Objective To estimate the prevalence of coronavirus disease 2019 (COVID-19) infection among patients with psoriatic arthritis (PsA), understand patients’ perspectives regarding their risk of COVID-19 infection, and evaluate the standard of virtual care offered during the early phases of the pandemic.

Methods An online survey was conducted between June 2021 and September 2021 in patients with PsA who had consented to email contact. The survey was completed by 152/193 (79%) patients who had consented to the study.

Results There were 86 (56.6%) men and 66 (43.4%) women with a mean age of 58 years and mean disease duration of 19 years. During the pandemic, the mean patient-reported symptom severity was 4.10, 3.24, and 3.72 for joint, skin, and overall symptom severity, respectively. Seventy-four percent of respondents would accept the effect of their PsA over the past month for the next few months. Of 79 patients who were tested for severe acute respiratory syndrome coronavirus 2, 4 tested positive. All 4 were admitted to hospital; 2 required oxygen. One hundred fifty-one patients (99%) had received at least 1 vaccine dose. Fifty-nine (38.8%) participants believed their PsA medications increased their COVID-19 infection risk. Of the 130 patients who had a telemedicine assessment, 83.1% were happy with their virtual consultations. Most were happy to continue with virtual consultations until the pandemic resolved. The average satisfaction level regarding pandemic care was 7.87 on a sliding 10-point scale.

Conclusion COVID-19 prevalence was low among our patients. Patients were satisfied with their care during the pandemic. Most patients would happily continue with virtual care for the duration of the pandemic.

Psoriatic arthritis (PsA) develops in 20% to 30% of patients with psoriasis (PsO).1 Nearly 20,000 Ontarians had PsA in 2015.2 Because of the permanent joint damage and disability that can result from the inflammatory and autoimmune pathophysiology of PsA, optimization of patient care remains a priority.3

Beginning in March 2020, progression of the coronavirus disease 2019 (COVID-19) outbreak caused by the novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), caused a rapid and significant increase in the use of virtual healthcare.4 Although prepandemic studies have reported on patient perspectives of virtual care, more real-world data are needed on whether virtual care has been an acceptable substitute for patients with PsA during the pandemic. Such data can go toward developing and implementing patient-informed virtual care to assist in maintaining positive relationships between healthcare providers and patients, with the ultimate goal of preventing negative outcomes.5

Immune-mediated inflammatory diseases (IMIDs), such as PsA, and their medications were investigated early in the pandemic to determine if they affected COVID-19 infection risk and severity. Through a large cross-sectional case-reporting registry, the COVID-19 Global Rheumatology Alliance (GRA) demonstrated that patients with rheumatic disease tend to have similar or only slightly worse COVID-19 outcomes compared to nonrheumatic disease populations.6 They made note of exceptions, such as in patients with comorbidities (including chronic lung disease and cardiovascular disease combined with hypertension) and in those who are older than 65 years of age.6,7 In addition, patients with moderate, high, or severe rheumatic disease activity were shown to have higher odds of COVID-19–related death compared to patients in remission or patients with low disease activity. This supports the importance of disease control in all patients. Finally, when compared to methotrexate monotherapy, increased odds of COVID-19–related death in patients with rheumatic disease were found in those who were on no disease-modifying antirheumatic drugs, sulfasalazine (stratified analysis showed that increased odds of death was limited to ever smokers), rituximab, or ≥ 10 mg of prednisone per day.6,7 Regardless of whether patients are aware of these data, they may have concerns regarding the effect of their PsA and associated medications on their risk of COVID-19 infection, risk of severe infection, and risk of worse outcomes from an infection. They may also harbor concerns about how the COVID-19 vaccine could affect them (eg, by causing a disease flare), although evidence has demonstrated that COVID-19 vaccines are highly effective in patients with IMIDs.8 Understanding patient beliefs around these topics and any reactionary behaviors they may adopt would be important in informing patient-provider interactions.

Several environmental factors put the global population at risk for infectious outbreaks in the future.9,10 Given the evolving nature of the SARS-CoV-2 virus, the drastic shift to virtual care in Canada that will likely remain beyond the pandemic, and the future potential for novel virus emergence, there remains a need to understand the concerns of patients with PsA surrounding a virus such as SARS-CoV-2 and their perspectives on virtual care. Data are limited in this space on patients with PsA in Canada, which presents an opportunity for further inquiry. To better understand the perspectives of patients with PsA, we surveyed patients from a PsA clinic in Toronto, Ontario, Canada, to gather data on their virtual care experiences, on their beliefs regarding their risk of negative COVID-19 outcomes, and to determine their COVID-19 exposure.

This was a cross-sectional study that administered an online questionnaire to patients from a single center. Our study sample was obtained from a pool of patients with PsA followed at the Psoriatic Arthritis Clinic at Toronto Western Hospital who had previously consented to be involved in research through the International Psoriasis and Arthritis Research Team (IPART) research program (REB 08-0630-AE), had contributed biologic samples, and had consented to be contacted through email.

The study comprised a web-based patient survey along with an extraction of previously recorded patient characteristic data through the IPART database (Table 1). The study was undertaken in a single PsA clinic in Toronto, Ontario, Canada. Patients are assessed in the PsA clinic at 6- to 12-month intervals. Each assessment includes a complete history, physical examination, laboratory evaluation, and patient-reported outcomes. Radiographs are performed at 2-year intervals. All data are stored on a web-based database. Research ethics approval was obtained prior to beginning the study.

Baseline demographic and disease characteristics for patients with PsA that consented to study participation.

Eligible patients drawn from our database fulfilled the Classification for Psoriatic Arthritis (CASPAR) criteria; had been contacted for review consultation through telephone or video conferencing from March 2020 to September 2020; and had been consulted and reviewed by clinical fellows and staff physicians within the PsA clinic using any virtual platform, including telephone or video conferencing, since March 2020.11 Patients were excluded if they were < 18 years of age or if they did not provide consent to participate. In the latter half of June 2021, eligible patients were sent individual emails explaining the study and asking for consent.

Patients who consented to participate were individually emailed a link to a one-time survey with unique login information. The survey was delivered through DADOS, an internet-based platform that hosts the database. If patients who were sent the survey did not complete it within 2 weeks, they were manually sent a follow-up reminder. In total, there were 36 survey questions. Where applicable, participants were asked to respond to questions based on the period between the second week of March 2020 and the date of survey completion. Almost all patients completed their survey between July 2021 and August 2021. Survey questions touched on PsA symptomatology, international travel, COVID-19 symptoms, working status, COVID-19 test status, quarantine and vaccination status, virtual care, and COVID-19 risk perceptions.

Patients who had provided email addresses were sent the study information. Of 600 patients who were contacted, 378 did not respond to the initial consent email, 20 had bounce-back email errors, 41 provided consent but did not complete the survey, and 152 completed the survey. There were no differences between patients who responded and those who did not. Of the 152 patients who completed the survey, 86 (56.6%) were male and 66 (43.4%) were female. These patients had a mean age of 58.3 years and mean disease duration of 18.9 years. At their most recent prepandemic visit (all performed by a rheumatologist), 41.4% had active arthritis. Comorbidities documented at their most recent prepandemic visit included lung disease in 38.2%, diabetes in 17.1%, and cardiac disease in 50%. Patient characteristics were well balanced between those who consented and completed the survey (n = 152), and those who consented but ultimately did not complete the survey (n = 41; Table 1). For certain questions (eg, “Did you have to undergo quarantine…”), the percentages for follow-up questions (eg, “If yes [to undergoing quarantine], what was the reason?”) add up to > 100% (ie, more participants responded with a reason for quarantine than who responded “Yes” to undergoing quarantine). One potential explanation for this is that participants may have mistakenly responded to either the main question or the follow-up question itself.

During the pandemic, the mean patient-reported joint symptom severity on a sliding 10-point scale was 4.10 (SD 2.3), the mean patient-reported skin symptom severity was 3.24 (SD 2.1), and the mean patient-reported overall symptom severity was 3.72 (SD 2.1). In terms of their PsA disease, 112 (73.7%) respondents found that they would find it acceptable to remain for the next few months as they had during the past month (Table 2).

Patient experiences with PsA during the pandemic.

From March 2020 to the date of survey completion, 15 (9.9%) patients had traveled internationally (Table 3). The predominant mode of international travel was by plane. At least 11 (7.2%) patients reported experiencing ≥ 1 of fever; new onset of cough; sore throat; chills; unexplained headaches; unexplained fatigue, malaise, or muscle aches; and/or a runny nose or stuffy nose without a known cause. Of 79 patients who were tested for SARS-CoV-2, 4 tested positive. All 4 were admitted to the hospital, with 2 requiring oxygen. At least 1 vaccine dose had been given to each of the 151 patients (99.3%). Antibiotics for a respiratory infection were prescribed to 5 (3.3%) patients during this period. There were 29 (19.1%) patients who underwent quarantine, mostly because of a history of international travel or close contact with someone who tested positive for COVID-19.

How patients with PsA may have been exposed to COVID-19.

When asked whether patients believed their PsA put them at a higher risk of being infected by COVID-19 compared to someone without PsA, 55 (36.2%) answered “not really” and 44 (29%) answered “quite a bit” or “extremely” (Table 4). When asked whether patients believed their PsA medications put them at a higher risk of being infected by the COVID-19 compared to someone not on those medications, 45 (29.6%) responded with “not really” and 59 (38.8%) responded with “quite a bit” or “extremely.” A subset of patients (11.8%) reported changing the dosage or frequency of their PsA medication by themselves during the pandemic.

Patient perspectives on PsA, medications, and COVID-19 interactions.

Virtual consultations were conducted by a rheumatologist for 130 (85.5%) participants, with 103 having telephone consultations, 25 having Ontario Telemedicine Network consultations, and 2 having unspecified consultations (Table 5). The majority (83.1%) of participants were happy with their virtual consultations. Most patients (83.6%) said they would happily continue with virtual consultations until the pandemic was overcome. The average satisfaction level regarding pandemic care was 7.87 (SD 2.6) on a sliding scale of 0 to 10.

Patient perspectives on virtual care during the pandemic.

In our study sample of patients with a PsA disease duration of approximately 19 years and an average age of 58 years, most patients had received a virtual consultation, were satisfied with their virtual consultation, and would happily continue with this mode of consultation until the end of the pandemic. The mean patient-reported overall symptom severity was mild to moderate, with 40% of our patients having active arthritis prior to the pandemic. Compared to previous rheumatology studies, a higher percentage of our patients reported being happy with their virtual consultation (approximately 83%).12,13,14 However, it should be noted that the majority of the patients have resumed in-person clinic visits, and only those who live very far away have continued with virtual visits. A subset of patients had concerns about the effect of PsA or PsA medications (29% and 39%, respectively) on their COVID-19 infection risk. However, most patients were not significantly concerned. COVID-19 prevalence was low in our patient sample.

Previous surveys of patients with IMIDs have reported similar outcomes on virtual care during the pandemic.12,13,14 A previous study surveyed 128 patients with PsA in the UK. Of those who rated their telemedicine appointment, 63% reported that their virtual consultation was at least somewhat or equally as effective as face-to-face consultation and 48% felt that virtual consultations would be beneficial after the pandemic.12 Open-ended questions elicited the drawbacks of virtual consultation, which included a lack of visual cues, lack of physical examination, and difficulty with open communication.12 Compared to patients with active disease, patients with well-controlled symptoms were more satisfied with remote appointments.12 A second UK study on 126 participants with PsA or PsO found that 78% were satisfied with their virtual consultation, 21% would be happy to have future remote consultations, and 39% would be happy to have future remote consultations but not for every consultation. Finally, 18% expressed a preference for alternating face-to-face and virtual consultations.13 The proportion of patients with PsA in this sample was not reported. Other studies have been conducted on broader IMID samples. One such study of 154 rheumatology patients, of which 58% had rheumatoid arthritis and were from North America, found that 71% of patients were satisfied with their virtual rheumatology appointment during the pandemic.14 Prescribed medications were discontinued by 14%.14 Finally, a survey of 679 American rheumatology patients found that 74% were satisfied with their virtual appointment and that advantages of these appointments included avoidance of potential infection and convenience.15 Our study adds to the limited data in Canada on PsA virtual care from the patient perspective. Based on our collection of demographic and symptom data, we can conclude that virtual care is acceptable for certain patients with PsA, at least during a pandemic.

Other studies have found a higher prevalence of concerns surrounding the effect of IMID conditions and IMID medications on COVID-19 infection and outcomes. Early in the pandemic, an Australian single-center study sent a text message survey to over 2000 patients.16 Of 550 respondents, 76% were highly concerned that their medication would increase the severity of COVID-19 symptoms, 63% planned on continuing their antirheumatic medications, and 28% felt that telehealth was only appropriate while infectious control measures were still in place.16 This study was published before data from the COVID-19 GRA and other sources revealed specific risk factors for negative outcomes among patients with IMIDs with COVID-19. This may partly explain the large proportion of concerned patients. However, ongoing research in this space points to the importance of assessing patient perceptions. A 2022 systematic review and metaanalysis compared the general population to those with rheumatic and musculoskeletal diseases (RMDs) in their risk of COVID-19 infection, developing severe COVID-19 infection, and mortality from COVID-19. Based on unadjusted data with moderately high between-study heterogeneity, the relative risk (RR) of developing SARS-CoV-2 infection was found to be 52% higher (RR 1.53, 95% CI 1.16-2.01) in patients with RMDs compared to the general population.17 A small number of studies compared hospitalization rates, oxygen supplementation rates, admission rates to intensive care units, and mechanical ventilation rates, showing no significant differences between RMDs and the general population.17 A metaanalysis of 13 studies with moderately high between-study heterogeneity resulted in an unadjusted odds ratio of 1.74 (95% CI 1.08-2.80) comparing the risk of death attributed to COVID-19 in patients with RMDs vs non-RMD comparator groups.17 These findings suggest that patients with RMDs may be at an increased risk of developing SARS-CoV-2 infection and COVID-19 mortality compared to the general population. Of note, this review did not publish data on patients with PsA specifically and did not analyze risk factors for negative outcomes among patients with RMDs.17

Our study is one of few that surveyed patients with PsA for their perspectives on their disease, COVID-19, and virtual care. In the process of this inquiry, there were limitations. This study was limited by the online distribution of the survey and the dependence on email communication. Many patients who were emailed the survey never responded. Beyond this, we missed including patients who were not accessible by email. Although our sample size was not small, it was not large enough to accurately gather COVID-19 infectious disease information. Finally, this study was carried out prior to the Omicron and other subsequent variants of the virus emerged.

The well-established use of virtual care in Canada and potential for novel virus emergence necessitate continued research on the satisfaction of patients with PsA and their perspectives to optimize patient care and prevent health decline. Future research can focus on specific populations of patients with PsA, such as those who have moderate to severe disease activity or require a certain level of care (eg, being on a certain type or number of medications), to evaluate their opinions on virtual care and COVID-19 risk.

In conclusion, this study provides updated data on patient perspectives following the release of initial scientific data on IMIDs and COVID-19 infection risk and severity. COVID-19 prevalence was low among our patients. Overall, our patients were satisfied with their virtual care during the pandemic. Most of our patients would happily continue with virtual care for the duration of the pandemic. The prevalence of patient concerns surrounding the effect of IMIDs and targeted medications should continue to be explored for the risk of behaviors such as stopping medications.

The psoriatic arthritis program is supported by a grant from the Krembil Foundation. NP was supported by a grant from the Institute of Medical Sciences.

The authors declare no conflicts of interest relevant to this article.

This is an Open Access article, which permits use, distribution, and reproduction, without modification, provided the original article is correctly cited and is not used for commercial purposes.