Implementation and Monitoring of a Telemedicine Model in Acromegalic Outpatients in a Low-Income Country During the COVID-19 Pandemic

Treatment and Monitoring of Acromegaly

Considering the relevant aspects regarding access and adherence to treatment and monitoring of acromegaly, 95.2% of patients kept their prescriptions updated. Only 22.2% delayed the injection of somatostatin analogs during the quarantine phase imposed during the pandemic. During this period, 75% of the patients were able to do laboratory tests and send them to the doctor via the internet. These results were comparable to adherence observed in conventional face-to-face consultations over the last 10 years, as previously published by our group.^13–15

In the survey applied after the second virtual visit, 52.4% of patients reported the desire to schedule a face-to-face consultation within the next 3 months.

COVID-19 Infection in Acromegalic Patients and Family

In this study, 45.5% of the patients reported relatives or close contacts infected by SARS-CoV-2 by the second appointment. About 18.2% of infected relatives lived in the same household as the acromegalic patient. Neighbors and coworkers corresponded to 13.5% of infected contacts, and 83.3% of reported contacts presented mild disease, but hospital stay was necessary in 16.6% and respiratory support in 8% of cases.

Considering the sample of 78 patients, 18 (23%) presented symptoms suggestive of COVID-19. The most common suspected symptoms were fever (72%), myalgia (64%), anosmia (53%), dyspnea (34%), and diarrhea (15%). These patients were tested for SARS-CoV-2 by different methods (real time protein chain reaction 17.4%, total antibodies 8.7%, and rapid screening tests 4.3%), but only 10 patients (12.8%) had a confirmed COVID-19 infection.

Of the 10 patients with a confirmed COVID-19 infection, 4 presented severe disease. One, aged 78 years, with severe pulmonary impairment, deceased after 14 days of intensive care. The second patient, aged 48 years, presented 75% of pulmonary impairment, with recovery after 21 days of hospital stay. The third patient, 72 years old, presented pituitary apoplexy with adrenal insufficiency, required corticotherapy and enoxaparin. The fourth patient, 63 years old, had diabetes as a comorbidity and presented acute renal insufficiency, requiring hemodialysis for 2 months. The other six patients showed mild disease, with fever, tiredness, and gastrointestinal (GI) symptoms (diarrhea, nausea, and vomiting).

Discussion

This study was innovative and allowed the implementation of telemedicine at the Neuroendocrinology Unit of the University Hospital of Brasilia. Our acromegalic patients had virtual consultations in an exceptional situation so they would not be exposed to other potentially infected people, following the recent recommendations.⁸ Elderly patients or those with a lower education level preferred phone calls or attended the appointment with the help of friends or relatives, which had the added benefit of allowing family to be more involved in understanding disease prognosis and treatment.

The use of video visits may improve communication, but requires internet access and technology navigation, which can highlight health care disparities.¹⁷ Effective communication is a pillar of the physician–patient relationship and compassionate medical practice, but virtual care includes the inability to utilize body language and barriers to traditional physical examination.¹⁸ These challenges may be essential obstacles to good medical practice. To attain good virtual care, the principles of professionalism, empathy, respect, and virtual physical examination should be applied.^18,19

Despite the low social and educational level of our patient cohort, we observed a very high adherence to the alternative of virtual appointments, and 96% of the survey questionnaires were sent back to the medical team within 24 h of being sent. The high acceptance of telemedicine in this cohort can be explained by the fact that only previously diagnosed patients in routine follow-up and treatment in our service were included. The interpersonal relationship between the medical team and patients was previously established in-person and allowed patient-centered virtual care. One limitation of this study is the absence of a matched control group, submitted to in-person consultations. Considering the exceptionality conferred by the pandemic, telemedicine became the only accessible option to maintain adequate medical assistance. That being said, the adherence in the study group was similar to that observed in face-to-face consultations carried out in previous years^13–15 and the medical effectiveness of the remote medical assistance seemed to be comparable to the conventional protocol in our service.

In our study, remodeling the health service structure was fundamental for the feasibility of telemedicine, allowed the avoidance of public transportation, integrated pharmacy and clinical teams, permitted home delivery of medicines, and simplified access to medical care. A crucial aspect in low- and middle-income countries is the reported financial savings when the patient does not need to pay for transportation to make multiple trips to different levels of health care and the reduction of absenteeism at work. Telemedicine can eliminate logistic barriers and increase access to clinical care.^20–23

In the first virtual survey filled after the first consultation, patients expressed satisfaction with the convenience, reduction in time spent to achieve the medical assistance, and saving money with transportation of telemedicine compared to previous face-to-face visits. Most patients felt supported by the medical team and kept their prescriptions updated.

Despite these advantages, there was a relevant difference in the patient’s choice for the next virtual appointment after 6 months of the first telemedicine meeting. Only 34.8% of patients would choose to maintain virtual consultations for long periods, relating a preference for face-to-face meetings, which represents a drastic reduction in patient´s engagement along the social isolation imposed by the pandemics.

Several factors that may have influenced the choice for in-person consultation in long-term follow-up: (1) most of our patients had a low level of education or were illiterate, needing family support to make the teleconsultation. This aspect was observed in other studies in underserved populations, where technological disparities, lack of computer literacy, or access to reliable internet to complete the video consultation successfully were found.²⁴ (2) The sample of patients with acromegaly is composed mostly of elderly patients, which prefer phone calls. Some authors have also described difficulties in acceptance of using electronic media to communicate with the patient instead of telephone calls,²⁵ even though recent reviews have demonstrated that video conferencing is feasible, acceptable, and can effectively be used in older adults.²⁶ Virtual care includes the inability to utilize body language and barriers to traditional physical examination. (3) The hospital team did not provide technological support to our patients. Most of them learned alone or with the help of friends or family, which imposes difficulties on the use of computers or other devices. Other authors suggested that the possibility of staff members being able to explain and train patients to use the technological resources may increase patient favorability toward teleconsultation. Such an intervention, however, may not be suitable for certain seniors who may be uncomfortable with technology or who do not have the necessary readiness to change to participate.²⁷ (4) Most of acromegalic patients have some physical disability due to the presence of comorbidities and complications of the disease, such as visual impairment related to tumoral compression of optic chiasma, acral enlargement, and restriction of fine movements, which hinders the use of small electronic devices. In a previously telehealth-naive clinic, however, some authors have shown successful implementation of telehealth for a diverse orthopedic population with low mobility.²⁸

The physicians’ perceptions of remote consultations were accessed by a web link survey, filled in, and sent back within 48 h after each consultation. The experience in our sample was positive, and the meetings were resolutive in most cases, requiring an in-person evaluation in less than 16% of cases. The absence of a physical examination did not impact the final care in our patient sample, which may be related to the fact that we only included patients with a known diagnosis of acromegaly, in long-term clinical follow-up in our service, in which the empathy and physician–patient relationships were previously established.

All the medical team was unfamiliar with telemedicine before the pandemic. The main disadvantages reported by physicians were the longer time spent trying to contact the patients, the inability to access records, and the subsequent virtual contacts necessary to complement information or laboratory tests. Our data are in accordance with other authors, and we agree that telemedicine can be used for selected groups of patients in the post-COVID-19 era.²⁹

During the first 6 months of virtual monitoring, 10 (13%) of acromegalic patients reported COVID-19. Most of the cases were mild and moderate, but four confirmed cases required hospitalization. Telemedicine improved communication between patients and the medical team allowed immediate notification of symptoms and confirmed PCR tests. Another great advantage was better contact and proximity with patients’ families during the course of the infection in outpatients.

Our data suggest that the sustainability of exclusive telemedicine for long periods of time is very difficult, and we highlight the need for better training of assistance teams for using the different platforms, for the achievement of the main objectives of good medical practice, including empathy, compassion, and ethics.³⁰

Telemedicine is a very important tool for maintaining essential health services during the pandemic, but can become a sustainable resource for educational initiatives and patient-centered care.^22–24 Telemedicine innovations should be designed to increase the quality of care, with safety, effectiveness, efficiency, and comparable to face-to-face visits.³¹

Conclusion

Telemedicine can complement traditional ambulatory and hospital-based practices, creating an opportunity to implement remote follow-up and patient-centered care. Wherever feasible, less costly solutions that take advantage of telemedicine’s capabilities should be incorporated into the future to reduce risks of health care disruption. In the nonurgent care setting, the forced transition to video visits have demonstrated its feasibility, satisfaction, and its value in promoting social distancing, concerning an important tool in low-incoming countries. Our study suggests that telemedicine could be adopted interchangeably with in-person consultations in acromegalic patients with stable disease.

Authors’ Contributions

L.A.N. contributed to the study design, clinical responsibilities, and writing and reviewing the report. I.N.R. contributed to the conceptualization of the study, data collection, and writing and collecting the forms. T.A.S.L., L.B.S., L.F.C., and L.A.C. contributed to writing and reviewing the text. All authors approved the article.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.