Artigos

Conteúdo (article):

Telehealth: a pathway to higher resolution rates in primary care?

Authors
Liza Yurie Teruya Uchimura; Hcor, Sao Paulo, Brazil; lytuchimura@gmail.com; ORCID 0000-0002-4935-2432;
Tiago Mendonça dos Santos; Hcor, Sao Paulo, Brazil; tiago@estatikos.com.br; ORCID 0000-0002-4223-9162;
Camila Pereira Pinto Toth; Hcor, Sao Paulo, Brazil; cppinto@hcor.com.br; ORCID 0000-0003-2194-4804;
Camila Roncon de Lima; Hcor, Sao Paulo, Brazil; crlima@hcor.com.br; ORCID 0000-0002-0625-1084;
Maria Leticia Carniel Brigliadori; Hcor, Sao Paulo, Brazil; mlbrigliadori@hcor.com.br; ORCID 0009-0001-6239-0695;
Mariangela Rosa de Oliveira; Hcor, Sao Paulo, Brazil; mrdoliveira@hcor.com.br; ORCID 0000-0002-3601-1268;
Patrícia Vendramim; Hcor, Sao Paulo, Brazil; pvendramim@hcor.com.br; ORCID 0000-0002-0679-365X.

Funding: this study formed part of the programme of specialised medical care by way of telemedicine in Brazil’s Northeast region, a project conducted by the Hospital do Coração, in partnership with the Ministry of Health, through the programme in support of institutional development in the Unified Health System (Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde, PROADI-SUS), under Law No. 12.101, of 2009 (Art.11 of Annex XCIII to Consolidation Order No. 5/GM/MS, of 28 September 2017).
 
Abstract
This quantitative, analytical-descriptive, cross-sectional study examined retrospective data from teleconsultations and teleinterconsultations conducted between November 2022 and September 2023 to assess the efficacy of care received by primary care users by these means. The data were analysed using descriptive statistical indicators, such as absolute frequency, percentages, and proportions, to identify patterns and trends in a total of 2,355 teleconsultations and teleinterconsultations. Of these, highest demand was for endocrinology (25.3%), psychiatry (21.7%) and cardiology (16.3%). No referral to face-to-face assessment in specialised care services was required following 96.5% of the tele-consultations or teleinterconsultations. In all, 71.2% of tele-consultations and 76.4% of teleinterconsultations resulted in counter-referrals to primary care services to schedule continued care. The study identified the main demands for referrals between primary care and specialised outpatient services and found more effective primary care and strengthening of the attributes of primary care teams.
Keywords: telehealth; primary health care; regional health planning.

Introduction
Use of information and communication technologies (ITCs) at the different levels of health care has facilitated interactions among healthcare professionals, users, and managers, broadening access to diagnostic and therapeutic support resources1. Telehealth has widened and enhanced capabilities for meeting demands in areas including planning, care, research and education2.
Telehealth, as a public policy strategy for Brazil’s national health system – the Unified Health System (Sistema Único de Saúde - SUS) – began in 2007, when the Ministry of Health (MoH) launched a landmark pilot project in telehealth applied to primary care3, which supported the creation of hubs in universities. In 2010, the MoH restructured the programme, renaming it the Brazil Networks National Telehealth Programme (Programa Nacional Telessaúde Brasil Redes)4. At present, telehealth is one component of Brazil’s Digital Health Strategy (Estratégia de Saúde Digital - e-Saúde).
Although a promising tool for disease diagnosis, treatment, and prevention as well as for the continued professional development of healthcare professionals, telehealth is still underutilized in Brazil5,6,7. Studies indicate that the main barriers impairing development of telehealth in Brazil are deficiencies in health service infrastructure and technology suited to primary health care (PHC)8 and in hospitals7.
Despite these challenges, the Brazil Networks National Telehealth Programme has driven expansion of PHC care services by facilitating direct contact with advanced health care centres, thus expanding access to specialists by way of a technological platform7,9. The programme is designed to strengthen the Family Health Strategy and the healthcare network10, as well as upgrading the quality of primary health care facilities, broadening the scope of care offered by health teams and fostering continued professional development11.
Prominent among the innovations introduced is the teleconsultation, defined as an ITC-mediated act of consultation among doctors, managers, and other health personnel, primarily aimed at addressing doubts relating to administrative procedures and health care measures12. Complementing this are teleinterconsultations, ITC-mediated consultations involving the participation of healthcare professionals at different physical locations, as well as the patient. This approach allows clinical cases to discussed in real time, thus facilitating the establishment of joint courses of action, and strengthening coordination of care.
The increasing use of telehealth, especially following onset of the SARS-CoV-2 pandemic, has driven use of the data generated, which can be applied to planning health measures and services. In that context, this study endeavoured to answer the following questions: (1) Will telehealth enable the care received by PHC users to achieve higher rates of resolution by means of teleconsultations and teleinterconsultations? and (2) Can teleconsultations and teleinterconsultations reduce the number of referrals from PHC to the secondary and tertiary levels of the health system?
This study described the ability of care received by PHC users to achieve resolution through teleinterconsultations. It also investigated the association of tele-consultations and teleinterconsultations with reductions in the number of referrals from PHC to other levels of care in the health system.

Methods
Study design
This quantitave, cross-sectional study, using retrospective data, formed part of the “Specialised medical care through telemedicine in Brazil’s Northeast region” (TeleNordeste) project operated by Hcor – Associação Beneficente Síria in partnership with the MoH and the national council of state secretaries of health (CONASS), through the programme to support institutional development in the national health service (PROADI-SUS), for the three-year period 2021-2023. The overall aim of the project was to offer specialised medical and multi-professional support by way of teleinterconsultations to selected health regions in Brazil’s Northeast region.

Study sites and period
The study was conducted at a referral hospital (Hcor) in the city of Sao Paulo and at PHC services in six health regions of the states of Paraíba and Pernambuco. Health regions distant from the state capitals and with difficult access to medium- and high-complexity medical care and facilities were selected jointly with the respective state health departments and councils of municipal health secretaries (COSEMSs). The health regions in this study were: (1) Paraíba 3rd region; (2) Paraíba 7th Region; (3) Paraíba 12th Region; (4) Paraíba 13th Region; (5) Paraíba 14th Region; and (6) Pernambuco 4th Region. As recommended by local managers, the regions included traditional primary healthcare facilities and those offering indigenous and prison health care. The study examined data generated between November 2022 and September 2023 by the Nilo Saúde telehealth system platform of the TeleNordeste project.
The data collection period, established to reflect the start of introduction of teleconsultations and teleinterconsultations in the health regions, corresponded to an interval of about one year of the execution of this intervention. That interval, from November 2022 to September 2023, was chosen so that the initial impacts of the strategies’ implementation could be described, and a preliminary assessment made of adherence to the services offered and of their reach and efficacy.

Variables
The data collected from teleconsultations and teleinterconsultations included signs and symptoms, diagnosis, medical care speciality, unit of the federation, health region and municipality, as well as information on scheduling, whether or not the patient was present during the teleinterconsultation and the type of outcome (discharge or referral). These data were then digitised to the telehealth platform and organised on an Excel spreadsheet.

Intervention
Teleinterconsultations were conducted on a triangular model, that is, among the primary health care doctor or nurse, the specialist Hcor doctor and the patient. In certain situations, the PHC doctors and other health personal were called to a tele-consultation to discuss the clinical cases.
All teleconsultations and teleinterconsultations were scheduled autonomously by the PHC personnel and Hcor doctors by way of the telehealth platform. All specialists were from the referral hospital in Sao Paulo.
Initially, the medical specialities offered by TeleNordeste were determined by demand from PHC personnel in the six regions. The selection of specialities offered by TeleNordeste resulted from a process of collaboration among local PHC managers and the referral hospital, who jointly analysed data on demand gathered through conversations with PHC managers and data from the SUS data system (DATASUS). As a result, consultations were first offered in what were identified as priority specialities: cardiology, endocrinology, psychiatry, and neurology. Five months after the start of the project, rheumatology was added. Later, eight months into the project, gynaecology, obstetrics, and paediatrics were included, to broaden the scope of the programme and meet growing demand.

Statistical analysis
The information was provided in absolute values. Data were generated at the following levels: consultation type, health service, municipality, health region and unit of the federation. The event type (teleconsultation, teleinterconsultation or medical speciality) was the smallest unit of identification in the database records.
Calculations were performed with the assistance of R software, version 4.0.513. Variables were presented as absolute and relative frequencies, by International Classification of Disease, ICD-10.

Ethical considerations
The study was approved by the research ethics committee of the Associação Beneficente Síria (CAEE 76475123.7.0000.0060). As this was a retrospective study, although entailing no involvement of the researchers with the research subjects or use of any personal data on those subjects, those responsible for the study signed a data use confidentiality declaration and a request for exemption from the declaration of free and informed consent, pursuant to the regulatory guidelines and standards described in National Health Council Resolution No. 466 of 12 December 2012, as complemented by Resolution 510/2010, Article 17, item VII. The Paraiba and Pernambuco state health secretaries signed a declaration of cooperation and adherence through the TeleNordeste project.

Results
Of the 2,355 consultations that occurred through the TeleNordeste initiative during the study period, 1,857 (78.8%) were teleinterconsultations and 52 (2.2%), teleconsultations. Most of these consultations (1,490; 63.3%) related to health regions in the state of Paraiba and 36.7% (864), the state of Pernambuco. The 4th health region of Pernambuco accounted for the largest number teleconsultations and teleinterconsultatons (36.1% of all instances). Most prominent among the municipalities were Piancó (Pernambuco) and Itabaiana (Paraíba), with 312 (13.3%) and 305 (13.0%) consultations. By type, the consultations averaged 81.7% teleinterconsultations and 24.6% teleconsultations, with 3.9% of records failing to specify the type of consultation.
The specialities most in demand for teleconsultations and teleinterconsultations were endocrinology (25.3%), psychiatry (21.7%) and cardiology (16.3%), while gynaecology (4.8%) and paediatrics (2.6%) were the least sought-after. Of the total of consultations scheduled, 446 (18.9%) did not take place. Patient absenteeism represented 3.1% of instances.
The PHC service doctors performed diagnoses in accordance with the ICD-10, the most frequent groups being: “IV – Endocrine nutritional and metabolic diseases” (22.9%); “V – Mental and behavioural disorders” (20.3%); “XXI – Factors influencing health status and contact with health services” (16.1%); and “XIII – Diseases of the musculoskeletal system and connective tissue” (14.2%). Group “VI - Diseases of the nervous system” accounted for 5.5% of consultations and “XVIII - Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified”, 4.7%. Other ICD-10 groups totalled less than 1% of consultations. The commonest diseases were diabetes mellitus (16.7%), arthralgia (11.7%), systemic arterial hypertension (8.8%), anxiety (7.7%), depression (5.5%) and thyroidopathy. Other morbidities, signs, and symptoms represented less than 1% of consultations.
Following teleconsultation or teleinterconsultation, 96.5% of cases required no referral to any in-person assessment by specialised services (Table 1). Also, 71.2% of teleconsultations and 76.4% of teleinterconsultations resulted in a counter-referral scheduling a primary health care service to continue care (Table 1).
Table 1

The rate of resolution – that is, the ability to solve patient problems without the need for referral to in-person specialised care – varied among medical specialities, with rates between 92.0% (neurology) and 99.7% (rheumatology). Neurology was the only speciality to show a counter-referral rate for teleinterconsultation or teleconsultation (0.8%). Neurology (7.3%) and cardiology (6.8%) were the medical specialities with highest rates of referral to in-person specialised care (Table 2).
Table 2

Discussion
The study identified the main demands for referrals between PHC and specialised outpatient services, and found improved rates of resolution in PHC, a strengthening of the attributes of PHC staffs and development of a culture of process digitisation in the six health regions.
Adherence to TeleNordeste enabled the health services of smaller municipalities to gain access to specialised medical consultations without prolonging user care. That result corroborates the findings of Sarti et al. (2022)14 that, in 2013 and 2014, 57.9% of primary health care services participating in teleconsultations and telediagnoses of the national programme to improve primary care access and quality (PMAQ-AB) were located in municipalities with populations of less than 10,000. Also, the experiences of the states of Rio Grande Sul and Minas Gerais have shown that teleconsultation (educational support for care), even in contexts with limited infrastructure and technology, has produced beneficial impacts on the quality of service provision and user care6, 15.
Here, as in other studies, consultations for the specialities of endocrinology and psychiatry were found to increase, together with the mounting number of cases of diabetes mellitus, depression, and anxiety in Brazil’s population16. Similarly, in the scoping review of various health systems by Beheshti et al. (2022)17, diabetes and hypertension were the conditions most treated by PHC telehealth services. The findings of this study underline the importance of telehealth for serving users in these specialities and the growing demand for mental health care, especially because of the difficulty of finding specialist doctors in the coverage regions.
Teleconsultations and teleinterconsultations have proved to be an effective strategy for optimising patient flows between levels of care and have significantly reduced referrals from PHC to other levels of care. Similar results have been found in previous studies: Maeyama et al. (2018)18, for instance, found a reduction of approximately 70.0% in endocrinology referrals and 50.0% in rheumatology, as well as improved care for patients, whose needs were met at PHC facilities after compulsory tele-consultation flows were introduced in Santa Catarina. In Rio Grande do Sul, RegulaSUS, a system that regulates flows between PHC and specialised care by telehealth, although not compulsory, also resulted in a reduction in inappropriate and unnecessary referrals to specialists, as well as in the number of hospital admissions and excessive use of health care resources6.
Brazil’s national primary health care policy (PNAB) stipulates resolution rate as a guideline to be operationalised in PHC19, with a view to guaranteeing the ability to resolve most demands in PHC itself, without the need for referrals to other, specialised services20. In various universal health systems, technologies applied to PHC have proven effective in raising these services’ resolution rates, optimising care, and averting unnecessary referrals21.
Most of the teleconsultations and teleinterconsultations considered in this study eliminated the need for referral to other levels of care, demonstrating that they were effective in optimising patient flow. Moreover, counter-referral scheduling of appointments with the PHC team reinforced the continuity of user care and contributed to strengthening user relations with service personnel. This finding corroborated the various contributions of telehealth to health care systems, which range from improved integration of care, continued professional development for staffs and easier user access to health care services17.
Telehealth offers potential to be used for various purposes in PHC, particularly as regards health system integration, by facilitating communication among health care personnel and clinical management. Brondani et al. (2016)22 highlighted the difficulties in communication among health services, which have implications for the quality of care, resulting from communication failures during referral and counter-referral.
This study made it possible to profile demand for consultations in medical specialities by teleconsultation or teleinterconsultation in smaller municipalities of six health regions of Paraiba and Pernambuco. The telehealth strategy can function as a solution to the problem of management of care for chronic conditions in various contexts in the health system. Although no appropriate parameters have been established for the use of telehealth services, it is reasonable to suppose that there is a need to expand the use and capacity of health care personnel.
This study, although limited by its use of incomplete secondary data, demonstrated the potential of partnering between primary care and referral services in other regions to strengthen user care, especially in regions with more limited supply of medical specialities. The study corroborates the usefulness of information technologies not only in broadening user access to better care, but also providing more effective, quality care. Nonetheless, additional, more complete studies are needed to confirm the evidence offered here and to understand the impact of this partnering in greater depth.
 
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