The current study showed a significant negative impact of the COVID–19 pandemic on the rheumatology practice. The impact was higher on the regular hospitalization, followed by outpatient clinic and the daily hospitalization for infusion. The differences in impact between the Levant, the Gulf, and North Africa are partly due to differences in the healthcare system (more private-based in the Levant, more public-based in the Gulf), as well as differences in the pandemic response pattern (earlier and more strict quarantine measures in the Gulf and North Africa, compared to the Levant).
This significant negative impact on the continuity of rheumatology care, coupled with the shortage in some cornerstone drugs, such as HCQ (47% in the current study), may have a substantial impact on the control of chronic rheumatic diseases, putting the patients at a high risk of disease flare and compromising the disease prognosis on the short and long term [33].
The impact on the practice also translated into a 43% impact on the income -so far-, reflecting the serious economic repercussions of the pandemic. This economic impact of the pandemic is global, as announced by a United Nations Conference on Trade and Development report [34]. Nevertheless, it is different from one country to another (lowest in the Gulf countries), reflecting the baseline socio-economic disparities between the countries.
A higher impact on the outpatient clinic was associated with higher use of telemedicine, probably to compensate compromised access of the patient to rheumatology care. However, telemedicine was mostly used in a “traditional way”, such as telephone or e-mail contact, which cannot replace a regular visit in rheumatology. Also, this traditional way may not be sustainable on the long term. In particular, the rheumatologists stated that telemedicine was reimbursed in only 12% of cases. This lack of appropriate compensation contributes probably to the reluctance of about half of the rheumatologists if implementing it in their practice.
The mental impact of the pandemic was also considerable, as 77% of the respondents had some sort of impact, even minor in 60%. This is expected, as healthcare professionals, in general, are faced with additional challenges during the pandemic, such as mental stress, physical exhaustion, separation from families, stigma, risk of personal infection, and the pain of losing patients and colleagues. In the current study, 22% of the rheumatologists were implicated in the frontline management of COVID–19, and 39% worked in frontline institutions, meaning that, even in a non-frontline specialty, physicians were highly implicated in the pandemic management.
The rate of rheumatologists’ infection with SARS-CoV2 was 1.8%, which may increase with time, as the pandemic evolves. Although this number may be underestimated, since the seriously infected rheumatologists may not be able to respond to this survey, it gives a preliminary estimate about the direct rate of infection among the rheumatologists, as this information is still lacking worldwide.
As for the reported patients’ infection, a high mortality rate (22% of the 156 reported cases) was noted in comparison to the figures reported by the COVID–19 Global Rheumatology Alliance physician-reported registry (9%) [13], and in cohort of patients with chronic rheumatic diseases from Spain and Italy (6 to 10%) [16, 35]. This result mostly reflects a bias towards more severe cases that “come to the attention” of rheumatologists, relative to an increased mortality. Also, this bias may be due to the fact that only individuals with severe symptoms are being tested for COVID–19 in most Arab countries.
Based on the open-ended responses, the authors developed suggestions to improve the rheumatology practice during the pandemic and in the deconfinement period (Table 4). The authors highlighted the need for local guidance for rheumatologists and patients, for working with health authorities to guarantee the availability of drugs for patients and PPE for HCP, and for establishing a reliable telemedicine platform that will help to rationalize human resources, reduce infection risk and ensure the proper continuity of rheumatology care.
The study has some limitations. The questionnaire was developed de novo, based on the available literature. However, it was validated by an independent scientific committee and pilot-tested successfully for readability, acceptability, and timing.
Also, the study was cross-sectional, covering a period where the pandemic had already reached its peak in some countries, whereas it was still in the ascending part of the curves in others. Therefore, the responses reflect the status in each country in a particular time frame of the pandemic. Also, the young age of the participants reflect the users of social media in the Arab region [36], and may jeopardize the external validity of the study.
Besides, the data presented in this study were self-reported and partly dependent on recall ability; thus, they may carry subjectivity and recall bias. Moreover, duplicate data, although very unlikely, cannot be ruled out. However, not collecting personal identification data was a choice that the authors had to make it to favor anonymity.
Nevertheless, the current study provides valuable information about the impact of COVID–19 on the rheumatology practice in the Arab regions. Although many studies have addressed the patients’ condition during the pandemic, data on physicians and practice remain very limited. The current study has gathered significant information from 27% of all rheumatologists across 15 Arab countries within 16 days. It was disseminated in two languages, catching the broadest audience in the region, as most Arab countries study and practice medicine in English and French, except for Syria. Also, the study presented the first estimates about the rate of rheumatologists’ infection and the outcomes of patients’ with COVID–19 in the Arab regions. Finally, the results allowed the development of local suggestions to improve the rheumatology practice during the COVID–19 pandemic and for the deconfinement period.