Scale up of implementation of a multidimensional intervention to enhance hypertension and diabetes care at the primary care setting: A protocol for a cluster-randomized study in Brazil.

BACKGROUND: Hypertension and diabetes mellitus (DM) are highly prevalent in low and middle-income countries (LMICs), and the proportion of patients with uncontrolled diseases is higher than in high-income countries. Innovative strategies are required to surpass barriers of low sources, distance and quality of health care. Our aim is to assess the uptake and effectiveness of the implementation of an integrated multidimensional strategy in the primary care setting, for the management of people with hypertension and diabetes mellitus in Brazil. METHODS: This scale up implementation study called Control of Hypertension and diAbetes in MINas Gerais (CHArMING) Project has mixed-methods, and comprehends 4 steps: (1) needs assessment, including a standardized structured questionnaire and focus groups with health care practitioners; (2) baseline period, 3 months before the implementation of the intervention; (3) cluster randomized controlled trial (RCT) with a 12-months follow-up period; and (4) a qualitative study after the end of follow-up. The cluster RCT will randomize 35 centers to intervention (n = 18) or usual care (n = 17). Patients ≥18 years old, with diagnosis of hypertension and/or DM, of 5 Brazilian cities in a resource-constrained area will be enrolled. The intervention consists of a multifaceted strategy, with a multidisciplinary approach, including telehealth tools (decision support systems, short message service, telediagnosis), continued education with an approach to issues related to the care of people with hypertension and diabetes in primary care, including pharmacological and non-pharmacological treatment and behavioral change. The project has actions focused on professionals and patients. CONCLUSIONS: This study consists of a multidimensional strategy with multidisciplinary approach using digital health to improve the control of hypertension and/or DM in the primary health care setting. We expect to provide the basis for implementing an innovative management program for hypertension and DM in Brazil, aiming to reduce the present and future burden of these diseases in Brazil and other LMICs. CLINICAL TRIAL IDENTIFIER: This study was registered in ClinicalTrials.gov. (NCT05660928).

COVID-19 Telehealth Service Can Increase Access to the Health Care System and Become a Cost-Saving Strategy.

Introduction: Data addressing the economic aspects of telehealth initiatives are incipient. This study aimed to evaluate the labor costs for running a COVID-19 telehealth system and its potential incremental access to health care service. Methods: From July 2020 to July 2021, data from a Brazilian teleconsultation service were analyzed. Labor costs were estimated by time-driven activity-based costing. A Generalized Reduced Gradient solving method was coded to maximize the mean incremental access rate and two scenarios were considered to compare the teleconsultation with the in-person consultation: (1) only the length of time that patients spent with a clinician in an in-person consultation was accounted and (2) in addition to the medical consultation, nursing screening was accounted. The mean incremental access rate of the teleconsultation service was defined as a maximization objective in the model. Results: Mean labor costs per medical and nursing teleconsultations are Int$ 24 and Int$ 10, based on data analyses from 25,258 patients. Telemonitoring a patient with a daily call for 7 days costs, on average, Int$ 14. COVID-19 teleconsultation service represents, on average, an incremental access to medical consultation rate of 35% to 52% (min 23% max 63%) for the scenarios (1) and (2), respectively, and considering the current consumed budget for this service. Discussion: A COVID-19 telehealth service contributes to increasing access to the health care system without increasing costs. These services can be included in the bundle of care strategies offered in a national public health care system that looks for more sustainable strategies to provide care.

The Challenges of Implementing a Text Message Intervention to Promote Behavioral Change in Primary Care Patients With Hypertension and Diabetes

Abstract Background Controlling blood pressure and glycemic levels is a challenge that requires innovative solutions. Objective To assess the feasibility of implementing a text message intervention among low-income primary care patients, as well as to assess self-reported behavioral change. Methods A set of 200 text messages was developed on healthy eating, physical activity, adherence, and motivation. Participants from Vale do Mucuri, MG, Brazil diagnosed with diabetes or hypertension or undergoing screening for those diseases, received 5 to 8 messages per week for 6 months. They answered a questionnaire to report their satisfaction and behavioral changes. Results Of the 136 patients, 117 (86.0%) answered the questionnaire. Most reported that the messages were very useful (86.3%), easy to understand (90.6%), and were very helpful for behavioral change (65.0%); 84.6% reported that they had started eating healthier. The most frequent reported lifestyle changes were: improved diet quality (85.5%), reduced portions (65.8%), and weight loss (56.4%). The majority of patients shared the messages (60.7%) with family or other acquaintances, considered the number of messages to be adequate (89.7%) and would recommend the program to others (95.7%). Conclusion An intervention based on text messages to promote behavioral change in patients with hypertension or diabetes in primary care is feasible in low-resource settings. Future studies are needed to assess the program's long-term effects on clinical outcomes.

Synchronous Teleconsultation and Monitoring Service Targeting COVID-19: Leveraging Insights for Postpandemic Health Care.

BACKGROUND: Although a great number of teleconsultation services have been developed during the COVID-19 pandemic, studies assessing usability and health care provider satisfaction are still incipient. OBJECTIVE: This study aimed to describe the development, implementation, and expansion of a synchronous teleconsultation service targeting patients with symptoms of COVID-19 in Brazil, as well as to assess its usability and health care professionals' satisfaction. METHODS: This mixed methods study was developed in 5 phases: (1) the identification of components, technical and functional requirements, and system architecture; (2) system and user interface development and validation; (3) pilot-testing in the city of Divinópolis; (4) expansion in the cities of Divinópolis, Teófilo Otoni, and Belo Horizonte for Universidade Federal de Minas Gerais faculty and students; and (5) usability and satisfaction assessment, using Likert-scale and open-ended questions. RESULTS: During pilot development, problems contacting users were solved by introducing standardized SMS text messages, which were sent to users to obtain their feedback and keep track of them. Until April 2022, the expanded system served 31,966 patients in 146,158 teleconsultations. Teleconsultations were initiated through chatbot in 27.7% (40,486/146,158) of cases. Teleconsultation efficiency per city was 93.7% (13,317/14,212) in Teófilo Otoni, 92.4% (11,747/12,713) in Divinópolis, and 98.8% (4981/5041) in Belo Horizonte (university campus), thus avoiding in-person assistance for a great majority of patients. In total, 50 (83%) out of 60 health care professionals assessed the system's usability as satisfactory, despite a few system instability problems. CONCLUSIONS: The system provided updated information about COVID-19 and enabled remote care for thousands of patients, which evidenced the critical role of telemedicine in expanding emergency services capacity during the pandemic. The dynamic nature of the current pandemic required fast planning, implementation, development, and updates in the system. Usability and satisfaction assessment was key to identifying areas for improvement. The experience reported here is expected to inform telemedicine strategies to be implemented in a postpandemic scenario.

Brazilian National Service of Telediagnosis in Electrocardiography.

Access to specialized care remains unsolved in Brazil. The National Telediagnosis Project was created to expand successful telediagnosis experiences nationwide. The Telehealth Network of Minas Gerais (TNMG) was selected as a reference for tele-electrocardiogram (ECG). We aim to describe the experience of TNMG of developing and implementing the Brazilian National Service of Telediagnosis in Electrocardiography. Implementation planning includes discussion of workflows, standard procedures, responsibility definition for stakeholders, and adaptation of TNMG telediagnosis system. Tele-ECG has been implemented in 79 municipalities in 5 states. In a survey with 152 health professionals, 57% noted that ECG was not available in the local public health system before, 63% indicated tele-ECG service utilization ≥3 days per week, 96% considered the service very useful and 89% were very satisfied with it. In conclusion, the service fills a gap in specialized care in the public system and can improve access to a basic exam in remote and underserved regions.

Associaçäo esferocitose hereditária e traço falciforme: relato de um caso e revisäo da literatura / Hereditary spherocytosis associated with sickle cell trait: a case report and literature review

A associaçäo da esferocitose hereditária e o traço falciforme tem sido raramente relatado na literatura médica, com apenas 17 casos descritos que foram revistos neste trabalho. Apresentamos um caso adicional desta associaçä em paciente do sexo feminino, 21 anos, portadora do traço falciforme com história de anemia e crises de hemólise desde os sete anos de idade. Necessitou de hemoterapia em várias ocasiöes. Foi realizada ampla propedêutica, incluindo estudo familiar. Submetida a esplenectomia, houve melhora do quadro. Este caso enfatiza a necessidade de um estudo mais detalhado em pacientes portadores de traço falciforme com sinais evidentes de hemólise.