Telemedicine

IJCS

Review Article

Challenges and Opportunities in Teaching and Training Pediatric Cardiac Critical Care in Developing Countries: A Narrative Review

Carolina Vieira de Campos et al. Carlos Roberto Ribeiro Carvalho

Abstract

Congenital heart disease (CHD) is a public health issue in developing countries. Effective teaching and training are vital for healthcare professionals to provide adequate care for critically ill cardiac children, but there are many obstacles to adequately training a cohort of healthcare professionals in low- and middle-income countries (LMIC), where education practice is not always aligned with current education evidence. Work overload, time constraints, language, and the healthcare structure itself hinder standardization of an optimal training process for this highly complex scenario. This narrative review aims to explore how current teaching methodologies may help overcome challenges in pediatric cardiac critical care (PCCC) education, thus helping clinical practice, with a special focus on developing countries and the Brazilian scenario.

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Original Article

Six-Month Remote Monitoring of Patients With Chronic Heart Failure Using Messaging Applications on Smartphones

Elena Zheleznykh et al. Anastasia Panova Aleksei Emelianov Daria Kutsakina … Andrei Nartov Valeria Nartova Nikolay Pavlov Yuri Belenkov Maria Kozhevnikova

Abstract

Background:

Patients with chronic heart failure (HF) require outpatient monitoring after hospital discharge. The ability to use a smartphone with a personal messaging application may help.

Objectives:

Tis study aimed to investigate the feasibility of remote monitoring and evaluate its impact on treatment adherence and prognosis in patients with HF.

Methods:

A total of 100 patients were enrolled in the study: 57 patients in the mHealth group and 43 in the control group. The observation period lasted six months. Remote monitoring included a daily survey sent to patients via a personal messaging application. This was an open, randomized trial. A p-value < 0.05 was considered statistically significant.

Results:

After six months, 46 patients (mean age 61.52 ± 13.05 years, 34 men) in the mHealth group and 43 patients (mean age 60.07 ± 10.19 years, 27 men) in the control group completed the study. A total of 11 patients were lost to follow-up. In the mHealth group, two patients (4%) reached the primary endpoint, compared to seven patients (7%) in the control group.

Conclusion:

The effectiveness of remote monitoring for patients with HF using self-reporting via a smartphone messaging application was demonstrated. Patient adherence to self-reporting was found to be 76%. Those in the mHealth group who reported regularly and consistently demonstrated greater engagement in self-monitoring of vital signs and higher adherence to prescribed therapy.

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IJCS

Original Article

Development and Implementation of a Computerized Decision Support System for Screening Hypertension and Diabetes in a Resource-Constrained Region

Laura Defensor Ribeiro de Melo et al. Antonio Luiz Pinho Ribeiro João Antonio de Queiroz Oliveira Junia Xavier Maia … Thábata Queiroz Vivas de Sá Vânia Soares de Oliveira e Almeida Pinto Marcia Maria Oliveira Lima Patrick Wander Enlich Leonardo Bonisson Ribeiro Christiane Correa Rodrigues Cimini Milena Soriano Marcolino

Abstract

Background

Strategies aimed at improving the diagnosis and treatment of cardiovascular diseases (CVD) are of utmost importance. Clinical decision support systems (CDSS) are guided by updated guidelines and may be capable of benefiting screening and early diagnosis initiatives in remote regions.

Objective

To develop a CDSS for screening hypertension and diabetes mellitus (DM), as well as to assess its feasibility and usability in the context of a primary care setting in a resource-constrained region.

Methods

This research focused on the strategy of screening hypertension and DM based on CDSS. A software was developed and implemented in 10 municipalities in the Northeast of the state of Minas Gerais, Brazil, from April 2017 to October 2018. Patients of 30 to 69 years of age were attended by primary care practitioners using the software. A Likert-scale questionnaire with 15 questions to assess usability (System Usability Scale) and satisfaction was applied to the professionals at the end of study. Groups were compared by applying the chi-squared test for categorical variables. Statistical significance was considered as p < 0.05.

Results

In the field study, 13,775 individuals were assessed; 185 patients were diagnosed with hypertension; 35 were diagnosed with DM, and 5 were diagnosed with both diseases. For the usability and satisfaction assessment, 258 healthcare professionals participated. Fifty-one percent considered their prior knowledge for the use of technologies to be good; 53.7% reported a desire to use the application frequently, and 78.4% would recommend the platform.

Conclusion

The implementation of a CDSS developed to assist in the screening of hypertension and DM was feasible in the context of a primary care setting in a resource-constrained region, with good user satisfaction.

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IJCS

Viewpoint

Value-based Health Care Impact on Cardiovascular and Metabolic Diseases

Ana Paula Beck da Silva Etges et al. Gabriela Boff Comiran Anna Luiza Reinehr Ferreira Carisi Anne Polanczyk

Final considerations

The development of a value-based health system that is centered around individual needs and scaled to deliver the best health outcomes within a budget constraint is possible and favored by structural changes to the system, such as payment methods and a technology base that enables real-life data-driven management. PHC centralization and the interconnection with data shared between the assisted population and specialized care systems seem to be a requirement for greater capacity for tracking, diagnosing, and managing cardiometabolic diseases in the health system. For Brazil’s current scenario, the challenges start with the precarious measurement culture and remuneration strategies that are centered on payment for the service delivery rather than the impact they have on population health.

As primary steps to establish a value-based health model for cardiometabolic diseases in Brazil, seeking inspiration from existing evidence, the following are recommended: start by disseminating mobile technologies that provide education and self-care and can be easily accessed by the population; advance towards implementing a measurement culture in PHC, sharing results with specialized care institutions and funding sources; and establish a better capacity for longitudinal monitoring of individuals in the care pathways, which can be driven by a change in the specific reimbursement strategy for each of care pathways.

[…]

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Original Article

Effectiveness of Telemedicine in Reducing Hospitalizations in Patients Discharged from the Hospital Due to Heart Failure: A Randomized Clinical Trial Protocol

Edmar Geraldo Ribeiro et al. Luisa Brant Lilian Cristina Rezende Renato Azeredo Teixeira … Laura Carvalho Parreiras Tulio Batista Franco Antônio Ribeiro Deborah Malta

Abstract

Fundament:

Telemedicine for follow-up in heart failure (HF) patients is effective in reducing hospitalizations, total and cardiovascular mortality. However, few studies were conducted in low and middle income, where lower access to technology and illiteracy could impact the results.

Objective:

To assess the effectiveness of associating telemedicine strategies, when compared to usual care, in reducing hospitalizations related to HF in patients discharged from the hospital due to HF.

Methods:

Controlled, randomized, multicenter, parallel-arm clinical trial, with an allocation ratio of 1:1, blinded to outcome evaluation, in which 340 patients who were discharged from public hospitals in Belo Horizonte due to HF will be randomized. Patients will be followed for 6 months and the intervention group will receive, in addition to the usual care, Structured Telephone Support (STS) from a nurse, a doctor, and an educational program. Counseling will be according to a clinical decision tree. The level of significance in the statistical analysis will be 5%.

Expected results:

Reduction in the number of hospital readmissions and/or in hospitalization time, in addition to developing a software with a clinical decision tree for remote follow-up and patient education about HF adapted to local culture.

Conclusions:

The intention of this study is to develop a telemedicine strategy and assess whether or not, in addition to the usual care, it is effective in reducing hospitalizations and mortality from HF. If effective, the aforementioned strategy could reduce costs and hospital needs in the Unified Health System (SUS, in Portuguese) for patients with HF. These results will be even more relevant considering the pandemic of COVID-19.

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Viewpoint

Smartphone-Based Screening for Cardiovascular Diseases: A Trend?

Thiago Mazzu-Nascimento et al. Danilo Nogueira Evangelista Obeedu Abubakar Meliza Goi Roscani … Rodrigo Santos Aguilar Silvana Gama Florêncio Chachá Priscila Raupp da Rosa Diego Furtado Silva

Abstract

Cardiovascular diseases are the leading cause of death in the world. People living in vulnerable and poor places such as slums, rural areas and remote locations have difficulty in accessing medical care and diagnostic tests. In addition, given the COVID-19 pandemic, we are witnessing an increase in the use of telemedicine and non-invasive tools for monitoring vital signs. These questions motivate us to write this point of view and to describe some of the main innovations used for non-invasive screening of heart diseases. Smartphones are widely used by the population and are perfect tools for screening cardiovascular diseases. They are equipped with camera, flashlight, microphone, processor, and internet connection, which allow optical, electrical, and acoustic analysis of cardiovascular phenomena. Thus, when using signal processing and artificial intelligence approaches, smartphones may have predictive power for cardiovascular diseases. Here we present different smartphone approaches to analyze signals obtained from various methods including photoplethysmography, phonocardiograph, and electrocardiography to estimate heart rate, blood pressure, oxygen saturation (SpO₂), heart murmurs and electrical conduction. Our objective is to present innovations in non-invasive diagnostics using the smartphone and to reflect on these trending approaches. These could help to improve health access and the screening of cardiovascular diseases for millions of people, particularly those living in needy areas.

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Original Article

Text Messages to Promote Secondary Prevention after Acute Coronary Syndrome (IMPACS trial)

Luiz Guilherme Passaglia et al. Luisa Campos Caldeira Brant José Luiz Padilha da Silva Bruno Ramos Nascimento Antônio Luiz Pinho Ribeiro

Abstract

Background

Short message service (SMS) to promote healthcare improves the control of cardiovascular risk factors, but there is a lack of evidence in low and middle-income countries, particularly after acute coronary syndromes (ACS).

Objective

This study aims to evaluate whether the use of SMS increases risk factor control after hospital discharge for ACS.

Methods

IMPACS is a 2-arm randomized trial with 180 patients hospitalized due to ACS at a tertiary hospital in Brazil. Eligible patients were randomized (1:1) to an SMS intervention (G1) or standard care (G2) upon hospital discharge. The primary endpoint was set to achieve 4 or 5 points in a risk factor control score, consisting of a cluster of 5 modifiable risk factors: LDL-C <70mg/dL, blood pressure (BP) <140/90mmHg, regular exercise (≥5 days/week, 30 minutes/session), nonsmoker status, and body mass index (BMI) <25 kg/m2] at 6 months. Secondary outcomes were components of the primary outcome plus rehospitalization, cardiovascular death, and death from any cause. Results are designated as significant if p<0.05.

Results

From randomized patients, 147 were included in the final analysis. Mean age was 58 (51–64) years, 74% males. The primary outcome was achieved by 12 (16.2%) patients in G1 and 15 (20.8%) in G2 (OR=0.73, 95%CI 0.32–1.70, p=0.47). Secondary outcomes were also similar: LDL-C<70 mg/dl (p=0.33), BP<140/90 mmHg (p=0.32), non-smoker (p=0.74), regular exercise (p=0.97), BMI (p=0.71), and rehospitalization (p=0.06). Death from any cause occurred in three participants (2%), including one cardiovascular death in each group.

Conclusion

SMS intervention did not significantly improve cardiovascular risk factor control when compared to standard care in patients discharged after ACS in Brazil.

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Original Article

An Approach to Technology Development and Current Medical Practice

Gilson Feitosa

Abstract

Background

An approach to technology development and the current medical practice.

Objective

To consider the many stages of medical-applied technological developments and its main consequences related to the current medical practice and speculate on future developments.

Methods

Assessment of historical publications and individual and metanalysis of comparative evaluation of old versus new techniques.

Results

Documentation of progressive improvement in diagnostic skill and therapeutics toward less invasive procedures along the last decades, since the introduction of the scientific medicine.

Conclusion

Progress has been unequivocally documented albeit an effort to maintain time-proven established previous technique is advised, especially in favor of stimulating a personal patient-physician relationship. (International Journal of Cardiovascular Sciences. 2020; [online].ahead print, PP.0-0)

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