Otimização do Sistema de Saúde no Brasil Com Telemedicina

1. AIM The aim of BRAHIT is to test a new model of care for patients with heart failure in Rio de Janeiro since the investigators can apply well-defined international guidelines for high-quality management of heart failure patients as success criteria, which have been endorsed and adapted in Brazil. Ultimately to provide a policy advice for innovative health management with telemedicine.
2. BACKGROUND Previous clinical trials that have randomized patients to conventional care or home monitoring with telemedicine solutions have failed to demonstrate a benefit of telemedicine. This is probably due to a selection bias. Accordingly, if only patients with high e-literacy, education and social level are selected for participating in telemedicine studies, it is probable that they have maximum advantage from any treatment, thus making it difficult to assess a benefit with telemedicine. In contrast, weaker patients who truly need a close care remain out of reach for cardiology expertise, remaining under primary care management, with scarce resources.

Another problem is that, once the participants have access to the new healthcare management to be studied, conventional management gets unavoidably changed and comparison is no longer possible. Therefore, in BRAHIT, randomization will not occur at the individual patient level, but through cluster randomization at the organizational level of the primary care clinics. Successful multifaceted programs for heart failure are based on multiple visits to cardiology outpatient clinics, and patients can be safely transferred to Primary Care, but can be too strenuous for frail patients or impossible in remote areas BRAHIT includes quality indicators that allow monitoring quality of care; telemedicine-based tools for patient education, to enhance e-health literacy and innovative communication and data-exchange to support integrated care between health sectors. Telemedicine in BRAHIT can bring cardiology expertise to socially frail patients and, thereby, overcome social inequality.

The Brazilian primary care sector is challenged with long waiting lists for referrals to specialist visits, elective surgeries, and to access higher technology services . This is aggravated in the last years, as Brazil is facing austerity measures.

The Brazilian primary Health Care Model has evolved to almost 60% coverage, based on Family Health Teams, composed by specialized general practitioners, a nurse, nursing technicians and community health agents, while the rest are Family Health Teams with "generalists" (under-graduated physicians).

The municipality of Rio de Janeiro, as it is particularly suitable for this project, with roughly six million habitants and a large social and cultural diversity. About 80% of the population has access to internet, electronic medical records and communication and information technology and Homecare teams are able to use social media and blogs in communicating with the local population. Therefore, it is feasible to use telemedicine communication in association with homecare teams to reach the entire population living in Rio de Janeiro. Furthermore, in BRAHIT, Primary care physicians training programs on heart failure will be based on action mapping, with adaptive technology-enhanced distance learning. 3. METHODS Participants Patients discharged from Instituto Nacional de Cardiologia (INC) with the heart failure as the primary reason for admittance (ICD-10): (DI-11.0, 13.0, 42.0, 42.6, 42.9, 50.0, 50.1, 50.9) and requests from Primary care to INC on questions for management of patients with heart failure diagnosis.