ACR Guiding Principles for Decision-Making for In-Person vs Virtual Nonurgent Medical Care

The American College of Rheumatology (ACR) has developed guiding principles for decision-making to distinguish between the need for in-person urgent and virtual nonurgent rheumatology care during the coronavirus disease 2019 (COVID-19) pandemic. This report is published on the ACR website.

The ACR recognizes the importance of physical (“social”) distancing to minimize patients’ risk for exposure to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that causes COVID-19. In addition, rheumatology patients may be at increased risk for complications should they contract COVID-19 because of their compromised immune systems, advanced age, or complex medical conditions. Furthermore, many of these patients with diseases and receiving medications require intensive monitoring, thus increasing the need to distinguish urgent from nonurgent medical care and achieve a balance between physical distancing vs face-to-face visits.

Guidance from the ACR for decision-making around in-person urgent vs virtual nonurgent medical care includes the following:

Authority

• Rheumatologists and rheumatology health professionals are the foremost authority to determine what defines routine, urgent and emergent care for rheumatology patients.
• Regulatory bodies who are not familiar with the needs of rheumatology patients should defer to professional healthcare providers for decisions regarding triage.
• Rheumatologists and rheumatology health professionals consider many factors, including severity of illness, risk for complications, and prevalence of COVID-19 in the local community, when advising on safe methods for delivering care; however, an accurate assessment may be hindered without a face-to-face encounter.
• Healthcare providers should not be subject to a post hoc regulatory audit of urgency during this time.

Urgency

• Circumstances of urgency for in-person vs virtual care must be determined on a case-by-case basis and may change over time with the progression of the COVID-19 pandemic. 
• Potential risks vs benefits of infusions should be based on individual cases. Forced nonmedical switching to a different drug or home infusions without patient or healthcare provider consent remains inappropriate during the COVID-19 pandemic. Withholding therapy for patients with high risk and/or active rheumatologic disease who are receiving subcutaneous and infusible medications increases flare risk and may be life-threatening in some cases. If a patient’s disease is well-controlled, drug holidays are low risk, and physical distancing is not feasible, infusions may be delayed or in-office injections may be reasonable. In addition, clinics may offer curbside pickup of medications to promote physical distancing.
• Face-to-face evaluation and/or treatment of acute flares or ongoing disease activity may be considered if rheumatologists or rheumatology health professionals estimate that the benefits outweigh the risks.
• In-person evaluations for aspiration and/or joint injections may be considered urgent based on severity of pain and/or functional limitation for septic arthritis.
• New patient evaluations for suspected rheumatologic conditions, including rheumatoid arthritis and systemic lupus erythematosus, may be considered as urgent.

Laboratory Monitoring

• Routine laboratory monitoring requires individualized decision-making by rheumatologists or rheumatology health professionals.
• Intervals between routine laboratory monitoring tests may be extended if local environmental factors prevent safe testing on schedule and patient factors, including dose and duration of therapy and prior abnormalities in laboratory test results, are favorable.

Telehealth

• The ACR supports the use of telehealth for eligible patients during the COVID-19 pandemic; however, use of telehealth technologies in these circumstances are complicated by state and regional regulations in terms of medical professionals providing care across state lines.
• The ACR recommends that all states clarify and loosen their regulations, including licensing, certification, and malpractice coverage, to allow appropriate care at a distance during the COVID-19 pandemic in accordance with federal guidance.

Reference

American College of Rheumatology. Guiding principles from the American College of Rheumatology for decision making around in-person urgent versus virtual non-urgent medical care. Published April 1, 2020. Updated April 12, 2020. Accessed April 12, 2020. https://www.rheumatology.org/Portals/0/Files/Guiding-Principles-Urgent-vs-Non-Urgent-Services.pdf

This article originally appeared on Rheumatology Advisor