With a little help from our friends: telemedicine support for caring of patients with heart failure in Rio de Janeiro, Brazil. The Brazilian Heart Insufficiency with Telemedicine Project (BRAHIT)

BACKGROUND: Heart failure is a global public health challenge and a common cause of recurrent hospital admissions and reduced quality of life. Healthcare sectors integration can improve outcomes for patients with heart failure. We hypothesise that telemedicine between cardiologists and primary care physicians (PCPs) is an efficient strategy to foster integration healthcare sectors. However, evidence regarding the effectiveness of telemedicine between providers on patient-relevant outcomes, such as hospital admission rates, mortality, and quality of life, is lacking. During the BRAHIT (Brazilian Heart Insufficiency with Telemedicine) project, a collaboration between academic institutions in Denmark and Brazil, we implemented telemedicine support from cardiologists to PCPs in Rio de Janeiro and evaluated the intervention. METHODS: Based on the UK Medical Research Council Framework for the Study of Complex Interventions, we have conducted three studies: 1 - a mixed-method feasibility study combining content analysis of focus groups and individual physicians' interviews with a before-and-after assessment of clinical data; 2 - a cross-sectional study where we analysed and compared the usage patterns and the content of the telemedicine interactions in two telemedicine services in Rio, one implemented within the BRAHIT project and other from the city's Health Department. We used the ICPC-3 to classify reasons for consultations and diagnoses, the Taxonomy of General Clinical Questions for clinical questions, and the Champlain eConsult BASETM classification for answers; 3 - a cluster-randomized trial to assess the effectiveness of telemedicine between providers on patient readmission rates and mortality (currently in the follow-up phase). RESULTS: Feasibility Study: Telemedicine was considered feasible and perceived as a good strategy among all groups. However, mineralocorticoid antagonist prescription had a 5% decline. Cross-sectional study: When comparing usage frequency of both studies services, the Health Department service use by the PCPs working in the city practices was higher (332/1093, 31%) compared to the BRAHIT project service (43/1331, 5%). The median answer time was much shorter in the Health Department service (19 min) than in the BRAHIT telemedicine service (two days). Most clinical questions (203/278, 73%) to the Health Department's service were about diagnosis, mainly regarding electrocardiography interpretation (190, 91%). The questions asked in the BRAHIT service were more frequently about treatment (30/68, 44.1%) and or case management (29/68, 42.6%). The analysis of both models and its contribution to future implementation projects and continuing medical education opportunities were discussed. EXPECTED RESULTS: Cluster-randomised trial: The ongoing trial will help determine whether the intervention effectively affects patient-relevant outcomes. CONCLUSIONS: Telemedicine between cardiologists and primary care physicians was feasible in the study setting. Significant barriers include the high workload and a lack of perceived relative advantage in primary care. Factors associated with the telemedicine delivery model may also influence uptake and use patterns, and a balance between practicality and complexity is needed. Shared care through telemedicine may present as a good strategy to integrate focal specialists and PCPs to care of patients with heart failure. The upcoming trial results will describe the effects on mortality, readmission rates, and quality of life.