessed via clinical portal using a web browser.
- Registered clinical staff have secure access to the portal via a web browser which allows them to view the data including graphical trends.
- Use of the web browser means no additional software needs to be purchased or installed on hospital computers.
- By using the smartphone app to collect ePROMS remotely, the clinical team can monitor their patients on a day-to-day basis without having to call or see them and take lengthy clinical histories.
- This means the clinical team can triage patients to ensure those with the greatest clinical need are seen promptly and those who are in remission are not offered unnecessary appointments.
- Patients can be invited to download the smartphone app at any point in their clinical care pathway.
- No additional physical or IT infrastructure is needed to use the technology.
- The app can then be used by patients at home, work, or any location to record timely disease activity information.
- The information is accessed via the clinical team to support the outpatient service.
Key learning points
- There is a potential to reduce unnecessary appointments, prioritising F2F reviews for patients with active disease.
- Longitudinal ePROM data:
- improves history taking (speed and reliability of patient recall).
- quickly highlights flares that may have happened since the last review.
- means that the clinical team can review patients asynchronously (i.e. review their data when they are not in clinic or on the telephone).
- supports medication optimisation decision-making in remote clinics.
- There is a spectrum of patient engagement – some really like recording their data, others need to be encouraged and clinical rationale for using the app needs to be explained.
- Patient and MDT involvement is key in any service redesign.
- MDT education is required to facilitate ongoing engagement of a new service.
- Reviewing data in clinic appointments is essential to reinforce use.
- There needs to be a clear clinical pathway and agreement with patients on how ePROMs will be used at the outset.
- Patients benefit from being able to see their own historical data.
- The data can be used for research and audit opportunities.
- For patients who cannot use the app, the clinical team completes outcome measure questionnaires verbally over the telephone with the patients. Paper versions are also available in clinics.
- The clinical pathway includes telephone and F2F appointments, so patients do not need a computer or smartphone to benefit from remote reviews.
- Over £70,000 has been saved per year in unnecessary appointments.
- The service change has released over 140 hours of specialist nurse and specialist pharmacist clinical time which has been reinvested in the service to improve efficiency.
Dr Philip Hamann. Consultant Rheumatologist and Honorary Clinical Lecturer, North Bristol NHS Trust, and University of Bristol
Chris Robson, CEO, Living With
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