Expanding Primary Care Access: A Telehealth Success Story

Patients’ preferences for telemedicine versus in-clinic consultation in primary care during the COVID-19 pandemic

Background

The Hybrid Patient Care system integrates telehealth and in-clinic consultation. While COVID-19 increased telehealth use, healthcare providers are still seeking the best combination of virtual and in-clinic consultation. Understanding patients’ tele-consultation-related preferences is vital for achieving optimal implementation. The discrete choice experiment (DCE) is the stated preference technique for eliciting individual preferences and is increasingly being used in health-related applications.

The study purpose was to evaluate attributes and levels of the DCE regarding patients’ preferences for telemedicine versus traditional, in-clinic consultation in primary care during the COVID-19 pandemic, in order to facilitate successful implementation.

Methods

A three-phase structure was used in the qualitative stage of the DCE: (1) a literature review and preparation of interview guides; (2) Eight focus group interviews comprised of 26 patients and 33 physicians; and (3) Attribute selection: a ranking exercise among 48 patients. The Think Aloud technique, in which respondents are asked to verbalize their thoughts, was used in the focus groups. Interview data were analyzed by thematic analysis.

Results

Eight attributes were proposed by the patients in the focus groups. The four most important attributes were then selected in pre-testing, and are described in this study: Availability, time until the appointment, severity of the medical problem, patient-physician relationship, and flexible reception hours.

Conclusions

This study has a theoretical contribution in post-COVID-19 patients’ preferences in Hybrid Medicine patient care. This provides a foundation to assess the rigors of this stage and provide additional evidence to the limited existing literature on attributes development for DCE patient preferences.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01640-y.

Quality of referrals to a rheumatology service before and after implementation of a triage system with telemedicine support

PURPOSE

To evaluate the quality of referrals for a first Rheumatology consultation at a tertiary care center in a southern Brazilian capital (Porto Alegre, RS), having as background findings from a similar survey performed in 2007/2008. Since then, our state has implemented referral protocols and a triage system with teleconsulting support exclusively for referrals from locations outside the capital, permitting a comparison between patients screened and not screened by the new system.

METHODS

Physicians of the Rheumatology Service at Hospital Nossa Senhora da Conceição prospectively collected information regarding first visits over a 6-month period (Oct 2017 to March 2018). We recorded demographic characteristics, diagnostic hypotheses, date of referral, and the municipality of origin (within the state of Rio Grande do Sul). We considered adequate referrals from primary health care when a systemic autoimmune inflammatory disease (SIRD) was suspected at first evaluation by the attending rheumatologist.

RESULTS

Three hundred fifty-seven patients/appointments were eligible for analysis (193 from the capital and 164 from small and medium towns). In 2007/2008, suspected SIRD occurred in 76/260 (29.2%) and 73/222 (32.9%) among patients from the capital and outside counties, respectively (P = 0.387). In 2017/2018, suspected SIRD occurred in 75/193 (38.9%) and 111/164 (67.7%) in patients from the capital and outside counties, respectively (difference: 28.8, 95% CI: 19.0 to 38.9, P < 0.001), indicating a marked improvement in referrals submitted to the new triage system.

CONCLUSION

The quality of Rheumatology referrals in our state improved over the 10-year interval under study, particularly among patients from locations submitted to referral protocols and teleconsulting support.

The management of COVID-19 cases through telemedicine in Brazil

In Dec 2020 Brazil became one of the worldwide epicenters of the COVID-19 pandemic with more than 7.2M reported cases. Brazil has a large territory with unequal distribution of healthcare resources including physicians. Resource limitation has been one of the main factors hampering Brazil's response to the COVID-19 crisis. Telemedicine has been an effective approach for COVID-19 management as it allows to reduce the risk of cross-contamination and provides support to remote rural locations. Here we present the analyses of teleconsultations from a countrywide telemedicine service (TelessáudeRS-UFRGS, TRS), that provides physician-to-physician remote support during the COVID-19 pandemic in Brazil. We performed a descriptive analysis of the teleconsultation incoming calls and a text analysis from the call transcripts. Our findings indicate that TRS teleconsultations in Brazil experienced an exponential increment of 802.% during a period of 6 days, after the first death due to COVID-19 was reported. However, the number of teleconsultations cases decreased over time, despite the number of reported COVID-19 cases continuously increasing. The results also showed that physicians in low-income municipalities, based on GDP per capita, are less likely to consult the telemedicine service despite facing higher rates of COVID-19 cases. The text analysis of call transcripts from medical teleconsultations showed that the main concern of physicians were "asymptomatic" patients. We suggest an immediate reinforcement of telehealth services in the regions of lower income as a strategy to support COVID-19 management.

Synchronous Telephone-Based Consultations in Teledentistry: Preliminary Experience of the Telehealth Brazil Platform

BACKGROUND

The Brazilian National Health System (NHS) has incorporated telehealth to improve the quality of care in recent decades. Among the actions taken, teleconsultations have been offered to support diagnosis and decision-making for health professionals.

METHODS

This cross-sectional study aimed to summarize the preliminary experience of a telephone-first consultation for oral health issues available for dentists and physicians from primary health care (PHC).

RESULTS

The study sample was 385 teleconsultations with oral health questions requested from all Brazil sent from May 2018 to July 2019, majority by dentists 83.2% (n = 332). Oral medicine was the main reason for teleconsultation (50.9%). Resolution in PHC was considered possible in 57.1% of cases (n = 220).

CONCLUSIONS

It was concluded that a telephone-first consultation may be useful to improve the resolvability and the quality of care in the PHC on oral health issues. The teledentistry allows the resolution of oral issues in PHC, avoiding the displacement of patients to more distant specialized centers. Teledentistry could be more useful in the actual coronavirus disease (Covid-19) pandemic.

Economic Evaluation of a Telemedicine Service to expand Primary Health Care in Rio Grande do Sul: TeleOftalmo's microcosting analysis

This study evaluated the cost of public telediagnostic service in ophthalmology. The time-driven activity-based costing method (TDABC) was adopted to examine the cost components related to teleophthalmology. This method allowed us to establish the standard unit cost of telediagnosis, given the installed capacity and utilization of professionals. We considered data from one year of telediagnoses and evaluated the cost per telediagnosis change throughout technology adaptation in the system. The standard cost calculated by distance ophthalmic diagnosis was approximately R$ 119, considering the issuance of 1,080 monthly ophthalmic telediagnostic reports. We identified an imbalance between activities, which suggests the TDABC method's ability to guide management actions and improve resource allocation. The actual unit cost fell from R$ 783 to R$ 283 over one year - with room to approach the estimated standard cost. Partial economic evaluations contribute significantly to support the incorporation of new technologies. The TDABC method deserves prominence, as it enables us to retrieve more accurate information on the cost of technology, improving the scalability and management capacity of the healthcare system.

The use of telemedicine to support Brazilian primary care physicians in managing eye conditions: The TeleOftalmo Project

PURPOSE

To determine whether teleophthalmology can help physicians in assessing and managing eye conditions and to ascertain which clinical conditions can be addressed by teleophthalmology in primary care setting.

METHODS

We evaluated the resolution capacity of TeleOftalmo, strategy implemented in the public health system of southern Brazil. Resolution capacity was defined as the ability to fully address patients' eye complaints in primary care with remote assistance from ophthalmologists. Data from tele-eye reports were collected over 14 months. Resolution capacity was compared across different age groups and different ocular conditions.

RESULTS

Overall, 8,142 patients had a tele-eye report issued in the study period. Resolution capacity was achieved in 5,748 (70.6%) patients. When stratified into age groups, the lowest capacity was 43.1% among subjects aged ≥65 years, while the highest was 89.7% among subjects aged 13-17 years (p<0.001). Refractive error (70.3%) and presbyopia (56.3%) were the most prevalent conditions followed by cataract (12.4%) and suspected glaucoma (7.6%). Resolution capacity was higher in cases of refractive error, presbyopia, spasm of accommodation and lid disorders than in patients diagnosed with other condition (p<0.001).

CONCLUSIONS

With telemedicine support, primary care physicians solved over two-thirds of patients' eye or vision complaints. Refractive errors had high case resolution rates, thus having a great impact on reducing the number of referrals to specialty care. Teleophthalmology adoption in primary-care settings as part of the workup of patients with eye or vision complaints promotes a more effective use of specialty centers and will hopefully reduce waiting times for specialty referral.

Telemedicine in the driver's seat: new role for primary care access in Brazil and Canada: The Besrour Papers: a series on the state of family medicine in Canada and Brazil

OBJECTIVE

To contrast how Brazil's and Canada's different jurisdictional and judicial realities have led to different types of telemedicine and how further scale and improvement can be achieved.

COMPOSITION OF THE COMMITTEE

A subgroup of the Besrour Centre of the College of Family Physicians of Canada and Canadian telemedicine experts developed connections with colleagues in Porto Alegre, Brazil, and collaborated to undertake a between-country comparison of their respective telemedicine programs.

METHODS

Following a literature review, the authors collectively reflected on their experiences in an attempt to explore the past and current state of telemedicine in Canada and Brazil.

REPORT

Both Brazil and Canada share expansive geographies, creating substantial barriers to health for rural patients. Telemedicine is an important part of a universal health system. Both countries have achieved telemedicine programs that have scaled up across large regions and are showing important effects on health care costs and outcomes. However, each system is unique in design and implementation and faces unique challenges for further scale and improvement. Addressing regional differences, the normalization of telemedicine, and potential alignment of telemedicine and artificial intelligence technologies for health care are seen as promising approaches to scaling up and improving telemedicine in both countries.

Choosing Video Instead of In-Clinic Consultations in Primary Care in Israel: Discrete Choice Experiment Among Key Stakeholders-Patients, Primary Care Physicians, and Policy Makers

BACKGROUND

Despite its innovative benefits, the adoption of video consultations (VCs) in primary care settings is complex and slow.

OBJECTIVES

To quantify the preferences of key stakeholders in Israel's primary care-patients, primary care practitioners, and policy makers-regarding VCs compared with traditional in-clinic consultations (ICC) in nonurgent conditions.

METHODS

Discrete choice experiment surveys were completed by 508 patients, 311 physicians, and 141 policy makers. These consisted of 12 choice tasks of 2 labeled alternatives (VC or ICC), with the 4 attributes most relevant to each stakeholder group. A random effects logit model analysis was used to estimate stakeholders' preferences.

RESULTS

All 4 experiments' attributes were significantly important in choosing VC versus ICC for the patient group and the physician group. Three out of 4 attributes were significantly important to policy makers. Differences and similarities between stakeholders were identified in attribute rank order, trade-offs, and VC uptake probabilities. Policy makers' VC uptake rate was 86%. Patients' preferences suggested that 68% of ICCs could be replaced by VCs. Physicians' VC uptake was 30% in cases in which the consultation purpose was to diagnose and provide treatment and 48% in cases in which the consultation purpose was follow-up.

CONCLUSIONS

Our findings show key stakeholders' preferences about VC integration, to be considered when these systems are introduced into primary care and optimize the implementation process. Although there is a stronger preference for ICC among physicians and patients, alternative combinations of attribute levels might be used to compensate and reconfigure a more preferred VC service.

Video or In-Clinic Consultation? Selection of Attributes as Preparation for a Discrete Choice Experiment Among Key Stakeholders

INTRODUCTION

Video consultations (VCs) provide increased accessibility of primary care to remote areas and overall improved care for chronic patients. They also contribute to higher patient satisfaction and improved resource management. Despite these benefits, VC integration into the health system is complex and slow. Understanding the VC-related preferences of three key stakeholders-patients, primary care physicians (PCPs) and policy makers (PMs)-is crucial for achieving optimal implementation.

OBJECTIVE

The aim of this study was to select relevant attributes and levels for a discrete choice experiment (DCE) of stakeholders' choice-VC or traditional in-clinic consultation (I-CC) in primary care.

METHODS

Ten semi-structured focus group interviews and 24 semi-structured individual interviews were conducted. Data analysis was performed inductively, using a thematic content analysis method. An attribute-ranking exercise was then conducted based on the results gleaned from the interviews.

RESULTS

The most important attributes when choosing either VC or I-CC, for both patients and PMs, were: (1) time to next available appointment; (2) time in line before consultation; (3) relationship to PCP; and (4) quality of consultation. For PCPs, the most important attributes were: (1) time in line before consultation; (2) patient's self-management ability; (3) consultation purpose; (4) quality of consultation.

CONCLUSIONS

This qualitative study identified attributes and levels for a DCE quantitative stage among three key stakeholder groups. It adds to the literature of examples of developing DCE attributes, and to literature about the stakeholder benefits in the area of telemedicine in healthcare.

Factors influencing patient adherence with diabetic eye screening in rural communities: A qualitative study

Objective

Diabetic retinopathy remains the leading cause of blindness among working-age U.S. adults largely due to low screening rates. Rural populations face particularly greater challenges to screening because they are older, poorer, less insured, and less likely to receive guideline-concordant care than those in urban areas. Current patient education efforts may not fully address multiple barriers to screening faced by rural patients. We sought to characterize contextual factors affecting rural patient adherence with diabetic eye screening guidelines.

Research design and methods

We conducted semi-structured interviews with 29 participants (20 adult patients with type 2 diabetes and 9 primary care providers) in a rural, multi-payer health system. Both inductive and directed content analysis were performed.

Results

Factors influencing rural patient adherence with diabetic eye screening were categorized as environmental, social, and individual using the Ecological Model of Health. Major themes included limited access to and infrequent use of healthcare, long travel distances to obtain care, poverty and financial tradeoffs, trusting relationships with healthcare providers, family members’ struggles with diabetes, anxiety about diabetes complications, and the burden of diabetes management.

Conclusions

Significant barriers exist for rural patients that affect their ability to adhere with yearly diabetic eye screening. Many studies emphasize patient education to increase adherence, but current patient education strategies fail to address major environmental, social, and individual barriers. Addressing these factors, leveraging patient trust in their healthcare providers, and strategies targeted specifically to environmental barriers such as long travel distances (e.g. teleophthalmology) may fill crucial gaps in diabetic eye screening in rural communities.

[Telehealth as state response strategy: systematic reviewLa telesalud como estrategia de respuesta del Estado: revisión sistemática]

Objective

To identify telehealth initiatives described in the literature as a strategy for national health policies.

Method

A systematic review was performed to identify articles focusing on the use of telehealth as a state response strategy to health problems or needs. The Virtual Health Library, PubMed, and Google Scholar were searched using the following keywords: "telessaude politicas", "implantacao telessaude", "telehealth policy", "telehealth America", "telehealth Asia", "telehealth Antartida", "telehealth Europe", "telehealth Africa", "telehealth Oceania". Data collection was performed from March 2016 to February 2017.

Results

Twenty-one articles describing telehealth initiatives in various countries, published in Portuguese, Spanish, and English, were analyzed. Concentration of studies on specific areas or regions was not detected. Most articles were published from 2014 to 2017. Telehealth initiatives have been used mainly to decrease health costs, for continued education of health care professionals, consultations between health care professionals, to strengthen primary health care, and to improve the access to health care in remote areas.

Conclusions

Telehealth is used as state policy across the five continents, with variations in the degree of implementation. The main differences in telehealth among countries refer to infrastructure, financing, engagement of patients and caretakers, and position of the state regarding the role of telehealth.