Telemedicine efficiently improves access to hepatitis C management to achieve HCV elimination in the penitentiary setting

Hepatitis C Elimination: Opportunities and Challenges in 2023

Hepatitis C Virus (HCV) infection is a leading etiology of liver cirrhosis and its associated complications, namely, decompensated cirrhosis. As such, hepatitis C potentially necessitates liver transplantation and may result in death. Recently, HCV treatment has evolved. Current HCV treatment is effective in curing HCV; some of the agents are pan-genotypic. Numerous countries have adopted an initiative to eliminate HCV. Achieving elimination poses many challenges; it requires improved availability and accessibility of pan-genotypic therapy. Barriers exist at the level of the collective healthcare system and at the level of the individual healthcare providers and patients. Therefore, organized national and local efforts are needed. Surmounting these barriers calls for interventions concerning screening, linkage to care, and treatment delivery. Pertinent barriers include inadequate availability of screening, ill-equipped laboratory testing before treatment, and insufficient access to treatment. Interventions should seek to decentralize laboratory testing and treatment provision, increase funding for resources and personnel, and spread awareness. Special consideration should be allocated to at-risk populations, such as intravenous drug users, refugees, and prisoners. Computerized medical filing and telemedicine have the potential to refine HCV management by enhancing detection, availability, accessibility, and cost-effectiveness.

A randomized controlled trial for a peer-facilitated telemedicine hepatitis c treatment intervention for people who use drugs in rural communities: study protocol for the "peer tele-HCV" study

BACKGROUND

Hepatitis C virus (HCV) transmission is primarily driven by injection drug use, and acute HCV infection rates are increased in rural communities with substantial barriers to care. Treatment of HCV in persons who use drugs (PWUD) is cost effective, decreases high risk behaviors and HCV transmission, and achieves high rates of treatment completion and sustained viral response. Adapting HCV care delivery to utilize peer support specialists, telemedicine technology, and streamlined testing and treatment strategies can better reach rural populations living with HCV.

METHODS

This is an open label, two-arm, non-blinded, randomized controlled trial designed to test the superiority of peer-facilitated and streamlined telemedicine HCV care (peer tele-HCV) compared to enhanced usual care (EUC) among PWUD in rural Oregon. In the intervention arm, peers conduct HCV screening in the community, facilitate pretreatment evaluation and linkage to telemedicine hepatitis C treatment providers, and support participants in HCV medication adherence. For participants assigned to EUC, peers facilitate pretreatment evaluation and referral to community-based treatment providers. The primary outcome is sustained virologic response at 12 weeks post treatment (SVR12). Secondary outcomes include: (1) HCV treatment initiation, (2) HCV treatment completion, (3) engagement with harm reduction resources, (4) rates of substance use, and (5) engagement in addiction treatment resources. The primary and secondary outcomes are analyzed using intention-to-treat (ITT) comparisons between telemedicine and EUC. A qualitative analysis will assess patient, peer, and clinician experiences of peer-facilitated telemedicine hepatitis C treatment.

DISCUSSION

This study uses a novel peer-based telemedicine delivery model with streamlined testing protocols to improve access to HCV treatment in rural communities with high rates of injection drug use and ongoing disease transmission. We hypothesize that the peer tele-HCV model will increase treatment initiation, treatment completion, SVR12 rates, and engagement with harm reduction services compared to EUC. Trial registration This trial has been registered with ClinicalTrials.gov (clinicaltrials.gov NCT04798521).

Research Priorities for Precision Medicine in NAFLD

NAFLD is a multisystem condition and the leading cause of chronic liver disease globally. There are no approved NAFLD-specific dugs. To advance in the prevention and treatment of NAFLD, there is a clear need to better understand the pathophysiology and genetic and environmental risk factors, identify subphenotypes, and develop personalized and precision medicine. In this review, we discuss the main NAFLD research priorities, with a particular focus on socioeconomic factors, interindividual variations, limitations of current NAFLD clinical trials, multidisciplinary models of care, and novel approaches in the management of patients with NAFLD.

Outcomes of an automated alert system from Microbiology to link diagnosis to treatment in patients with hepatitis C virus

INTRODUCTION

simplification strategies for the care circuit of patients with hepatitis C virus (HCV) are key to achieve eradication. An electronic identification system was set up for HCV serology to link diagnosis to specialist management, aimed to reduce patient loss.

MATERIAL AND METHODS

a retrospective, single-center study was performed in patients with HCV identified from 15/3/2020 to 15/12/2021, using an alert system from Microbiology that notified specialists of positive cases. The patient was contacted and appointed a Fibroscan® and viral load measurement, with antiviral therapy prescribed on the same day. Origin, public health data, patient location rate and antiviral therapy prescription were recorded.

RESULTS

of 174 patients identified, 171 had positive viremia, with a mean age of 59.6 ± 15.9 years, 61.5 % were males and 81.2 % were Spanish nationals. Origin in the outpatient setting predominated (57.9 %, 99/171), particularly Primary Care (51/171), penitentiaries (21/171) and addiction units (14/171). Overall, 43.3 % (74/171) were aware of their diagnosis; 19.4 % (20/103) of patients had F3 fibrosis and 25.2 % (26/103) had F4 fibrosis. Also, 78.4 % (134/171) were deemed candidates for treatment. Of these, 74.6 % (100/134) were located and treatment was initiated, and all those who completed their treatment achieved a sustained viral response (96/96). This system managed 58.5 % (100/171) of the patients identified. The only association found between antiviral therapy and patient variables was comorbidities with being untreated (OR, 7.14; p ˂ 0.001).

CONCLUSIONS

this alert system allows to minimize patient loss in the care circuit and provides high rates of treated patients.

mHealth in sub-Saharan Africa and Europe: A systematic review comparing the use and availability of mHealth approaches in sub-Saharan Africa and Europe

Background

mHealth can help with healthcare service delivery for various health issues, but there's a significant gap in the availability and use of mHealth systems between sub-Saharan Africa and Europe, despite the ongoing digitalization of the global healthcare system.

Objective

This work aims to compare and investigate the use and availability of mHealth systems in sub-Saharan Africa and Europe, and identify gaps in current mHealth development and implementation in both regions.

Methods

The study adhered to the PRISMA 2020 guidelines for article search and selection to ensure an unbiased comparison between sub-Saharan Africa and Europe. Four databases (Scopus, Web of Science, IEEE Xplore, and PubMed) were used, and articles were evaluated based on predetermined criteria. Details on the mHealth system type, goal, patient type, health concern, and development stage were collected and recorded in a Microsoft Excel worksheet.

Results

The search query produced 1020 articles for sub-Saharan Africa and 2477 articles for Europe. After screening for eligibility, 86 articles for sub-Saharan Africa and 297 articles for Europe were included. To minimize bias, two reviewers conducted the article screening and data retrieval. Sub-Saharan Africa used SMS and call-based mHealth methods for consultation and diagnosis, mainly for young patients such as children and mothers, and for issues such as HIV, pregnancy, childbirth, and child care. Europe relied more on apps, sensors, and wearables for monitoring, with the elderly as the most common patient group, and the most common health issues being cardiovascular disease and heart failure.

Conclusion

Wearable technology and external sensors are heavily used in Europe, whereas they are seldom used in sub-Saharan Africa. More efforts should be made to use the mHealth system to improve health outcomes in both regions, incorporating more cutting-edge technologies like wearables internal and external sensors. Undertaking context-based studies, identifying determinants of mHealth systems use, and considering these determinants during mHealth system design could enhance mHealth availability and utilization.

HCV hotline facilitates Hepatitis C elimination during the COVID-19 pandemic

The COVID-19 pandemic necessitates healthcare restrictions that also affected ongoing hepatitis C virus (HCV) elimination efforts. We assessed the value of a physician-operated HCV hotline on treatment and cure rates throughout the pandemic. All HCV patients undergoing HCV therapy at the Vienna General Hospital from 2019 to 2021 were included. An HCV hotline was established in 2019 and provided services including phone calls, text messages and voicemails. Patients were stratified by date of HCV therapy: 2019 (pre-COVID) vs. 2020/2021 (during-COVID) and use of the HCV hotline: users vs. non-users. Overall, 220 patients were included (pre-COVID: n = 91 vs. during-COVID: n = 129). The prevalence of intravenous drug use (60.5%) and alcohol abuse (24.8%) was high during COVID. During COVID, the number of DAA treatment starts declined by 24.2% (n = 69) in 2020 and by 34.1% (n = 60) in 2021 vs. pre-COVID (n = 91, 100%). Significantly more patients used the HCV hotline during-COVID (95.3%) vs. pre-COVID (65.9%; p < .001). Sustained virologic response (SVR) was 84.6% pre-COVID and 86.0% during-COVID. HCV hotline users achieved higher SVR rates during-COVID (88.2% vs. 33.3%, p = .004), but also pre-COVID (96.7% vs. 61.3%, p < .001) compared with non-users. Considering only patients with completed DAA treatments, SVR rates remained similarly high during-COVID (96.9%) versus pre-COVID (98.1%). HCV treatment initiations decreased during-COVID but importantly, nearly all DAA-treated HCV patients used the HCV hotline during the COVID pandemic. Overall, the SVR rate remained at 88.2% during COVID and was particularly high in HCV phone users-most likely due to facilitation of adherence.

Real-world effectiveness of sofosbuvir/velpatasvir for the treatment of hepatitis C virus in prison settings

Background: People in prison are at high risk of hepatitis C virus (HCV) infection and often have a history of injection drug use and mental health disorders. Simple test-and-treat regimens which require minimal monitoring are critical. Methods: This integrated real-world analysis evaluated the effectiveness of once daily sofosbuvir/velpatasvir (SOF/VEL) in 20 prison cohorts across Europe and Canada. The primary outcome was sustained virological response (SVR) in the effectiveness population (EP), defined as patients with a valid SVR status. Secondary outcomes were reasons for not achieving SVR, adherence and time between HCV RNA diagnosis and SOF/VEL treatment. Results: Overall, 526 people in prison were included with 98.9% SVR achieved in the EP (n = 442). Cure rates were not compromised by drug use or existence of mental health disorders. Conclusion: SOF/VEL for 12 weeks is highly successful in prison settings and enables the implementation of a simple treatment algorithm in line with guideline recommendations and test-and-treat strategies.

Can Telemedicine Optimize the HCV Care Cascade in People Who Use Drugs? Features of an Innovative Decentralization Model and Comparison with Other Micro-Elimination Strategies

Simple Summary

The global fight against the hepatitis C virus (HCV) involves the processes of micro-elimination of populations at risk. People who use drugs (PWUDs) represent a viral reservoir, due to the historical challenge in treating this population. In particular, the difficulties in the linkage to care of these patients, as well as low adherence to therapies and follow-up and the risk of re-infection make PWUDs a “difficult-to-treat” population. In view of this, the testing of effective management and treatment models for chronic HCV infection in PWUDs is crucial for promoting its elimination. Telemedicine could be a successful solution in the integration and decentralization of care services.

Abstract

People who use drugs (PWUDs) are a crucial population in the global fight against viral hepatitis. The difficulties in linkage to care, the low adherence to therapy, the frequent loss to follow-up and the high risk of re-infection make the eradication process of the hepatitis C virus (HCV) really hard in this viral reservoir. Several management and treatment models have been tested with the aim of optimizing the HCV care cascade in PWUDs. Models of decentralization of the care process and integration of services seem to provide the highest success rates. Giving this, telemedicine could favor the decentralization of diagnostic-therapeutic management, key for the implementation of linkage to care, reduction of waiting times, optimization of adherence and results and reduction of the costs. The purpose of this literature review is to examine the role and possible impact of telemedicine in optimizing the HCV care cascade, comparing the different care models that have shown to improve the linkage to care and therapeutic adherence in this special population.

A Global Systematic Review of Hepatitis C Elimination Efforts through Micro-Elimination

Microelimination targets specific subpopulations and/or geographic settings for hepatitis C virus (HCV) elimination. This review reports on global HCV microelimination literature published from 2013 to 2020. Data were extracted from publications to report a score based on the four key components defining microelimination. Sustained virologic response (SVR) and treatment initiation proportions were calculated for each manuscript and grouped means of these estimates were compared depending on microelimination score and care setting. A total of 83% of the studies were from high-income settings and mainly included people who use drugs or those incarcerated. Among manuscripts, 18 had "low" microelimination scores, 11 had "high" scores, and the differences in mean proportion who initiated treatment and achieved SVR between low and high score groups were statistically significant. Microelimination can be a useful complementary strategy for driving engagement in HCV treatment and cure. Our analysis suggests that adhering to more of the core microelimination components can improve outcomes. This study is registered with Prospero, registration identification: CRD42020175211.

The effect of direct-acting antiviral regimens and telemedicine on the treatment of inmates with hepatitis C virus infection in Israeli prisons

BACKGROUND

Direct-acting antiviral (DAA) regimens and telemedicine services are both options for treating hepatitis C virus (HCV) within the prison setting. We aimed to compare factors associated with HCV treatment success over the past decade in Israeli prisons, specifically the influence of DAAs and telemedicine.

METHODS

We retrospectively reviewed the medical records of inmates with HCV infection in Israeli prisons from 2010 through 2020. Demographic, clinical, and laboratory data were recorded, including treatment regimens and success rates.

RESULTS

A total of 273 inmates were treated; mean age 45 ± 9.36 years; 98.2% males; 63.9% with a history of drug abuse. Advanced fibrosis was documented in 42.9%. The most common genotypes were 1 (46%) followed by 3 (40.7%). Interferon-based regimens were given to 68 inmates between 2010 and 2017. DAA agents were introduced in 2016, with pan-genotype regimens being exclusively used since 2019. Telemedicine services were used in 140 patients (51.3%), starting in February 2019. The sustained viral response (SVR) rate with interferon-based therapy was 78.8% and 98.8% with DAA treatment, giving an overall SVR of 93.2%. This difference between regimens proved to be the only statistically significant predictor of treatment success. The number of prisoners being treated with DAAs increased exponentially after telemedicine was introduced. Comparable SVR rates were achieved with either in-person or telemedicine consultation.

CONCLUSION

Screening of this high-risk population and using telemedicine for treatment may be an effective strategy for the elimination of HCV from the prison population.

Pan-Genotypic Direct-Acting Antiviral Agents for Undetermined or Mixed-Genotype Hepatitis C Infection: A Real-World Multi-Center Effectiveness Analysis

Although the pan-genotypic direct-acting antiviral regimen was approved for treating chronic hepatitis C infection regardless of the hepatitis C virus (HCV) genotype, real-world data on its effectiveness against mixed-genotype or genotype-undetermined HCV infection are scarce. We evaluated the real-world safety and efficacy of two pan-genotypic regimens (Glecaprevir/Pibrentasvir and Sofosbuvir/Velpatasvir) for HCV-infected patients with mixed or undetermined HCV genotypes from the five hospitals in the Changhua Christian Care System that commenced treatment between August 2018 and December 2020. This retrospective study evaluated the efficacy and safety of pan-genotypic direct-acting antiviral (DAA) treatment in adults with HCV infection. The primary endpoint was the sustained virological response (SVR) observed 12 weeks after completing the treatment. Altogether, 2446 HCV-infected patients received the pan-genotypic DAA regimen, 37 (1.5%) patients had mixed-genotype HCV infections and 110 (4.5%) patients had undetermined HCV genotypes. The mean age was 63 years and 55.8% of our participants were males. Nine (6.1%) patients had end-stage renal disease and three (2%) had co-existing hepatomas. We lost one patient to follow-up during treatment and one more patient after treatment. A total of four patients died. However, none of these losses were due to treatment-related side effects. The rates of SVR12 for mixed-genotype and genotype-undetermined infections were 97.1% and 96.2%, respectively, by per-protocol analyses, and 91.9% and 92.7% respectively, by intention-to-treat population analyses. Laboratory adverse events with grades ≥3 included anemia (2.5%), thrombocytopenia (2.5%), and jaundice (0.7%). Pan-genotypic DAAs are effective and well-tolerated for mixed-genotype or genotype-undetermined HCV infection real-world settings.

Hepatitis C diagnosis slowdown in high-prevalence groups and using decentralised diagnostic strategies during the COVID-19 pandemic

INTRODUCTION

The COVID-19 pandemic has had a major impact on hepatitis C virus (HCV) diagnosis by hindering the path to elimination, although probably in an uneven manner depending on the risk group and diagnostic strategy.

METHODS

We recorded the requests of antibodies/RNA by venipuncture at the hospital and primary care centres (centralised), as well as the requests via venipuncture or dried blood spot test at prison and drug treatment centres referred for central processing (integrated decentralised), for one year before and after the onset of the COVID-19 health alarm.

RESULTS

A total of 20,600 tests (51% male, 47.9±15.8 years) were recorded. Among them, 96.5% of the cases came from centralised and 3.5% from decentralised settings, with an active infection rate of 0.2% and 2.3% (p<0.001), respectively. There was a 31.3% decrease in the number of requests during the pandemic compared to the pre-pandemic period, which was more pronounced in decentralised diagnosis than centralised (60 vs. 30%, p<0.001). In addition, there was a 31.5% decline in screening and an 18.2% decrease in the diagnosis of new cases of active infection, showing a statistically significant decrease in decentralised compared to centralised diagnosis.

CONCLUSIONS

During the COVID-19 pandemic, a decline in HCV diagnostic effort has been observed, especially in decentralised strategies with a higher prevalence of infection. Our results suggest a diagnostic delay that will prevent Spain from reaching the elimination target in 2023, and therefore the reactivation of strategies particularly targeting the priority groups is urgently required.

Eliminating hepatitis C on the Balearic Islands, Spain: a protocol for an intervention study to test and link people who use drugs to treatment and care

INTRODUCTION

The hepatitis C virus (HCV) is a highly infectious and deadly disease, affecting some 58 million people worldwide. Of the 1.13 million people living in the Balearic Islands, Spain, about 1350 individuals have untreated HCV. Of these, about 1120 (83%) are estimated to be people who use drugs (PWUD), who are one of the key at-risk groups for HCV infection globally. Carrying out micro-elimination approaches focused on this population is crucial to achieve the WHO goal of eliminating HCV by 2030. Thus, the primary objective of this study is to validate a model of care that simplifies the screening and linkage to HCV care pathways for PWUD on the Balearic Islands.

METHODS AND ANALYSIS

This intervention study will be implemented across 17 sites, in 4 different settings: addiction service centres (n=12), non-governmental organisation centres (n=3), a mobile methadone unit and a prison, with an estimated 3725 participants. Together with the healthcare staff at each centre, the intervention protocols will be adapted, focusing on four phases: recruitment and testing; linkage to care; treatment for those who test positive; and monitoring of sustained virological response 12 weeks after treatment and reinfection. The primary outcomes will be the number of tested and treated individuals and the secondary outcomes will include individuals lost at each step in the cascade of care. Descriptive analysis and multivariable logistic regression of the data will be undertaken.

ETHICS AND DISSEMINATION

The Hospital Clínic Barcelona, Spain, Ethics Committee approved this study on 18 February 2021 (HCB/2020/2018). Findings will be disseminated through peer-reviewed publications, conference presentations and social media. The results of this study could provide a model for targeting PWUD for HCV testing and treatment in the rest of Spain and in other settings, helping to achieve the WHO HCV elimination goal.

Progress and challenges in the comprehensive management of chronic viral hepatitis: Key ways to achieve the elimination

Chronic viral hepatitis is a significant health problem throughout the world, which already represents high annual mortality. By 2040, chronic viral hepatitis due to virus B and virus C and their complications cirrhosis and hepatocellular carcinoma will be more deadly than malaria, vitellogenesis-inhibiting hormone, and tuberculosis altogether. In this review, we analyze the global impact of chronic viral hepatitis with a focus on the most vulnerable groups, the goals set by the World Health Organization for the year 2030, and the key points to achieve them, such as timely access to antiviral treatment of direct-acting antiviral, which represents the key to achieving hepatitis C virus elimination. Likewise, we review the strategies to prevent transmission and achieve control of hepatitis B virus. Finally, we address the impact that the coronavirus disease 2019 pandemic has had on implementing elimination strategies and the advantages of implementing telemedicine programs.

Strategy for the Micro-Elimination of Hepatitis C among Patients with Diabetes Mellitus-A Hospital-Based Experience

Hepatitis C virus (HCV) infection can induce insulin resistance, and patients with diabetes mellitus (DM) have a higher prevalence of HCV infection. Patient outcomes improve after HCV eradication in DM patients. However, HCV micro-elimination targeting this population has not been approached. Little is known about using electronic alert systems for HCV screening among patients with DM in a hospital-based setting. We implemented an electronic reminder system for HCV antibody screening and RNA testing in outpatient departments among patients with DM. The screening rates and treatment rates at different departments before and after system implementation were compared. The results indicated that the total HCV screening rate increased from 49.3% (9505/19,272) to 78.2% (15,073/19,272), and the HCV-RNA testing rate increased from 73.4% to 94.2%. The anti-HCV antibody seropositive rate was 5.7%, and the HCV viremia rate was 62.7% in our patient population. The rate of positive anti-HCV antibodies and HCV viremia increased with patient age. This study demonstrates the feasibility and usefulness of an electronic alert system for HCV screening and treatment among DM patients in a hospital-based setting.

Elimination of hepatitis C among HIV-positive population in Asia: old and new challenges

Hepatitis C virus (HCV) prevalence is high among people living with HIV co-infected with HCV, people who inject drugs, men who have sex with men and inmates in correctional settings. The barriers to eliminate HCV among these key populations include diagnosis challenges, lack of awareness, discrimination and stigmatization. In addition, scaling up of HCV treatment has been a challenge in Asia–Pacific with the lack of national policies, targets and unavailability of appropriate direct-acting antivirals regimens. In order to achieve HCV micro elimination within these high-risk populations, novel strategies to improve the cascade of care from diagnosis to treatment with direct-acting antivirals, complemented by behavioral change interventions, harm reduction services for people who inject drugs, civil society led advocacy and policies from the government, will be necessary.

Hepatitis C Micro-Elimination beyond Prison Walls: Navigator-Assisted Test-and-Treat Strategy for Subjects Serving Non-Custodial Sentences

Background and Aims: The Spanish prison population includes two groups: people in prison and those who are serving non-custodial sentences. The latter has not yet been studied. This study aims to describe this population and the results of a test-and-treat strategy for hepatitis C including a holistic health assessment. Method: This prospective study included all subjects serving non-custodial sentences at the Center for Social Integration. It was assisted by the medical team, a navigator, and a systematic screening of HCV (Hepatitis C Virus) performed by point-of-care tests. All cases with active infection are evaluated using telemedicine by a specialist to prescribe antiviral treatment. The navigator facilitates continuity for medical and social assistance. Results: The screening rate reached 92.8% (548/590). HCV seroprevalence and viraemia prevalence were 8% (44) and 2.9% (16), respectively. Regarding comorbidities: problems related to drug dependence were detected in 264 (48.2%), suspected serious mental disorder in 44 (8.3%), and previous stay in prison in 122 cases (22.2%). The navigator monitored 59 (15.2%) patients regarding HCV treatment or comorbidities. All patients (10/10) completing 12 weeks follow-up achieved sustained virological response. Conclusions: The population serving non-custodial sentences is a challenging group with a high prevalence of HCV infection. Micro-elimination programs using point of care diagnostic tests, telemedicine, and a navigator are necessary in this underserved vulnerable population.

Retrieval of lost patients in the system for hepatitis C microelimination: a single-center retrospective study

Background

Hepatitis C virus (HCV) is one of the major causes of chronic liver disease, cirrhosis, and liver cancer. Most of the infected people have no clinical symptoms. The current strategy for HCV elimination includes test and treatment. In this study, we aimed to evaluate the campaign for retrieving patients who were lost to follow-up, for subsequent re-evaluation.

Methods

From January 2020 to October 2020, patients who had prior tests for positive anti-HCV antibody in 2010–2018 in our hospital were enrolled for our patient callback campaign. Patients who had unknown HCV RNA status or no documented successful antiviral therapy history were selected for anti-HCV therapy re-evaluation. To facilitate patient referral in the hospital, we developed an electronic reminding system and called the candidate patients via telephone during the study period.

Results

Through the hospital electronic system, 3783 patients with positive anti-HCV antibody documentation were identified. Among them, 1446 (38.22%) had tested negative for HCV RNA or had anti-HCV therapy, thereby excluded. Of the 2337 eligible patients, 1472 (62.99%) were successfully contacted and called back during the study period for subsequent HCV RNA testing and therapy. We found that 42.19% of the patients had positive HCV RNA and 88% received subsequent anti-HCV therapy.

Conclusions

A significant number of patients with positive HCV serology were lost for HCV confirmatory test or therapy in the hospital. Therefore, this targeted HCV callback approach in the hospital is feasible and effective in achieving microelimination.

Implementation of a hepatology and gastroenterology teleconsultation for our penitentiary center

The use of telemedicine in Penitentiary Centers (PC) is an effective measure to improve quality access to specialized care (secondary prevention) and reduces the inherent costs derived from physical consultations of inmates in hospitals.