clinicaltrials.gov Identifier: NCT00404534.

The case of TelessaúdeRS/UFRGS shows that even in the presence of structural limitations, telemedicine is potentially useful to improve the quality of care and streamline the flow between different levels of care.

Introduction The association between erectile dysfunction (ED) and coronary artery disease (CAD) has been described in various settings, but it is unclear if there is an independent interaction with age. Aim To investigate the interaction of age in the association between ED and CAD. Methods This case-control study was conducted among 242 patients referred for elective coronary angiography. One hundred fourteen patients with significant CAD were identified as cases and 128 controls without significant CAD. ED was evaluated by the erectile function domain of the International Index of Erectile Function (IIEF) questionnaire, determined by a score ≤25 points. Main Outcome Measures Significant CAD was based on stenosis of 50% or greater in the diameter in at least one of the major epicardial vessels or their branches. The analysis was conducted in the whole sample and according to the age strata, controlling for the effects of cardiovascular risk factors, testosterone, and C-reactive protein. Results Patients had on average 58.3 ± 8.9 years. CAD and ED were associated exclusively in patients younger than 60 years (ED in 68.8% of patients with CAD vs. 46.7% of patients without CAD, P  = 0.009). The association was independent of cardiovascular risk factors, testosterone and C-reactive protein (risk ratio 2.3, 95% confidence interval from 1.04 to 5.19). Severity of CAD was higher in patients younger than 60 years with ED. Conclusions Men with less than 60 years of age who report ED presented a higher risk of having chronic CAD and more severe disease diagnosed by coronary angiography.

Resumo Na Atenção Primária à Saúde (APS) acesso e integralidade são fortemente influenciados pela coordenação do cuidado, que por sua vez recebe impacto positivo da articulação de ações de telessaúde para a telerregulação da assistência. Criamos uma metodologia de telerregulação (Projeto RegulaSUS) baseada em protocolos específicos firmemente alicerçados em evidências. A partir de dados do sistema de regulação e do TelessaúdeRS exploramos os efeitos do RegulaSUS na APS e no acesso ao cuidado especializado. A metodologia foi capaz de criar protocolos abrangentes, com expressiva redução média da fila de consultas especializadas de 30% em 360 dias. Reduziu o tempo de espera na marcação de consultas em especialidades clínicas (mediana de 66 dias), mas não em cirúrgicas. Tempos de espera nos casos mantidos em fila variaram de forma inversa, aumentado em especialidades clínicas e diminuindo em cirúrgicas. O uso de teleconsultorias espontâneas aumentou com a exposição dos profissionais ao RegulaSUS. A intervenção tem potencial na integração de sistemas de saúde, principalmente em países de baixa e média renda, e faz com que a telessaúde atue como metasserviço, construindo redes eficientes, qualificadas e equânimes.

Novos desafios epidemiológicos e demográficos demandam novas formas de organizar os sistemas de saúde. O presente ensaio propõe a telessaúde como ferramenta organizativa, capaz de suavizar o triângulo de ferro da atenção à saúde e de facilitar a busca pelo triple aim, pelo seu potencial de aumento do acesso e qualidade com redução de custo. A integração da telessaúde ao processo de referência e transição entre serviços assistenciais aumenta a resolutividade da Atenção Primária à Saúde (APS), favorece a coordenação do cuidado, promove adesão terapêutica, diminui reinternações e estimula a prevenção quaternária. Este ensaio propõe a telessaúde como metasserviço que confere densidade tecnológica à APS e permite que ela se torne coordenadora efetiva do cuidado, passando a organizar o fluxo de informações, pessoas e insumos. Frente às inovações propostas, é essencial avaliar o impacto de ações já existentes de telessaúde para viabilizar a sua aplicação como metasserviço de saúde.

BackgroundMany Brazilian patients with complex diseases who are treated in tertiary referral clinics have been stable for long periods. The main needs of these patients involve monitoring of risk factors and review of drug prescriptions, which could be satisfactorily done in primary care facilities. The goal of this protocol is to evaluate the safety and effectiveness of telemedicine services to support the transition of patients with stable chronic coronary artery disease from the tertiary to the primary level of care.Methods/designWe designed a randomized non-inferiority protocol that will include 280 patients with stable coronary artery disease (for at least 12 months). Patients will be selected from the Ischemic Heart Disease Clinic in a tertiary care hospital in southern Brazil. Enrolled participants will be randomized into one of two groups: 12 months of follow-up at the same clinic; or 12 months of follow-up at a primary care facility with clinical support from a telemedicine platform including a toll-free line for physicians (intervention group). In the intervention group, decisions to refer patients to tertiary care during follow-up will be made jointly by primary physicians and medical teleconsultants. The groups will be compared in terms of the primary outcome—maintenance of baseline functional class 1 or 2 after 12 months. Secondary outcomes include control of risk factors and instability of the disease.DiscussionWe intend to determine the effectiveness of using telemedicine to qualify the transition of patients with chronic coronary disease from the tertiary to the primary level of care. This should facilitate the access of patients to the healthcare system, since care will be provided closer to their homes, and provide more opportunities for treatment of severe cases at tertiary care hospitals that are often overcrowded.Trial registrationClinicalTrials.gov # NCT02489565 – trial registration date May 13, 2015

Our challenge was to structure a telemedicine framework that is capable of expanding access to services and testing while increasing the quality of the services provided. In this report, we describe the development of a telemedicine project in Brazil and its impact on increasing access to specialist consultations, diagnostic testing, and specialized medical advice to physicians. WHO & WHEREIn early By December, 2016, more than 83,000 hotline teleconsultations had been provided, with user satisfaction rates close to 95%. Specialist consultation was rendered unnecessary in 2 out of every 3 cases discussed.The state of Rio Grande do Sul struggles with large waiting lists in various medical specialties. The wait time can in many cases exceed 3 years. We worked with the Rio Grande do Sul State Department of Health to improve the quality of specialist referrals through development of referral protocols and clinical discussion of waitlisted patients. This has been implemented for 13 medical specialties, with protocols developed for 147 health conditions. As a result, the backlog of specialty appointments was reduced from 190,000 to 68,000 in just 2 years (July 2014 to Dec 2016). We had no problem adding specialists because we created a new field of work for them within the project.We have also expanded our portfolio with telediagnosis and tele-education initiatives. Tele-education actions include the provision of health apps (230,000 downloads so far), distance learning (15,000 students), a YouTube channel, (more than 1 million views) and a website where all our services are centralized. In 2013, we added a telespirometry service, which has already provided 13,000 tests using 9 spirometers distributed across the state of Rio Grande do Sul, enough to cover 100% of the state population of 11 million. This alone has sharply reduced wait times for pulmonary medicine consults (See the Supplemental Appendix).Brazil's medical residency programs are expected to encourage residents to use our tools, which are also promoted through contact with coordinators and presentations at national congresses. In our university, all 140 medical students in their final year are required to make at least 2 teleconsultations in the 3 months of internship. LEARNINGThrough this project, we have learned that effective information and communication technologies can be extremely valuable in health care. Telehealth represents the future of primary health care, and there is no way back.

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).