Telehealth for Supporting Referrals to Specialized Care During COVID-19.

Introduction: The coronavirus disease 2019 (COVID-19) pandemic led to the suspension or postponement of care for non-urgent conditions worldwide. Regula Mais Brasil is an initiative of the Unified Health System (SUS) in Brazil to optimize the management of referrals to specialized care by using telehealth. Objectives: To report the expansion of telehealth activities of Regula Mais Brasil in response to COVID-19 and to assess qualification of referrals in primary health care (PHC) units as well as the added value of teleconsultation in qualifying referral cases. Methods: Descriptive study of the teleconsultations carried out as an additional strategy to the remotely operated referral management system, responsible for navigating cases from PHC units to specialized care in Recife, Brazil, between May 6, 2020 and September 30, 2020. Teleconsultation was implemented as a tool for reducing delays in the access to health care due to COVID-19 and ultimately allowed for reclassification of the referral adequacy and priority. Changes in referral priority ratings and referral decisions after teleconsultation were analyzed. Results: A total of 622 referral cases were analyzed. Approved referrals represented 51.9% of cases. The main reason for approved referrals was the need for diagnostic resources. There was a reduction in priority ratings in 449 cases (72.2%) after teleconsultation. There was a statistically significant association between the change of priority ratings and the decision on referral (Pearson's χ2, p-value <0.0001). Results show that telemedicine had an impact on the prioritization and qualification of cases referred to specialized services. Conclusions: A need was detected to rapidly adapt tools available for telemedicine in Brazil. Our results demonstrate that teleconsultation as an additional strategy to the remotely operated referral management system has contributed toward improving equitable access to specialized services.

Health-related quality of life associated with diabetic retinopathy in patients at a public primary care service in southern Brazil.

OBJECTIVE: This study aimed to establish the utility values of different health states associated with diabetic retinopathy in a Brazilian sample to provide input to model-based economic evaluations. METHODS: This cross-sectional study was performed in a sample of patients with type 2 diabetes mellitus (T2D) who underwent teleophthalmology screening at a primary care service from 2014 to 2016. Five diabetic retinopathy health states were defined: absent, non-sight-threatening, sight-threatening, and bilateral blindness. Utility values were estimated using the Brazilian EuroQol five dimensions (EQ-5D) tariffs. Descriptive statistics were calculated. Analysis of covariance was performed to adjust the utility values for potential confounders. RESULTS: The study included 206 patients. The mean (± standard deviation [SD]) utility value was 0.765 ± 0.19 (95% confidence interval [CI], 0.740-0.790). The adjusted mean utility value was 0.748 (95% CI, 0.698-0.798) in patients without diabetic retinopathy, 0.752 (95% CI, 0.679-0.825) in those with non-sight-threatening state, 0.628 (95% CI, 0.521-0.736) in those with sight-threatening state, and 0.355 (95% CI, 0.105-0.606) in those with bilateral blindness. A significant utility decrement was found between patients without diabetic retinopathy and those with a sight-threatening health state (0.748 vs. 0.628, respectively, p = 0.04). CONCLUSION: The findings suggest that a later diabetic retinopathy health state is associated with a decrement in utility value compared with the absence of retinopathy in patients with T2D. The results may be useful as preliminary input to model-based economic evaluations. Further research is needed to investigate the impact of diabetic retinopathy on health-related quality of life in a sample more representative of the Brazilian population.

Effect of anatomical region on the formation of metal artefacts produced by dental implants in cone beam computed tomographic images.

OBJECTIVES: To quantitatively compare metal artefacts produced by implants in different maxillomandibular regions on cone beam CT (CBCT) images. METHODS: A total of 200 implants selected from CBCT examinations were divided into four groups: Group 1 (n = 50)-implants located in the anterior maxilla; Group 2 (n = 50)-implants located in the posterior maxilla; Group 3 (n = 50)-implants located in the anterior mandible and Group 4 (n = 50)-implants located in the posterior mandible. The implants were further classified as isolated or adjacent to other implants. Three axial reconstructions were selected for each sampled implant (apical, middle and cervical). On each slice, the artefacts produced by the implants were counted. The Mann-Whitney test was used to compare the variables between groups. The Kruskal-Wallis and Student-Newman-Keuls tests were used to compare the axial reconstructions. RESULTS: The mandible showed a greater number of artefacts than the maxilla (apical image: p = 0.0024; middle image: p < 0.0001). The anterior region produced more artefacts than the posterior region (apical image: p = 0.0105; middle image: p < 0.0316). There was no significant difference in the number of artefacts between isolated and adjacent implants, and the cervical image was most affected by artefacts. CONCLUSIONS: Dental implants always produce metal artefacts in CBCT images, and these artefacts are affected by the anatomical location in the dental arch.

Efficacy of an education course delivered to community health workers in diabetes control: A randomized clinical trial.

BACKGROUND: Community health workers are community members who provide education and care for patients for a broad range of health issues, including diabetes mellitus. However, few community health workers are trained for diabetes education and little is known about the effectiveness of their interventions. The aim of this study is to evaluate the effect of a diabetes education program delivered to community health workers in improving the metabolic control of patients with type 2 diabetes mellitus. METHODS: Eight community health workers, providing care for 118 patients, were randomized in two groups to receive a 1-month diabetes education program (intervention, patients n = 62) or an education course in other health issues (control, patients n = 56). Each community health worker was responsible for transmitting the acquired knowledge to patients. Primary outcome was changed in HbA1C 3 months after the intervention. RESULTS: PARTICIPANTS: Mean age was 61 ± 11 years, 35% were men and 62% were whites. HbA1c levels reduced in both groups (intervention: 9.1 ± 2.2 vs. 7.9 ± 1.9%; control: 9.1 ± 2.1 vs. 8.4 ± 2.5%, p < 0.001), but no statistically significant differences were observed between groups (p between groups = 0.13). Total cholesterol (intervention: 192 ± 43 vs. 182 ± 39 mg/dl; control: 197 ± 44 vs. 191 ± 45 mg/dl, p between groups = 0.035) and triglycerides (intervention: 158 [106-218] vs. 135 [106-215]; control: 128 [100-215] mg/dl vs. 146 [102-203] mg/dl, p between groups = 0.03) reduced overtime only in intervention group. CONCLUSIONS: In this study, a significant decrease in HbA1c was observed during patients' follow-up, but it was similar in intervention and control groups. The diabetes mellitus education course delivered to community health workers was able to improve patients' lipid profile.