Maria Beatriz Moreira Alkmim

Telemedicine application in the care of diabetes patients: systematic review and meta-analysis.

Background The impact of telemedicine application on the management of diabetes patients is unclear, as the results are not consistent among different studies. The objective of this study is to conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) assessing the impact of telemedicine interventions on change in hemoglobin A1c (HbA1c), blood pressure, LDL cholesterol (LDL-c) and body mass index (BMI) in diabetes patients. Methods Electronic databases MEDLINE, Cochrane Central Register of Controlled Trials and LILACS were searched to identify relevant studies published until April 2012, supplemented by references from the selected articles. Study search and selection were performed by independent reviewers. Of the 6.258 articles retrieved, 13 RCTs (4207 patients) were included. Random effects model was applied to estimate the pooled results. Results Telemedicine was associated with a statistically significant and clinically relevant absolute decline in HbA1c level compared to control (mean difference -0.44% [-4.8 mmol/mol] and 95% confidence interval [CI] -0.61 to -0.26% [-6.7 to -2.8 mmol/mol]; p<0.001). LDL-c was reduced in 6.6 mg/dL (95% CI -8.3 to -4.9; p<0.001), but the clinical relevance of this effect can be questioned. No effects of telemedicine strategies were seen on systolic (-1.6 mmHg and 95% CI -7.2 to 4.1) and diastolic blood pressure (-1.1 mmHg and 95% CI -3.0 to 0.8). The 2 studies that assessed the effect on BMI demonstrated a tendency of BMI reduction in favor of telemedicine. Conclusions Telemedicine strategies combined to the usual care were associated with improved glycemic control in diabetic patients. No clinical relevant impact was observed on LDL-c and blood pressure, and there was a tendency of BMI reduction in diabetes patients who used telemedicine, but these outcomes should be further explored in future trials.

Cost-benefit of the telecardiology service in the state of Minas Gerais: Minas Telecardio Project

BACKGROUND Telecardiology is a tool that can aid in cardiovascular care, mainly in towns located in remote areas. However, economic assessments on this subject are scarce and have yielded controversial results. OBJECTIVE To evaluate the cost-benefit of implementing a Telecardiology service in remote, small towns in the state of Minas Gerais, Brazil. METHODS The study used the database from the Minas Telecardio (MTC) Project, developed from June 2006 to November 2008, in 82 towns in the countryside of the state. Each municipality received a microcomputer with a digital electrocardiograph, with the possibility of transmitting ECG tracings and communicating with the on-duty cardiologist at the University hospital. The cost-benefit analysis was carried out by comparing the cost of performing an ECG in the project versus the cost of performing it by patient referral to another city. RESULTS The average cost of an ECG in the MTC project was R

Implementation of a telecardiology system in the state of Minas Gerais: the Minas Telecardio Project

28.92, decomposed into R

Implantação de um sistema de telecardiologia em Minas Gerais: projeto Minas Telecardio

8.08 for the cost of implementation and R

Coordinated regional care of myocardial infarction in a rural area in Brazil: Minas Telecardio Project 2

20.84 for maintenance. The cost simulation of the ECG with referral ranged from R

Prevalence of normal electrocardiograms in primary care patients

30.91 to R

Teleconsultorias de fonoaudiologia em um serviço público de telessaúde de larga escala

54.58, with the cost-benefit ratio being always favorable to the MTC program, regardless of the type of calculation used for referral distance. The simulations considered the financial sponsors and societys points-of-view. The sensitivity analysis with variation of calibration parameters confirmed these results. CONCLUSION The implementation of a Telecardiology system as support to primary care in small Brazilian towns is feasible and economically beneficial, and can be used as a regular program within the Brazilian public health system.

Implantación de un sistema de telecardiología en Minas Gerais: proyecto Minas Telecardio

FUNDAMENTO: Embora as doencas cardiovasculares sejam a maior causa de morbimortalidade em todo Brasil, o acesso das populacoes de cidades pequenas a eletrocardiografia e a avaliacao cardiologica e limitado. O uso da telecardiologia para facilitar o acesso da populacao de municipios remotos a eletrocardiografia e a segunda opiniao em cardiologia e promissora, entretanto nao foi formalmente testada. OBJETIVO: Avaliar a viabilidade de se implantar o sistema publico de telecardiologia de baixo custo em pequenas cidades brasileiras. METODOS: Foram selecionadas 82 cidades do Estado de Minas Gerais, com populacao 70% de cobertura pelo Programa Saude da Familia (PSF), com interesse do gestor e acesso pela internet. Em cada municipio foi instalado um aparelho de eletrocardiografo (ECG) digital, com subsequente treinamento da equipe. A implantacao foi coordenada pelo HC/UFMG, em conjunto com outros quatro hospitais universitarios mineiros (UFU, UFTM, UFJF e UNIMONTES). Os ECGs foram realizados nos municipios e enviados pela internet para analise imediata em plantao de telecardiologia. Realizaram-se discussoes de casos medicos on-line e off-line e cursos de atualizacao via web. RESULTADOS: No periodo de implantacao, foram treinados 253 profissionais de saude. De julho de 2006 a novembro de 2008, o projeto atendeu 42.664 pacientes, realizando 62.865 ECGs. Foram efetuados 2.148 atendimentos de urgencia e 420 teleconsultorias. A avaliacao intermediaria apontou boa aceitacao da tecnologia implantada e uma diminuicao de 70% de encaminhamentos de pacientes para outros centros de referencia. CONCLUSAO: E factivel a utilizacao de recursos habituais de informatica para facilitar o acesso de populacoes de cidades pequenas a eletrocardiografia e avaliacao cardiologica especializada.BACKGROUND Although cardiovascular diseases are the main cause of morbimortality in Brazil, the access of small-town populations to electrocardiography and cardiology assessment is limited. The use of telecardiology to assist the access of distant towns to electrocardiography and a second opinion in cardiology is promising; however, it has not been formally assessed. OBJECTIVE To assess the feasibility of implementing a low-cost public telecardiology system in small Brazilian towns. METHODS A total of 82 towns in the state of Minas Gerais, with a population < 10,500 inhabitants, presenting > 70% coverage by the Family Health Program (Programa Saude da Familia-PSF), local government compliance and internet access, were selected. Each town was supplied with digital electrocardiography (ECG) device and a team was trained. The implementation was coordinated by HC/UFMG, together with four university hospitals in the state of Minas Gerais (UFU, UFTM, UFJF and UNIMONTES). The ECG assessments were carried out in the towns and sent through the Internet for prompt analysis by an on-duty telecardiology team. Online and offline discussions on the medical cases were carried out through the Internet, as well as refreshment courses. RESULTS During the implementation period, a total of 253 health professionals were trained. From July 2006 to November 2008, the project assisted 42,664 patients, with a total of 62,865 ECG assessments being performed. A total of 2,148 emergency cases were treated, as well as 420 teleconsultations. The intermediate evaluation showed good acceptance of the implemented technology and a 70% decrease in patient referrals to other reference centers. CONCLUSION The use of the customary resources in informatics to assist the access of small-town populations to electrocardiography and specialized cardiology assessment is feasible.

Improving patient access to specialized health care: the Telehealth Network of Minas Gerais, Brazil.

FUNDAMENTO: Embora as doencas cardiovasculares sejam a maior causa de morbimortalidade em todo Brasil, o acesso das populacoes de cidades pequenas a eletrocardiografia e a avaliacao cardiologica e limitado. O uso da telecardiologia para facilitar o acesso da populacao de municipios remotos a eletrocardiografia e a segunda opiniao em cardiologia e promissora, entretanto nao foi formalmente testada. OBJETIVO: Avaliar a viabilidade de se implantar o sistema publico de telecardiologia de baixo custo em pequenas cidades brasileiras. METODOS: Foram selecionadas 82 cidades do Estado de Minas Gerais, com populacao 70% de cobertura pelo Programa Saude da Familia (PSF), com interesse do gestor e acesso pela internet. Em cada municipio foi instalado um aparelho de eletrocardiografo (ECG) digital, com subsequente treinamento da equipe. A implantacao foi coordenada pelo HC/UFMG, em conjunto com outros quatro hospitais universitarios mineiros (UFU, UFTM, UFJF e UNIMONTES). Os ECGs foram realizados nos municipios e enviados pela internet para analise imediata em plantao de telecardiologia. Realizaram-se discussoes de casos medicos on-line e off-line e cursos de atualizacao via web. RESULTADOS: No periodo de implantacao, foram treinados 253 profissionais de saude. De julho de 2006 a novembro de 2008, o projeto atendeu 42.664 pacientes, realizando 62.865 ECGs. Foram efetuados 2.148 atendimentos de urgencia e 420 teleconsultorias. A avaliacao intermediaria apontou boa aceitacao da tecnologia implantada e uma diminuicao de 70% de encaminhamentos de pacientes para outros centros de referencia. CONCLUSAO: E factivel a utilizacao de recursos habituais de informatica para facilitar o acesso de populacoes de cidades pequenas a eletrocardiografia e avaliacao cardiologica especializada.BACKGROUND Although cardiovascular diseases are the main cause of morbimortality in Brazil, the access of small-town populations to electrocardiography and cardiology assessment is limited. The use of telecardiology to assist the access of distant towns to electrocardiography and a second opinion in cardiology is promising; however, it has not been formally assessed. OBJECTIVE To assess the feasibility of implementing a low-cost public telecardiology system in small Brazilian towns. METHODS A total of 82 towns in the state of Minas Gerais, with a population < 10,500 inhabitants, presenting > 70% coverage by the Family Health Program (Programa Saude da Familia-PSF), local government compliance and internet access, were selected. Each town was supplied with digital electrocardiography (ECG) device and a team was trained. The implementation was coordinated by HC/UFMG, together with four university hospitals in the state of Minas Gerais (UFU, UFTM, UFJF and UNIMONTES). The ECG assessments were carried out in the towns and sent through the Internet for prompt analysis by an on-duty telecardiology team. Online and offline discussions on the medical cases were carried out through the Internet, as well as refreshment courses. RESULTS During the implementation period, a total of 253 health professionals were trained. From July 2006 to November 2008, the project assisted 42,664 patients, with a total of 62,865 ECG assessments being performed. A total of 2,148 emergency cases were treated, as well as 420 teleconsultations. The intermediate evaluation showed good acceptance of the implemented technology and a 70% decrease in patient referrals to other reference centers. CONCLUSION The use of the customary resources in informatics to assist the access of small-town populations to electrocardiography and specialized cardiology assessment is feasible.

Teleconsultorias no apoio à atenção primária à saúde em municípios remotos no estado de Minas Gerais, Brasil

Aims In Brazil, there are considerable disparities in access to healthcare. The aim of this study was to assess how implementation of a coordinated regional management protocol for patients with ST-elevation myocardial infarction (STEMI) affected quality of care and outcomes in a rural and deprived Brazilian region with considerable social inequalities. Methods and results The quality of care and outcomes of STEMI was evaluated in two cohorts before (n = 214) and after (n = 143) implementation of the coordinated regional management protocol. Central to this protocol was a tablet-based digital electrocardiogram (ECG) recording in the emergency ambulance that was transmitted for analysis by trained professionals. If the pre-hospital ECG was diagnostic, it triggered a management cascade involving a direct transfer to the regional intervention centre with reperfusion by primary percutaneous coronary intervention (PPCI) or pre-hospital fibrinolysis for anticipated journey times of less than or greater than 2 h, respectively. Following implementation of the protocol, the adjusted medical delay (system delay - transport time) decreased by 40% (95% confidence intervals: -66%, -13%). The proportion of patients who received reperfusion therapy increased from 70.6 to 80.8% (P = 0.045), with increases in treatment with aspirin [94.2-100% (P = 0.003)] and P2Y12 inhibitors [87.5-100% (P < 0.001)]. The odds of in-hospital death showed a non-significant decrease [odds ratio 0.73 (95% confidence intervals: 0.34-1.60)]. Conclusion The implementation of a coordinated regional management protocol for patients with STEMI led to marked improvements in the quality of care in a remote Brazilian region with limited resources.