The coronavirus disease 2019 (COVID-19) is highly infectious with significant associated mortality 1 .
Not surprisingly, its effects on people and societies are multiple. To combat this pandemic, several measures for infection prevention have been implemented. Stay at home (shelter-in-place), social distancing and other measures to reduce transmission have been adopted by many countries worldwide, including the U.S. 2 .
The COVID-19 pandemic has had a significant impact on healthcare and healthcare delivery systems.
Three major changes involved the conversion of regular in-person clinic visits to telephone/video healthcare visits, the use of personal protective equipment by both patients and healthcare providers during in-person healthcare visits and the performance of some work duties by healthcare providers while working from home 3 . The reduced in-person access to healthcare providers and health information is worrisome for people with rheumatic diseases that require close long-term monitoring. Provision of optimal healthcare in these suboptimal circumstances is very challenging.
The Veterans Affairs (VA) is the largest integrated healthcare system in the U.S. with 1,255 health facilities that provides care to more than 9 million veterans annually 4 . The VA has had a state-of-the-art electronic healthcare record system since 1998 that has helped to improve quality of health care. The VA pioneered telehealth more than a decade ago 5 . VA telemedicine visits, including using telephone or video (with a facilitator for examination [clinical video telehealth, CVT] or without facilitator [VA video connect, VVC; direct-to-patient]), were performed for 702,000 veterans in the fiscal year 2016 6 . In 2019, over 900,000 veterans received care through VA telemedicine 5 .
Most VA facilities switched from in-person outpatient visits to telemedicine, using telephone or video (CVT or VVC) visits, between March 16 and 20, 2020, with many facilities prohibiting routine in-person outpatient visits. Our study objective was to conduct a cross-sectional survey of a nationally representative sample of rheumatologists at the VA during the first few months of the COVID-19 pandemic, to assess their experience, views and opinions about rheumatic disease healthcare issues and understand the impact of the pandemic on VA rheumatologists and their patients.
This study was approved by the human ethics committee at the University of Alabama at Birmingham (UAB). We obtained a list of email addresses of VA rheumatologists from the VA Rheumatology Consortium (VARC). VARC is a volunteer work group of VA rheumatologists who practice across the US.
This article is protected by copyright. All rights reserved After pre-piloting with 6 rheumatologists, we finalized the survey. We used Qualtrics™ survey software to send an anonymous survey to all VA rheumatologists who were VARC members on April 16, 2020.
Non-responders received reminders to complete the survey from April 21 to May 18, 2020.
The survey assessed providers' views and opinions about the new healthcare delivery methods, including the best healthcare delivery modality (in-person, telephone or video visit) for the management of each rheumatic disease, diseases appropriate for alternative methods, perceived risk of COVID-19 in rheumatic diseases, rheumatic disease medication shortage, and safety of a future COVID-19 vaccine with rheumatic disease medications. Only a few, but not all questions included CVT with a facilitator, since it is used much less frequently compared to telephone visit or VVC. Provider resilience, or stress coping ability, was measured with a validated 2-item Connor-Davidson Resilience Scale (CD-RISC2), 7 scored from 0 to 8, higher scores corresponding with higher resilience, with a general population mean of 6.9. Physicians have higher resilience scores compared to the general employed population 8 .
Summary statistics were assessed as proportions. Since the number of people completing the surveys was close to 100, the actual numbers presented in the tables were close to the percentages, which are presented in the results section. Logistic regression assessed whether provider age, sex, years of experience and provider resilience (categorized as high resilience, score of 7 or 8, i.e., scores at par with the general population or higher) were independently associated with comfort with technology in providing virtual care to new or established clinic patients. We obtained the information on sex and age for all potential participants from Healthgrades and other publicly available search websites. Analyses were done using IBM® SPSS v25 (Armonk, NY, USA).
Of the 153 eligible VA rheumatologists, 103 completed the survey (67% response rate). Of these 26% each were in the 45 to 54 years and 55 to 64 years age groups; 56% were white, 27% Asian, 6% African American and 5% Hispanic; and 63% were female. More than two thirds had practiced rheumatology for 10 years or more (Appendix 1).
Non-responder characteristics. Potential participants were slightly older (16% vs. 11% were ≥65 yrs) and more likely to be male compared to the survey responders (45% vs. 38%).
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Best modality for established patients. Two-third or more rheumatologists chose telephone follow-up visit as the best modality for gout, osteoporosis, polymyalgia rheumatica, stable rheumatoid arthritis, stable spondyloarthritis (SpA), and osteoarthritis (Figure 1 ). One-third or more rheumatologists chose a video-based VA video connect (VVC) visit follow-up visit as the best modality for local musculoskeletal conditions, tendinitis, rheumatoid arthritis with active medication (DMARD/biologic) changes and patients with stable lupus, scleroderma or vasculitis (Figure 1 ). In contrast, 41-53% of responders selected an in-person follow-up visit as the best modality for people with lupus, scleroderma, or vasculitis with immunosuppressive or glucocorticoid dose changes and rheumatoid arthritis or spondyloarthritis with active medication (DMARD/biologic) changes ( Figure 1 ).
Provision of Healthcare Safely and Efficiently. 43% responders agreed or strongly agreed that they were able to provide healthcare efficiently, 68% were able to provide it safely, and >50% spent a lot of extra time providing this care.
Of the responders, 50% reported using their personal desktop and laptop, 69% were using a VA desktop and 18% were using a VA laptop for providing VA healthcare during the COVID-19 pandemic (providers could choose multiple responses). Of these, 31% were working entirely from the VA hospital or VA clinic, 14% from a non-VA location (or home) and the rest were working from both non-VA and VA locations.
Survey responders reported providing VA healthcare to veterans with rheumatic disease using multiple methods during COVID-19 pandemic: 91% used telephone visits, 59% used video-based VA video connect (VVC) visits, 7% used clinical video telehealth (CVT) visits with a facilitator, and 59% used in-person visits.
A significant proportion of providers reported a 50% or more increase in the following types of visits related to COVID-19: (1) telephone visits, 53%; (2) video-based VA video connect (VVC) visits, 44%; and (3) clinical video tele-health (CVT) visits with a facilitator, 29% (Appendix 2).
Established patients. The proportion of responders who were somewhat or very comfortable while providing healthcare to established clinic patients using each of these methods was as follows: (1) telephone visits, 87%; (2) video-based VA video connect (VVC) visits, 64%; and (3) in-person visits, 54% (Figure 2 ).
This article is protected by copyright. All rights reserved New patients. The proportion of responders who were somewhat or very comfortable providing healthcare to new clinic patients was as follows: (1) telephone visits, 25%; (2) video-based VA video connect (VVC) visits, 34%; and (3) in-person visits, 58% (Figure 2 ). More than 2/3 of responders reported that it was feasible to evaluate a new patient scheduled in their clinic during COVID-19 pandemic.
Among respondents, a majority agreed or strongly agreed that Veterans with autoimmune rheumatic diseases were at a higher risk of COVID-19 infection even in the absence of immunosuppressive drugs (54%) and when currently using immunosuppressive drugs (71%). Similarly, only a small proportion (23%) agreed or strongly agreed that Veterans with non-autoimmune rheumatic diseases were at a higher risk of COVID-19 infection.
About 32% of responders reported a medication shortage. Responders indicated some (little or extreme) shortage for the following: hydroxychloroquine in 45%; IL-6 inhibitors, 15%; non-TNF biologics, 1%;
TNF-biologics, 0%; Janus-inhibitors, 1%; other immunosuppressives, 1%.
Live vaccine. Most responders would not withhold hydroxychloroquine (95%) or sulfasalazine for a live COVID-19 vaccine (74%). A majority would withhold methotrexate or leflunomide (66%) and glucocorticoids of 20 mg/day or higher (52%) for 2 weeks or less; and would withhold anti TNF-biologics (85%), anti-IL-17/23 biologics (82%), , Janus-kinase inhibitors (78%), belimumab (77%), non-TNF biologics (76%), and immunosuppressive drugs such as azathioprine (64%), for 3-8 weeks.
Killed vaccine. A majority of responders (55-100%) would not withhold these drugs for a killed COVID-19 vaccine; another 5-30% would hold them off for <2 weeks.
Convalescent sera. A majority of responders, i.e., 50% or more would not withhold any of these drugs for a convalescent sera treatment of COVID-19.
A significant proportion of responders perceived an increase in healthcare disparities during the COVID-19 pandemic in the following groups: (1) African Americans: 40%; (2) Hispanics, 31%; (3) other racial
This article is protected by copyright. All rights reserved minorities, 19%; (4) low socioeconomic groups, 47%; (5) Females, 8%; (6) Rural residents, 23%; and (7) those with non-service-connected illnesses, 12%.
Of responders, 24% had had a family member or friend with a COVID-19+ test. Three responders had been tested for COVID-19, one reported a negative test result and two received care for COVID-19 at home.
Resilience was high among responders. The mean CD-RISC2 score was 6.35 (SD, 1.260; scores were 6 or higher for more than 80% of people: 46%, 16% and 23% of the responders had high resilience scores of 6, 7 and 8 respectively.
Adjusted for age, sex and ethnicity, a high provider resilience score was independently associated with a significantly higher odds ratio (OR) of more comfort with technology (somewhat or very comfortable) 
We performed a national cross-sectional study of rheumatologists at the VA, the largest integrated health care system in the US. The survey response rate was 67%, higher than the average 61% response rate for physician surveys 9 . Survey responders were similar in age and sex distribution to all potential participants, with slight differences. The survey was conducted 1 month after COVID-19 associated outpatient healthcare delivery changes at the VA. Therefore, findings mostly represent provider experience and practice patterns early in the COVID-19 pandemic. Several study findings deserve further discussion.
During the COVID-19 pandemic, telemedicine has emerged as one of the main ways to deliver healthcare. Telemedicine is an acceptable alternative to an in-person visit from the patient perspective. It can ameliorate the economic burden of clinic visits for people traveling long distances and patients are satisfied with telemedicine visits in these situations 10 . In an observational study of 85 patients with inflammatory Accepted Article arthritis at a single Veterans Affairs Medical Center, patient-reported outcomes for care delivered via telemedicine were similar to usual care, with a significant cost and distance savings 11 .
In a meta-analysis of telemedicine studies in rheumatology, feasibility and patient satisfaction rates were high or very high for various telemedicine interventions and effectiveness was similar to a standard inperson approach 12 . On the other hand, the majority of people preferred an in-person over telemedicine visit for pediatric rheumatology care despite travel and inconvenience 13 . These papers highlight the contrast in patient preference for telemedicine versus in-person visits. High rates of patient satisfaction with telemedicine care (when offered and provided to selected patients) and higher patient preference for inperson over telemedicine visits can co-exist in an ideal world. Telemedicine is a viable alternative to in-person rheumatology follow-up visits during the COVID-19 pandemic.
Telemedicine and specific rheumatic diseases. Our study is the first national study of VA rheumatologists to examine which rheumatic conditions were considered appropriate for virtual visits using the telephone during the COVID-19 pandemic. Survey responders made a clear distinction between conditions that were appropriate for telemedicine versus in-person visits. More than 90% of rheumatologists surveyed considered gout, osteoporosis, osteoarthritis and polymyalgia rheumatica (PMR) to be appropriate for telephone visits or video-based healthcare visits for established patients. Active systemic autoimmune rheumatic conditions (RA, SpA, lupus, vasculitis, scleroderma etc.) with ongoing changes to disease modifying, immunosuppressive or biologic medications were considered most appropriate for in-person visits during the COVID-19 pandemic by the majority of responders. However, one-third favored video visits. These patterns may change over time.
Comfort with technology. Our study found that most respondents were comfortable with telemedicine technology to provide healthcare to established patients with rheumatic diseases. In contrast, less than one third of responders were comfortable with telemedicine technology in providing care to new patients. Previous studies have shown that physicians are satisfied with telemedicine when providing care in specific specialties including cardiology, 14 neurology 15 and primary care 16 . Our national study is among the first to assess this for various rheumatic diseases. Our study describes VA rheumatology providers' views and preferences 4-8 weeks after the switch from in-person regular outpatient visits to telemedicine at VA facilities due to the COVID-19 outbreak in the U.S.
Association between resilience and Telemedicine use outcomes. We found that a high provider resilience score was associated with a 3 to 5-fold higher odds of comfort with technology for telephone and Accepted Article video visits for new patients, with no difference for in-person visits. To our knowledge, there are no published studies of the relationship between provider resilience and higher comfort levels with using telemedicine. Our study provides new data that will need confirmation in other studies. Mean resilience score of 6.35 for VA rheumatologists was similar to 6.49 for US physicians from a recent survey 8 .
Future COVID-19 vaccine in patients with rheumatic diseases. We found that 55-100% of VA rheumatology providers would not withhold one or more treatments for rheumatic diseases or withhold it for <2 weeks to administer an inactivated/killed COVID-19 vaccine. In contrast, >75% would withhold biologic therapy for 2-8 weeks for administering a live COVID-19 vaccine.
Medication shortage. The VA rheumatology providers reported some shortage of hydroxychloroquine (45%) and IL-6 inhibitors (16%) for their VA patients with rheumatic diseases. Due to the potential for hydroxychloroquine and IL-6 inhibitors to be treatments for COVID-19, shortages have been reported by patients with rheumatic diseases 17 .
Racial Disparities. Poor outcomes in African Americans with COVID-19 point to racial healthcare disparities in the U.S. 18 VA Rheumatologists, however, perceived a potential increase in healthcare disparities not only in African Americans and Hispanics, but also in people in the low socioeconomic groups and living in rural areas.
Our study findings must be interpreted considering limitations. These findings cannot be generalized to non-VA settings without an additional similar study. Even though our study responders were similar to non-responders in age and sex, we do not have information on other characteristics and therefore nonresponse bias is a limitation. Several outcomes represent VA rheumatology provider views and opinions, which might change as the COVID-19 epidemic evolves. However, given the nature of healthcare delivery changes related to COVID-19, examining provider views and opinions was our study goal. Prior experience with telemedicine was not assessed, which might have influenced comfort with technology and the likelihood of using telemedicine visits. Providers could only choose one best modality for follow-up visits; it's possible that for some conditions two modalities might be equally good, which our survey is unable to detect.
In conclusion, we conducted a study of experiences, view and opinions of VA rheumatology providers.
The VA is the largest integrated healthcare system in the United States and therefore these findings are important and have implications for the VA system. The knowledge of barriers to the use of telemedicine, medication shortage, increasing healthcare disparities and considerations for future COVID-19 vaccines, can inform future delivery healthcare to patients with rheumatic diseases.
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