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Klinična študija / Clinical study Klinična študija / Clinical study
ACTA MEDICO–BIOTECHNICA
2023; 16 (1): 38-43
Članek prispel / Received
27. 3. 2023
Članek sprejet / Accepted
14. 4. 2023
ABSTRACT
Purpose: The aim of this study was 
to assess the impact of the SARS-CoV-2 
pandemic and protective measures on 
the QoL of patients with inflammatory 
rheumatic diseases (IRDs) who received 
treatment at the Department of Rheu-
matology at the University Medical 
Centre Maribor (UMC).
Methods: A questionnaire was sent to 
IRD patients who visited a rheumatolo-
gy outpatient clinic or were contacted by 
phone or virtually at least once between 
February 1, 2020 and May 30, 2021. 
The questionnaires were included if re-
turned to UMC by January 1, 2022 
and were completed correctly and in 
full.
Results: Of the 125 patients who 
met the inclusion criteria, 57 (45.6%) 
had no cancelled rheumatology ap-
pointments, 52 (41.6%) had one, 15 
(12.0%) had two, and one patient 
(0.8%) had three. The most preferred 
mode of communication was in-person 
IZVLEČEK
Namen: Namen raziskovalne naloge 
je bil oceniti vpliv pandemije SARS-
-CoV-2 in zaščitnih ukrepov na kako-
vost življenja bolnikov z določenimi 
revmatskimi boleznimi, ki se zdravijo 
na Oddelku za revmatologijo v Uni-
verzitetnem kliničnem centru Maribor 
(UKC MB). 
Metode: Raziskava je bila opravljena 
na podlagi vprašalnika pri bolnikih, ki 
so vsaj enkrat od 1. 2. 2020 do 30. 5. 
2021 obiskali revmatološko ambulanto 
oziroma so vzpostavili stik po telefonu 
ali virtualno. Vključeni so bili vprašal-
niki, ki so na naslov UKC MB prispeli 
do 1. 1. 2022 in so bili pravilno ter v 
celoti izpolnjeni.
Rezultati: Vključenih je bilo 125 
bolnikov. 57 (45,6 %) bolnikom ni 
odpadel noben termin pri revmatologu, 
52 (41,6 %) je odpadel eden, 15 (12,0 
%) dva in enemu (0,8 %) bolniku trije. 
Srečanja z revmatologom v živo so bila 
najbolj priljubljena pri 89% bolnikov, 
Ključne besede:  
SARS-CoV-2, revmatske bolezni, 
kakovost življenja, epidemija, tele-
medicina
Key words: 
severe acute respiratory syndrome–
coronavirus 2, rheumatic diseases, 
quality of life, epidemic, telemedi-
cine
Vpliv epidemije SARS-CoV-2 na kakovost življenja 
bolnikov z vnetnimi revmatskimi boleznimi 
Impacts of the 2019 pandemic of severe acute 
respiratory syndrome–coronavirus 2 on the quality of life 
of patients with inflammatory rheumatic diseases
Avtor / Author Domen Lah1, Iztok Holc1,2
Ustanova / Institute 1Univerza v Mariboru, Medicinska fakulteta, Maribor, Slovenija; 2Univerzitetni klinični center 
Maribor, Klinika za interno medicine, Oddelek za revmatologijo, Maribor, Slovenija;
1University of Maribor, Faculty of Medicine, Maribor, Slovenia; 2University Medical Centre 
Maribor, Division of Internal Medicine, Department of Rheumatology, Maribor, Slovenia;
Naslov za dopisovanje /  
Correspondence
Doc. dr. Iztok Holc, dr. med.
iztok.holc@ukc-mb.si
https://doi.org/10.18690/actabiomed.248, CC BY 4.0
© 2023 Avtor(ji) / The Author(s)
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Klinična študija / Clinical study Klinična študija / Clinical study
ACTA MEDICO–BIOTECHNICA
2023; 16 (1): 38-43
INTRODUCTION
The 2019 pandemic of severe acute respiratory 
syndrome–coronavirus 2 (SARS-CoV-2) caused millions 
of deaths worldwide (1). Patients with chronic diseases 
and weakened immunity are at a greater risk for 
several comorbidities and more severe disease than the 
healthy population (2, 3). Many European governments 
implemented restrictions that limited access to healthcare 
services, which negatively affected the mental health and 
quality of life (QoL) of patients (4), especially those with 
chronic inflammatory rheumatic diseases (IRDs), such as 
rheumatoid arthritis (RA), systemic lupus erythematosus 
(SLE), and psoriatic arthritis (PsA) (5).
Since the declaration of the SARS-CoV-2 pandemic on 
March 11, 2020 by the World Health Organization  (6), 
governments worldwide restricted movements of the 
public, ordered mandatory wearing of masks, initiated 
quarantine requirements, and closed national borders. 
Access to healthcare services was also limited. Thus, 
many patients with IRDs could no longer meet with 
a rheumatologist in-person and had to communicate 
remotely to avoid cancellations or rescheduling. Despite 
the introduction of telemedicine, many patients were 
not able to communicate with a doctor because of the 
lack of knowledge about the use of telecommunication 
devices or delayed implementation in everyday practice, 
additional financial burdens, and restrictions to public 
transport (7). Most notably, many studies have reported 
the profound impact of the pandemic on mental health 
(e.g., loneliness, cognitive decline, and depression) in 
addition to worsening musculoskeletal symptoms of 
IRD patients due to changes in the availability of drugs 
and therapies, and increased anxiety about family life, 
finances, and employment status (8). Therefore, the aim 
of the present study was to assess the impact of the 2019 
pandemic of SARS-CoV-2 on QoL, attitudes towards 
the SARS-CoV-2 vaccine, and effects on health of IRD 
patients.
MATERIALS AND METHODS
A questionnaire in the Slovene language was distributed 
to patients with IRDs (RA, PsA and SLE) and returned 
by post to the University Medical Centre Maribor UMC. 
The questionnaire focused on sociodemographics, 
general health, IRD status, treatment methods, impact 
of the SARS-CoV-2 pandemic on QoL, attitudes towards 
the SARS-CoV-2 vaccine, and the effects of SARS-CoV-2 
infection on health. Some clinical and laboratory data 
of the included patients were obtained from medical 
records.
The study cohort was limited to adult patients diagnosed 
with RA (American College of Rheumatology [ACR] and 
European Alliance of Associations for Rheumatology 
srečanja po video klicu pa pri 1%. Zgolj 2 % bolnikov sta v 
času epidemije težko pridobivala zdravila, nihče pa zaradi teh 
težav ni navajal posledic na stanje bolezni. 58 % bolnikov se 
je z ukrepi omejitev zaradi epidemije strinjalo, 5 % pa je me-
nilo, da bi z izvajanjem ukrepov morali prenehati. 70 % bol-
nikov se je cepilo proti SARS-CoV-2, okužbo s SARS-CoV-2 
pa je navedlo 21 %. Povprečna vrednost DAS-28 je znašala 
3,100 ± 1,292 (revmatoidni artritis = 3,252 ± 1,209; psori-
atični artritis = 2,927 ± 1,376; p = 0,274; t = 1,101).
Zaklju~ek: Ocenjujemo, da je epidemija s pridruženimi 
ukrepi deloma poslabšala kakovost življenja bolnikov.
meetings with a rheumatologist (89%) and the least was a 
video call (1%). Only 2% of patients had problems obtain-
ing medication during the pandemic, but none reported con-
sequences with disease status. More than half (58%) of pa-
tients agreed with the restrictions during the pandemic and 
5% stated the restrictions should be terminated. Most (70%) 
patients were vaccinated against SARS-CoV-2 and 21% re-
ported SARS-CoV-2 infection. The mean disease activity score 
(DAS-28) was 3.100 ± 1.292 (rheumatoid arthritis, 3.252 
± 1.209; psoriatic arthritis, 2.927 ± 1.376; p = 0.274; t = 
1.101).
Conclusion: The pandemic and associated protective mea-
sures had deleterious effects on the QoL of IRD patients.
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Klinična študija / Clinical study Klinična študija / Clinical study
classification criteria), PsA (Classification Criteria for 
Psoriatic Arthritis), or SLE (ACR or Systemic Lupus 
International Collaborating Clinics classification 
criteria). Patients registered with the electronic system 
of UMC and who visited the Rheumatology Outpatient 
Clinic at least once between February 1, 2020 and May 
30, 2021 were eligible for participation in this study. 
Completed questionnaires from the first 130 patients 
in each of the three groups (RA, PsA, and SLE) were 
reviewed for inclusion in this study. The questionnaire 
included explanations of the content and purpose of 
the study, together with a consent form. In total, 125 
questionnaires that were completed in full and received 
by UMC by January 1, 2022 were included for analysis. 
The study protocol was approved by the Medical Ethics 
Committee of UMC Maribor on July 7, 2021 (approval 
no. UKC-MB-KME-48/21).
Statistical analysis (Student’s t-test, Pearson’s or 
Spearman’s correlation test, and Hi2 test) was performed 
using IBM SPSS Statistics for Windows, version 28.0 
(IBM Corporation, Armonk, NY, USA). A probability 
(p) value < 0.05 was considered statistically significant.
RESULTS
As described in Table 1, the patient cohort consisted 
of 125 patients (39 men, 86 women; mean age, 60.2 ± 
13.3 years; age range, 23–92 years). The PsA, RA, and 
SLE groups consisted of 40 (32%), 44 (35%), and 41 
(33%) patients, respectively. The average duration of IRD 
symptoms was 13.6 ± 10.0 (range, 1–45) years. 
Of the 125 patients, 57 (45.6%) had no cancelled 
rheumatology appointments, 52 (41.6%) had one, 15 
(12.0%) had two, and 1 (0.8%) had three. More than 
one-third (38%) of patients lived in cities, while 62% 
lived in rural areas. In regard to the highest level of 
education, 1% of patients held a doctorate (PhD) degree, 
3% had a master’s degree, 26% had a faculty degree, 36% 
had a high school degree, 18% had a vocational school 
degree, and 17% had a primary school degree. In regard 
to employment status, 9% of patients were unemployed, 
38% were employed, 52% were retired, and 1% were still 
in school. The employed group were more likely to prefer 
tele-meetings with a rheumatologist as compared to the 
other groups (18.8% vs. 6.5%, respectively, p = 0.035).
All patients regularly met with a rheumatologist and 
94% maintained the prescribed medication regimen. 
Only 2% of patients reported problems obtaining 
medication during the pandemic, but none reported any 
impact on disease status. During the pandemic, patients 
communicated with a rheumatologist through in-person 
meetings, telephone calls, and electronic mail (e-mail). 
An in-person meeting was the most preferred mode of 
communication and a video call was the least preferred 
(89% and 1%, respectively). Most (70%) patients had 
at least one comorbidity in addition to an IRD, which 
included diabetes, high blood pressure, kidney, heart, 
lung, liver or skin disease, an additional autoimmune 
disease, high blood cholesterol concentration, or allergies.
More than half (58%) of patients agreed with the 
restrictions imposed during the pandemic, 24% 
considered the SARS-CoV-2 to be very dangerous, 
12% considered SARS-CoV-2 as dangerous as the 
influenza virus, and 5% thought the measures should be 
terminated and life continued as before the pandemic. By 
Table 1. Comparison of statistical data between subject groups.
RA PsA SLE All
Number of patients 44 (35.2%) 40 (32.0%) 41 (32.8%) 125 (100.0%)
Average age±SD (years) 66.8±13.2 57.5±9.4 55.7±14.1 60.2±13.3
M:F 8:36 23:17 8:33 39:86
Symptom duration±SD (years) 13.0±9.2 13.8±9.8 14.0±11.0 13.6±10.0
Employed 20.5% 52.5% 43.9% 38.4%
Vaccinated  68.2%  75.0% 68.3% 70.4% 
Abbreviations: F, female; M, male; PsA, psoriatic arthritis; RA, rheumatoid arthritis; SD, standard deviation; 
SLE, systemic lupus erythematosus.
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the end of the patient response period (January 1, 2022), 
70% of patients had been vaccinated against SARS-
CoV-2 (AstraZeneca, 22%; Johnson & Johnson, 3%; 
Moderna, 16%; Pfizer-BioNTech, 59%). Relatively few 
(5.6%) patients reported worsening of IRD symptoms 
after vaccination. The most common reason for refusing 
vaccination was fear of the disease worsening (44%), 
while 3% would refuse vaccination if given a choice. 
Vaccinated patients were older than the unvaccinated 
(62.2 ± 12.3 vs. 55.5 ± 14.4 years, respectively, p = 0.009). 
To prevent infection, all patients adhered to at least one 
of the measures listed in Figure 1.
Of the 125 patients, 26 (21%) were infected by 
SARS-CoV-2, which included 2 (7.7%) who required 
hospitalization and 9 (35%) who reported worsening 
of IRD symptoms. Meanwhile, 15 (12%) patients were 
both vaccinated and infected and 19 (15%) reported 
exacerbation of the disease during the pandemic.
Complications of SARS-CoV-2 infection included 
hyposmia/anosmia (16.0%), fatigue (14.4%), and 
ageusia (14.4%) (Figure 2). The most common 
combinations of symptoms/signs were ageusia, 
headache, anosmia, myalgia, non-productive cough, 
and fatigue.
The disease activity score (DAS-28) was calculated for 
the RA and PsA patients. The mean DAS-28 score 
of the RA and PsA groups was 3.100 ± 1.292. The 
mean DAS-28 score was higher in the RA group 
than the PsA group (3.252 ± 1.209 vs. 2.927 ± 1.376, 
respectively, p = 0.274; t = 1.101), and significantly 
higher in women than men (3.362 ± 1.297 vs. 2.641 ± 
1.167, respectively, p = 0.017). The DAS-28 score was 
negatively correlated with education level (r = -0.287; 
p = 0.011) and positively correlated with erythrocyte 
sedimentation rate (p < 0.001; r = 0.480), C-reactive 
protein (p = 0.020; r = 0.299), leucocyte count (p = 
0.002; r = 0.323), and platelet count (p = 0.034; r = 
0.210). The average DAS-28 score was significantly 
higher in patients who reported worsening of IRD 
symptoms during the pandemic (4.152 ± 1.421 vs. 
2.886 ± 1.163, respectively, p < 0.001).
DISCUSSION
Of the 125 patients included in this study, 38.4% were 
employed. Of these, 54% felt that the SARS-CoV-2 
pandemic, or the virus itself, had negatively affected 
their careers and two reported job losses. IRDs are 
among the most common causes of physical disability, 
contributing to socioeconomic losses and reduced 
productivity in the workplace. As compared to the 
healthy population, IRD patients work fewer hours, 
receive less promotions, require more sick leave, and 
retire earlier (9).
Furthermore, all patients met with a rheumatologist 
regularly and 94% adhered to medication regimens. More 
than half (54%) of patients had at least one cancelled 
Figure 1. Protective measures against SARS-
CoV-2 infection.
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Klinična študija / Clinical study Klinična študija / Clinical study
rheumatology appointment. 
Garrido-Cumbrera et al. reported 
that 58.4% of 1800 patients had at 
least one cancelled rheumatology 
appointment and 45.6% received 
no information about the possible 
impacts of SARS-CoV-2 infection 
on IRDs. This study also reported 
increased alcohol consumption and 
smoking, with decreased exercise and 
deterioration in general well-being 
(4). Additionally, more meetings 
were held via telecommunications 
than in-person (7). 
SARS-Cov-2 vaccines were 
developed relatively quickly during 
Figure 2. Signs and symptoms of SARS-CoV-2 infection.
CONCLUSIONS
IRDs affected approximately 2%–3% of the general 
population and posed an increased risk of more severe 
infections, including SARS-CoV-2. Overall, the pandemic 
had a negative impact on the QoL of IRD patients. 
Despite the restrictions on travel, patients maintained 
contact with their rheumatologist (in person or remotely) 
and had access to necessary medications. Most (70%) 
IRD patients were vaccinated against SARS-CoV-2 and 
relatively few (6%) reported worsening of symptoms. 
A higher proportion of patients reported worsening of 
symptoms after recovery from SARS-CoV-2 infection 
than after the vaccination. Most patients agreed with and 
adhered to the restrictive measures during the pandemic. 
Despite the restrictive measures, it is necessary to strive 
to maintain comprehensive and integrated healthcare 
and ensure uninterrupted access to healthcare services 
to maintain QoL of IRD patients.
ACKNOWLEDGMENTS
We would like to thank all of the patients for completing 
the questionnaire and Prof. Dr. Artur Pahor for support 
with this study.
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the pandemic and became available in Slovenia at the 
beginning of 2021. Among the patients in the present 
study, 88 (70%) were vaccinated against SARS-CoV-2. 
The findings of this study support those of several 
previous reports, which concluded that vaccines were 
well tolerated by those with RA, PsA, or SLE and that 
the occurrence of serious side effects or exacerbations 
was rare. Furthermore, vaccination had a beneficial 
effect on the psychosocial well-being of patients, who 
reported feeling safer, had more social contacts, and 
visited more public places, leading to a higher QoL (10-
12). Additionally, previous studies reported significantly 
reduced immunoglobulin G responses to vaccination in 
SLE patients treated with immunosuppressants. Hence, 
these studies proposed withholding of immunosuppressive 
therapy for 1 week to improve vaccine efficacy without 
leading to clinical flares (13).
Disease activity was determined with the DAS-28 in 
patients with RA and PsA. A prior study reported 
a significant difference in the average DAS-28 score 
before and after lockdowns in 85 RA patients (4.7 vs. 
5.16, respectively, p = 0.0011) (14), indicating a shift 
from moderate to high disease activity. Additionally, 
Gica et al. found that the outbreak of a new coronavirus 
strain increased the prevalence of stress, anxiety, and 
psychosomatic problems. Furthermore, patients scored 
lower on tests assessing disease activity, suggesting lower 
QoL during the pandemic (15). 
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