[Use of medical apps and online platforms among German rheumatologists : Results of the 2016 and 2018 DGRh conference surveys and research conducted by rheumadocs]

[Acceptance of video consultation among patients with inflammatory rheumatic diseases depends on gender and location-Results of an online survey among patients and physicians]

INTRODUCTION

In order to successfully integrate telemedicine into the daily routine of rheumatology, both the patient's and the physician's perspective are important. For this purpose, a detailed study by means of a web-based survey was conducted by the Working Group Young Rheumatology (AGJR) of the German Society for Rheumatology (DGRh) and the German Rheumatism League National Association. By means of subgroup analysis of the data regarding video consultation, the aim was now to find out which requirements and wishes patients and physicians have for video consultations.

METHODS

The prospective survey was distributed via social media, QR code and email. Descriptive statistics and regression analysis related to video consultation were performed and correlations were shown.

RESULTS

The data indicated positive attitudes toward video consultation on the part of both patients (n = 299) and rheumatologists (n = 129). A correlation between age and positive opinion of the video consultation was found among the patients (r = 0.161, p = 0.006), especially among female patients a positive approval of the video consultation was found with increasing age (r = 0.244, p < 0.001 to male patients: r = -0.190, p = 0.145). Regarding the travelling time to the treating rheumatologist, male patients found the video consultation more attractive with increasing travelling time (r = 0.229, p = 0.078). With respect to the wishes of patients and physicians, video consultation should be used primarily for follow-up or emergency appointments. Video consultation for initial appointments, on the other hand, was very rarely mentioned.

CONCLUSION

During the COVID 19 pandemic, video consultation was increasingly popular among rheumatology patients as well as among rheumatologists.

Factors Associated With Telemedicine Use Among German General Practitioners and Rheumatologists: Secondary Analysis of Data From a Nationwide Survey

Background

Previous studies have demonstrated telemedicine (TM) to be an effective tool to complement rheumatology care and address workforce shortage. With the outbreak of the SARS-CoV-2 pandemic, TM experienced a massive upswing. However, in rheumatology care, the use of TM stagnated again shortly thereafter. Consequently, the factors associated with physicians’ willingness to use TM (TM willingness) and actual use of TM (TM use) need to be thoroughly investigated.

Objective

This study aimed to identify the factors that determine TM use and TM willingness among German general practitioners and rheumatologists.

Methods

We conducted a secondary analysis of data from a German nationwide cross-sectional survey with general practitioners and rheumatologists. Bayesian univariate and multivariate logistic regression analyses were applied to the data to determine which factors were associated with TM use and TM willingness. The predictor variables (covariates) that were studied individually included sociodemographic factors (eg, age and sex), work characteristics (eg, practice location and medical specialty), and self-assessed knowledge of TM. All the variables positively and negatively associated with TM use and TM willingness in the univariate analysis were then considered for Bayesian model averaging analysis after a selection based on the variance inflation factor (≤2.5). All analyses were stratified by sex.

Results

Univariate analysis revealed that out of 83 variables, 36 (43%) and 34 (41%) variables were positively or negatively associated (region of practical equivalence≤5%) with TM use and TM willingness, respectively. The Bayesian model averaging analysis allowed us to identify 13 and 17 factors of TM use and TM willingness, respectively. Among these factors, being female, having very poor knowledge of TM, treating <500 patients per quarter, and not being willing to use TM were negatively associated with TM use, whereas having good knowledge of TM and treating >1000 patients per quarter were positively associated with TM use. In addition, being aged 51 to 60 years, thinking that TM is not important for current and future work, and not currently using TM were negatively associated with TM willingness, whereas owning a smart device and working in an urban area were positively associated with TM willingness.

Conclusions

The results point to the close connection between health care professionals’ knowledge of TM and actual TM use. These results lend support to the integration of digital competencies into medical education as well as hands-on training for health care professionals. Incentive programs for physicians aged >50 years and practicing in rural areas could further encourage TM willingness.

One year of digital health applications (DiGA) in Germany - Rheumatologists' perspectives

BACKGROUND

Based on given legislation the German approach to digital health applications (DiGA) allows reimbursed prescription of approved therapeutic software products since October 2020. For the first time, we evaluated DiGA-related acceptance, usage, and level of knowledge among members of the German Society for Rheumatology (DGRh) 1 year after its legal implementation.

MATERIALS AND METHODS

An anonymous cross-sectional online survey, initially designed by the health innovation hub (think tank and sparring partner of the German Federal Ministry of Health) and the German Pain Society was adapted to the field of rheumatology. The survey was promoted by DGRh newsletters and Twitter-posts. Ethical approval was obtained.

RESULTS

In total, 75 valid response-sets. 80% reported to care ≥ 70% of their working time for patients with rheumatic diseases. Most were working in outpatient clinics/offices (54%) and older than 40 years (84%). Gender distribution was balanced (50%). 70% knew the possibility to prescribe DiGA. Most were informed of this for the first time via trade press (63%), and only 8% via the scientific/professional society. 46% expect information on DiGA from the scientific societies/medical chambers (35%) but rarely from the manufacturer (10%) and the responsible ministry (4%). Respondents would like to be informed about DiGA via continuing education events (face-to-face 76%, online 84%), trade press (86%), and manufacturers' test-accounts (64%). Only 7% have already prescribed a DiGA, 46% planned to do so, and 47% did not intend DiGA prescriptions. Relevant aspects for prescription are provided. 86% believe that using DiGA/medical apps would at least partially be feasible and understandable to their patients. 83% thought that data collected by the patients using DiGA or other digital solutions could at least partially influence health care positively. 51% appreciated to get DiGA data directly into their patient documentation system/electronic health record (EHR) and 29% into patient-owned EHR.

CONCLUSION

Digital health applications awareness was high whereas prescription rate was low. Mostly, physician-desired aspects for DiGA prescriptions were proven efficacy and efficiency for physicians and patients, risk of adverse effects and health care costs were less important. Evaluation of patients' barriers and needs is warranted. Our results might contribute to the implementation and dissemination of DiGA.

Efficacy and safety of a mobile app intervention in patients with inflammatory arthritis: a prospective pilot study

EULAR highlighted the essential role of digital health in increasing self-management and improving clinical outcomes in patients with arthritis. The objective of this study was to evaluate the efficacy and safety of the digital health application (DHA) in patients with inflammatory arthritis. We assessed demographic parameters, treatment regimen, disease activity, and other patient-reported outcomes at baseline and after 4 weeks of DHA use added to standard care treatment. Of 17 patients, who completed the study, 7 (41.2%) patients were male, ranging from 19 to 63 (40.5 ± 12.2) years. No significant change in antirheumatic treatment was observed during the study. Statistically significant improvements (p < 0.05) were noted for health-related quality of life (increase in Physical Component Summary of Short Form-36 (SF-36) by 23.6%) and disease activity (decrease of Clinical Disease Activity Index and Simple Disease Activity Index by 38.4% and 39.9%, respectively). Clinically significant improvement was demonstrated for SF-36 Total Score (+ 14.4%), disease activity (Rheumatoid Arthritis Disease Activity Index− 5 to 15.9%), and depression (Patient Health Questionnaire− 9 to 13.5%). None of the efficacy parameters showed negative trends. No adverse events were reported throughout the study. The usability level was high i.e., the mean mHealth Application Usability Questionnaire Score of 5.96 (max.: 7.0) demonstrated a high level of application usability. This suggests that using a personalized disease management program based on DHA significantly improves several measures of patient-reported outcomes and disease activity in patients with inflammatory arthritis in a timely manner. These findings highlight the potential of complementary digital therapy in patients with inflammatory arthritis.

Review and Analysis of German Mobile Apps for Inflammatory Bowel Disease Management Using the Mobile Application Rating Scale: Systematic Search in App Stores and Content Analysis

Background

Patients suffering from inflammatory bowel disease (IBD) frequently need long-term medical treatment. Mobile apps promise to complement and improve IBD management, but so far there has been no scientific analysis of their quality.

Objective

This study evaluated the quality of German mobile apps targeting IBD patients and physicians treating IBD patients using the Mobile Application Rating Scale (MARS).

Methods

The German Apple App Store and Google Play Store were systematically searched to identify German IBD mobile apps for patient and physician use. MARS was used by 6 physicians (3 using Android smartphones and 3 using iPhones) to independently assess app quality. Apps were randomly assigned so that the 4 apps with the most downloads were rated by all raters and the remaining apps were rated by 1 Android and 1 iOS user.

Results

In total, we identified 1764 apps in the Apple App Store and Google Play Store. After removing apps that were not related to IBD (n=1386) or not available in German (n=317), 61 apps remained. After removing duplicates (n=3) and apps for congresses (n=7), journals (n=4), and clinical studies (n=6), as well as excluding apps that were available in only 1 of the 2 app stores (n=20) and apps that could only be used with an additional device (n=7), we included a total of 14 apps. The app “CED Dokumentation und Tipps” had the highest overall median MARS score at 4.11/5. On the whole, the median MARS scores of the 14 apps ranged between 2.38/5 and 4.11/5. As there was no significant difference between iPhone and Android raters, we used the Wilcoxon comparison test to calculate P values.

Conclusions

The MARS ratings showed that the quality of German IBD apps varied. We also discovered a discrepancy between app store ratings and MARS ratings, highlighting the difficulty of assessing perceived app quality. Despite promising results from international studies, there is little evidence for the clinical benefits of German IBD apps. Clinical studies and patient inclusion in the app development process are needed to effectively implement mobile apps in routine care.

Rheumatic?-A Digital Diagnostic Decision Support Tool for Individuals Suspecting Rheumatic Diseases: A Multicenter Pilot Validation Study

Introduction

Digital diagnostic decision support tools promise to accelerate diagnosis and increase health care efficiency in rheumatology. Rheumatic? is an online tool developed by specialists in rheumatology and general medicine together with patients and patient organizations. It calculates a risk score for several rheumatic diseases. We ran a pilot study retrospectively testing Rheumatic? for its ability to differentiate symptoms from existing or emerging immune-mediated rheumatic diseases from other rheumatic and musculoskeletal complaints and disorders in patients visiting rheumatology clinics.

Materials and Methods

The performance of Rheumatic? was tested using in three university rheumatology centers: (A) patients at Risk for RA (Karolinska Institutet, n = 50 individuals with musculoskeletal complaints and anti-citrullinated protein antibody positivity) (B) patients with early joint swelling [dataset B (Erlangen) n = 52]. (C) Patients with early arthritis where the clinician considered it likely to be of auto-immune origin [dataset C (Leiden) n = 73]. In dataset A we tested whether Rheumatic? could predict the development of arthritis. In dataset B and C we tested whether Rheumatic? could predict the development of an immune-mediated rheumatic diseases. We examined the discriminative power of the total score with the Wilcoxon rank test and the area-under-the-receiver-operating-characteristic curve (AUC-ROC). Next, we calculated the test characteristics for these patients passing the first or second expert-based Rheumatic? scoring threshold.

Results

The total test scores differentiated between: (A) Individuals developing arthritis or not, median 245 vs. 163, P < 0.0001, AUC-ROC = 75.3; (B) patients with an immune-mediated arthritic disease or not median 191 vs. 107, P < 0.0001, AUC-ROC = 79.0; but less patients with an immune-mediated arthritic disease or not amongst those where the clinician already considered an immune mediated disease most likely (median 262 vs. 212, P < 0.0001, AUC-ROC = 53.6). Threshold-1 (advising to visit primary care doctor) was highly specific in dataset A and B (0.72, 0.87, and 0.23, respectively) and sensitive (0.67, 0.61, and 0.67). Threshold-2 (advising to visit rheumatologic care) was very specific in all three centers but not very sensitive: specificity of 1.0, 0.96, and 0.91, sensitivity 0.05, 0.07, 0.14 in dataset A, B, and C, respectively.

Conclusion

Rheumatic? is a web-based patient-centered multilingual diagnostic tool capable of differentiating immune-mediated rheumatic conditions from other musculoskeletal problems. The current scoring system needs to be further optimized.

Digitalisierung in der Rehabilitation von rheumatischen Erkrankungen: Was ist sinnvoll, was ist bewiesen, welche Perspektiven gibt es?

In Deutschland besteht ein deutlicher Mangel an internistischen Rheumatologen. Um diese Versorgungslücke zu reduzieren, können verschiedene technische Anwendungen genutzt werden. Dies reicht von der Hilfe bei der Früherkennung und Diagnostik für Hausärzte, über Konsilsysteme mit Telemedizin, bis hin zur Videosprechstunde mit den Patienten nach Koordination in einem entsprechenden Netzwerk, das stufenförmig aufgebaut ist, um die vorhandenen Spezialisten möglichst effektiv einzusetzen. Auch Apps für die Nutzung am Smartphone oder Tablet können sowohl Ärzte in Diagnostik und Therapie unterstützen, aber auch vielfältig Patienten bei den jeweiligen Krankheitsbewältigungen helfen. Eine Sonderform sind dabei „Digitale Gesundheitsanwendungen“ (DiGAs), die geprüft wurden und als Medizinprodukte zugelassen und verordnungsfähig sind. Für die Unterstützung von Bewegungsübungen, wie sie bei rheumatischen Erkrankungen so wichtig sind, kommen auch Telemedizinische Assistenzsysteme in Betracht, bei denen über 3D-Kamera und Computeranalyse zu Hause ein individuelles Übungsprogramm angeleitet und kontrolliert wird. Studien zu Anwendungen und Bewertungsoptionen für Apps liegen bereits einige vor, hier besteht aber noch hoher Nachholbedarf.

[Identification of rheumatological health apps in the Apple app store applying the "semiautomatic retrospective app store analysis" method : A longitudinal observation]

Hintergrund

Die App Stores von Apple und Google bieten eine Vielzahl von Gesundheits-Apps an. Das Auffinden qualitativ hochwertiger Apps ist immer noch eine Herausforderung.

Fragestellung

Lassen sich unter Anwendung der SARASA(„semiautomated retrospective App Store analysis“)-Methode für das Fachgebiet Rheumatologie deutschsprachige Apps identifizieren?

Material und Methode

SARASA ist eine Methode zur teilautomatisierten Auswahl und Charakterisierung von App Store-gelisteten Apps nach formalen Kriterien. Nach der ersten Anwendung in 02/2018 wurde SARASA 02/2020 erneut auf den Apple App Store angewendet.

Ergebnisse

In 02/2018 konnten für Apps in den Store-Kategorien „Medizin“ oder „Gesundheit und Fitness“ Metadaten zu 103.046 Apps und bei einer erneuten Erhebung in 02/2020 Daten zu 94.735 Apps über das deutsche Frontend des Apple App Stores ausgelesen werden. Im Jahr 2018 wurden nach Anwendung der Suchbegriffe 59 Apps mit einer deutschsprachigen Beschreibung für das Fachgebiet Rheumatologie identifiziert, 2020 waren dies 53 Apps, die jeweils manuell weiter überprüft wurden; 2018 waren noch mehr der gefundenen Apps für Patienten als für Ärzte vorgesehen, dies war 2020 ausgeglichener. Zudem zeigte sich, dass bei bestimmten Krankheitsbildern von den App-Entwicklern keine Bearbeitungen erfolgten. Die prozentuale Verteilung von Treffern nach Suchbegriffen zeigte im Vergleich von 2018 zu 2020 große Schwankungen.

Diskussion

Die SARASA-Methode stellt ein hilfreiches Werkzeug dar, um Gesundheits-Apps teilautomatisiert zu identifizieren, die vordefinierten, formalen Kriterien entsprechen. Die inhaltliche Qualität muss anschließend manuell überprüft werden. Weiterentwicklungen der SARASA-Methode und die weitere Konsentierung und Standardisierung von Qualitätskriterien sind sinnvoll. Qualitätskriterien sollten beim Angebot von Gesundheits-Apps in den App-Stores berücksichtigt werden.

Digital Approaches for a Reliable Early Diagnosis of Psoriatic Arthritis

Psoriatic arthritis (PsA) is a chronic inflammatory disease that develops in up to 30% of patients with psoriasis. In the vast majority of cases, cutaneous symptoms precede musculoskeletal complaints. Progression from psoriasis to PsA is characterized by subclinical synovio-entheseal inflammation and often non-specific musculoskeletal symptoms that are frequently unreported or overlooked. With the development of increasingly effective therapies and a broad drug armamentarium, prevention of arthritis development through careful clinical monitoring has become priority. Identifying high-risk psoriasis patients before PsA onset would ensure early diagnosis, increased treatment efficacy, and ultimately better outcomes; ideally, PsA development could even be averted. However, the current model of care for PsA offers only limited possibilities of early intervention. This is attributable to the large pool of patients to be monitored and the limited resources of the health care system in comparison. The use of digital technologies for health (eHealth) could help close this gap in care by enabling faster, more targeted and more streamlined access to rheumatological care for patients with psoriasis. eHealth solutions particularly include telemedicine, mobile technologies, and symptom checkers. Telemedicine enables rheumatological visits and consultations at a distance while mobile technologies can improve monitoring by allowing patients to self-report symptoms and disease-related parameters continuously. Symptom checkers have the potential to direct patients to medical attention at an earlier point of their disease and therefore minimizing diagnostic delay. Overall, these interventions could lead to earlier diagnoses of arthritis, improved monitoring, and better disease control while simultaneously increasing the capacity of referral centers.

Comparison of the Differences Between Web-Based and Traditional Questionnaire Surveys in Pediatrics: Comparative Survey Study

BACKGROUND

A web-based survey is a novel method for data capture. Some studies have applied web-based surveys in pediatrics, but few of them have reported data on the differences between web-based and traditional questionnaire surveys.

OBJECTIVE

The objective of our study was to evaluate the internal consistency of a web-based survey and compare it with a traditional questionnaire survey in pediatrics.

METHODS

A convenience sample of caregivers was invited to participate in the survey on feeding patterns and their children's eating behaviors if their children were aged 2 to 7 years. A web-based survey and a traditional questionnaire survey were carried out between October 2018 and July 2019. A total of 1085 caregivers were involved in this study, and they were divided into the following three groups based on methods and sources: (1) web-based survey from a web source, (2) web-based survey from a hospital source, and (3) traditional questionnaire survey from a hospital source. The data were then compared and analyzed.

RESULTS

A total of 735 caregivers participated in the web-based survey and 350 caregivers participated in the traditional questionnaire survey, and 816 cases were then included in the analyses after data processing. The effective rate of the web-based survey was 70.1% (515/735), and the completeness rate of the traditional questionnaire survey was 86.0% (301/350). There were no significant differences between web-based surveys from different sources. However, demographic characteristics were significantly different between the web-based and traditional questionnaire surveys, mainly in terms of age and caregivers (χ²₄=16.509, P=.002 and χ²₄=111.464, P<.001, respectively). Caregivers of children aged 2 to 3 years and grandparents were more likely to respond to the web-based survey. Age-specific stratified analysis showed that the score of "monitoring" and the reporting rate of "poor appetite" in children aged 2 to 3 years were significantly higher in the web-based survey compared to the traditional questionnaire survey after adjusting for demographic characteristics.

CONCLUSIONS

A web-based survey could be a feasible tool in pediatric studies. However, differences in demographic characteristics and their possible impacts on the results should be considered in the analyses.

Quality of a Supporting Mobile App for Rheumatic Patients: Patient-Based Assessment Using the User Version of the Mobile Application Scale (uMARS)

Introduction: Mobile applications promise to improve current health care. However, current mobile app quality ratings are mostly physician-based. The aim of this study was (1) to assess the quality of the self-management app Rheuma Auszeit using the validated uMARS (User Version of the Mobile App Rating Scale) app quality assessment tool and (2) to evaluate the association between uMARS scores and patients' characteristics.

Materials and Methods: Consecutive patients with rheumatoid arthritis, psoriatic arthritis and spondyloarthritis were seen at the rheumatology clinic at university hospital Erlangen, Germany. They were asked to test Rheuma Auszeit, evaluate its quality using uMARS and complete a paper-based survey evaluating the individual preferences, attitudes and ehealth literacy. The association between uMARS scores and patients' characteristics was further explored.

Results: Between December 2018 and January 2019, a total of 126 patients evaluated Rheuma Auszeit using uMARS and filled out the paper-based survey. The median uMARS score was 3.9, IQR 0.7. Functionality was the domain with the highest rating (median 4.8, IQR 0.8), followed by aesthetics (median 4.0, IQR 0.7), information (median 3.5, IQR 0.8), and engagement (median 3.2, IQR 1.0). Subjective quality was average (median 3.0, IQR 1.0). The lowest scoring individual item was customization with a median of 2.5/5. Lower functionality scores were reported among older female rheumatic patients (P < 0.004). Older male rheumatic patients reported a higher subjective quality score (P < 0.024). Perceived disease activity and disease duration did not significantly correlate with any uMARS subdomain scores. eHealth literacy significantly correlated with functionality uMARS subdomain ratings (Rho = 0.18; P < 0.042). Preferred time of app usage significantly correlated with engagement (Rho = 0.20; P < 0.024), functionality (Rho = 0.19; P < 0.029), total uMARS score (Rho = 0.21; P < 0.017) and subjective quality score (Rho = 0.21; P < 0.017). The vast majority of rheumatic patients would consider recommending Rheuma Auszeit to other patients (117/126; 92.9%).

Conclusion: Rheuma Auszeit was well-accepted by German patients suffering from rheumatoid arthritis, psoriatic arthritis and ankylosing spondyloarthritis. Lacking customization could lead to low app compliance and should be improved. Lower functionality scores among older female rheumatic patients highlight the need for patient education. The study underlines the potential and feasibility of therapeutic complementary digital solutions in rheumatology.

A Real-World Rheumatology Registry and Research Consortium: The German RheumaDatenRhePort (RHADAR) Registry

Real-world data are crucial to continuously improve the management of patients with rheumatic and musculoskeletal diseases (RMDs). The German RheumaDatenRhePort (RHADAR) registry encompasses a network of rheumatologists and researchers in Germany providing pseudonymized real-world patient data and allowing timely and continuous improvement in the care of RMD patients. The RHADAR modules allow automated anamnesis and adaptive coordination of appointments regarding individual urgency levels. Further modules focus on the collection and integration of electronic patient-reported outcomes in between consultations. The digital RHADAR modules ultimately allow a patient-centered adaptive approach to integrated medical care starting as early as possible in the disease course. Such a closed-loop system consisting of various modules along the whole patient pathway enables comprehensive and timely patient management in an unprecedented manner.

Acceptance of Telerheumatology by Rheumatologists and General Practitioners in Germany: Nationwide Cross-sectional Survey Study

Background

The worldwide burden of musculoskeletal diseases is increasing. The number of newly registered rheumatologists has stagnated. Primary care, which takes up a key role in early detection of rheumatic disease, is working at full capacity. COVID-19 and its containment impede rheumatological treatment. Telemedicine in rheumatology (telerheumatology) could support rheumatologists and general practitioners.

Objective

The goal of this study was to investigate acceptance and preferences related to the use of telerheumatology care among German rheumatologists and general practitioners.

Methods

A nationwide, cross-sectional, self-completed, paper-based survey on telerheumatology care was conducted among outpatient rheumatologists and general practitioners during the pre-COVID-19 period.

Results

A total of 73.3% (349/476) of survey participants rated their knowledge of telemedicine as unsatisfactory, poor, or very poor. The majority of survey participants (358/480, 74.6%) answered that they do not currently use telemedicine, although 62.3% (291/467) would like to. Barriers to the implementation of telemedicine include the purchase of technology equipment (182/292, 62.3%), administration (181/292, 62.0%), and poor reimbursement (156/292, 53.4%). A total of 69.6% (117/168) of the surveyed physicians reckoned that telemedicine could be used in rheumatology. Surveyed physicians would prefer to use telemedicine to communicate directly with other physicians (370/455, 81.3%) than to communicate with patients (213/455, 46.8%). Among treatment phases, 64.4% (291/452) of participants would choose to use telemedicine during follow-up. Half of the participants would choose telecounseling as a specific approach to improve rheumatology care (91/170, 53.5%).

Conclusions

Before COVID-19 appeared, our results indicated generally low use but high acceptance of the implementation of telerheumatology among physicians. Participants indicated that the lack of a structural framework was a barrier to the effective implementation of telerheumatology. Training courses should be introduced to address the limited knowledge on the part of physicians in the use of telemedicine. More research into telerheumatology is required. This includes large-scale randomized controlled trials, economic analyses, and the exploration of user preferences.

Digital rheumatology in the era of COVID-19: results of a national patient and physician survey

OBJECTIVE

To analyse the impact of the COVID-19 pandemic on rheumatic patients' and rheumatologists' usage, preferences and perception of digital health applications (DHAs).

METHODS

A web-based national survey was developed by the Working Group Young Rheumatology of the German Society for Rheumatology and the German League against Rheumatism. The prospective survey was distributed via social media (Twitter, Instagram and Facebook), QR code and email. Descriptive statistics were calculated, and regression analyses were performed to show correlations.

RESULTS

We analysed the responses of 299 patients and 129 rheumatologists. Most patients (74%) and rheumatologists (76%) believed that DHAs are useful in the management of rheumatic and musculoskeletal diseases (RMDs) and felt confident in their own usage thereof (90%; 86%). 38% of patients and 71% of rheumatologists reported that their attitude had changed positively towards DHAs and that their usage had increased due to COVID-19 (29%; 48%). The majority in both groups agreed on implementing virtual visits for follow-up appointments in stable disease conditions. The most reported advantages of DHAs were usage independent of time and place (76.6%; 77.5%). The main barriers were a lack of information on suitable, available DHAs (58.5%; 41.9%), poor usability (42.1% of patients) and a lack of evidence supporting the effectiveness of DHAs (23.2% of rheumatologists). Only a minority (<10% in both groups) believed that digitalisation has a negative impact on the patient-doctor relationship.

CONCLUSION

The COVID-19 pandemic instigated an increase in patients' and rheumatologists' acceptance and usage of DHAs, possibly introducing a permanent paradigm shift in the management of RMDs.

[Position paper of the commission on digital rheumatology of the German Society of Rheumatology: tasks, targets and perspectives for a modern rheumatology]

Digitalization in the healthcare system is a great challenge for rheumatology as for other medical disciplines. The German Society for Rheumatology (DGRh) wants to actively participate in this process and benefit from it. By founding the commission on digital rheumatology, the DGRh has created a committee that deals with the associated tasks, advises the DGRh on questions and positions associated with digital health. For the DGRh, this affects the most diverse areas of digitalization in medicine and rheumatology. This position paper presents the topics and developments currently handled by the commission and the tasks identified.

[Mobile apps and their usage in rheumatology]

The increasing use of smartphones is accompanied by a significant increase in the use of mobile applications (apps). Chronically ill patients could permanently profit from this development.This development is fuelled by the Digital Healthcare Act (DVG), whereby patients have a legal claim to certain apps, so-called digital health applications (DiGAs), which are reimbursed by the statutory health insurance companies. Especially in the field of rheumatology, there are various opportunities to implement apps in the management of chronic diseases and their comorbidities. Furthermore, rheumatic patients and rheumatologists are becoming interested in apps and are willing to use them in the daily routine. This article tries to shed light on the chances and risks of apps and gives a first insight into the digital landscape of rheumatology apps in Germany.

Mobile Health Usage, Preferences, Barriers, and eHealth Literacy in Rheumatology: Patient Survey Study

Background

Mobile health (mHealth) defines the support and practice of health care using mobile devices and promises to improve the current treatment situation of patients with chronic diseases. Little is known about mHealth usage and digital preferences of patients with chronic rheumatic diseases.

Objective

The aim of the study was to explore mHealth usage, preferences, barriers, and eHealth literacy reported by German patients with rheumatic diseases.

Methods

Between December 2018 and January 2019, patients (recruited consecutively) with rheumatoid arthritis, psoriatic arthritis, and axial spondyloarthritis were asked to complete a paper-based survey. The survey included questions on sociodemographics, health characteristics, mHealth usage, eHealth literacy using eHealth Literacy Scale (eHEALS), and communication and information preferences.

Results

Of the patients (N=193) who completed the survey, 176 patients (91.2%) regularly used a smartphone, and 89 patients (46.1%) regularly used social media. Patients (132/193, 68.4%) believed that using medical apps could be beneficial for their own health. Out of 193 patients, only 8 (4.1%) were currently using medical apps, and only 22 patients (11.4%) stated that they knew useful rheumatology websites/mobile apps. Nearly all patients (188/193, 97.4%) would agree to share their mobile app data for research purposes. Out of 193 patients, 129 (66.8%) would regularly enter data using an app, and 146 patients (75.6%) would welcome official mobile app recommendations from the national rheumatology society. The preferred duration for data entry was not more than 15 minutes (110/193, 57.0%), and the preferred frequency was weekly (59/193, 30.6%). Medication information was the most desired app feature (150/193, 77.7%). Internet was the most frequently utilized source of information (144/193, 74.6%). The mean eHealth literacy was low (26.3/40) and was positively correlated with younger age, app use, belief in benefit of using medical apps, and current internet use to obtain health information.

Conclusions

Patients with rheumatic diseases are very eager to use mHealth technologies to better understand their chronic diseases. This open-mindedness is counterbalanced by low mHealth usage and competency. Personalized mHealth solutions and clear implementation recommendations are needed to realize the full potential of mHealth in rheumatology.

Acceptance, Usage, and Barriers of Electronic Patient-Reported Outcomes Among German Rheumatologists: Survey Study

Background

The use of patient-reported outcomes (PROs) allows for patient-centered, measurable, and transparent care. Electronic PROs (ePROs) have many benefits and hold great potential to improve current usage of PROs, yet limited evidence exists regarding their acceptance, usage, and barriers among rheumatologists.

Objective

This study aims to evaluate the current level of acceptance, usage, and barriers among German rheumatologists regarding the use of ePROs. The importance of different ePRO features for rheumatologists was investigated. Additionally, the most frequently used PROs for patients with rheumatoid arthritis (RA) were identified.

Methods

Data were collected via an online survey consisting of 18 questions. The survey was completed by members of the Working Group Young Rheumatology of the German Society for Rheumatology (Arbeitsgemeinschaft Junge Rheumatologie der Deutschen Gesellschaft für Rheumatologie [DGRh]) at the 2019 annual DGRh conference. Only members currently working in clinical adult rheumatology were eligible to complete the survey.

Results

A total of 119 rheumatologists completed the survey, of which 107 (89.9%) reported collecting PROs in routine practice and 28 (25.5%) already used ePROs. Additionally, 44% (43/97) were planning to switch to ePROs in the near future. The most commonly cited reason for not switching was the unawareness of suitable software solutions. Respondents were asked to rate the features of ePROs on a scale of 0 to 100 (0=unimportant, 100=important). The most important features were automatic score calculation and display (mean 77.50) and simple data transfer to medical reports (mean 76.90). When asked about PROs in RA, the respondents listed pain, morning stiffness, and patient global assessment as the most frequently used PROs.

Conclusions

The potential of ePROs is widely seen and there is great interest in them. Despite this, only a minority of physicians use ePROs, and the main reason for not implementing them was cited as the unawareness of suitable software solutions. Developers, patients, and rheumatologists should work closely together to help realize the full potential of ePROs and ensure a seamless integration into clinical practice.

Development of an application for mobile phones (App) based on the collaboration between the Spanish Society of Rheumatology and Spanish Society of Family Medicine for the referral of systemic autoimmune diseases from primary care to rheumatology

Management of systemic autoimmune diseases is challenging for physicians in their clinical practice. Although not common, they affect thousands of patients in Spain. The family doctor faces patients with symptoms and non-specific cutaneous, mucous, joint, vascular signs or abnormal laboratory findings at the start of the disease process and has to determine when to refer patients to the specialist. To aid in disease detection and better referral, the Spanish Society of Rheumatology and the Spanish Society of Family Medicine has created a group of experts who selected 26 symptoms, key signs and abnormal laboratory findings which were organized by organ and apparatus. Family doctors and rheumatologists with an interest in autoimmune systemic diseases were selected and formed mixed groups of two that then elaborated algorithms for diagnostic guidelines and referral. The algorithms were then reviewed, homogenized and adapted to the algorithm format and application for cell phone (apps) download. The result is the current Referral document of systemic autoimmune diseases for the family doctor in paper format and app (download). It contains easy-to-use algorithms using data from anamnesis, physical examination and laboratory results usually available to primary care, that help diagnose and refer patients to rheumatology or other specialties if needed.

[Wearables in the treatment of neurological diseases-where do we stand today?]

Fitness and lifestyle trackers raise the awareness for wearable sensors in medical applications for clinical trials and healthcare. Various functional impairments of patients with neurological diseases are an ideal target to generate wearable-derived and patient-centered parameters that have the potential to support prevention, prediction, diagnostic procedures and therapy monitoring during the clinical work-up; however, substantial differences between clinical grade wearables and fitness trackers have to be acknowledged. For the application in clinical trials or individualized patient care distinct technical and clinical validation trials have to be conducted. The different test environments under laboratory conditions during standardized tests or under unsupervised home monitoring conditions have to be included in the algorithmic processing of sensor raw data in order to enable a clinical decision support under real-life conditions. This article presents the general understanding of the technical application for the most relevant functional impairments in neurology. While wearables used for sleep assessment have already reached a high level of technological readiness due to the defined test environment (bed, sleep), other wearable applications, e.g. for gait and mobility during home monitoring require further research in order to transfer the technical capabilities into real-life patient care.

German Mobile Apps in Rheumatology: Review and Analysis Using the Mobile Application Rating Scale (MARS)

Background

Chronic rheumatic diseases need long-term treatment and professional supervision. Mobile apps promise to improve the lives of patients and physicians. In routine practice, however, rheumatology apps are largely unknown and little is known about their quality and safety.

Objective

The aim of this study was to provide an overview of mobile rheumatology apps currently available in German app stores, evaluate app quality using the Mobile Application Rating Scale (MARS), and compile brief, ready-to-use descriptions for patients and rheumatologists.

Methods

The German App Store and Google Play store were systematically searched to identify German rheumatology mobile apps for patient and physician use. MARS was used to independently assess app quality by 8 physicians, 4 using Android and 4 using iOS smartphones. Apps were randomly assigned so that 4 apps were rated by all raters and the remaining apps were rated by two Android and two iOS users. Furthermore, brief app descriptions including app developers, app categories, and features were compiled to inform potential users and developers.

Results

In total, 128 and 63 apps were identified in the German Google Play and App Store, respectively. After removing duplicates and only including apps that were available in both stores, 28 apps remained. Sixteen apps met the inclusion criteria, which were (1) German language, (2) availability in both app stores, (3) targeting patients or physicians as users, and (4) clearly including rheumatology or rheumatic diseases as subject matter. Exclusion criteria were (1) congress apps and (2) company apps with advertisements. Nine apps addressed patients and 7 apps addressed physicians. No clinical studies to support the effectiveness and safety of apps could be found. Pharmaceutical companies were the main developers of two apps. Rheuma Auszeit was the only app mainly developed by a patient organization. This app had the highest overall MARS score (4.19/5). Three out of 9 patient apps featured validated questionnaires. The median overall MARS score was 3.85/5, ranging from 2.81/5 to 4.19/5. One patient-targeted and one physician-targeted app had MARS scores >4/5. No significant rater gender or platform (iOS/Android) differences could be observed. The overall correlation between app store ratings and MARS scores was low and inconsistent between platforms.

Conclusions

To our knowledge, this is the first study that systematically identified and evaluated mobile apps in rheumatology for patients and physicians available in German app stores. We found a lack of supporting clinical studies, use of validated questionnaires, and involvement of academic developers. Overall app quality was heterogeneous. To create high-quality apps, closer cooperation led by patients and physicians is vital.