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Hundred Days of Teleconsultations and Their Usefulness in the Management of COVID-19: Experience of the COVID-19 National Call Center in Bolivia

Editor


Introduction

On December 31, 2019, a new virus emerged globally, which would mark a before and after global public health.1 Then, a real dilemma would begin for many countries; however, we are sure of one thing, nations were not prepared to face a situation of this magnitude. In Bolivia, after the arrival of the SARS-CoV-2 on March 10, 2020, in the municipality of San Carlos in the department of Santa Cruz, the first measures were taken to deal with the problem.2

Thus, 6 days later, a strategy proposed by the National TeleHealth Program began to operate, which consisted of implementing a method for detecting suspected cases of COVID-19 at the national level, helping the mediated care, monitoring, and follow-up of these patients through teleconsultation.3

Nowadays, in Latin America, and particularly in Bolivia, despite the time of the pandemic, there is little evidence on the effectiveness of implementing strategies to solve public health problems through the use of information and communication technologies (ICT) in combination with telemedicine.4

Early detection of patients allows us to manage the cases in their early stages and control the development of the disease to prevent possible complications. During a pandemic, this is important because we can also cut the chain of infection of the virus by isolating the patient timely and adequately to assist with the containment of COVID-19 in Bolivia.

In those cases with moderate or severe manifestations of the disease, the patient’s transfer can be coordinated, immediate, and timely, prioritizing isolation or care in intermediate and intensive care units for proper management. This critical aspect can only be achieved through a well-established triage system, which allows timely referral of the patient; with the development of ICT and its application in telemedicine, this is probably possible.

Then, the objective of this study was to evaluate whether the joint application of a call center and teleconsultation is a valuable and effective tool for the early detection of suspected cases of COVID-19, the mediated care of patients, and the early detection of possible complications through monitoring and follow-up for their timely referral.

Methodology

STUDY DESIGN

An observational, cross-sectional, and descriptive study of patients recruited by the Call Center-COVID-19, monitored and followed up at home through teleconsultations.

SCOPE OF STUDY

The area where this study was implemented corresponds to the entire national territory of Bolivia where the National Telehealth Program is implemented, which has a network of telecenters in a total of 340 remote care clinics throughout 338 top municipalities in the 9 existing departments in the country; all of them are equipped with digital medical devices that help to perform the telediagnosis according to the decisive level where they are located (first level or Tele 1, second-level or Tele 2, third level or Tele 3) and a central server (Tele 4), thus becoming the largest telehealth network in Latin America per capita, and given the size of the country, the most prominent national telehealth network in absolute terms is Brazil, which has grown significantly in these past 2 years.5 Therefore, it is a reasonable and necessary bastion in telehealth in these difficult times for the Bolivian population.

STUDY POPULATION

The study population corresponds to all those who requested the COVID-19 Call Center service and the monitoring and follow-up through teleconsultation. Exclusion criteria were established for those people who, due to their characteristics, could not use this service, as well as those who freely decided to use the face-to-face method.

VARIABLES

For data collection, an ad hoc COVID-19 Teleconsultation Form was designed, which contains the variables of this study, based on the “COVID-19 Epidemiological Record and Laboratory Studies” prepared by the Epidemiology Unit of the Bolivian Ministry of Health.6 It is composed of 22 variables synthesized into 7 data types, as shown in Table 1.

Table 1. Types of Synthesized Data
NO. TYPES OF SYNTHESIZED DATA
1 Monitoring and follow-up start date.
2 Identification of the doctor who performs the care and his or her reference location from where he or she performed the remote care.
3 Identification of patients and their referential location.
4 Clinical/epidemiological data of the patient.
5 Laboratory data.
6 Monitoring and follow-up reports on a daily basis between 14 and 21 days.
7 The patient’s condition up to the date of the cut.

DATA COLLECTION AND COMPILATION

The study was carried out from March 16 to June 23, 2020, which corresponds to the first 100 days of implementing the COVID-19 Call Center and the monitoring and follow-up through teleconsultation. The early detection method of individuals with suspected COVID-19 was carried out through a call center consisting of a space (DATACOM—Entel Bolivia) equipped for this purpose, for which two toll-free lines were enabled (800-10-11-04 and 800-10-11-06); the site was operated by a team of 50 doctors from different ministerial programs (TeleHealth, Juana Azurduy Bonus, SAFCI, Mi Teleférico, National School of Public Health, and those in charge of the Short-Term Security System).

As a tool for this study, an action protocol was developed based on a care flowchart. In the flowchart, once the operator receives the call, the user’s data are recorded in the form, the reason for the call is established, and the established algorithm is applied to assess whether (1) it meets emergency criteria, in which case it is communicated or (2) it meets criteria for attention by teleconsultations for monitoring and follow-up (Figs. 1 and 2).

Fig. 1.

Fig. 1. Call Center COVID-19—teleconsulting attention flowchart.

Fig. 2.

Fig. 2. Transfer flowchart for serious and critical patients.

For this study, we detected those individuals who presented the following characteristics: (1) patient with acute respiratory infection (fever and at least one sign/symptom of respiratory disease, e.g., cough, shortness of breath), and without other symptomatology that thoroughly explains the clinical presentation and history of travel or residence in a country/area of territory that reported local infection of COVID-19 disease during the 14 days before symptom onset; or (2) patient with an acute respiratory infection who had contact with a confirmed COVID-19 case in the last 14 days before symptom onset; or (3) patient with any severe acute respiratory infection (fever and at least one sign/symptom of respiratory disease, e.g., cough, shortness of breath), requiring hospitalization and with no other etiology that thoroughly explains the clinical presentation.7

Once a possible suspected case has been identified, according to the definition used by the Ministry of Health, after triage, it is referred to a physician of the National TeleHealth Program, who is in charge of monitoring and follow-up through teleconsultation, which consisted of remote care from the doctor’s office to the patient’s home through the use of ICT, in the form of videoconferencing (Zoom, meet, or other) or telephone call; this follow-up was carried out periodically 1, 2, or even 3 times a day, in which the physician responsible for the care assesses the patient’s clinical condition through questioning guided by the identification of COVID-19 signs and symptoms; treatment is indicated according to the clinical picture of such patient based on the management protocols established in the “Quick guide for the management of patients with COVID-19,”8 of the Bolivian Ministry of Health; triage of the patient and activation of the rapid response team of the Departmental Health Service corresponding to the department and municipality of residence of the patient; this team is the first face-to-face medical contact who performs the on-site care and is the one that determined the following:

(1)

The timely transfer of the patient to a health facility according to his/her condition (end of teleconsultation).
(2)

If the patient does not need to be transferred, the epidemiological notification form is filled out, and the sample is taken. Teleconsultation is continued until the patient is discharged or until the case requires a new on-site evaluation.

The detection time was determined by calculating the difference between the date of patient contact with a person with laboratory-confirmed COVID-19 (reverse transcriptase-polymerase chain reaction [RT-PCR]) and the start date of the teleconsultation. The mean of the times found for all the individuals under study was calculated to estimate the detection timing.

STATISTICAL ANALYSIS

A descriptive analysis was performed for each variable: in qualitative variables with absolute and relative frequencies. In quantitative variables with mean/median and standard deviation (SD)/interquartile range. This study’s follow-up and monitoring time was 14–21 days and was estimated using the Kaplan–Meier analysis by the actuarial method. The comparison of qualitative variables was performed with Pearson’s chi-square test, and the comparison of normally distributed quantitative variables with Student’s t-test. Values with a p < 0.05 were considered statistically significant. The software used for the statistical analysis was Statistical Package for the Social Sciences (SPSS)® version 25.

ETHICAL CONSIDERATIONS

This study was validated and approved by the Vice-Ministry of Health System Management of the Ministry of Health and Sports of the Plurinational State of Bolivia (by memo MSyD/VGSS/NI/227/201.).

Results

The study included 3,278 patients, representing 12.45% of the total number of new cases in Bolivia during the study. Tables 2 and 3 shows the flow of calls received by the call center in the first 100 days of its implementation; the number of suspected cases detected through these calls shows an exponential increase toward June, and the numbers of days of monitoring and follow-up performed on the patients were 26,610, which on average was 8.12 days (SD 5.42). The main results, grouped by category, are as follows:

Table 2. Flow of Calls Received by the Call Center in the First 100 Days of Its Implementation
MONTH ANSWERED CALLS SUSPICIOUS CASES DETECTED MONITORING AND FOLLOW-UP (DAYS) AVERAGE
March 61,118 316 1,867 5.91
April 37,803 455 3,248 7.14
May 26,725 993 9,510 9.58
June 41,615 1,514 11,985 7.92
Total 167,261 3,278 26,610 8.12

Table 3. Flow of Calls Received by the Call Center in the First 100 Days of Its Implementation
VARIABLE POPULATION (n = 3,278) VARIABLE POPULATION (n = 3,278)
Gender (female) 1,617 (49.3%) They were notified to the service of
Mean age (SD) years 37.48 (15.20) Yes n = 442 (14.4%)
Rank 0–98 They needed attention
Age groups, years Yes n = 859 (28.6%)
 0–<1 0.80% They required isolation at home and/or hospitalization
 1–4 1.10% Home isolation n = 1,923 (93.8%)
 5–14 2.40% Hospitalization n = 127 (6.2%)
 15–29 27.80% Comorbidities present in patients
 30–44 38.70% None n = 2,470 (75.4%)
 45–59 20.50% Cardiovascular n = 220 (6.7)
 60–74 7.20% Endocrinometabolic n = 196 (6.0%)
 >75 1.60% Chronic pulmonary n = 113 (3.4%)
Country of origin of the patient Cancer n = 66 (2.0%)
 Bolivia n = 3,251 (99.2%) Gastrointestinal n = 64 (2.0%)
 Foreign country n = 10 (0.3%) Chronic infectious diseases n = 53 (1.6%)
 Undetermined n = 17 (0.5%) Rheumatological n = 29 (0.9%)
Residence department Upper airways n = 28 (0.9%)
 Chuquisaca n = 20 (0.6%) Hematologic n = 26 (0.8%)
 La Paz n = 1,068 (32.6%) Chronic kidney n = 13 (0.4%)
 Cochabamba n = 532 (16.2%) Patient status as of the cutoff date
 Oruro n = 39 (1.2%) High n = 2,484 (75.8%)
 Potosi n = 24 (0.7%) Tracing n = 605 (18.5%)
 Tarija n = 9 (0.3%) Transferred to an ES n = 128 (3.9%)
 Santa Cruz n = 1,468 (44.8%) Passed away n = 61 (1.9%)
 Beni n = 83 (2.5%) Sign-symptomatological spectrum
 Pando n = 5 (0.2%) First in order:
 Another state abroad n = 6 (0.2%) Asymptomatic n = 429 (13.1%)
 Undetermined n = 24 (0.7%) Thermal boost n = 968 (29.5%)
They had direct contact with the case Headache n = 399 (12.2%)
 Yes n = 1,253 (38.2%) Second in order:
Place of direct contact Dry cough n = 380 (11.6%)
 Home n = 930 (28.4%) Headache n = 368 (11.2%)
 Does not know n = 328 (10.0%) Thermal boost n = 351 (10.7%)
 Workplace n = 137 (4.2%) Third in the order:
 Health facility n = 66 (2.0%) Odynophagia n = 285 (8.7%)
 Airport n = 14 (0.4%) Dry cough n = 250 (7.6%)
 Church n = 6 (0.2%) Headache n = 229 (7.0%)
 Closed public space n = 51 (1.6%)    
 On the street n = 56 (1.7%)    
 Does not know n = 328 (10.0%)    
 Undetermined n = 1,690 (51.6%)    
(1)

Case detection time. On average, patients were identified by the call center in 7.6 days (SD 6.92) between the day of contact with a laboratory-confirmed positive case (RT-PCR) and the day the teleconsultation began.
(2)

Frequency of remote care. The highest frequency of remote consultations occurred in the department of Santa Cruz (mode = 7). Fifty percent of the teleconsultations attended remotely were from seven of the nine departments of Bolivia (median = 3); the remaining 2 (La Paz and Chuquisaca) only performed teleconsultations locally, to at least one kind of population within the same department. This also means that on average (4.32), the teleconsultations were generated from more than four departments of the nine existing in Bolivia; 25% (Q1) of the teleconsultations were made from the departments of Chuquisaca and La Paz, which correspond to the capital city and the seat of government, respectively. The remaining 75% (Q2, Q3) were performed from the rest of the departments (Table 1).
(3)

Clinical/epidemiological characteristics. On average, patients were 37.5 years old (SD 15.2; range 0–98). The age range with the highest demand for the service was 30–44 years (mode = 30). Fifty percent of the patients were older than 35 years of age (median 35). In terms of gender, 1,648 (50.6%) were male and 1,606 (49.4%) were female. In Figure 3, it can be seen that there are two convexities in the pyramid toward the upper and lower extreme age groups.
Fig. 3.

Fig. 3. Age and sex distribution pyramid.

The number of teleconsultations according to the epidemiological calendar, Figure 4, showed an increase of teleconsultations of almost three times the frequency in the first weeks, from week 17 and 18 in the case of Santa Cruz; La Paz and Cochabamba showed increases from week 22. The three departments showed peaks of consultations in week 25. The rest of the general characteristics of the patients are shown in Table 1.

Fig. 4.

Fig. 4. Evolution by epidemiological weeks of teleconsultations provided.

Regarding the municipality of residence, there was a greater demand for the service by residents from the municipality of Santa Cruz de la Sierra (mode = 1) 1,468 (44.8%), La Paz 697 (21.3%), Cercado 383 (11.7%), El Alto 350 (10.7%), Trinidad 63 (1.9%), Sacaba 530 (1.6%), Andréz Ibañez 48 (1.5%), Quillacollo 43 (1.3%), and Oruro 34 (1.1%). The remaining 53 municipalities reported 243 (7.4%) consultations.

(4)

Laboratory results. From the total number of teleconsultations performed, only 132 (4.0%) were reported positive by a laboratory (RT-PCR), and 653 (19.9%) were negative. In addition, from the total, 2,493 (76.1%) corresponded to suspected (not confirmed) COVID-19 cases that were clinically managed in the same way as those laboratory confirmed.
(5)

Patient monitoring and follow-up time. The mean monitoring and follow-up time was 6.7 days (SD 4.87; range 2–38 days) (95% confidence interval 6.537–6.911). Figure 5 shows the evolution over time of the discharges, so most of them, 96.08%, taking place between 2 and 15 days of follow-up, 2.76% between 16 and 21 days, and 1.16% reaching 38 days of follow-up.
(6)

Patient status as of the cutoff date. From the 3,278 patients who were identified, monitored, and followed up by teleconsultations, 2,460 (75.6%) were clinically discharged as recovered, 605 (18.6%) continued with monitoring and clinical follow-up, 128 (3.9%) required referral to health facilities and hospitalization, and 61 (1.9%) died (Fig. 6).
Fig. 5.

Fig. 5. Evolution over time of the discharges.

Fig. 6.

Fig. 6. Patient status as of the cutoff date.

Discussion

This study shows how the implementation of the COVID-19 Call Center and teleconsultation as a tool in Bolivia managed to strengthen the National Epidemiological Surveillance System and the Health Systems of the Plurinational State of Bolivia through these strategies proposed by the Ministry of Health and Sports in the fight against the COVID-19 pandemic. One of the main ideas of this study was to show the country’s experience regarding the lessons learned and the opportunities that telemedicine also brings to Latin American countries, such as Bolivia and others in this region. This is the first study covering the use of ICT and its applicability in the COVID-19 pathology throughout the national territory. This is possible thanks to the most extensive telehealth network within a national territory in Latin America.5

The National Telehealth Program was born as a decision of the National Government, which will incorporate the telehealth technology tool and the Bolivian social network, to reduce social exclusion, promoting alternatives to improve access to health, overcoming geographical barriers, optimization of skills and capacities of specialized and subspecialized resources, within the framework of the Community and Intercultural Family Health policy of Bolivia.

Since many countries are still coping with the second and thirds waves and are still underserved, without easy access to vaccine programs (most countries in Latin America have <15% of their populations fully vaccinated, June 30, 2021), telemedicine is a vital tool for public health. However, first, it is necessary to highlight how this strategy strengthened the National Epidemiological Surveillance System by passively searching for possible suspected cases of the disease, identifying patients in their primary infection phase (first 7 days) when they have a higher viral load.9,10 This makes this tool an excellent method for early detection and a potential strategic tool to achieve “traceability” or tracking of cases and their contacts, identify third or more persons exposed, establish the speed of transmission (R0),11 in a given place and time, and recommend actions to reduce the transmission of an infectious agent such as the one causing the current COVID-19 pandemic.12 This is one of the main contributions of this study, which may serve in the future to control outbreaks and epidemics of other infectious diseases or future pandemics in Bolivia and other Latin American countries.

On the contrary, teleconsultation as a tool for the monitoring and follow-up of patients with high suspicion of COVID-19 is helpful to assist with the containment actions of an outbreak, coordinating actions directed with the “Emergency Coordination Centers” by early identifying the cases that require face-to-face emergency intervention and transferring them to health facilities according to the needs of the patients, as well as carrying out the prioritization tasks according to the occupancy rate of the different facilities and the triage performed as some studies have shown.13

Likewise, teleconsultation is safe due to its following characteristics14: (1) remote and efficient care avoiding physical contact of health professionals, (2) accessibility and scope allowing access to the most remote rural territories and populations, and (3) economic savings by avoiding the use of fixed facilities and excess staff, adapting demand to supply, mainly in those places where there is a higher incidence of contagion, preventing excessive saturation of health systems.15

Compared with other interventions carried out in other countries, a Spanish peer-reviewed study found a mean monitoring and follow-up time of 11.64 days (SD 3.58),16 a higher result than our study. This is probably because the study in question only followed high-risk patients. Our strategy of detecting patients in the initial stages of the disease was performed on the entire population that required the service.

An increase in the number of cases detected was observed in the month of May 2020, and therefore, there was an increase in the number of days of follow-up and monitoring of cases, however, it is necessary to mention that the variation in the number of calls received was higher in March 2020 compared with June 2020; this due to the increase in the effectiveness of the call center as a method of passive surveillance and the detection of suspicious cases; also, on the contrary, because the call center also attends calls from users in search of general information on the COVID-19 or the notification of complaints of various kinds.

From our perspective, teleconsultation in our sociocultural, geographic, and political context is helpful because it is the doctor belonging to the geographical area of residence of patients, steeped in the customs and traditions of the place, the beliefs of patients and traditional medicine, who is responsible for the implementation of monitoring and follow-up; however, this does not prevent him or her from following up people in other areas thanks to ICT, breaking geographical barriers and improving access to telehealth services to strengthen the approach of accessibility of health systems.

A considerable proportion denied a history of chronic diseases, indicating that most of our target populations were not high-risk individuals. Therefore, we must point out that our objective was to detect and follow up on these cases and each suspected case since they constitute potential individuals to disseminate the virus to the surrounding environment. This is why there was no need for on-site medical care in a significant proportion of the patients.

It is necessary to point out that we encountered limitations in performing this study. First, the number of calls received and taken by the call center turned out to be significantly higher than the number of teleconsultations of patients with suspected COVID-19 who were referred. That may indicate that the patients’ perception of requiring immediate attention is not always valid, at least in our population. On the contrary, due to the large number of calls received to meet the information needs of the population, these calls received were higher when compared with those calls that had direct contact with a laboratory-confirmed case of COVID-19. Many people without COVID-19 or close contact with cases called just to receive information.

Also, there were missing data due to the sociocultural limitations of our target population, in some cases, the instability of connectivity had an impact on data, as well as due to the lack of follow-up as a result of the perception of care provided by some people, however, in most of our variables there were no significant proportions of the same. Also, the impossibility of transferring our medical devices for logistical and legal reasons meant carrying out the task to the patient’s homes. In addition, this study lacks a control group to compare the evolution and outcomes of patients under telehealth in Bolivia with those attended nonvirtually.

Among the main strengths of this study is the first study conducted in Latin America on ICT and COVID-19, including an entire national territory. This is why we have a highly representative sample, including the different departments’ population and, therefore, urban and rural areas.

Conclusions

We are currently in a moment of public emergency where the different governments need systems to prevent the spread of the SARS-CoV-2 virus. Therefore, it is necessary to innovate new tools that help in the different strategies. Telemedicine and tele-epidemiology systems are ideal for preventing the collapse of hospitals by allowing the correct classification of patients. The Bolivian experience of implementing a call center and the use of telemedicine in the fight against COVID-19 has shown how the use of ICT has proven helpful in managing the challenge of the COVID-19 pandemic, as well as how it can be used to address health care in other areas as a result of this experience.

Disclosure Statement

No competing financial interests exist.

Funding Information

This study was funded by the Ministry of Health and Sports, La Paz, Bolivia.

Acknowledgments

To all the healthcare workers of the Telehealth program of Bolivia.

REFERENCES





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