Keywords: Telemedicine - Health Services Accessibility, Health Equity - Primary Health Care
- Neurology
Palavras-chave: Telemedicina - Acesso aos Serviços de Saúde - Equidade em Saúde - Atenção Primária
à Saúde - Neurologia
INTRODUCTION
Brazil’s national health system, the Sistema Único de Saúde (SUS) has undergone major changes over the last 20 years: a structured and coordinated
healthcare system has been created and primary care has been defined as the main setting
of the healthcare system. Despite these changes, the population complains about difficult
access to medical care and fragmentation of its service network, with important gaps
between primary and specialized healthcare. Many referrals of patients to specialized
care are made without adequate information, without definition of priority level and
without counter-referral. Consequently, referral processes frequently result in lack
of continuity of care and delays in health assistance[1 ],[2 ],[3 ],[4 ].
There is a pent-up high demand for consultations within secondary and tertiary care.
Especially in neurology, there are long waiting lists for consultations. In the city
of Porto Alegre, in the south of Brazil, the average waiting time for a neurology
consultation was 342 days in December 2018[5 ]. Nonetheless, the complexity of the cases does not seem to justify the increasing
numbers of referrals to neurologist. Studies in Brazil have reported that the main
complaints in neurological clinics are headache, secondary prevention of stroke, epilepsy
follow-up[6 ] and diagnoses of dementia[7 ], depending on the cohort.
Approximately 80% of cases can be diagnosed and resolved within primary care by a
good clinical doctor with adequate training and support. Through this, referral of
serious or surgical cases can be prioritized, considering that delays in diagnosing
and treating neurological conditions can worsen patient care and quality of life[8 ],[9 ],[10 ]. Telemedicine may be a solution for supporting doctors in remote areas in a continental
country like Brazil who have different levels of training due to the absence of any
policy of continuing medical education. This could help primary care physicians (PCPs)
to manage some neurological conditions in the primary care setting[11 ], as already reported in Canada by Bradi et al., where direct communication between
PCPs and specialists through the eConsult system avoids 30% of referrals[12 ].
In a pragmatic effort to solve the related problems of referrals from primary healthcare
(PHC) to different specialists, the Brazilian Ministry of Health (MH) launched the
project “Regula Mais Brasil” in a public-private partnership with Hospital Sírio-Libanês,
a major private hospital in São Paulo. This was inspired by the successful experience
of the pilot telehealth study TelessaúdeRS-UFRGS in the south of Brazil[13 ]. The “Regula Mais Brasil” goal is to qualify the management of patients with frequent
problems within primary health care and to reduce the waiting times for specialized
consultations through an e-referral system and telephone-based support in different
Brazilian regions.
The objectives of this article were to describe the most frequent doubts presented
by PCPs during teleconsultations, to compare decision-making between neurologists
or other specialists when guiding the conduct of cases over the phone and to evaluate
how a teleconsulting service between doctors can reduce the numbers of unnecessary
referrals to secondary and tertiary care.
METHODS
In this partial analysis on the “Regula Mais Brasil” project, we report on 1687 neurology
teleconsultations that were carried out between January 10, 2019, and December 2,
2019. As part of the institutional development support program for SUS, a federal
law of 2009 determines that hospitals certified for excellence will receive tax exemptions
to subsidize projects. The thematic areas and purposes of these projects are defined
by the Ministry of Health, along with the population or cities to be benefited. It
is the responsibility of hospitals of excellence to deliver the scientific production,
infrastructure and payments of the professionals that are needed to carry out these
projects.
Project infrastructure and logistics
The technological infrastructure was formed by three call centers located in São Paulo,
Porto Alegre and Brasília. Information on this has been published in another study[14 ].
A free call phone line is open Mondays through Fridays, from 8:00 a.m. to 5:30 p.m.,
to PCPs in two cities (Porto Alegre, capital and largest city of Rio Grande do Sul,
and Belo Horizonte, capital and largest city of Minas Gerais), one state (Amazonas)
and the Brazilian Federal District ([Figure 1 ]). The participating locations were determined by the Ministry of Health and obeyed
predefined criteria: intervention by local governments with the Ministry of Health
requesting support, length of the queue, waiting time and number of judicial procedures
that had been filed, demanding consultations with specialists. Neurology assistance
by means of teleconsultation is available for Porto Alegre, Belo Horizonte and the
Federal District, totaling a population of 6 million people involved on this study.
Through teleconsultations, not only neurologists, but also family physicians and other
specialists answer the PCP questions in real time, using evidence-based-medicine protocols
and guidelines, and taking local conditions into consideration. Referral decisions
are based on the referral protocols for consultations with specialists, as published
by the Health Department of Rio Grande do Sul, and approved by the Ministry of Health
for use in the project. The document considered nine pathological conditions that
would be sensitive to PHC and guided referrals for emergencies in severe cases or
in the presence of warning signs. The final decision about referral always belonged
to the PCP and the legal accountability was shared between the physicians.
Figure 1 Causes of teleconsultation according to group of disorders.
Through this service, PCPs have the opportunity to discuss cases and decide, with
the specialist support, whether referral is required. Furthermore, they can discuss
the management of clinical cases in the primary care setting, whether the patient
has been referred to a specialist or not. No contact between the patient and teleconsultant
occurs during the e-Consult process. This is a teleconsultation service that does
not extend to patients. It is important to note that for a case to be referred, the
PCP needs to submit the case description via the online referral platform for reading
and evaluation by the teleconsulting doctors of the “Regula Mais Brasil” project.
To make the call, prior referral via the platform is not mandatory. Thus, many PCPs
prefer to first discuss the case over the phone and then submit it on the platform.
Patients are not required to provide their informed consent because the research ethics
committee has taken the view that the intervention that the project is implementing
is a modification in the patient management process that does not harm the patient’s
autonomy. The “Regula Mais Brasil” project has been approved by the ethics committee
of Hospital Sírio-Libanês.
A cost-effectiveness study is being carried out to inform the Brazilian government
whether the telemedicine strategy is associated with improvement of the patient management
process.
Statistical analysis
A qualitative evaluation was done by one of the neurologist teams using Business intelligence
tools. Teleconsultations were grouped according to decision, place, reason for referral
and expert who conducted the discussion. A qualitative analysis was performed by an
auditing physician, to identify the type of orientation and the need for a second
opinion between teleconsultants.
A descriptive analysis was conducted with the aim of presenting the characteristics
of the patients who were referred and the referral requests. The questions were categorized
according to topic and type and were analyzed quantitatively. Categorical variables
were expressed as the absolute frequency (n) and percentage (%). Quantitative variables
were described as the mean and standard deviation. Associations between categorical
variables were ascertained using the chi-square and Fisher's exact tests. Analyses
with p<0.05 were considered statistically significant.
RESULTS
A total of 1687 teleconsultations relating to neurology, with data available, were
conducted between January 10 and December 2, 2019, from the cities of Belo Horizonte
and Porto Alegre, and from the Federal District. During this period, the project received
10,780 calls relating to all 12 specialties served. The average length of time per
call was 6.8 minutes. The city of Belo Horizonte had the highest number of calls,
totaling 1,388 cases discussed over the period. The most common international disease
codes (ICD-10) were G40 (epilepsy and idiopathic epileptic syndromes defined by their
(focal) (partial) location with focal onset seizures), R51 (headache) and I64 (stroke,
not specified as hemorrhagic or ischemic), respectively 23.7, 17.0 and 8.2% ([Figure 1 ]). The patients’ mean age was 49.5 years and 58.6% were women.
Most of the cases (54.2%) were discussed with a neurologist, while 35.1% were discussed
by a PHC and 10.7% by physicians in other specialties, guided by protocol decisions.
The service is available 47.5 h per week and neurologists cover 73% of the service
period ([Table 1 ]).
Table 1
Epidemiological and demographic characteristics.
Sociodemographic characteristics
Age, mean (SD)
49.5 (20.8)
Place (n, %)
Belo Horizonte
1,388 (82.3)
Porto Alegre
151 (8.9)
Federal District
148 (8.8)
An overall analysis on the sample showed that 25% of the referrals were avoided using
the teleconsultations and that there were no differences in decision made, based on
the teleconsultant physician’s specialty (approval indexes of 72.3, 72.6 and 66.5%
for neurologists, family physicians and other specialists, respectively) among cases
referred for teleconsultation.
Comparison of neurologists versus family doctors or physicians certified in other
specialties showed that there were no statistical differences between the numbers
of patients approved for specialist consultation, referred to an emergency service
or returned for PHC resolution. However, in comparison with family physicians, teleconsultants
from focal medical specialties other than neurology guided more case management at
PHC units (33.5 vs. 25%; p=0.042), through returning referrals to PHC, while family
physicians referred patients more often to an emergency service than did physicians
in other specialties (2.4 vs. 0%; p=0.042).
Out of the total, 906 cases were discussed by PCPs in an attempt to accelerate referrals
that had already been completed on the online platform but had not yet been attended
at the secondary center. Of these, 72.7% were approved for consultations with neurologists.
In the meantime, 663 phone contacts were made before the PCPs send the referrals,
i.e. these cases was not submitted to the online platform. The objective was to ask
for orientation in making decisions about diagnoses and treatments. Out of these,
60.1% were cases that could not be resolved at the PHC unit, and referral was approved
by the teleconsultant. Placing the referral on the referral platform before the discussion
seems to influence the teleconsultation outcome, given that the number of approvals
is greater than it is in cases with discussion without previous referral (72.7 vs.
60.1%; p<0.000). The decision rates according to the teleconsultant's specialty are
shown in [Table 2 ].
Table 2
Decision rate according to the teleconsultant's specialty.
Cases already referred for consultation with a neurologist
Teleconsultant’s specialty (total=906)
Referral to a neurologist, n (%)
Recommendation of treatment and follow-up at PHC, n (%)
Neurologist (452)
353 (78.1)
99 (21.9)
Family Medicine (340)
254 (74.7)
86 (25.3)
Other specialties (114)
85 (74.6)
29 (25.4)
Cases with shared decision-making before the referral
Teleconsultant’s specialty (total=663)
Referral to a neurologist, n (%)
Recommendation of treatment at PHC, n (%)
Referral to emergency service, n (%)
Neurologist (401)
254 (63.3)
130 (32.4)
17 (4.2)
Family Medicine (214)
145 (67.8)
65 (30.4)
4 (1.9)
Other specialties (48)
33 (68.8)
10 (20.8)
5 (10.4)
Complete data were available for a total of 1,569 cases.
A detailed analysis of the teleconsulting electronic records showed that neurologist
teleconsultants recommended treatment or diagnostic tests more often than did family
physicians or other focal specialist teleconsultants (26.1, 17.3 and 28.9%; p=0.000,
Pearson chi-square).
Out of the 1687 cases discussed, the diagnosis or treatment approach in 394 cases
(23.4%) was altered through discussion of the case, which gave rise to suggestions
for the diagnosis or treatment ([Table 3 ]).
Table 3
Teleconsultants’ recommendations of treatment or diagnostic tests, stratified according
to teleconsultant specialties.
Specialty (total=1,687)
Cases with diagnostic or therapeutic orientation, n (%)
Neurologist (919)
240 (26.1)
Family Medicine (588)
102 (17.3)
Other specialties (180)
52 (28.9)
Out of all the cases seen, 23.4% received some type of guidance regarding treatment
and diagnosis. PCPs tended to advise less frequently than did other specialists, in
a significant way (p<0.000).
DISCUSSION
This is one of the first published papers about telehealth in neurology in Brazil.
In a scenario of scarcity of data on the attendance of certain pathological conditions
within PHC, this study makes a contribution through bringing to light the profile
of the frequent doubts of PHC doctors regarding the neurology specialty. It confirms
that telemedicine is a tool that may add to the care provided for patients. In this
project, the referral process based on teleconsultation avoided almost 30% of specialist
referrals, which corroborates the findings from studies conducted in other countries
with different public healthcare setups[12 ],[15 ]. In one of these, in Canada, eConsult was able to avoid 34% of referrals, and the
PCPs received information for a new course of action[12 ].
Referral systems are organizational structures that play an important role in improving
access to care. They bridge the gaps between levels of care, prioritize cases of greater
severity and avoid unnecessary referrals[16 ],[17 ],[18 ],[19 ]. Specialists are limited in number and have irregular geographical distribution.
A teleconference between a PCP and a neurologist may anticipate the patient’s treatment
and even avoid long-distance travel for this patient. Improvement in technology has
allowed some problems to be managed more easily, and telephone support for primary
care can make up for some professional shortages in poorer regions. Nonetheless, even
if this increases the ability of PHC to resolve cases, we believe that investments
in and policies to promote continuing medical education for PCPs is crucial for improving
healthcare in Brazil.
Future results from the “Regula Mais Brasil” project may provide support for defining
public policies aimed towards structuring complex regional telemedicine coordination
and improving the population's access to specialists. A project that was scheduled
for completion in December 2020 has already evaluated 342,000 cases and aims to reach
500,000 people in five locations.
Neurological conditions are highly prevalent among patients who seek healthcare and
PCPs routinely diagnose and manage many common neurological diseases by taking a holistic
view in which the patient’s context is understood[20 ]. Opportunities to apply teleneurology beyond acute ischemic stroke have encouraged
formation of a network to enable patients to have an early diagnosis and adequate
treatment, thereby increasing the scope of neurologists’ assistance when approached
from PHC via telemedicine.
The heterogeneity of neurologist distribution within Brazil is an important factor
to be considered. Our study involved regions with a higher average number of neurologists.
Overall, Brazil has an average of 2.46 neurologists per 100,000 inhabitants[21 ], i.e., greater than the average of 0.7 for all the Americas[22 ]. The average for the Federal District is 6.18; Porto Alegre (state of Rio Grande
do Sul) 3.66; and Belo Horizonte (state of Minas Gerais) 2.38[21 ]. However, some locations in Brazil, like most of the states in the northern region,
have less than 1.0 neurologist per 100,000 inhabitants (the state of Amazonas has
1.16), and the geographical distribution of these specialists within states is unequal[21 ]. It is also important to realize that these rates include all the specialists registered
in Brazil and do not represent the rate of specialists available for PHC referrals
within the public secondary and tertiary networks. In addition, the number of specialist
consultations available to patients who depend exclusively on the public healthcare
system is not always proportional to these rates. These considerations lead us to
infer that in the north of Brazil, use of telemedicine to support healthcare professionals
may be more effective than in the cities evaluated in this paper.
As a non-randomized study, this investigation was not appropriate for testing the
agreement between assessments made by neurologists versus those made by physicians
in other specialties during discussions on cases. However, it could be seen that there
was no difference in outcome between neurologists and physicians in other specialties.
These preliminary findings show the feasibility of providing training and comprehensive
protocols for physicians with generalist training, to enable them to screen for neurological
disease that are sensitive to PHC, such as headache and secondary prevention post-stroke.
Nevertheless, neurologists seemed to contribute more information about treatment during
teleconsultations, which leads us to speculate whether this might be related to the
reliability of receiving direct recommendations from specialists.
Our focus in this paper was to show that referrals can be avoided through telehealth
support. One limitation of our study was that we did not follow the cases that we
have discussed to ascertain their outcomes. Therefore, we do not know whether patients
had searched for another way to consult a neurologist, by using the supplementary
healthcare system (private system) or finding a neurologist in the public healthcare
system without going through the referral system. However, we believe that this is
not necessarily a bias, because the PCPs could rediscuss the cases whenever they needed
to and had the central role in making referral decisions.
In the emergency context, use of telemedicine in neurology is widespread, with expansion
of telestroke coverage over the last decade in different countries. However, there
are also opportunities for use of telemedicine in managing neurological disorders[23 ]. These include replacing or complementing in-office evaluations, decreasing the
time between follow-up visits, reducing the disparities in access to healthcare and
promoting education and training through interactions between PCPs and tertiary referral
centers.
Telehealth support can help PCPs avoid 29% of referrals. This could be used in locations
where there are shortages of neurologists and could help to reduce care costs. In
Brazil, the country with the fifth largest population in the world, with continental
dimensions, regional social and cultural differences and inequity in medical service
availability, telehealth could be used to make up for these differences, thereby improving
medical outcomes and patient access to healthcare at the appropriate level of complexity.
