Telemedicine use by pediatric rheumatologists during the COVID-19 pandemic

Abstract

Background To characterize various aspects of telemedicine use by pediatric rheumatology providers during the recent pandemic including provider acceptability of telehealth practices, clinical reliability, and clinical appropriateness. Methods An electronic survey was generated and disseminated amongst the Childhood Arthritis and Rheumatology Research Alliance (CARRA) listserv (n = 547). Survey items were analyzed via descriptive statistics by question. Results The survey response rate was 40.8% (n = 223) with the majority of respondents in an attending-level role. We observed that musculoskeletal components of the exam were rated as the most reliable components of a telemedicine exam and 86.5% of survey respondents reported engaging the patient or patient caregiver to help conduct the virtual exam. However, 65.7% of providers reported not being able to elicit the information needed from a telemedicine visit to make a complete clinical assessment. We also noted areas of disagreement regarding areas of patient engagement and confidentiality. We found that approximately one-third (35.8%) of those surveyed felt that their level of burnout was increased due to telemedicine. Conclusion In general, providers found exam reliability (specifically around focused musculoskeletal elements) in telemedicine visits but overall felt that they were unable to generate the information needed to generate a complete clinical assessment. Additionally, there were suggestions that patient engagement and confidentiality varied during telemedicine visits when compared to in-person clinical visits. Further qualitative work is needed to fully explore telemedicine use in pediatric rheumatology.

The Telemedicine-Based Pediatric Examination of the Neck and Upper Limbs: A Narrative Review

“…A survey of pediatric rheumatologists performing virtual musculoskeletal exams revealed that 62% of the cervical spine assessments were reliably performed over videoconference. 16 When comparing virtual cervical spine consultations in adults to their face-to-face counterpart, a high degree of concurrent validity as well as excellent interand intra-rater reliability was observed for neck posture, active ROM, and DNFET. 34 Additionally, substantial and near-perfect intra-rater reliabilities were observed for Lhermitte's sign and the Spurling test, respectively.…”

“…As a final point, we urge physicians to remain cautious of their findings as strength assessment in children has been shown to be reliable in only 29% of videoconference appointments. 16 It is also worth noting that no reliable method of eliciting reflexes over telemedicine has been identified, except clonus at the ankles and the Babinski reflex, 8,18,38 although the latter has questionable applicability. 37,39…”

“…A study of pediatric rheumatologists performing video consultations of the elbows, wrists, and hands concluded that 63% of assessments were reliably executed. 16 In adults, one study investigating remote consultations for elbow pathologies compared conventional face-to-face physical findings (including ROM, self-palpation, strength, neural tension and special testing) and pathoanatomical diagnoses to those obtained through videoconference appointments. 55 It showed that 73% of the diagnoses were either similar or identical.…”

“…These include the American Telemedicine Association's "Operating Procedures for Pediatric Telehealth" 14 and the Virtual Pediatric Gait, Arms, Limbs, and Spine (V-pGALS) exam, 15 the latter of which was reported to be the most commonly used standardized exam approach among pediatric rheumatologists. 16 Our recent review also illustrates how to perform a virtual pediatric examination of the back and lower limbs and summarizes the advantages and limitations of performing these examinations over telemedicine. 17 In addition, there are several papers describing how to perform a virtual musculoskeletal examination in adults.…”

“…A recent study revealed that physicians performing remote pediatric musculoskeletal examinations enlisted patient or caregiver support in 86.5% of consultations. 16 While caregiver support is generally required for most visits, our own experience suggests that certain maneuvers can be self-performed by older children and adolescents alone. In addition to these guidelines, we include our own recommendations for performing certain examination components.…”