Telehealth for Supporting Referrals to Specialized Care During COVID-19

Introduction

COVID-19 outbreak challenged the ability of health systems to deal with a global health crisis.¹ Brazil declared coronavirus disease 2019 (COVID-19) a national public health emergency in February 2020² and a series of measures were put in place to try to slow down the spread of the disease³ and to allow the Unified Health System (SUS), the Brazilian universal health care system, to adapt to the rapidly growing demand for hospital beds, especially in intensive care units, and to prevent the health system from collapsing. As part of the urge to organize care for the increasing number of patients with COVID-19, SUS faced the need to organize the health care network.

Restriction to circulation and measures to stimulate social distancing⁴ caused non-emergency health services, such as outpatient consultations and elective surgeries to be suspended or postponed.^5,6 Although these were legitimate measures, suppression of health care activities, such as the monitoring of patients with chronic conditions, led to discontinuation of treatments and aggravation of medical conditions, which expanded the negative effects of the pandemic.⁶ Therefore, it was necessary to adapt health care related to other medical conditions by reorganizing patient flow within the health care network and creating new entry gateways to the health system.^7,8

In accordance with its fundamental principle of universality of services, SUS developed a referral management system to guide the navigation of cases in health services considering distinct levels of complexity,⁹ which was officially instituted in 2008.¹⁰ The referral management system is responsible for guaranteeing access to specialized services in accordance with clinical criteria and risk definition.¹¹ Despite such mechanism, adequate and timely access to specialized services has been a challenge faced by SUS long before the advent of the pandemic.¹²

In the context of the pandemic, telehealth has gained special prominence by bringing opportunities to enhance articulation within the health care network and to facilitate access to specialists, promoting integrated care. Telehealth strategies are an alternative to provide assistance to less severe cases that do not require hospitalization and for chronic conditions,¹³ counterbalancing the delay or suspension of elective health services imposed by the pandemic and thus reducing pent-up demand.

Regula Mais Brasil is a project of the Brazilian Ministry of Health carried out jointly by the five hospitals that are part of SUS’s Institutional Development and Support Program (PROADI-SUS). The Regula Mais Brasil project was designed to allow qualification and streamlining of the referral process from primary health care (PHC) to specialized care by using telehealth. Actions within the scope of the project consist of risk assessment based on standardized protocols; interconsultations between specialists and PHC providers; and teleconsultation to confirm or discard the need for a given referral. Due to the restricted offer of specialized outpatient services imposed by the COVID-19 pandemic, the project expanded its initial scope by starting to offer teleconsultation as an alternative way to provide those services, especially for patients with more complex health conditions on waiting lists.

The present study describes this realistic and generalizable strategy deployed to improve the referral management to specialized health care by employing telehealth. It also discusses the ecology of care in Brazil, considering the results achieved in Recife, a state capital in the northeastern Brazil during the COVID-19 pandemic.

Methods

STUDY DESIGN

Descriptive study of a remotely operated referral management system, responsible for navigating cases from PHC units to specialized care, in the universal health care system in Recife, Brazil, between May 6 and September 30, 2020. The research protocol was approved by the institutional Research Ethics Committee of Hospital Sírio-Libanês on February 10, 2020, under the number 28453420.5.0000.5461, with waiver of informed consent.

SOCIOECONOMIC AND DEMOGRAPHIC CHARACTERISTICS OF THE LOCALITY

Recife is the capital city of the state of Pernambuco, located on the northeastern coast of Brazil. The estimated population is 1.7 million inhabitants, with predominance of women (53.3%) and young individuals aged 20 to 39 years. The region is marked by social disparities, with most households presenting no income (33.1%) or a minimum wage (29.2%), and the minority of the population (1.8%) reporting income values greater than 20 times the minimum wage. The human development index of Recife is 0.772, according to estimates for 2010.¹⁴

Recife plays a strategic role in the regional health network, since it provides multiple services at the macro-regional level and at the state level.¹⁴ Being responsible for the coordination of the local health network, Recife has been developing initiatives for optimizing the referral of cases to specialized care, including the implementation of protocols for risk assessment. The development of the current project was, thus, perceived as aligned with the priorities set by the local leadership.

PHASES OF THE IMPLEMENTATION AND OPERATIONAL ACTIVITIES

In early March 2020, a technical visit was conducted to allow for a situational diagnosis. A set of criteria were previously established to define which medical specialties would be included in the project. These criteria included waiting times from the moment of referral up to consultation; referrals of cases potentially managed in PHC; number of patients on waiting lists; adherence to protocols developed by the Ministry of Health of Brazil; and operational capacity. After having assessed these criteria, the remotely operated referral management system was implemented for navigating cases in the field of neurology, endocrinology, cardiology, orthopedics, and rheumatology.

Waiting lists were scrutinized to assess the reasons for the referral of cases to specialized care, by applying standardized protocols. These protocols are official, specialty-specific documents developed by the Ministry of Health and intended to standardize the prioritization of cases in accordance with the risk of having the clinical condition aggravated while waiting for medical assistance.

Once confirmed that the referral request was made in accordance with such protocols, face-to-face consultation would be authorized, or teleconsultation would be scheduled, according to the type of clinical condition. Cases eligible for teleconsultation within each medical specialty were previously defined by the Ministry of Health to orientate the decision-making process. The initial objective of adding the option of teleconsultation was to reduce the impact of postponement or cancelation of elective appointments caused by the pandemic, and, also, to minimize the risk of contamination of individuals during presential appointments. Teleconsultations additionally opened up the opportunity to reassess risk prioritization of cases in waiting lists. After each teleconsultation, the case would be either returned to PHC or reinserted into the system to schedule a face-to-face visit.

Alongside these procedures, additional information related to case referrals would be requested from PHC units, whenever crucial data were missing. An interconsultation with a specialist from the project (teleconsultant) over a toll-free telephone number would be offered to support the referral management directly from the PHC units.

DATA ACQUISITION

All operational activities were performed by employing RegMais, the system specially developed as part of the project to assist in the navigation of cases from PHC units to specialized care.

Analyzed data were directly extracted from RegMais. All cases occurring in the period comprised in the study were extracted for analysis. Cases with missing data were excluded from analysis.

VARIABLES AND OUTCOMES

Extracted data comprised the priority ratings of referrals as recorded by PHC providers; the priority ratings of referrals as recorded by teleconsultants; the decision on referral at the last registered teleconsultation; International Classification of Diseases 10th revision (ICD-10) codes as recorded by PHC units; and ICD-10 codes as recorded by teleconsultants.

Priority ratings were classified as (1) very high; (2) high; (3) moderate; and (4) low. Very high priority was applied to urgent cases; high priority to cases that should be moved to the top of the waiting list, due to a considerable risk of complication while waiting for specialized care; moderate priority to cases with a low risk of complication, while waiting for specialized care; and low priority to cases potentially managed at the PHC unit.

Decisions on referrals were described as approved or rejected. Subcategories within these two major categories were additionally defined. Among approved cases, categories included (1) need for specialized care to optimize clinical management; (2) need for specialized care for diagnostic procedures; and (3) need for specialized care due to restricted access to PHC. Among rejected cases, subcategories included (1) possibility of management in PHC, once therapeutic goal has been achieved; (2) possibility of clinical investigation in PHC; and (3) possibility of follow-up in PHC due to the type of health condition.

DATA ANALYSES

Mann–Whitney U test and Pearson’s chi-squared test were applied to assess differences between approved and rejected groups. Pearson’s chi-squared test was used to investigate the association between change of priority ratings and decisions on referral. Descriptive and inferential analyses were performed with SPSS v22.0 by a statistician.

Results

During the period of analysis, a total of 38,663 referrals to specialized care were registered, of which 643 cases were supported by teleconsultation. Due to missing data, 21 cases (3.3%) were disregarded for analysis. The rate of teleconsultations per the total number of referrals was 1.7%.

Approved referrals represented 51.9% of analyzed cases (Table 1). There were statistically significant differences between approval and rejection rates related to age, with a predominance of older patients among approved cases (Mann–Whitney U test, p-value <0.001), and related to medical specialty (χ² test, p < 0.001). There was no statistically significant difference regarding sex (χ² test, p = 0.098).

Among the approved cases, 34.4% were approved based on the need of specialized care for optimizing clinical management; 65% were approved based on the need of specialized care for diagnostic procedures; and 0.6% were related to restricted access to PHC. Rejected cases were also distributed into three categories: possibility of follow-up in PHC, once therapeutic goal has been achieved, in 44.8%; possibility of clinical investigation in PHC in 39.5%; and possibility of follow-up in PHC due to the type of health condition in 15.7% (Table 2).

Most frequent ICD-10 codes registered in PHC were codes Z72.9, which represents “Problem related to lifestyle, unspecified” and Z27.9 “Need for immunization against unspecified combinations of infectious diseases.” Together, these two codes accounted for 79.8% of assigned ICD-10 codes (Table 3). Unspecified and symptom-based codes represented 90.4% of cases, whereas more specific ICD-10 codes accounted for 9.6% of the total. There was no statistically significant difference regarding the type of ICD-10 code and the referral decision after teleconsultation (Pearson’s χ², p-value = 0.221).

Changes in priority ratings after teleconsultation are depicted in Figure 1. There was a reduction in priority ratings in 449 cases (72.2%) after teleconsultation, considering all cases. For approved cases, there was a reduction of priority ratings in 174 cases (53.9%) and for rejected cases in 275 cases (92%), with most of them moving to category 4. Only 41 cases were moved to greater priority ratings after teleconsultation (Table 4). There was a statistically significant association between change in priority ratings and decision on referral (Pearson’s χ², p-value <0.0001).

Table 4. Change of Priority and Decision on Referral

CHANGE OF PRIORITY RATINGS	APPROVED n (%)	REJECTED n (%)	ALL CASES n (%)
No change	109 (33.7)	23 (7.7)	132 (21.2)
Reduction of priority	174 (53.9)	275 (92.0)	449 (72.2)
Increase of priority	40 (12.4)	1 (0.3)	41 (6.6)
Total	323 (100)	299 (100)	622 (100)

Discussion

The institution of teleconsultations as an additional intervention of the project Regula Mais Brasil aimed at optimizing the access to health care during the COVID-19 pandemic, but it also prompted the comprehension of how the management of case referrals from PHC to specialized care has been carried out. Even considering that our study focused on the flow to specialized care in one locality and as part of SUS, our results provide important insights on the ecology of health care in Brazil. To the best of our knowledge, this is the first study carried out to assess the role of teleconsultation to support the management of cases referred to specialized care in a universal health care system. All cases that occurred in the period of analysis were considered for inclusion in the study, with a final inclusion of 96.7% cases registered in the database, totaling 622 teleconsultations.

The major reason for referral approvals in our study was to allow for access to diagnostic procedures (65% of cases). Only 34.4% of cases were referred with the goal of optimization of clinical management. By contrast, cases were returned to PHC for diagnostic and therapeutic reasons in a more balanced proportion (39.5% vs. 44.8%). These results may suggest a pattern of concentration of diagnostic resources at the secondary care level. A certain level of concentration of diagnostic resources at the secondary care level, needed to handle more complex health conditions, would be desirable. However, an excessive concentration leads to a great number of referrals that would be preventable if strategic diagnostic resources were made available at the PHC level.¹⁵ This knowledge has been stressed by previous authors who recognized the need for proper actions to filter cases in health systems where low-complexity cases are recurrently referred to specialized care.¹⁶

The limitations of this study are inherent to the way referral management has been conducted within SUS. Nearly 80% of the ICD-10 codes assigned in PHC units referred to Z72.9 and Z27.9 codes, with only a 2-digit position change between these unspecified codes. The predominance of unspecified ICD-10 codes may be explained by the fact that registration of cases into the referral management system is done by non-health care professionals in PHC units, instead of being performed by the health care professionals responsible for assisting the case. This ultimately leads to vague and inaccurate information related to ICD-10 codes. The high prevalence of inaccurate and highly unspecified ICD-10 codes is problematic since it imposes the need of reassessments for the efficient management of case referrals. We planned to compare ICD-10 codes as assigned in PHC units with those obtained after teleconsultation, but we found this confrontation to be unreasonable due to the inaccuracy of the assignment of ICD-10 codes in PHC units.

Results on the reduction of the priority rates for referrals after teleconsultation reveal the general project’s objective, namely the management of waiting lists in accordance with standardized protocols by using telehealth strategies to promote equity in a context where the first come, first served model prevailed earlier. Agreement between priority levels as assigned by PHC providers and those assigned by teleconsultants predicted referral approvals in our study, as well as the increase of the priority level after teleconsultation. This fact stresses the importance of having accurate judgment on priority levels at PHC and sheds light on the importance of well-designed initiatives to capacitate PHC providers.

Worldwide, the potential of telemedicine to provide timely and efficient care is being confirmed. The COVID-19 pandemic triggered the implementation of telemedicine services in health systems worldwide, which are incorporating telemedicine to allow continuity of care for patients presenting with different clinical conditions.^8,17,18 In Brazil, teleconsultation as a strategy to support referrals to specialized care within SUS may bring a new paradigm for health care, by promoting coordination of care and patient engagement, besides supporting the use of well-designed evidence-based protocols to guide clinical management, effectively reducing queue sizes for specialized care, and establishing a more agile flow of referral management, as previously demonstrated.^19,20

Other types of telehealth strategies have been studied in Brazil.^21–24 It is logical to assume that the implementation of telediagnostic services would maximize the resolution of low-complexity cases at the PHC level and would bring efficiency to the system, since most referral approvals in this study were related to the need of diagnostic resources. Advantages related to telediagnosis rely mainly on its potential for being integrated to PHC, improving the organization of the health system. The use of telehealth for defining priority levels and telediagnosis would also allow exposure to procedures to be less harmful and untimely, as proposed by quaternary prevention.

For a successful implementation of telemedicine in different contexts, some challenges will have to be properly addressed. First, proper information technology infrastructure should be made available to minimize technical issues and to allow a better teleconsulting experience.²⁵ In settings marked by social inequality, efforts should be made to not allow telemedicine to increase disparities in access to health services, which would promote inequality. These include widespread Internet access and the promotion of digital literacy.²⁶ In addition, in some countries in Latin America, such as Peru, Argentina, and Brazil, implementation of telemedicine services will also depend on a revision of regulatory norms. These countries share a regulatory scenario in which telehealth activities were restricted before the pandemic, which forced a rapid response to enable the regulation of telemedicine in this specific context.²⁷

Overall, the implementation of digital strategies for telehealth should be considered by SUS as a real possibility to increase the resolution of cases at the PHC level, toward the achievement of a model based on patient centricity. Telehealth has been proved to proportionate a better navigation of health conditions across different complexity levels of health systems. Tele-interconsultation expands interaction between PHC providers and specialists, allowing integrated care.

The promotion of a network connecting teleconsultants to Family Health Strategy teams, by telehealth strategies, would also be advantageous. Family Health Strategy teams can be strengthened by digital assistance and be recognized as a major tool for increasing coordinated and comprehensive care within SUS. These strategies strengthen the protagonism of PHC as an orchestrating element of patient care, especially for complex health care needs, such as those determined by chronic non-communicable conditions.

Challenges imposed by the health crisis related to COVID-19 pandemic induced health systems to react in effective ways. The experience of employing telehealth strategies in Recife, Brazil, amid the pandemic, provides valuable insights on how the organization of care in SUS could still be enhanced, by the empowerment of PHC with specialized remote support.

Conclusions

The pandemic of COVID-19 had a transformative impact on health care systems worldwide. In the Brazilian universal health care system, there was a need to rapidly adapt tools available for the practice of telemedicine. Our results demonstrate a consistent contribution of teleconsultation to the management of referrals from PHC to specialized care. In our study, telemedicine contributed to the promotion of equity, since decisions on referrals and risk prioritizations were made in accordance with protocols recommended by the Ministry of Health in Brazil. In addition, telemedicine contributed to the access to specialized services.

The results obtained and the growing evidence of the effects of telemedicine in optimizing efficiency of health systems should be considered for redesigning referral management systems, by incorporating telehealth tools as a strategic intervention to promote universality and equity in health systems.

Authors’ Contributions

S.S.: Conceptualization; Writing—Original Draft, Supervision. C.R.d.L.A.: Conceptualization; Writing—Original Draft. J.B.: Conceptualization; Investigation; Data Curation; Writing—Original Draft. Carlos Eduardo Alves Batista: Conceptualization; Writing—Original Draft. I.d.C.B.: Conceptualization; Writing—Original Draft. F.C.C.: Conceptualization; Writing—Original Draft. E.D.d.C.F.: Conceptualization; Investigation; Writing—Original Draft. L.A.V.C.: Conceptualization; Writing—Original Draft. L.G.G.: Conceptualization; Writing—Original Draft. K.Y.K.: Conceptualization; Writing—Original Draft. M.A.M.: Conceptualization; Writing—Original Draft. É.d.B.M.: Conceptualization; Writing—Original Draft. Renata Albaladejo Morbeck: Conceptualization; Writing—Original Draft. M.M.O.: Conceptualization; Writing—Original Draft; Supervision; Project administration. D.V.P.: Conceptualization, Methodology; Writing—Original Draft; Writing—Review and Editing. Á.S.R.: Conceptualization; Writing—Original Draft. C.F.d.S.: Conceptualization; Writing—Original Draft. C.P.P.T.: Conceptualization; Writing—Original Draft. S.D.G.: Conceptualization, Methodology; Writing—Original Draft; Supervision; Project administration.

Acknowledgments

The authors are grateful to Marcia Pivatto Serra, who conducted statistical analyses.

Disclosure Statement

No competing financial interests exist.

Funding Information

Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde (PROADI-SUS).

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