European Docs See Smooth Post-COVID Future in Rheumatology

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COPENHAGEN — Nobody in the rheumatology world thinks their profession will avoid long-term changes because of COVID-19, including the Italian researcher chosen to argue that point at the European Alliance of Associations for Rheumatology’s (EULAR) annual meeting.

“COVID-19 will have no impact on rheumatology practice in 3 years” was the title of a EULAR debate held here Thursday, and Maria-Antonietta D’Agostino, MD, PhD, of Universitá Cattolica del Sacro Cuore in Rome, clearly decided it was a no-win position if taken literally.

Instead, she sought to persuade the audience of about 150 that there would be no negative long-term impact on balance.

A vote taken at the end proved that she made a wise choice, as two-thirds of attendees agreed that the changes would mostly be benign, if not actually positive, despite a powerful presentation by her opponent, Philip Conaghan, MBBS, PhD, of the University of Leeds in England.

Conaghan, tasked with arguing that there would indeed be substantial long-term impacts, ticked off a number of likely legacies from COVID-19, some clinical and patient-oriented but more having to do with health economics and day-to-day professional practice. Some were positive, but not many.

Conaghan noted that, during the pandemic’s worst phase, rheumatology clinics largely hibernated as patients were seen by primary care physicians, and often through telemedicine. As a result, use of steroids and opioids in patients with rheumatologic conditions soared. Excessive steroid treatment and opioid dependency on one hand, and lack of true disease-modifying therapy on the other, will inevitably have negative long-term consequences for patients, he argued.

During those months, proper diagnoses also weren’t made in timely fashion for some patients, whose condition worsened irreversibly as a result. And many patients took up smoking and began drinking more. “We don’t know if that will reverse” as COVID recedes, Conaghan said.

Meanwhile, rheumatology practices are in the midst of massive upheaval that will not run its course for years to come, Conaghan suggested. Telemedicine is now here to stay. It has a mix of positive and negative aspects for patients and clinicians, but that there will be some permanent impact can’t be denied, he said.

Rheumatologist training essentially stopped in 2020, and those interns and residents are now having to catch up. While D’Agostino argued that trainees’ redeployment to front-line COVID care made them better doctors, and Conaghan didn’t disagree, he did contest her assertion that they can quickly acquire the specialist skills they didn’t learn when they ordinarily would have.

As well, “long COVID” is a new addition to the rheumatologist’s portfolio. Fatigue is its most common symptom, and musculoskeletal complaints follow closely. “Those patients are going to be referred to me, at least to give them a label,” he said. Rheumatologists must also pay more attention to vaccinations and answer patients’ questions about them and continuing risks from COVID. Currently, he said, he spends 5 minutes in every patient encounter discussing COVID-related issues and that will likely continue.

Other items on Conaghan’s list of long-tail impacts included:

  • Curtailed and terminated research projects
  • Diminished research funding
  • Continued pressure on health system budgets
  • Increased inequality between rich and poor countries

For her part, D’Agostino ignored the economic issues and instead focused on patients’ clinical status, which she said would likely return to the pre-pandemic normal with improvements added in.

Research has shown that vaccinations can be carried out safely and effectively, and indeed much has been learned about how patients on immunomodulatory therapies react to vaccines. In fact, she asserted, we may soon learn how to prevent long COVID with vaccines or other interventions.

Telemedicine’s ramp-up will prove an advantage to patients and clinicians, she continued, by speeding up certain aspects of care. Also, while Conaghan viewed the increased role of primary care physicians in rheumatologic disease management as a negative, D’Agostino characterized it as largely positive. (It may matter that Conaghan’s recent experience is in Britain’s National Health Service whereas D’Agostino works in continental Europe, with their vast differences in funding mechanisms and physician practice parameters.)

She cited another pandemic-forced change in practice that works to everyone’s benefit: The community learned that certain drugs formerly given by IV infusion can be successfully and safely administered via subcutaneous injection, relieving a significant burden on patients and clinics.

She also cited “greater awareness” of autoimmune inflammatory diseases and their treatment among non-rheumatologist physicians as a positive that will outlast COVID.

D’Agostino had the last word in the formal debate since Conaghan went first. That may have helped her win over the audience as well as the moderators, who agreed with her that, despite the debate’s original title, the proper question is whether COVID-19’s lasting impact will be negative. (An audience vote prior to Conaghan and D’Agostino’s presentations went 2:1 that there would indeed be impacts, and D’Agostino later admitted that “we can stop now” if that’s the question.)

In a final Q&A, Conaghan remained unpersuaded that rheumatologists won’t ultimately see that the pandemic hurt them and their patients. If nothing else, he pointed out, the “millions of deaths,” including many healthcare workers, will permanently scar the survivors in ways that won’t easily be offset by improvements elsewhere.

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    John Gever was Managing Editor from 2014 to 2021; he is now a regular contributor.

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