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Diabetes is the 7th leading cause of death in Brazil (1), with a self-reported prevalence of 5.6% (1). Despite the great need for diabetic retinopathy screening, access to ophthalmological consultations in the public health care system is limited, with a long waiting list. Because of that, in the southern Brazilian state of Rio Grande do Sul – where about 12 million people live (3) – a teleconsulting service for Teleophthalmology was implemented in June 2017 at in seven municipalities (4). It should be noted that telemedicine is not full regulated medical practice in Brazil. Until nowadays, Teleconsultation between physician and patient is not allowed (5). Because of this, teleophthalmology is only accessible to patients referred for evaluation by primary care physicians. After an ophthalmologist's remote assessment, an opinion is issued and the PHC physician prescribes the treatment (including glasses) based on this technical report.
Teleophthalmology consultations are available all the week, during working hours. A nurse and a physician are available locally for contact with the remote ophthalmologist if needed. Presently, the median waiting time is 170 days for teleophthalmology consultations in the state capital Porto Alegre and approximately 150 days in other cities. Although this may seem like a long wait, it is still less than the wait for face-to-face consultations – currently median of 423 days. Differently from what is described by Liu et al. (6), du...
Teleophthalmology consultations are available all the week, during working hours. A nurse and a physician are available locally for contact with the remote ophthalmologist if needed. Presently, the median waiting time is 170 days for teleophthalmology consultations in the state capital Porto Alegre and approximately 150 days in other cities. Although this may seem like a long wait, it is still less than the wait for face-to-face consultations – currently median of 423 days. Differently from what is described by Liu et al. (6), during the first evaluation patients have their pupils dilated following the guidelines of the American Diabetes Association. Two images are obtained, a 30º image from the disk and a 45º image from the macula. The medical report is issued in real time.
The barriers we face are similar to those described in the article (6). There are about 14 thousand people in the state waiting for a face-to-face consultation with an ophthalmologist today. The estimate is that we have 634,457 diabetic individuals who need to be screened for retinopathy. Nevertheless, diabetic retinopathy screening accounts for 13.14% of the Teleophthalmology visits (total of 1,894 cases). This is a small number, which suggests that few primary care physicians are requesting retinopathy screening in diabetic patients.
Physicians are also unfamiliar with Teleophthalmology. Since the program began, only 975 PHC have requested this service (out of an estimated 3 thousand). And, of course, we also face the logistical problem, with only seven locations in the State.
In spite of the difficulties, some results are encouraging. In 18 months, 14,417 consultations were provided. Of these, 70.5% of the people did not require a face to face ophthalmology consultation to address the specific problem they were screened for. Also, 97.7% of PHC doctors were very satisfied or satisfied with the evaluation of their patients. Another important advantage is the issue of the ophthalmologic report at the time of care. Besides, the median waiting time for teleophthalmology is 273 days less as compared to face-to-face consultations.
Given these promising results, we are working hard to overcome the barriers, reduce the queue, and enhance the participation of physicians and patients in what we believe is an effective program to improve health.
1. Institute for Health Metrics and Evaluation (IHME). GBD Compare Data
Visualization. Seattle, WA: IHME, University of Washington; 2017 [cited 2019
Mar]. Available from http://www.healthdata.org/brazil
2. BRASIL. Ministério da Saúde. Secretaria de Vigilância em Saúde. Secretaria de Gestão Estratégica e Participativa. Vigitel-Brasil 2011: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília, 2012.
3. Instituto Brasileiro de Geografia e Estatística. Panorama Rio Grande do Sul [cited 2019 Mar]. Available from https://cidades.ibge.gov.br/brasil/rs/panorama
4. Conselho Federal de Medicina (Brasil). Revogação da Resolução Nº 2.2227/2018 [cited 2019 Mar]. Available from https://portal.cfm.org.br/index.php?option=com_content&view=article&id=2...
5. Universidade Federal do Rio Grande do sul. Núcleo de Telessaude. Teleoftalmo [cited 2019 Mar]. Available from https://www.ufrgs.br/telessauders/nossos-servicos/telediagnostico/teleof...
6. Liu Y, Zupan NJ, Swearingen R, et al. Identification of barriers, facilitators and system-based implementation strategies to increase teleophthalmology use for diabetic eye screening in a rural US primary care clinic: a qualitative study. BMJ Open 2019;9:e022594. doi: 10.1136/bmjopen-2018-022594