Efetividade de intervenções por telemedicina no manejo de pacientes egressos de internação hospitalar por insuficiência cardíaca

Abstract

Introduction: Heart failure (HF) is a complex clinical syndrome in which patients exhibit symptoms and signs of pulmonary congestion and/or low cardiac output at rest and/or during exertion. HF is a severe condition affecting over 64 million people worldwide, representing the final manifestation and the leading cause of hospitalization due to cardiovascular diseases (CVD). Strategies that contribute to improving self-care in HF patients, identifying early changes that could lead to clinical decompensation, and optimizing the recommended guideline-based treatment have the potential to reduce hospitalization and mortality associated with the disease. Objective: To evaluate the effectiveness of adding telemedicine strategies, compared to standard care, in reducing HF-related hospitalizations in patients discharged from the hospital with HF. Methods: This thesis is structured into four articles. Article 1 - "Impact of the COVID-19 pandemic on hospital admissions for cardiovascular diseases in a large urban center in Brazil": conducted a time series analysis using administrative data from the national "Hospital Information System" from 2010 to February 2020 to understand the prevalence of cardiovascular and HF hospitalizations during the pandemic, aiming to plan the recruitment of patients for the randomized clinical trial. Article 2 - "Effectiveness of telemedicine in reducing hospitalizations in patients discharged from heart failure hospitalization: a randomized clinical trial protocol": development of the randomized clinical trial protocol. Article 3 - "Effect of telemedicine interventions on heart failure hospitalizations: a randomized clinical trial", a randomized, non-blinded, multicenter trial conducted in public hospitals in Belo Horizonte, Minas Gerais. Article 4 - "Patients' perceptions of telemedicine interventions in the management of heart failure: a qualitative approach study", conducted through two focus groups (control and intervention) of HF patients participating in the randomized clinical trial to assess the effect of digital strategies for HF management. Results: Article 1 - There was a 16.3% reduction in the number of CVD hospitalizations compared to projected figures, a 24.1% reduction in the number of intensive care admissions, and a 17.4% reduction in the number of in-hospital deaths. Article 2 - The research protocol was published in 12 May 2022 with the aim of evaluating the effectiveness of adding telemedicine strategies, compared to standard care, in reducing HF-related hospitalizations in patients discharged from the hospital with HF. To facilitate the planning and conduct of the research, a software with a clinical decision tree for remote monitoring and education of HF patients was developed. Article 3 - A total of 127 patients were randomized, with 70 in the intervention group (IG) and 57 in the control group (CG). The IG received structured telephone support from a case manager, combined with a remote educational program, while the CG received usual care from the network of the Unified Health System (Sistema Único de Saúde or SUS) to which it belongs. The intervention and control groups were homogeneous. The IG showed a lower rate of HF-related re hospitalizations (p=0.01), fewer hospitalizations for all causes (p=0.03), and a lower composite outcome of death from all causes or hospitalizations (p=0.04) compared to the CG. Survival analysis also demonstrated a higher hospitalization-free survival in the IG (log-rank test p=0.03). Regarding all-cause mortality, there was no statistically significant difference between the groups (p=0.92). Article 4 - The study included 5 participants and 1 caregiver in the IG, and 4 participants and 1 caregiver in the CG. The IG, which received messages and structured telephone support, demonstrated that these interventions were well-accepted and led to a better understanding of self-care and HF. Conclusions: There was a reduction in hospitalizations for CVD during the COVID-19 pandemic, possibly attributed to the fear of contracting the infection in hospitals and the reorganization of health systems. A telemedicine strategy was developed, in addition to standard care, for patients discharged from hospitalization for HF, which would be particularly useful in the context of the pandemic. The strategy was tested and demonstrated effectiveness in reducing rehospitalizations, as well as contributing to improved self-care and knowledge about the disease. This study could serve as a reference for implementing similar strategies on a broader scale within the SUS, considering that HF is the leading cause of hospitalization for CVD in Brazil.