Telemedicine/trends – ABC CARDIOL

IJCS

Editorial

Challenges in Telemedicine: Even When the Road is Hard, Never Give up

Erito Marques de Souza Filho et al. Alexandra Monteiro

“Even when the road is hard, never give up” – Tupac Shakur and The Outlawz

The above quote is from the hit song “Baby Don’t Cry” immortalized by Tupac and The Outlawz. The song is about a young woman who faces challenges and receives encouragement to persevere and not give up. In a similar way, telemedicine faces several challenges on an arduous path. In this way, imbued with a tenacious spirit, its users have had remarkable experiences. In the current issue of the International Journal of Cardiovascular Sciences, Esmerio and colleagues presented a successful application of a telecardiology service. They emphasized that the work contributed to reducing the distance between patients and specialized professionals, and they highlighted a high level of satisfaction for both patients and health Professionals. Experiences like this represent the relevant role of telemedicine in providing quality health services and generating value. However, these tools still face important challenges that need to be overcome.

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Original Article

Reperfusion Therapy Optimization in Acute Myocardial Infarction with ST-Segment Elevation using WhatsApp®-Based Telemedicine

Alessandra Batista Teixeira et al. Leonardo Fiaschi Zancaner Fernando Fonseca de França Ribeiro José Paulo Pintyá … André Schmidt Benedito Carlos Maciel José Antônio Marin Neto Carlos Henrique Miranda

Abstract

Background

About 40% of patients with ST-segment elevation myocardial infarction (STEMI) in Brazil do not receive reperfusion therapy.

Objective

The use of a telemedicine network based on WhatsApp^® could increase the percentage of patients receiving reperfusion therapy.

Methods

A cross-sectional study analyzed outcomes before and after the organization of a telemedicine network to send the electrocardiogram via WhatsApp® of patients suspected of STEMI from 25 municipalities that are members of the Regional Health Department of Ribeirão Preto (DRS−XIII) to a tertiary hospital, which could authorize immediate patient transfer using the same system. The analyzed outcomes included the percentage of patients who received reperfusion therapy and the in-hospital mortality rate. A p value < 0.05 was considered statistically significant.

Results

The study compared 82 patients before (February 1, 2016 to January 31, 2018) with 196 patients after this network implementation (February 1, 2018 to January 31, 2020). After implementing this network, there was a significant increase in the proportion of patients who received reperfusion therapy (60% vs. 92%), relative risk (RR): 1.594 [95% confidence interval (CI) 1.331 – 1.909], p < 0.0001 and decrease in the in-hospital mortality rate (13.4% vs. 5.6%), RR: 0.418 [95%CI 0.189 – 0.927], p = 0.028.

Conclusion

The use of WhatsApp^®-based telemedicine has led to an increase in the percentage of patients with STEMI who received reperfusion therapy and a decrease in the in-hospital mortality rate.

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Original Article

Implementation of a Telecardiology Service in a Health Unit in the City of Porto Alegre, Brazil: A Pilot Study

Francieli Giachini Esmerio et al. Silvia Goldmeier Eduardo Costa Duarte Barbosa Luis Marcelo Segredo … Rodolfo Silva Maria Claudia Irigoyen Bruna Eibel Patricia Oliveira Dias

Abstract

Background:

The implementation of Telecardiology in primary care in the city of Porto Alegre, Brazil, is a viable and promising strategy. It would decrease the distance between patient and specialized professional services by reducing unnecessary referrals and improving the quality of primary care and satisfaction of patients and health professionals.

Objective:

To implement a Telecardiology service and assess user satisfaction using the CARDIOSATIS scale.

Methods:

This was a pilot study developed by a partnership between the Institute of Cardiology and the Telehealth Center of Rio Grande do Sul. The study was carried out at Eri Flores-Vila Vargas health center in the city of Porto Alegre, from May to October 2019, and included 21 patients attending the health center. The descriptive analysis of data was performed using the SPSS program (Statistical Package for the Sciences) version 23. Data normality was checked using the Kolmogorov-Smirnov test. Statistical significance was set at 10%.

Results:

Mean age of participants was 43.8 ± 16.1 years. The most common risk factors in the sample were physical inactivity (81%) and smoking (43%). Most patients had normal electrocardiogram (ECG) readings. The time elapsed from the performance of the ECG test, transmission of the ECG traces to Telehealth, and return of the final ECG report to the health center was 0-7 days. The CARDIOSATIS scale revealed a high prevalence of “very satisfied” users for the general satisfaction domain, and only 14.3% of patients were dissatisfied with their health.

Conclusions:

Telecardiology reduced the distance between patient and the specialized professional, with a high level of patient and health professional satisfaction. Our study can serve as a basis for the implementation of a telecardiology network in the city of Porto Alegre in the future.

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Viewpoint

Acute Coronary Syndromes in the Current Context of the Covid-19 Pandemic

Raphael Boesche Guimarães et al. Breno Falcão Ricardo Alves Costa Marcelo Antônio Cartaxo Queiroga Lopes … Roberto Vieira Botelho Ricardo Petraco Rogério Sarmento-Leite

Introduction

COVID-19, initially described at the end of 2019 in China, may present as atypical pneumonia and severe respiratory failure. Classified in February 2020 as a pandemic by the World Health Organization (WHO), COVID-19 has had major clinical, social, political and economic implications. Society as a whole has had to adapt to a new reality, forcing hospitals to rewrite their routine practices and clinical pathways. Specific measures have had to be put in place to prevent hospital transmission of the infection. Also, dedicated COVID units have been set up and infection control protocols implemented. Finally, additional human, material and financial resources have been allocated in order to provide patients with the best possible care, without compromising the safety of healthcare workers.

Social isolation as a way of containing the spread of the disease may have helped, in some places, to “flatten the curve”, preventing the collapse of healthcare systems. However, the duration of the pandemic, as well as the precise risk of transmission are still largely unknown.

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Echoes of Telecardiology Guideline

Silvio Henrique Barberato et al. Marcelo Antônio Cartaxo Queiroga Lopes

Echocardiography has an established role in the diagnosis, prognostic evaluation and therapeutic orientation in several cardiovascular diseases. The great technological development in the last decades has allowed the digitization and standardization of medical images (DICOM), miniaturization of echocardiography equipment (portable cardiac ultrasound) and the transfer of images over the internet. In this scenario, strategies for the use of telemedicine-associated echocardiography, called tele-echocardiography, have been employed in the context of clinical research with the support of teleconsultation for remote expert review, in real time or after image storage and submission. In recognition of the demands generated by the ongoing digital transformation in health, the Brazilian Society of Cardiology recently published the Telemedicine Guideline in Cardiology. The document recognizes tele-echocardiography as a strategy for early detection of congenital heart disease in newborns and screening for early detection of subclinical cases of rheumatic heart disease in children and adolescents (both recommended as indication class IIa, level of evidence B). In addition, it evokes potential application in primary health care in remote locations, where it could enable early detection of cases of heart disease and assist in prioritizing referrals to specialized care (indication class IIb, level of evidence C). It should be emphasized that such recommendations are made within the conditions of regular use of the method in Brazil, which would include the need for doctors at both ends, i.e., the execution and interpretation of the exam. The text of the Guideline explicitly states the need for regulation and legal provision for the participation of other professionals in performing diagnostic procedures (in this case, obtaining echocardiographic images by non-doctors), currently not allowed by the country’s legislation.

In recent years, tele-echocardiography has extended the application of the method to individuals in geographically distant locations, such as remote rural communities or even space. A rural area is classified as remote when 50% of the local population needs at least 45 to 60 minutes of travel by motor vehicle to reach a population center of at least 50,000 inhabitants. Several situations have been experimentally tested, with a study on focused echocardiographic by non-cardiologist physicians,^, non-physicians,^, or remote-operated robotic devices, combined with remote interpretation by echocardiography cardiologists.

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Editorial

Behavioral Economics and Innovation Uptake: Building New Capabilities to Overcome Barriers to Technology-Enabled Care

Alexandre Siciliano Colafranceschi

Introduction

The Federal Medical Council (CFM) has recently published a new resolution on telemedicine in Brazil. The 2227/2018 resolution, establishing the criteria for the use of telemedicine, was published in Diario Oficial da União (DOU, the official journal of the federal government of Brazil) on February 6, 2019. This new policy, aimed at defining telemedicine as a way of providing medical services by means of technology, is much more aggressive than the previous one published in 2002, which limited the use of telemedicine to medical consultations made by telephone or internet, and implied the presence of a health professional at both ends of the communication channel. The current resolution expanded the concept of telemedicine in providing technological solutions for remote patient monitoring and treatment (drug prescription and surgical interventions), and analysis of laboratory results. However, soon after its release, the new document caused an intense public debate on the theme dividing stakeholders for and against the incorporation of telemedicine into practice nationwide. The debate was so intense that the Federal Medical Council revoked the resolution, as published in the DOU on March 6, 2019.

The revocation of the policy after intense societal debate indicates the significant challenges regarding the implementation of technology-enabled care in Brazil. Such debate should not be the end, but rather, the beginning of a social mobilization to reframe the use of connected technology in healthcare in the country. To tackle the barriers to the uptake of technology-enabled care in Brazil, one should better understand the stakeholder positions, and consider the political and cultural environment, the ethical and legal apparatus and the available technology infrastructure.

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Editorial

Economic Burden of Cardiovascular Diseases in Brazil: Are Telemedicine and Structured Telephone Support the Solution?

Suzana Alves da Silva et al. Pedro Paulo Magalhães Chrispim Yang Ting Ju Ary Ribeiro

The study by Stevens et al. results from a project of Delloite Consulting, financed by Novartis and aimed at estimating the economic burden that heart failure, acute myocardial infarction, atrial fibrillation and systemic arterial hypertension (SAH) impose on Latin American countries, and at assessing the cost-effectiveness of telemedicine and structured telephone support as interventions that can relieve it. The publication in this issue of the Arquivos Brasileiros de Cardiologia focused on presenting the results of the assessment in the Brazilian scenario.

This study provided us with the opportunity to reflect on important questions related to quality, interpretation and applicability of economic studies. Such studies have gained increasing relevance in the incorporation/disincorporation of technologies and the development of health policies and programs to improve healthcare quality. In addition, they are often used in other countries to support decision-making processes, although that is not a routine in Brazil.

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