The Challenges of Implementing a Text Message Intervention to Promote Behavioral Change in Primary Care Patients With Hypertension and Diabetes

Abstract Background Controlling blood pressure and glycemic levels is a challenge that requires innovative solutions. Objective To assess the feasibility of implementing a text message intervention among low-income primary care patients, as well as to assess self-reported behavioral change. Methods A set of 200 text messages was developed on healthy eating, physical activity, adherence, and motivation. Participants from Vale do Mucuri, MG, Brazil diagnosed with diabetes or hypertension or undergoing screening for those diseases, received 5 to 8 messages per week for 6 months. They answered a questionnaire to report their satisfaction and behavioral changes. Results Of the 136 patients, 117 (86.0%) answered the questionnaire. Most reported that the messages were very useful (86.3%), easy to understand (90.6%), and were very helpful for behavioral change (65.0%); 84.6% reported that they had started eating healthier. The most frequent reported lifestyle changes were: improved diet quality (85.5%), reduced portions (65.8%), and weight loss (56.4%). The majority of patients shared the messages (60.7%) with family or other acquaintances, considered the number of messages to be adequate (89.7%) and would recommend the program to others (95.7%). Conclusion An intervention based on text messages to promote behavioral change in patients with hypertension or diabetes in primary care is feasible in low-resource settings. Future studies are needed to assess the program's long-term effects on clinical outcomes.

Teleophthalmology Screening for Diabetic Retinopathy in Brazil: Applicability and Economic Assessment.

Introduction: Early diagnosis and prompt therapy of diabetic retinopathy (DR) are essential to prevent visual loss, but access of the diabetic population to regular fundus examination by an ophthalmologist remains a challenge. Methods: This prospective comparative study, including two referral health centers in the state of Minas Gerais, Southeastern Brazil, assesses applicability and economic viability of fundus photography-based teleophthalmology screening for DR. Results: A total of 2,662 eyes of 1,331 patients were examined at both health centers. Mean age was 57 years, with 836 (62.8%) females. Quality of fundus photographs was acceptable for 2,398 eyes (90.1%). The presence of DR was disclosed in 394 patients (29.6%), with 28 patients (2.1%) presenting evidence of advanced disease (severe nonproliferative or proliferative DR). Economic assessment revealed cost reduction of 28.76 US$ per patient, with a calculated break-even point of 112 exams/month or 1,344 exams/year. Conclusions: For the situation studied under the perspective of public health service, teleophthalmology was viable and cost effective when compared with ordinary ophthalmology examination. In addition, teleophthalmology allowed rapid resolution of repressed demand for fundus examination of diabetic patients locally at the two sites, with early DR diagnoses and referrals. Fundus photography-based teleophthalmology was a viable, effective, and significantly cheaper strategy for the screening of DR.

Telehealth solutions to enable global collaboration in rheumatic heart disease screening.

Background The global burden of rheumatic heart disease is nearly 33 million people. Telemedicine, using cloud-server technology, provides an ideal solution for sharing images performed by non-physicians with cardiologists who are experts in rheumatic heart disease. Objective We describe our experience in using telemedicine to support a large rheumatic heart disease outreach screening programme in the Brazilian state of Minas Gerais. Methods The Programa de Rastreamento da Valvopatia Reumática (PROVAR) is a prospective cross-sectional study aimed at gathering epidemiological data on the burden of rheumatic heart disease in Minas Gerais and testing of a non-expert, telemedicine-supported model of outreach rheumatic heart disease screening. The primary goal is to enable expert support of remote rheumatic heart disease outreach through cloud-based sharing of echocardiographic images between Minas Gerais and Washington. Secondary goals include (a) developing and sharing online training modules for non-physicians in echocardiography performance and interpretation and (b) utilising a secure web-based system to share clinical and research data. Results PROVAR included 4615 studies that were performed by non-experts at 21 schools and shared via cloud-telemedicine technology. Latent rheumatic heart disease was found in 251 subjects (4.2% of subjects: 3.7% borderline and 0.5% definite disease). Of the studies, 50% were preformed on full functional echocardiography machines and transmitted via Digital Imaging and Communications in Medicine (DICOM) and 50% were performed on handheld echocardiography machines and transferred via a secure Dropbox connection. The average time between study performance date and interpretation was 10 days. There was 100% success in initial image transfer. Less than 1% of studies performed by non-experts could not be interpreted. Discussion A sustainable, low-cost telehealth model, using task-shifting with non-medical personal in low and middle income countries can improve access to echocardiography for rheumatic heart disease.

2,000,000 Electrocardiograms by Distance: An Outstanding Achievement for Telehealth in Brazil.

Our aim is to describe the evolution of the telediagnostic service of the Telehealth Network of Minas Gerais (TNMG), a public telehealth service in Brazil. It started in 2006 with 82 cities, restricted to electrocardiography analysis. Currently it extends to 772 cities--performing also Holter, ambulatory blood pressure monitoring and retinography analysis--and 48 ambulances in the north of the state, as part of a myocardial infarction system of care. Using low-cost equipment and simple technology, TNMG has employed various strategies to increase telehealth use. The number of ECGs performed by TNMG has progressively increased. It was expected to achieve 2 million in February 2015. The utilization rates were around 90%. It proved to be economically sound, promoting savings of 45M USD for an investment of 10.2M USD. It is currently a regular health service in the state, integrated into the healthcare system. In conclusion, the telehealth model developed in Minas Gerais produced good clinical and economical results.