In a study published in the journal Einstein (Sao Paulo), researchers from the organization analyzed every telemedicine encounter from between March 2020 and August 2021 to evaluate how well the international guidelines were adopted and followed.

While unnecessary drug prescriptions—primarily of antimicrobials—exceeds 75% worldwide for suspected and confirmed COVID-19 patients treated via telemedicine, this figure was below 1% at the Brazilian institution in the time period analyzed.

“The quality of care and safety for telemedicine-discharged patients with suspected respiratory infections are closely related to low rates of prescriptions of unjustified and high-risk medications,” wrote the authors.

The results were obtained by examining medical records, with several quality indicators taken into account. Physicians were given feedback based on their own metrics, with recommendations based on the IDSA guidelines.

The study included all adults treated with respiratory symptoms in the prior 14 days who sought telemedicine consultations in the period under analysis. All patients had suspected or confirmed COVID-19 or other respiratory tract infections.

Antibiotic prescriptions reduced

Of the 221,128 patients evaluated:

• 42,042 (19%) were confirmed to have a SARS-CoV-2 infection
• 104,021 (47%) were suspected of having COVID-19
• 75,065 (33%) received other diagnoses

The average patient age was 35 years. In total:

• 125,107 (85%) of patients were treated at home
• 2,552 (1.7%) were referred for non-urgent hospital care
• 17,185 (11%) were referred to the emergency room

The rate of antibiotic prescription in suspected and confirmed cases was 0.46% to 0.65%, while the rate for prescriptions without scientific evidence was between 0.01% and 0.005%.

The study concluded that guideline-based training and feedback for physicians from supervisors can lead to fewer prescriptions of antibiotics and antimicrobials for suspected or confirmed cases of COVID-19.

“The adoption of prescription-focused protocols may improve guideline adherence and reinforce the quality of care and safety in telemedicine encounters,” the authors concluded.

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Alyson Moadel-Robblee, a psychologist from the center who specializes in oncology, presented the results at the annual meeting of the American Society of Clinical Oncology (ASCO). The society was founded in 1964 to connect doctors and health professionals working in oncology around the world, with the aim of encouraging research and actions related to cancer treatment.

In partnership with the technology company MyndYou, researchers created a conversational AI bot capable of contacting patients who failed to show up to their exams.

The technology helped double colonoscopy completion rates in the group.

According to Moadel-Robblee, automated tracking of no-shows is essential because the hospital’s employees alone are simply not able to get hold of the 3,000 patients who miss colorectal exams every year.

“Since the pandemic, the demand and load on our healthcare team is huge. They can only do so much,” the psychologist said during the event, according to a report published on the website Statnews. “They can’t call in the evening or whenever.”

The AI, named MyEleanor, calls patients who did not show up or canceled their appointments. If they pick up, “she” has two assignments: transfer them to a human attendant, and if the patient consents, guide them through a brief survey about why they missed their appointment.

“Our virtual navigator doesn’t sleep. So she can call earlier, later, or on different days,” explains Moadel-Robblee.

She also emphasizes that great care was taken to ensure that MyEleanor did not appear too human.

MyEleanor thus maintains the speech of a robot, but without seeming impersonal,Moadel-Robblee is keen to emphasize. “She’s really warm,” said her creator. “She says: ‘I’m Eleanor. I speak English and Spanish, which would you prefer? I’m part of the care team.’”

A quarter of the population of the Bronx speaks Spanish, and many people in the US miss appointments because of a language barrier, making the AI’s ability to speak Spanish a major advantage.

More exams and spare time

Of the 2,400 patients MyEleanor called, 57% stayed on the line with the bot. Of these, more than half agreed to be transferred to an attendant to try to reschedule their appointment.

Human operators were then able to increase the proportion of no-show patients who completed a colonoscopy from 10% to 19%. The robot also helped free up an average of 52 hours of work per month for each attendant.

The figures are considered very promising, given that a significant proportion of Bronx residents are underserved and may face multiple barriers to accessing care.

According to the study, in addition to many patients being Spanish speakers, about 40% of them are Black, 32% are unemployed, and only 40% are educated beyond high school level.

Black and Latino patients are more likely to be diagnosed with colorectal cancer at a young age.

Doctors and cancer researchers at the ASCO conference praised the initiative, according to Statnews.

“This is truly an innovative means of increasing cancer screening,” said Fumiko Chino, a radiation oncologist at Memorial Sloan Kettering Cancer Center.

“It really offloads the burden from an overworked healthcare workforce by leveraging AI technology to optimize the outreach capacity to vulnerable populations,” Chino added.

According to Moadel-Robblee, the aim is for MyEleanor to later be used in other cancer prevention programs, including for lung and breast cancer.

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The book Um tempo para não esquecer: A visão da ciência no enfrentamento da pandemia do coronavírus e o futuro da saúde (A time to not be forgotten: A science-based perspective on facing the COVID-19 pandemic and the future of health), by pulmonologist Margareth Dalcolmo, a researcher at the Oswaldo Cruz Foundation (FIOCRUZ).

WHY IS IT WORTH READING?

Margareth Dalcolmo’s book, released in December 2021, is well worth reading. The book addresses the recent period during which we all experienced the COVID-19 pandemic and documents how we had to organize and act in the face of the then novel coronavirus.

I had the opportunity to meet and work alongside the author, who brilliantly recounts, in this book, how science and the healthcare field saved lives. It is also a message of hope and of how capable we are of overcoming adversity.

Um tempo para não esquecer features articles written weekly by Dalcolmo for O Globo newspaper, forming a historical record produced “in the throes of the pandemic.”

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The researchers, led by professor Jennifer Steel, of the University of Pittsburgh, also observed a lower risk of cardiovascular diseases in the family members who care for these patients, as well as lower costs for the healthcare system.

Researchers calculated that, if the measures were adopted, the healthcare system would save US$4 million for every 250 patients, even if the treatment were offered free of charge (the United States does not offer public healthcare). This was the first intervention carried out in the United States, in the context of cancer, to show financial savings.

“The current standard of care, which includes screening patients for these symptoms and referring them to a provider for treatment, is not working,” said Steel in a press release. “Our integrated screening and treatment program provides meaningful support to patients and can save hospitals millions of dollars by preventing readmissions,” she added.

Half of the patients underwent integrated mental health screening and were referred to an intervention group, as well as being connected with a professional for weekly cognitive-behavioral therapy (CBT) sessions.

The one-hour sessions, via telemedicine, were integrated into the oncology treatment plan and were conducted for 12 weeks. If CBT alone was not proving beneficial, the patients were offered the appropriate medication.

Fewer hospitalizations

Those who received integrated mental health treatment along with cancer treatment visited the ER less often and had fewer hospitalizations, spending fewer days in the hospital than those who did not undergo the intervention.

Many studies have already demonstrated that symptoms such as depression and pain are associated with higher rates of visits to the ER and new hospitalizations, in addition to high healthcare costs and low survival rates.

For nearly two decades, screening for depressive symptoms and referral for treatment has become standard in the United States, Canada, Europe, and Australia. However, many barriers prevent most patients from beginning mental health treatment.

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The authors note that, apart from Vitamin D, especially for those who are deficient, and occasionally high-quality adjuvant melatonin, there are no natural products or supplements recommended to reduce cancer recurrence and prolong survival.

The study concludes by stating that the authors support “an integrative approach to healthcare,” to “offer patients a comprehensive treatment plan that leads to optimal health, quality of life, and improved cancer survival.” The authors also add several important caveats, such as that integrative healthcare should not replace conventional treatment. They also recognize the need for more studies on integrative approaches.

The review study references a set of recommendations published in 2022 and 2023, drafted with input from the American Society of Clinical Oncology (ASCO), which establishes evidence-based guidelines for the use of integrative medicine in cancer patients.

One such guideline, published in September 2022 in partnership with the Society for Integrative Oncology (SIO), suggests that practices such as acupuncture, reflexology, hypnosis, and massage could be used to alleviate pain in cancer patients, considering the scientific literature already available on the practices.

Other approaches, such as music therapy, cause no harm to patients, but currently have less empirical support, according to the publication.

The guidelines for the joint ASCO and SIO working group, coordinated by Jun J. Mao, from the Memorial Sloan Kettering Cancer Center, in New York, were published in the Journal of Clinical Oncology. As part of their research, Mao and his colleagues reviewed 227 previous studies in an attempt to estimate the quality of the evidence they contained.

In addition to the experts, the panel included a representative for cancer patients who use this type of therapy. The team searched the PubMed and Cochrane Library databases for studies published between 1990 and 2021, including randomized controlled trials, systematic reviews, and meta-analyses on the topic.

The studies had to include adult or pediatric patients who suffered from pain during any stage of cancer treatment and received integrative interventions to minimize the problem (pain prevention techniques were not included). The primary outcome should be a reduction in pain frequency or intensity, and at least 20 participants should be included in each study.

Based on these criteria, the initial 1,346 scientific articles analyzed dropped to 227. Even for the studies that met the inclusion criteria, the team highlights that there is considerable variability in methodology and primary outcome.

“This disparity precluded a quantitative analysis, so we only carried out a descriptive review,” write the authors.

In the paper, Mao and his colleagues highlight that, in addition to the pain caused by the tumor itself or its effect on bones, nerve tissue, and muscles, patients often have to deal with pain triggered by conventional cancer treatments, such as joint pain caused by aromatase inhibitors, commonly used against breast cancer, and pain associated with chemotherapy-induced peripheral neuropathy.

Faced with these and other issues, the authors concluded that some integrative practices achieved a quality of evidence considered intermediate. These are moderately recommended for cancer patients.

This is the case with acupuncture, which is indicated to treat joint and muscle pain caused by aromatase inhibitors in breast cancer patients.

Acupuncture

In this case, a phase III clinical trial (which evaluates efficacy) with 226 patients showed, for example, that acupuncture is more effective at reducing pain than using needles at “fake” acupuncture points (not traditionally stimulated by acupuncturists) or standard treatment (solely pharmacological).

Very similar conclusions were reached for reflexology and hypnosis in those undergoing systemic cancer treatment, or for massage in those receiving palliative care.

As for approaches such as music therapy, a review of the medical literature indicates that these practices tend to be more beneficial than harmful for patients. However, the quality of the evidence is considered low and, therefore, the guidelines only “tentatively” recommend its use.

The most solid evidence, for the time being, comes from studies performed on adult patients. According to the research, data on the use of integrative practices to minimize pain in pediatric cancer patients has not yet reached sufficient critical mass to make recommendations.

Biologist Elisa Harumi Kozasa, a researcher at Hospital Israelita Albert Einstein, in Brazil, highlights the need for more studies. “As of yet, very few integrative treatments have scientific backing,” says Kozasa, who works with studies on mind-body practices, such as meditation and yoga, which, according to her, have extensive literature backing them up.

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