ABSTRACT:

Objective:

to analyze the sociodemographic and clinical profile of patients treated by the remote care service “Telessaúde-COVID” and the factors associated with positive results for COVID-19.

Methods:

an exploratory and analytical study, carried out based on the analysis of patient records treated by a remote care service called “Telessaúde-COVID”. Characteristics of the patients treated and variables related to the service’s functioning were evaluated. A descriptive, inferential analysis was performed by logistic regression.

Results:

1,854 new patients were evaluated and an estimate of 8,630 visits. Female patients were predominant (60.9%), aged between 20 and 59 years (75.9%). The most frequent signs and symptoms were: headache (41.8%), cough (33.3%) and runny nose (30.0%). Of the total number of patients, 66.4% were reported as suspected case of COVID-19 and 14.5% tested positive for COVID-19. The age of 60 years or more was more common among confirmed cases (26.6%). Most patients (80.4%) did not require face-to-face assistance. Confirmed cases of COVID-19 were associated with the age of the patients (OR 1,020; IC95% 1,007 - 1,032); home contact with a confirmed/suspected case (OR 1,902; IC95% 1,178 - 3,070); presence of nausea/vomiting (OR 2,403; IC95% 1,148 - 5,029) and changes in smell (OR 2,827; IC95% 1,294 - 6,176).

Conclusion:

“Telessaúde-COVID” was relevant in the management and notification of cases, avoiding the search for face-to-face consultations without clinical indication. Among the suspected cases, positivity for COVID-19 was associated with aging, history of home contact, gastrointestinal and olfactory symptoms.

Keywords:
SARS-CoV-2 infections; Telemedicine; Health care quality, access, and evaluation; Public health surveillance

INTRODUCTION

In December 2019, a new coronavirus highly infectious-contagious for humans was identified in China, SARS-CoV-2, responsible for the occurrence of the disease named COVID-19¹1. Zhou P, Yang XL, Wang XG, Hu B, Zhang L, Zhang W, et al. Discovery of a novel coronavirus associated with the recent pneumonia outbreak in humans and its potential bat origin. bioRxiv. 2020; 914952. https://doi.org/10.1101/2020.01.22.914952
https://doi.org/https://doi.org/10.1101/... . Since then, the incidence of COVID-19 has been increasing in many countries, including Brazil. The mortality rate ranged from 5.8% in Wuhan to 0.7% in China²2. Wu Y, Guo C, Tang L, Hong Z, Zhou J, Dong X, et al. Prolonged presence of SARS-CoV-2 viral RNA in faecal samples. Lancet Gastroenterol Hepatol. 2020; 5 (5): 434-5. https://doi.org/10.1016/S2468-1253(20)30083-2
https://doi.org/https://doi.org/10.1016/... . Most deaths occurred in people in advanced age ranges or with underlying diseases¹1. Zhou P, Yang XL, Wang XG, Hu B, Zhang L, Zhang W, et al. Discovery of a novel coronavirus associated with the recent pneumonia outbreak in humans and its potential bat origin. bioRxiv. 2020; 914952. https://doi.org/10.1101/2020.01.22.914952
https://doi.org/https://doi.org/10.1101/... ^,22. Wu Y, Guo C, Tang L, Hong Z, Zhou J, Dong X, et al. Prolonged presence of SARS-CoV-2 viral RNA in faecal samples. Lancet Gastroenterol Hepatol. 2020; 5 (5): 434-5. https://doi.org/10.1016/S2468-1253(20)30083-2
https://doi.org/https://doi.org/10.1016/... . In Brazil, up to May 1 of 2021, there were 13,242,665 confirmed cases, 406,437 deaths and 2.8% lethality³3. Brasil. Ministério da Saúde. Guia de Vigilância Epidemiológica. Emergência de Saúde Pública de Importância Nacional pela Doença pelo Coronavírus 2019. Vigilância Integrada de Síndromes Respiratórias Agudas. Doença pelo Coronavírus 2019, Influenza e outros vírus respiratórios. Brasília: Ministério da Saúde; 2020. [citado maio 10, 2020]. Disponível em: Disponível em: https://www.saude.gov.br/images/pdf/2020/April/06/GuiaDeVigiEp-final.pdf
https://www.saude.gov.br/images/pdf/2020... ^,44. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Centro de Operações de Emergências em Saúde Pública. Centro de Operações de Emergência em Saúde Pública para infecção humana pelo novo Coronavírus (COE-nCoV). Doença pelo Coronavírus 2019: ampliação da vigilância, medidas não farmacológicas e descentralização do diagnóstico laboratorial. Brasília: Ministério da Saúde; 2020. [citado maio 07, 2020]. Disponível em: Disponível em: http://maismedicos.gov.br/images/PDF/2020_03_13_Boletim-Epidemiologico-05.pdf
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Studies on SARS-CoV-2 have shown progress in relation to its natural history. It is known that this is a transmissible pathogen and that prevention measures, including social distancing, vaccination, mass testing, surveillance and territorial care, in order to intercept the transmission chain, reduce the spread of the disease and bring better outcomes in health⁵5. Garcia LP, Duarte E. Intervenções não farmacológicas para o enfrentamento à epidemia da COVID-19 no Brasil. Epidemiol Serv Saúde. 2020; 29 (2): e2020222. https://doi.org/10.5123/S1679-49742020000200009
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Care management strategies to fight COVID-19 also continue to evolve at all levels of health care. The pandemic caused several changes in the provision of health care, including the adoption of technological resources such as remote appointments, or telehealth programs⁶6. Eberly LA, Kallan MJ, Julien HM, Haynes N, Khatana SAM, Nathan AS, et al. Patient characteristics associated with telemedicine access for primary and specialty ambulatory care during the COVID-19 pandemic. JAMA Netw Open. 2020; 3 (12): e2031640. https://doi.org/10.1001/jamanetworkopen.2020.31640
https://doi.org/https://doi.org/10.1001/... ^,77. Ramirez AV, Ojeaga M, Espinoza V, Hensler B, Honrubia V. Telemedicine in Minority and Socioeconomically Disadvantaged Communities Amidst COVID-19 Pandemic. Otolaryngol Head Neck Surg. 2021; 164 (1): 91-92. https://doi.org/10.1177/0194599820947667
https://doi.org/https://doi.org/10.1177/... ^,88. Centers for Disease Control and Prevention. Using Telehealth to Expand Access to Essential Health Services during the COVID-19 Pandemic. Atlanta: CDC; 2020. [citado maio 07, 2020]. Disponível em: https://www.cdc.gov/coronavirus/2019-ncov/hcp/telehealth.html.. The term telehealth refers to the use of information and communication technologies to offer health care at a distance, including several care modalities, like telemonitoring and teleconsultation⁹9. Caetano R, Silva AB, Guedes ACCM, Paiva CCN de, Ribeiro G da R, Santos DL et al. Desafios e oportunidades para telessaúde em tempos da pandemia pela COVID-19: uma reflexão sobre os espaços e iniciativas no contexto brasileiro. Cad. Saúde Pública. 2020; 36 (5): e00088920. https://doi.org/10.1590/0102-311X00088920
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The use of telehealth aims to reduce the circulation of people, the spread of the virus, the overload of health services and expenses with personal protective equipment⁷7. Ramirez AV, Ojeaga M, Espinoza V, Hensler B, Honrubia V. Telemedicine in Minority and Socioeconomically Disadvantaged Communities Amidst COVID-19 Pandemic. Otolaryngol Head Neck Surg. 2021; 164 (1): 91-92. https://doi.org/10.1177/0194599820947667
https://doi.org/https://doi.org/10.1177/... ^,88. Centers for Disease Control and Prevention. Using Telehealth to Expand Access to Essential Health Services during the COVID-19 Pandemic. Atlanta: CDC; 2020. [citado maio 07, 2020]. Disponível em: https://www.cdc.gov/coronavirus/2019-ncov/hcp/telehealth.html.. Also worth highlighting the ability of telehealth services to expand access to healthcare, especially if we consider people who live in remote locations, in addition to helping to coordinate the care of people being monitored.

Thus, the COVID-19 pandemic allowed the increase in use of telehealth as a way to identify and monitor people with suspected or confirmed COVD-19, among other situations such as acute or chronic diseases. It is noteworthy that, prior to the pandemic, this technology was already used by other services, having been applied in other public health emergencies such as the Middle East Respiratory Syndrome (MERS) (2003), the H1N1 influenza (2009), the H7N9 influenza (2013) in China and the Ebola outbreak in Africa (2014). This reiterates a gradual trend of increase in this type of service by health professionals and users¹⁰10. American Medical Association. AMA digital health research: physicians’ motivations and requirements for adopting digital health adoption and attitudinal shifts from 2016 to 2019. Illinois: American Medical Association; 2020. [citado maio 07, 2020]. Disponível em: Disponível em: https://www.ama-assn.org/system/files/2020-02/ama-digital-health-study.pdf .
https://www.ama-assn.org/system/files/20... ^,1111. Orlando JF, Beard M, Kumar S. Systematic review of patient and caregivers’ satisfaction with telehealth videoconferencing as a mode of service delivery in managing patients’ health. PLoS One. 2019; 14 (8): e0221848. https://doi.org/10.1371/journal.pone.0221848
https://doi.org/https://doi.org/10.1371/... .

Studies confirm that telehealth services offer essential care to people, increase the potential to reach the most vulnerable groups, improve access, can improve health outcomes, promote qualified care and improve epidemiological health surveillance. Furthermore, this type of service and outpatient management are believed to be suitable for most people with COVID-19, considering that 80% are mild cases⁷7. Ramirez AV, Ojeaga M, Espinoza V, Hensler B, Honrubia V. Telemedicine in Minority and Socioeconomically Disadvantaged Communities Amidst COVID-19 Pandemic. Otolaryngol Head Neck Surg. 2021; 164 (1): 91-92. https://doi.org/10.1177/0194599820947667
https://doi.org/https://doi.org/10.1177/... ^,88. Centers for Disease Control and Prevention. Using Telehealth to Expand Access to Essential Health Services during the COVID-19 Pandemic. Atlanta: CDC; 2020. [citado maio 07, 2020]. Disponível em: https://www.cdc.gov/coronavirus/2019-ncov/hcp/telehealth.html.^,1212. Reed ME, Huang J, Graetz I, Lee C, Muelly E, Kennedy C, et al. Patient characteristics associated with choosing a telemedicine visit vs office visit with the same primary care clinicians. JAMA Netw Open. 2020; 3 (6): e205873. https://doi.org/10.1001/jamanetworkopen.2020.5873
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The monitoring of people with suspected or confirmed COVID-19 may initially take place by telephone as a strategy for identification, assessment of risk factors, severity of symptoms and evolution of the disease. When necessary, referrals to health services are made. It is, therefore, an excellent strategy in epidemic situations, with high potential to take care of people, families and communities¹³13. Turer RW, Jones I, Rosenbloom ST, Slovis C, Ward MJ. Electronic personal protective equipment: A strategy to protect emergency department providers in the age of COVID-19. J Am Med Inform Assoc. 2020; 27 (6): 967-971. https://doi.org/10.1093/jamia/ocaa048
https://doi.org/https://doi.org/10.1093/... ^,1414. Greenhalgh T, Wherton J, Shaw S, Morrison C. Video consultations for covid-19. BMJ. 2020; 368: m998. https://doi.org/10.1136/bmj.m998
https://doi.org/https://doi.org/10.1136/... .

Therefore, this article aims to analyze the sociodemographic and clinical profile of patients treated by the remote service “Telessaúde-COVID” and the factors associated with positive COVID-19 tests. Few studies have analyzed this type of health practice and evidence is lacking as to the outcomes of remote and home monitoring, especially for COVID-19¹⁵15. Ohannessian R. Telemedicine: Potential applications in epidemic situations TT - Télémédecine: applications potentielles en situations épidémiques. Eur Res Telemed. 2015; 4 (3): 95-8. https://doi.org/10.1016/j.eurtel.2015.08.002
https://doi.org/https://doi.org/10.1016/... .

METHODS

This is an exploratory, analytical study based on the analysis of secondary data obtained through the records of patients assisted by the remote care service called “Telessaúde-COVID”, registered in the Health Care Network (HCN) of a medium-sized Brazilian municipality in the state of Minas Gerais. The municipality is located in the region named “Zona da Mata Mineira”, with estimated population in 2019 of 78,846 inhabitants. From a managerial perspective, it is home to the surrounding health micro-regions, made up of ten municipalities. In addition, it houses a Federal University founded in 1922.

“Telessaúde-COVID” is a notification and telemonitoring service for patients with suspected respiratory symptoms of COVID-19. It was established in the city in April 2020 and provides assistance every day of the week, with a 12-hour shift. The service works at this emergency moment as a Regulation Center, helping to direct the flow of patients within the municipality’s HCN. It is composed of a multidisciplinary team of medicine and nursing interns and health professionals from the areas of medicine, nursing, veterinary medicine, physical education, and psychology. The service’s communication with the local health network takes place online and in real time.

The population assisted by “Telessaúde-COVID” is made up of people living in the city who have respiratory symptoms. Contact with the service is made by phone, spontaneously. Users are registered in the Epidemiological Surveillance Information System and monitored by the multidisciplinary team via telemonitoring. As an initial protocol, every suspected or confirmed case of COVID-19 should be monitored for 14 days from the onset of symptoms. Asymptomatic cases remain under telemonitoring for 72 hours, being discharged from the service after this period. The frequency of telephone contact varies, with a minimum interval of 24 hours for people over 60 years of age or a maximum of 48 hours for those with risk factors for complications, considering other situations.

This study included data from patients assisted by Telessaúde-COVID from April 22 to August 31 of 2020, totaling 1,854 patients. A descriptive analysis of the total number of visits (n=1,854) and an analysis of factors associated with reverse transcriptase reaction followed by positive polymerase chain reaction (RT-PCR) for COVID-19 was performed among patients who underwent the test during care (n=722).

The following variables were evaluated: date of assistance, date of notification, date of telemonitoring; characteristics of patients such as gender, age, presence of risk factor for complications, history of household contact with a suspected or confirmed case of COVID-19, diagnosis of flu syndrome, reported signs and symptoms (headache, cough, runny nose, sore throat, fever, myalgia, dyspnea and/or respiratory discomfort, diarrhea, prostration, sneezing, nasal obstruction, nausea and/or vomiting, changes in taste, chest pain, changes in smell, fatigue, chills, dizziness, abdominal pain, drowsiness, saturation of oxygen <95% and others), comorbidities (systemic arterial hypertension, chronic lung disease, diabetes mellitus, psychiatric disorders, obesity, cardiovascular disease, immunosuppression/neoplasia, neurological disease, smoking habit, pregnancy, chronic kidney disease, coagulopathy and chronic liver disease); and characteristics of the service such as a case notified by the service, days between first assistance and notification, indication of a diagnostic test, performance of a diagnostic test, days between notification and performance of the test, type of test performed, result of the diagnostic test, diagnostic test interpretation and required referrals.

Data were entered into a Microsoft Excel spreadsheet and analyzed using Stata version 14.0 (Stata Corp, College Station, TX, USA) and IBM^® Statistical Package for Social Sciences version 23.0 for Windows (SPSS^®, Chicago, IL, USA). The descriptive analysis consisted of obtaining absolute and relative frequencies. To test the normality of distribution of quantitative variables, the Shapiro-Wilk test was applied. A comparative analysis of the characteristics of cases with positive and negative RT-PCR results for COVID-19 was carried out using the Pearson’s chi-square test. Bonferroni correction was used in cases with more than two categories. Variables that presented p<0.20 in the univariate analysis were included in the logistic regression analysis, using the Backward Stepwise Wald method. The final model had a log likelihood of 576309, with a Nagelkerke R2 of 0.071. The goodness of fit was verified by the Hosmer and Lemeshow X2 11855 test, p = 0.158. The final model included variables with a statistical significance level at α < 5%.

This study is part of a larger project entitled “The Covid-19 pandemic in the state of Minas Gerais: an investigation in the scope of health care, education, management and research”, approved by the Research Ethics Committee of the institution, under the Certificate of Presentation for Ethical Appraisal (CAAE) 31128920.5.0000.5153, opinion nº 4,019,269. It is, therefore, in line with the research ethics recommendations of the Declaration of Helsinki and the Regulated Guidelines and Norms for Research Involving Human Beings contained in Resolution No. 466, of December 12, 2012, by the National Health Council.

RESULTS

A total of 1,854 new patients were evaluated, with an estimated 8,630 total consultations during the period, considering the initial consultations and remote monitoring of suspected or confirmed cases. The distribution of consultations carried out according to the epidemiological weeks is shown in Figure 1, which discriminates the consultations, the notifications and the estimated total of consultations, which comprise both the consultations and monitoring in the period.

As shown in Table 1, as to the profile of individuals assisted by Telessaúde-COVID, female patients (60.9%) aged between 20 and 59 years (75.9%) were predominant. The presence of at least one risk factor for complications was observed in 29.9% of the individuals. History of close or home contact with a confirmed or suspected case was detected in, respectively, 20.8% and 17.6% of patients. Flu syndrome diagnosis was made in 29.1% of the visits. The most frequent signs and symptoms were: headache (41.8%), cough (33.3%), runny nose (30.0%), sore throat (28.5%), fever (25.3%) and myalgia (22.7%). It should be noted that changes in taste or smell occurred in 5.9 and 3.9% of cases, respectively. Asymptomatic patients were 20.3% of the sample. The most common comorbidities were systemic arterial hypertension (10.6%), chronic lung disease (8.1%) and diabetes mellitus (3.7%).

The median period between the onset of symptoms and the call for the health service was 3 days (1 - 5 days). As shown in Table 2, of the total number of visits, 66.4% were notified as suspected cases of COVID-19. Among the notifications, 93.3% occurred on the day of the first visit. A confirmatory test was indicated for 62.8% of the individuals assisted and, of these, 76.4% had performed it. RT-PCR was the most frequently performed exam (83.4%), followed by the rapid immunological test (11.0%). Information about the test result was obtained in 99.7% of the cases, and 14.5% of the individuals tested positive for COVID-19. Regarding referrals, 80.4% of the individuals were monitored by the service, and those who had an indication for face-to-face evaluation were referred for outpatient evaluation (11.9%) or to the hospital (3.1%).

Variables related to sex, age, history of contact and signs and symptoms were compared for confirmed cases or ruled out by RT-PCR (n=722). There were no differences related to sex. However, as shown in Table 3, positive RT-PCR tests for COVID-19 were more frequent among individuals aged ≥60 years compared to those aged ≤19 years (26.6 versus 8.8%, p = 0.003); and between 20 and 59 years (26.6 versus 13.4%; p = 0.005). In addition, 20.0% of patients with a positive test had had household contact with a suspected or confirmed case, while 12.4% did not maintain any contact (p = 0.016). Among the signs and symptoms presented by the patients, there was a significant difference between the complaint of nausea/vomiting and smell alterations, more frequent in patients with COVID-19. Sore throat, in turn, was more present among patients whose RT-PCR result was negative for COVID-19 (90 versus 84.3%; p = 0.045). The variables described in Table 3 had a p-value <0.20 in the chi-square test and were included in the logistic regression model.

With the analysis of the logistic regression model, confirmed cases of COVID-19 were found to be associated with the age of the patients (Odds Ratio - OR 1,020; confidence interval - 95%CI 1,007 - 1,032); household contact with a positive or suspected case (OR 1,902; 95%CI 1,178 - 3,070); presence of nausea/vomiting (OR 2,403; 95%CI 1,148 - 5,029) and changes in smell (OR 2,827; 95%CI 1,294 - 6,176), as shown in Table 4.

DISCUSSION

SOCIODEMOGRAPHIC AND CLINICAL PROFILE OF PATIENTS ASSISTED BY THE SERVICE

The Telessaúde-COVID remote care service evaluated 1,854 new patients, in 8,630 estimated calls. In addition, 1,224 notifications were made, making up 31% of those computed in the municipality during the period evaluated. The importance of tracking and monitoring the contacts of suspected and confirmed cases for epidemiological control of the disease is highlighted, and They were also monitored by the service¹⁶16. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Guia de vigilância epidemiológica. emergência de saúde pública de importância nacional pela doença pelo coronavírus 2019. Vigilância de síndromes respiratórias agudas COVID-19. 2020. [citado oct. 09, 2020]. Disponível em: Disponível em: https://portalarquivos.saude.gov.br/images/af_gvs_coronavirus_6ago20_ajustes-finais-2.pdf
https://portalarquivos.saude.gov.br/imag... .

The median period between the onset of symptoms and the appointment call was three days (1 - 5 days), with a predominance of females (60.9%) and patients aged between 20 and 59 years (75.9%). A study carried out in São Paulo also showed a predominance of females (59%) in young age (mean 34.7 ± 10.5 years). In that study, patients sought the telemedicine service, on average, 4.67 ± 4.82 days after the onset of symptoms. We can infer that an early search by patients for the service could be associated with the wide dissemination of advertising made by the municipality about the telehealth service, with the aim of early managing positive or symptomatic cases and, thus, avoiding hospital overload¹⁷17. Accorsi TAD, Amicis K, Brígido ARD, Belfort DSP, Habrum FC, Scarpanti FG, et al. Assessment of patients with acute respiratory symptoms during the COVID-19 pandemic by Telemedicine: clinical features and impact on referral. Einstein (São Paulo). 2020; 18: eAO6106. https://doi.org/10.31744/einstein_journal/2020AO6106
https://doi.org/https://doi.org/10.31744... . The most common signs and symptoms in the present study were headache (41.8%), cough (33.3%) and runny nose (30.0%). The aforementioned study carried out in São Paulo showed cough in 74.4% of patients, followed by runny nose (65.6%). Sore throat and sneezing were less common, occurring in 38.6% and 20.6% of cases, respectively¹⁷17. Accorsi TAD, Amicis K, Brígido ARD, Belfort DSP, Habrum FC, Scarpanti FG, et al. Assessment of patients with acute respiratory symptoms during the COVID-19 pandemic by Telemedicine: clinical features and impact on referral. Einstein (São Paulo). 2020; 18: eAO6106. https://doi.org/10.31744/einstein_journal/2020AO6106
https://doi.org/https://doi.org/10.31744... . As observed in the present investigation, fever was not among the most common symptoms, occurring in only 25.3% of cases. This evidence is supported by the review of diagnostic criteria carried out in August 2020, in which fever was no longer considered an obligatory symptom¹⁶16. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Guia de vigilância epidemiológica. emergência de saúde pública de importância nacional pela doença pelo coronavírus 2019. Vigilância de síndromes respiratórias agudas COVID-19. 2020. [citado oct. 09, 2020]. Disponível em: Disponível em: https://portalarquivos.saude.gov.br/images/af_gvs_coronavirus_6ago20_ajustes-finais-2.pdf
https://portalarquivos.saude.gov.br/imag... .

20.3% of the individuals in this study were asymptomatic and continued on telemonitoring. The literature reports that the number of asymptomatic individuals is inconclusive, and their classification is diversified. Asymptomatic infection has been proven in several studies and it is believed to be greater in younger age ranges¹⁸18. Mizumoto K, Kagaya K, Zarebski A, Chowell G. Estimating the asymptomatic proportion of coronavirus disease 2019 (COVID-19) cases on board the Diamond Princess cruise ship, Yokohama, Japan, 2020. Euro Surveill. 2020; 25 (10): 2000180. https://doi.org/10.2807/1560-7917.ES.2020.25.10.2000180
https://doi.org/https://doi.org/10.2807/... ^,1919. Sutton D, Fuchs K, D’Alton M, Goffman D. Universal screening for SARS-CoV-2 in women admitted for delivery. N Engl J Med. 2020; 382 (22): 2163-4. https://doi.org/10.1056/NEJMc2009316
https://doi.org/https://doi.org/10.1056/... ^,2020. Baggett TP, Keyes H, Sporn N, Gaeta JM. Prevalence of SARS-CoV-2 infection in residents of a large homeless shelter in boston. JAMA. 2020; 323 (21): 2191-2. https://doi.org/10.1001/jama.2020.6887
https://doi.org/https://doi.org/10.1001/... . A review showed that 40 to 45% of infections are asymptomatic, with potential for viral transmission over a long period. It is confirmed that, due to the silent spread of the virus, tracking asymptomatic people and implementing intelligent strategies through epidemiological surveillance is essential²¹21. Oran DP, Topol EJ. The proportion of SARS-CoV-2 infections that are asymptomatic: a systematic review. Ann Intern Med. 2021; 174 (5): 655-62. https://doi.org/10.7326/M20-6976
https://doi.org/https://doi.org/10.7326/... .

The population provided with the service had systemic arterial hypertension, chronic lung disease and diabetes mellitus as the most common comorbidities. Among cases confirmed by RT-PCR, 17.3% were associated with arterial hypertension, 7.1% with diabetes mellitus, and no patient reported chronic lung disease. The literature shows that comorbidities in adults of any age increase the likelihood of serious complications from COVID-19²²22. Centers for Disease Control and Prevention. People with Certain Medical Conditions. Illinois: American Medical Association ; 2021. [citado maio 07, 2020]. Disponível em: Disponível em: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html .
https://www.cdc.gov/coronavirus/2019-nco... ^,2323. Ejaz H, Alsrhani A, Zafar A, Javed H, Junaid K, Abdalla AE, et al. COVID-19 and comorbidities: deleterious impact on infected patients. J Infect Public Health. 2020; 13 (12): 1833-9. https://doi.org/10.1016/j.jiph.2020.07.014
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The service provided by Telessaúde-COVID follows the protocol and assistance flow elaborated by the service itself, in line with the local health network and based on current scientific knowledge²⁴24. Freitas BAC, Prado MRMC, Fialho WL. Telessaúde COVID: teleatendimento e telemonitoramento de pacientes com suspeita ou confirmação de COVID-19: parceria entre o Departamento de Medicina e Enfermagem da Universidade Federal de Viçosa e a Secretaria Municipal de Saúde de Viçosa-MG/Universidade Federal de Viçosa. 2020. [citado maio 07, 2020]. Disponível em: Disponível em: http://www.unimedmg.coop.br/informe/centraldecomunicacao/Manual_UFV_covid.pdf
http://www.unimedmg.coop.br/informe/cent... . We noticed that 90% of notifications were made on the first day of care. For 62.8% of service users, diagnostic tests were indicated, with RT-PCR being the mostly performed (83.4%). In addition, test results were obtained by the service almost in all cases. These findings corroborate the relevance of Telessaúde-COVID and its articulation with the health care network.

Most patients (80.4%) did not need face-to-face care and continued to be monitored by the service, 11.9% were referred for outpatient evaluation and 3.1% to the hospital. This places Telessaúde-COVID as a central strategy for the control of outbreaks, enabling the reception of patients, the development of a therapeutic plan, the identification of warning signs and the referral of patients to the most suitable care when needed.

Important to note that the service identifies and prescribes according to clinical evolution, always based on scientific evidence. This is configured as a strategy to keep individuals asymptomatic or with mild to moderate symptoms at home, referring cases to outpatient evaluation as required and severe clinical pictures to hospitals. The reduction of the burden on health services and the improvement of assistance to users are, therefore, evident⁹9. Caetano R, Silva AB, Guedes ACCM, Paiva CCN de, Ribeiro G da R, Santos DL et al. Desafios e oportunidades para telessaúde em tempos da pandemia pela COVID-19: uma reflexão sobre os espaços e iniciativas no contexto brasileiro. Cad. Saúde Pública. 2020; 36 (5): e00088920. https://doi.org/10.1590/0102-311X00088920
https://doi.org/https://doi.org/10.1590/... .

As noted, 80.4% of the patients assisted by the service did not require face-to-face consultation, being followed up only by Telessaúde-COVID, which shows its resolving capacity. In fact, this is what is expected from primary health care services, the level of care in which Telessaúde-COVID is inserted⁷7. Ramirez AV, Ojeaga M, Espinoza V, Hensler B, Honrubia V. Telemedicine in Minority and Socioeconomically Disadvantaged Communities Amidst COVID-19 Pandemic. Otolaryngol Head Neck Surg. 2021; 164 (1): 91-92. https://doi.org/10.1177/0194599820947667
https://doi.org/https://doi.org/10.1177/... . In this way, referral is optimized by avoiding inadequate face-to-face assessment and allowing low-risk patients to be properly guided. Thus, Telessaúde-COVID can be considered an efficient strategy for the initial assessment and follow-up of acute patients¹⁷17. Accorsi TAD, Amicis K, Brígido ARD, Belfort DSP, Habrum FC, Scarpanti FG, et al. Assessment of patients with acute respiratory symptoms during the COVID-19 pandemic by Telemedicine: clinical features and impact on referral. Einstein (São Paulo). 2020; 18: eAO6106. https://doi.org/10.31744/einstein_journal/2020AO6106
https://doi.org/https://doi.org/10.31744... .

Virtual care strategies are being widely accepted by people and represent a powerful and crucial tool to provide safe and immediate health care²⁵25. Crane SJ, Ganesh R, Post JA, Jacobson NA. Telemedicine consultations and follow-up of patients with COVID-19. Mayo Clin Proc. 2020; 95 (9): S33-4. https://doi.org/10.1016/j.mayocp.2020.06.051
https://doi.org/https://doi.org/10.1016/... , being evidenced in this study as capable of meeting the demands of people with suspected or confirmed COVID-19.

FACTORS ASSOCIATED WITH POSITIVE COVID-19 TEST

Laboratory diagnosis of the SARS-CoV-2 virus is performed with real-time RT-PCR techniques, serological or antigen testing, validated by reference institutions¹⁶16. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Guia de vigilância epidemiológica. emergência de saúde pública de importância nacional pela doença pelo coronavírus 2019. Vigilância de síndromes respiratórias agudas COVID-19. 2020. [citado oct. 09, 2020]. Disponível em: Disponível em: https://portalarquivos.saude.gov.br/images/af_gvs_coronavirus_6ago20_ajustes-finais-2.pdf
https://portalarquivos.saude.gov.br/imag... .

Positive COVID-19 tests occurred in 14.5% of the population assisted by the service. Although patients who sought the service had the most common signs and symptoms of headache, cough and runny nose, these were not associated with positive COVID-19 test. On the other hand, positive COVID-19 tests were associated with patients’ age (OR 1,020; 95%CI 1,007 - 1,032); household contact with confirmed or suspected case (OR 1,902; 95%CI 1,178 - 3,070); presence of nausea/vomiting (OR 2,403; 95%CI 1,148 - 5,029) and changes in smell (OR 2,827; 95%CI 1,294 - 6,176).

Age equal to or greater than 60 years was more frequent among confirmed cases (26.6%), despite the greater number of tests performed for the age groups below 60 years. We did not find differences as to sex. Literature reports a higher frequency of positive tests for females and older age groups²⁶26. Lian J, Jin X, Hao S, Cai H, Zhang S, Zheng L, et al. Analysis of epidemiological and clinical features in older patients with coronavirus disease 2019 (COVID-19) outside Wuhan. Clin Infect Dis. 2020; 71 (15): 740-7. https://doi.org/10.1093/cid/ciaa242
https://doi.org/https://doi.org/10.1093/... .

In this study, 20.0% of patients with positive test had a history of household contact with a suspected or confirmed case, which is similar to the history of contact in 24.7% reported by other researchers²⁶26. Lian J, Jin X, Hao S, Cai H, Zhang S, Zheng L, et al. Analysis of epidemiological and clinical features in older patients with coronavirus disease 2019 (COVID-19) outside Wuhan. Clin Infect Dis. 2020; 71 (15): 740-7. https://doi.org/10.1093/cid/ciaa242
https://doi.org/https://doi.org/10.1093/... . A cohort of contacts of patients with confirmed cases showed a different percentage, with more than 50.0% of contacts testing positive, and most infected individuals not developing respiratory symptoms or fever²⁷27. Poletti P, Tirani M, Cereda D, Trentini F, Guzzetta G, Sabatino G, et al. Association of age with likelihood of developing symptoms and critical disease among close contacts exposed to patients with confirmed SARS-CoV-2 infection in Italy. JAMA Netw open. 2021; 4 (3): e211085. https://doi.org/10.1001/jamanetworkopen.2021.1085
https://doi.org/https://doi.org/10.1001/... .

We also observed changes in smell in 10% of patients who tested positive for COVID-19, with sensitivity and specificity of 27 and 86.7%, respectively. Other studies detected symptoms with an early onset (median three days) in 61.2% of patients, with olfactory dysfunction being described in the literature in 33.9 - 68% of patients with COVID-19, which reinforces the need for special attention in its investigation²⁸28. Speth MM, Singer-Cornelius T, Oberle M, Gengler I, Brockmeier SJ, Sedaghat AR. Olfactory dysfunction and sinonasal symptomatology in COVID-19: prevalence, severity, timing, and associated characteristics. Otolaryngol Head Neck Surg. 2020; 163 (1): 114-20. https://doi.org/10.1177/0194599820929185.
https://doi.org/https://doi.org/10.1177/... ^,2929. Meng X, Deng Y, Dai Z, Meng Z. COVID-19 and anosmia: A review based on up-to-date knowledge. Am J Otolaryngol. 2020; 41 (5): 102581. https://doi.org/10.1016/j.amjoto.2020.102581
https://doi.org/https://doi.org/10.1016/... .

The literature reports that studies on telehealth services have been more expressive in developed countries. Scientific evidence about the feasibility and application of this type of service and their potential to transform health care in locations with limited resources and in developing countries is still scarce³⁰30. Doraiswamy S, Abraham A, Mamtani R, Cheema S. Use of telehealth during the COVID-19 pandemic: scoping review. J Med Internet Res. 2020; 22 (12): e24087. https://doi.org/10.2196/24087
https://doi.org/https://doi.org/10.2196/... .

We understand that one of the limitations of this study is the fact that only individuals suspected of having the disease were tested; however, we emphasize that the service has its own protocol, available online and in open access²⁴24. Freitas BAC, Prado MRMC, Fialho WL. Telessaúde COVID: teleatendimento e telemonitoramento de pacientes com suspeita ou confirmação de COVID-19: parceria entre o Departamento de Medicina e Enfermagem da Universidade Federal de Viçosa e a Secretaria Municipal de Saúde de Viçosa-MG/Universidade Federal de Viçosa. 2020. [citado maio 07, 2020]. Disponível em: Disponível em: http://www.unimedmg.coop.br/informe/centraldecomunicacao/Manual_UFV_covid.pdf
http://www.unimedmg.coop.br/informe/cent... , in line with the local health network and based on current scientific knowledge.

Given the above, Telessaúde-COVID was proven relevant and efficient in the care, monitoring and adequate guidance of patients in the city’s healthcare network. With the uncertain permanence of the COVID-19 pandemic, it is recommended that this type of service be offered to the population, as it offers the possibility of expanding access and qualifying care, both in terms of individualized monitoring and to proper guidance of users within the health care network. Finally, we emphasize the articulating power presented by Telessaúde-COVID when promoting the integration of primary care with other levels of care, putting into effect the principle of integrality in fighting the pandemic within the scope of the Unified Health System.

Acknowledgments:

We would like to thank the National Council for Scientific and Technological Development (CNPq) for the scientific initiation scholarships.

References

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