Keywords
Telemedicine - Public Health Systems - Neurology - Child
INTRODUCTION
According to the World Health Organization (WHO, 2010),[1] telemedicine is “the use of telecommunications to diagnose and treat diseases and
ill-health.” This model has shown numerous benefits in the care of acute and chronic
diseases for patients, families, caregivers, and health systems, as it leverages informatics
strategies to deliver comprehensive and specialized medical services at reduced costs.[2]
[3]
[4]
Numerous studies have validated its effectiveness, particularly in managing diseases
like epilepsy, headaches, as well as movement and developmental disorders. The growing
implementation of telemedicine in pediatric neurology during the COVID-19 pandemic
has underscored its relevance as an essential tool in delivering continuous care.
This practice has been notably beneficial in conditions like epilepsy,[5] in which telemedicine allows for remote management, reduces travel costs, and limits
disruptions to family life.[6] In pediatric epilepsy, for example, this modality has shown to be a feasible and
effective alternative to in-person visits, maintaining or improving seizure control
and ensuring high satisfaction among caregivers.
Beyond epilepsy, telemedicine has also proven valuable in the early diagnosis and
management of other neurological conditions like autism spectrum disorder (ASD) and
migraines. Studies have demonstrated that this approach is not only viable for diagnosing
ASD but can also be an essential part of early intervention.[7]
[8] This broad-based evidence emphasizes the potential of telemedicine to improve neurological
care in pediatric populations globally. A more detailed literature review reveals
a growing body of work supporting its effectiveness across various settings, with
findings consistently pointing to its cost-efficiency, accessibility, and positive
patient and caregiver satisfaction outcomes.
Virtual visits, or teleconsultations, are approaches that can be performed between
patients or physicians without direct contact. Information technology facilitates
these visits and safeguards user data protection measures. In Brazil, telemedicine,
including teleconsultation, is validated by the resolution No 2.314/2022 of the Federal
Council of Medicine,[9] which marks substantial progress in enhancing healthcare accessibility throughout
the country.[10]
In 2023, Brazil had a rate of 2.6 physicians per 1,000 inhabitants,[11] slightly below the Organization for Economic Co-operation and Development (OECD)
average of 3.36.[12] Although this rate is growing, the distribution of doctors within the country remains
uneven among states, especially among specialists, as with pediatric neurologists.[11] Furthermore, professionals tend to concentrate primarily in significant capitals,
making it difficult for the countryside population to access specialized healthcare.
These adversities lead to prolonged waiting queues for appointments and impose physical
and emotional burdens on patients, families, and caregivers.[13] Therefore, telehealth strategies emerge as a viable solution to address these challenges,
particularly in underserved regions where healthcare professionals are limited, and
transportation costs are high. Healthcare systems can overcome resource constraints
and geographical barriers by leveraging these technologies, ultimately enhancing their
efficiency and effectiveness.[3]
[14]
In response to the healthcare needs of a population with limited access to it, the
TeleNortheast program was designed to bridge the healthcare gap in northeastern states
of Brazil, where it is more pronounced. The provision of specialties included in the
program was based on the needs expressed by local managers, consideration of the queue,
the waiting time, telehealth's capability, and the sensitivity of Primary Care Units
to the most prevalent conditions of each specialty. This initiative is part of the
Specialized Medical Assistance through Telemedicine program in the Northeast region,
coordinated by the Institutional Development Support Program for the Unified Health
System (IDSP-UHS) under the Brazilian Ministry of Health.[15]
The program was held in Sergipe, with a human development index (HDI) of 0.70 (17th in Brazil) and a total population of 2.2 million inhabitants in 2022,[16] divided into 75 municipalities. Information from the latest report on the medical
demographic[11] demonstrates that Sergipe has a ratio of 2.15 professionals per thousand inhabitants
and the worst distribution of doctors throughout the state. In the metropolitan regions
(including the capital), this ratio is 13 times higher than in the other municipalities.
Of the total, 63.1% are specialists. In comparison, 36.9% are general practitioners,
establishing a ratio of 1.71 specialists for every general practitioner, with 91.8%
of these physicians concentrated in the capital, highlighting the need for such a
program in this state.
The objective of this study is to demonstrate the results of the teleconsultations
conducted between the pediatric neurology team of the Hospital Alemão Oswaldo Cruz
(HAOC), located in São Paulo, and the primary care physicians from the state of Sergipe,
between January and October of 2023, within the TeleNortheast program. We further
aim to assess this approach's importance in delivering pediatric neurological care
and explore patient and provider perspectives on its use. In the Supplementary Material (available at https://www.arquivosdeneuropsiquiatria.org/wp-content/uploads/2024/12/ANP-2024.0080-Supplementary-Material.docx), we estimate the distance and costs of travel to the capital for consultations.
This data contributes to the debate on the potential benefits of telemedicine in Brazil.
METHODS
This cross-sectional study utilizes retrospective data from teleconsultations conducted
as part of the TeleNortheast program by the pediatric neurology team between January
and October 2023. All patients scheduled for neuropediatric consultations by Primary
Care Units (UBS) were included in this study. The neuropediatric team at Hospital
Alemão Oswaldo Cruz (HAOC) offered specific dates and times available, which were
then filled at the discretion of primary care physicians in Sergipe, Brazil.
The inclusion criteria encompassed children up to 17-years-old referred by their primary
care physicians for neurological evaluation. The healthcare units included in the
study were selected based on collaboration with local health authorities, prioritizing
those with a significant number of neuropediatric on their waiting lists. Only units
with a reliable internet connection for real-time teleconsultations were eligible
for participation. Units that could not meet the technical requirements, such as stable
internet connectivity or the presence of a primary care physician, were excluded.
Virtual visits were performed between primary care professionals and pediatric neurologists
from HAOC. Each teleconsultation lasted a maximum of 30 minutes, and all four neuropediatric
underwent prior training following institutional protocols on conducting teleconsultations
effectively, following established institutional guidelines to ensure a structured
and efficient consultation process. The primary care physicians were also trained
to facilitate these sessions, particularly in patient preparation and follow-up coordination.
The data analysis involved retrospectively compiling relevant patient information,
which was then organized and processed in Microsoft Excel (Microsoft Corp., Redmond,
WA, USA) and the R (R Foundation for Statistical Computing, Vienna, Austria) software
for subsequent descriptive statistical analysis, with analysis of frequencies and
relative frequencies, means, and bivariate analyses. This process provided a comprehensive
overview of the dataset, including patient demographics, diagnoses, and consultation
outcomes, offering valuable insights into the distribution and nature of pediatric
neurology cases addressed through telemedicine by the pediatric neurology team as
part of the TeleNortheast program, from January to October 2023.
The data analysis process involved compiling relevant information, which was then
organized and inputted into Excel for subsequent statistical analysis to provide a
comprehensive overview of the dataset's distribution was obtained from the Hospital
Alemão Oswaldo Cruz database and encompassed the following information: children's
age at the time of consultation, gender, reason for referral to the pediatric neurologist,
diagnosis, and consultation outcomes. Following each virtual visit, patients were
categorized into three different groups regarding potential outcomes:
-
Recommendation of a scheduled Telehealth return for further discussion with the specialist
(return to primary care with teleconsultation);
-
Recommendation of referral for in-person specialized care; or
-
Recommendation of follow-up in primary care only.
A total of 506 individual patients were included in the study, resulting in 548 teleconsultations
(506 initial and 42 follow-ups).
Per ordinance No. 2.488/200717, in cases that do not provide transportation, the patient
and their companion receive an allowance of $8.40 each for food, excluding overnight
stays, and $4.75 for every 50 kilometers of land travel relative.
The Institutional Review Board (IRB) of the hospital Alemão Oswaldo Cruz approved
this research, with registration number 65491722.0.0000.0070.
RESULTS
The TeleNortheast program covered 34 municipalities across the state, for which [Table 1] shows some sociodemographic indicators, as well as the capital Aracaju (nonparticipant).
A total of 315 Primary Care Units participated in the program, and, except for one
case, all the teleconsultations were accompanied by primary care physicians, with
131 doctors attending a minimum of one consultation and a maximum of 22.
Table 1
Sociodemographic indicators of Sergipe municipalities covered by the TeleNortheast
program
|
Median
|
Min
|
Max
|
Aracaju
|
|
Primary care coverage (%)
|
95
|
0
|
100
|
74%
|
|
Doctors/1,000hab*
|
0.78
|
0.37
|
2.21
|
4.6
|
|
Life expectancy (in years)
|
70.4
|
66.9
|
73.0
|
74.3
|
|
Population with basic sanitation (%)
|
26%
|
1%
|
64%
|
85.3%
|
|
Population
|
23,139
|
3,309
|
106,015
|
672,614
|
|
Bolsa família coverage**
|
65%
|
44%
|
98%
|
22%
|
|
Distance to Aracaju (km)
|
83
|
21
|
151
|
|
Notes: *Number of doctors per 1,000 inhabitants. ** A social welfare program in Brazil
aimed at providing financial aid to low-income families.
Source: Instituto de Estudos para Políticas de Saúde data (IEPSDATA).
[Table 2] provides a comprehensive descriptive analysis of the participant profile in this
study. Most patients were identified as male, constituting 73% of the overall cohort
sample, while females composed 27%. The age distribution depicts a diverse representation.
The highest frequency was observed in the 0 to 4-year-old group, encompassing 35%
of participants, closely followed by the 5 to 8-year-old group (32%). Subsequent age
categories include 9 to 12 (26%) and 13 to 17 (7%) years. The average age of boys
was 7.3 years, while that of girls was 6.4 years. The small sample and the multiplicity
of diagnoses are significant limitations to correlation analyses between patient characteristics
and diagnoses. Taking this restriction into account, when we examined the 97 patients
diagnosed with ASD, we observed a higher incidence in boys (22%) than in girls (11%),
confirming data from the literature in the area.[17]
[18]
Table 2
Patients' profiles
|
Frequency
|
%
|
|
Sex
|
Male
|
368
|
72.7
|
|
Female
|
138
|
27.3
|
|
Age (in years)
|
0–4
|
145
|
28.7
|
|
5– 8
|
130
|
25.7
|
|
9–12
|
103
|
20.4
|
|
13–17
|
28
|
5.5
|
|
Without data
|
100
|
19.
|
|
Outcome
|
Discharge
|
48
|
9.5
|
|
Referral to in-person consultation
|
7
|
1.4
|
|
Return to primary care with teleconsultation
|
451
|
89.1
|
Considering the outcome of the consultations for the 506 patients, 89% (n = 451) of
cases, patients continued their treatment within the primary care system with further
teleconsultations, indicating no need for in-person referrals. Discharge from specialist
care through teleinterconsultation was recommended in 109.5% (4,852) of cases, suggesting
resolution or independent management by the primary care physician improvement. Only
1.4% (7) of the cases required referral for specialized in-person consultation, demonstrating
the efficacy of teleconsultations in avoiding unnecessary travel and further intervention.
Regarding diagnoses, 48.6% of patients had undetermined diagnoses at the time of the
initial teleconsultation ([Figure 1]). This demonstrates the complexity of the referred cases and highlights the need
for follow-up consultations for further evaluation and pediatric neurological management.
Among those with confirmed diagnoses, the most prevalent condition was ASD, affecting
19.2% of patients, followed by epilepsy (7.1%), Attention-Deficit/Hyperactivity Disorder
(ADHD) with 6.7%,[17]
[18] and intellectual disability at 5.9%. Other conditions with lower prevalence included
cerebral palsy (2.6%) and headache (2%). Diagnoses with lower prevalence were grouped
under the “other cases” diagnostic group and included nonepileptic events, cranial
nerve palsy, traumatic brain injury, neonatal anoxia, sleep disorders, and brain cysts.
Figure 1 Diagnostic of the studied population.
In addition to the teleconsultations analyzed in this study, there were 13 appointments
in which patients did not show up, resulting in an abstention rate of 2.3%, significantly
lower than the rate recorded in primary care units,[19]
[20] which is around 25%.
DISCUSSION
In the current study, we presented the results of teleconsultations conducted between
the neuropediatric team of Hospital Alemão Oswaldo Cruz (HAOC) and primary care physicians
in the Northeast region of Brazil under the TeleNortheast program.
In 89% of cases, the clinical outcome was a return to telemedicine in the primary
care environment without the need to travel to an in-person consultation in another
location. That demonstrates that the teleconsultation interaction tool is sensitive
to neuropediatrics. Only 1.4% of cases showed the necessity of a neuropediatric neurology
specialist's in-person intervention, significantly reducing waiting queues. In the
remaining 9.5% of cases, there was a suggestion to discharge patients from the specialist's
care and continue monitoring within primary health.
Therefore, teleconsultation offers two direct outcomes that enhance patient access
to healthcare. First, it provides immediate access to care through interactions between
primary care physicians and specialists, enabling prompt initiation of necessary interventions
and ongoing management when required. Second, these interactions may empower primary
care physicians with enhanced expertise in case management, improving diagnosis, treatment,
and referral decisions without additional teleconsultations for similar cases. Consequently,
access to specialists in person, typically regulated by waiting lists, is reserved
for more complex and challenging cases that often need direct resolution. This process
of professional development ensures the sustainability of project gains.
The diagnostic landscape found in this sample demonstrated a variety of conditions,
with ASD standing out as the predominant category considering the determined diagnosis.
That follows the recent increase in ASD prevalence.
The latest report from the Centers for Disease Control and Prevention monitoring studies
showed a prevalence of 1 case for every 36 children in 2020. In 2000, the prevalence
was 1:150 children, considering the age range of 8 years.[18] In Brazil, although there are no robust surveys determining the actual prevalence
of neurodevelopmental disorders,[21] estimations, and small studies indicate the high burden of these diseases on the
healthcare system,[21]
[22]
[23] underscoring the importance of further research and comprehensive data collection
efforts to accurately assess the prevalence and impact of neurodevelopmental disorders
in this population.
The high prevalence of neurodevelopmental disorders also contributed to the considerable
number of patients with undetermined diagnoses by the time of the teleconsultation.
In our experience, although many patients were referred because there were signs of
ASD, in almost half of the cases, it was impossible to safely diagnose them in a single
30 minute appointment, requiring a return consultation for further analysis ([Figure 1]). The time needed for ASD diagnosis can vary considerably depending on symptom severity,
specialist availability, and access to healthcare.[24] A study on diagnostic practices in Canada estimated an average timeframe of 7 months
from referral to formal diagnosis,[25] with instances where the process extends for over a year.[26]
A significant proportion of patients in this study, 48.5%, remained with undetermined
diagnoses after the initial teleconsultation. This finding highlights the complexity
of pediatric neurological cases and the inherent challenges in reaching a definitive
diagnosis in a single consultation. In conditions like ASD and epilepsy, multiple
consultations are often required before a precise diagnosis can be made. For example,
the diagnostic process for ASD is particularly complex, with studies showing that
the time from referral to formal diagnosis can take several months and often requires
follow-up consultations to observe the child's development and behavior over time.[18] Similarly, in epilepsy, although telemedicine can be effective in managing care
remotely, it frequently necessitates further evaluations to confirm the diagnosis.[3] The high percentage of undetermined diagnoses underscores the necessity of follow-up
consultations in telemedicine to ensure accurate diagnoses and appropriate management,
particularly for complex neurodevelopmental and neurological disorders in pediatric
populations.
Considering that specialists primarily operate in the state's capital, Aracaju, we
face another challenge: addressing the transportation and associated user costs. In
the Brazilian Unified Health System, authorities must arrange their transfer to another
town for assistance when it lacks the necessary health resources for a patient. For
instance, if pediatric neurologists are only available in Aracaju, patients from other
cities must travel to the capital for the visit.[27] In such scenarios, their city of residence becomes responsible for covering the
costs of transportation, food, and accommodation.
Considering the rates applied in the SUS, a consultation in Aracaju could have a transport
cost of up to R$76.20 for patients from cities such as Garuru and Poço Verde, located
150 km from the capital (Supplementary Material). For comparison purposes, data from the National Supplementary Health Agency indicate
that the average cost of a specialist consultation in the Brazilian private healthcare
market is $73. In contrast, the public healthcare system pays only R$10 to states
and cities to provide this service. This amount needs to be supplemented with the
budget of these federative entities. Furthermore, other immaterial benefits of telehealth
must be considered, such as the rapid access to specialized assessment in the primary
care service itself, avoiding the risks of long car journeys, and a lower absenteeism
rate.
This study contributes valuable insights into the effectiveness of teleconsultations
in addressing healthcare gaps, especially in underserved regions. It is essential
to acknowledge the invaluable support pediatric neurologists provide in facilitating
and enhancing the quality of healthcare provided by general practitioners, who coordinate
patient care. The TeleNortheast program, as part of the Specialized Medical Assistance
through Telemedicine Program,[15] exemplifies a successful initiative in bridging healthcare disparities. The findings
underscore the potential of telemedicine in improving accessibility, particularly
for pediatric neurology services, and emphasize the need for continued efforts to
develop telehealth strategies in addressing diverse needs in healthcare.
Our research has certain limitations that should be acknowledged. One fundamental
limitation is that the study focuses exclusively on the Northeast region of Brazil,
specifically in Sergipe, which may limit the generalizability of the findings to other
areas with different demographic, socioeconomic, or health characteristics. Additionally,
the study spanned a relatively brief period, from January to October 2023, potentially
constraining the capture of long-term trends or seasonal variations in the use of
this approach in pediatric neurology. The absence of a control group also limits the
study's ability to compare telemedicine with conventional in-person approaches in
pediatric neurology.
Another significant limitation is the need for more data on internet infrastructure,
which plays a critical role in the success of telemedicine. In regions with poor or
unstable connections, the quality of care may be compromised, leading to delayed diagnoses
or miscommunication between healthcare professionals. Moreover, the present study
did not account for the socioeconomic challenges patients face, such as access to
technology, digital literacy, or the availability of technological resources, all
of which could influence the success of teleconsultations, particularly in underserved
areas.
Additionally, there needs to be more age data for approximately one hundred individuals
in our dataset, a limitation inherent in the study's retrospective nature, where data
was collected from preexisting medical records. These studies often need more datasets
due to variable record practices, leading to occasional omissions. Although this absence
limits age-based analysis, the available data remains valuable for understanding overall
trends in telemedicine use. Future research should focus on evaluating these factors
and addressing such data gaps, as they are essential for comprehensively understanding
the impact of telemedicine on healthcare delivery.
In conclusion, the implementation of the Brazilian resolution 2.314/2022 marks a significant
advancement in telemedicine by establishing a robust regulatory framework that supports
various telehealth strategies, including teleconsultations. This regulatory initiative
has notably enhanced healthcare access in regions with limited resources, particularly
in underserved areas such as Sergipe. The study emphasizes the success of teleconsultations
between the pediatric neurology team at Hospital Alemão Oswaldo Cruz in São Paulo
and primary care physicians in Sergipe, demonstrating the efficient resolution of
such cases.
Furthermore, beyond the economic benefits, the study highlights immaterial advantages
such as reducing long-distance travel, providing timely access to specialists, and
improving care coordination. These aspects reduce costs and waiting times and foster
strong collaboration between primary and specialized care, resulting in more efficient
treatments and fewer missed appointments.
While this study focused on Sergipe, the results have broader implications. The telemedicine
model for pediatric neurology can be extended to other regions in Brazil facing similar
healthcare access challenges. Moreover, this approach is adaptable to other medical
specialties like cardiology and psychiatry, where shortages of specialists and the
need for long travel distances to receive care are significant barriers. Integrating
telemedicine into various specialties allows the public health system to bridge healthcare
gaps further, ensuring more equitable and timely care for underserved populations
nationwide.
These findings confirm telemedicine's potential to reshape healthcare delivery in
Brazil. It offers economic and qualitative improvements that enhance care efficiency
and patient outcomes across multiple specialties.
Bibliographical Record
Daniela Laranja Gomes Rodrigues, Melina Alves da Frota, Maísa Vieira da Silva Malta,
Marcos Aurélio Maeyama, Frederica Padilha, Adriana Miyauchi, Vanessa dos Santos Gonçalves
Senra, André Felipe Martins de Araújo Silva, Deyse Mirelle Souza Santos, Eno Dias
de Castro Filho, Nídia Cristina de Sousa, Ana Paula Marques de Pinho, Fernanda Saks
Hahne. Revolutionizing pediatric neurology care: telemedicine advancements and regulatory
impact in the Northeast of Brazil. Arq Neuropsiquiatr 2025; 83: s00451806733.
DOI: 10.1055/s-0045-1806733
