Clinical and bioethical implications of health care interruption during the COVID-19 pandemic: A cross-sectional study in outpatients with rheumatic diseases

Abstract

Background To determine the impact of health care interruption (HCI), on clinical status of the patients reincorporated to an outpatient clinic for rheumatic diseases (OCDIR), from a tertiary care level center who was temporally switched to a dedicated COVID-19 hospital, and to provide a bioethical analysis. Methods From March to June 2020, the OCDIR was closed; since June, it is limited to evaluate 25% of the ongoing outpatients. This cross-sectional study surveyed 670 consecutive rheumatic outpatients between June 24th and October 31th, concomitant to the assessment of the rheumatic disease clinical status by the attendant rheumatologist, according to disease activity level, clinical deterioration and adequate/inadequate control. Multiple logistic regression analysis identified factors associated to HCI and to clinical deterioration. Results Patients were middle-aged females (86.7%), with median disease duration of 10 years, comorbidity (38.5%) and 138 patients (20.6%) had discontinued treatment. Primary diagnoses were SLE and RA, in 285 (42.5%) and 223 (33.3%) patients, respectively. There were 344 patients (51.3%) with HCI. Non-RA diagnosis (OR: 2.21, 95%CI: 1.5–3.13), comorbidity (OR: 1.7, 95%CI: 1.22–2.37), patient’s need for rheumatic care during HCI (OR: 3.2, 95%CI: 2.06–4.97) and adequate control of the rheumatic disease (OR: 0.64, 95%CI: 0.45–0.9) were independently associated to HCI. There were 160 patients (23.8%) with clinical deterioration and associated factors were disease duration, substantial disease activity previous HCI, patients need for rheumatic care and treatment discontinuation. Conclusions HCI during COVID-19 pandemic impacted course of rheumatic diseases and need to be considered in the bioethical analysis of virus containment measures.

Quality of life of patients with rheumatic diseases during the COVID-19 pandemic: The biopsychosocial path

“…The survey five components were (Please refer to the S1 Appendix ): patient’s HCI (Yes/No) and reasons (two items), patient’s need for medical care and hospitalization during HCI (three items), patient’s need for communication with attending physicians or additional healthcare professionals (six items), patients modification of rheumatic disease-related treatment and reasons (three items) and patients perception of risk for SARS-CoV-2 infection (16 items, adapted from [ 31 ]). Relevant survey results had been previously described [ 29 ].…”

“…Also, attendant rheumatologists (21 assigned to the OCDIR) scored the patient’s clinical status according to the current level of disease activity, the course of disease activity, and the rheumatic disease control [ 29 ].…”

“…Finally, at baseline (and six-month follow-up) patient’s risk perception for the SARS-CoV-2 infection component survey was applied [ 29 , 31 ]. The component was part of the COVID-19 survey ( S1 Appendix ).…”

“…HCI was defined as the cancelation of a scheduled face-to-face appointment to the OCDIR without re-scheduling within the next 3 months AND/OR care not provided to patients who required rheumatologic emergency care AND/OR patients’ decision not to attend the OCDIR; the outcome was based on the answer provided to the first component of the survey [ 29 ]. The baseline characteristics of patients with and without HCI were compared using the X 2 test for the categorical variables, Student’s t-test for continuous variables with a normal distribution, and the Mann-Whitney U test for continuous variables with non-normal distribution.…”

“…We previously showed that health care interruption (HCI) during the COVID-19 pandemic impacted the clinical status of the underlying rheumatic disease, which was assessed from the physician’s perspective, among 670 patients with different rheumatologic diagnoses [ 29 ]. To approach the patient’s perspective, we evaluated the impact of HCI on four dimensions of patients’ QoL- the physical, psychological, social relationships and environment dimensions, and two additional facets- overall QoL and general health; we also explored factors associated to the QoL when patients were reinstalled at the outpatient clinic, and after six months of continuous follow-up.…”