Implementation and Monitoring of a Telemedicine Model in Acromegalic Outpatients in a Low-Income Country During the COVID-19 Pandemic

Abstract

Background:

Telemedicine is a resource to provide health care to patients social distancing and prevent their exposure to the risk of contamination by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in medical-hospital settings. This study evaluated a virtual model of care in acromegalic patients.

Methods:

We recruited 78 acromegalic patients, 65% female, median age 63 years. Outpatient management was remodeled to simplify access to care by (1) adoption of virtual meetings; (2) collection of blood samples at home; (3) abolishment of printed prescription and provision of electronic files directly to central pharmacy; and (4) drugs delivered to patients' home. Patients and physicians filled electronic surveys 48 h after each consultation.

Results:

The patients expressed satisfaction with convenience (91.1%), decreased wait time (85.1%), and saving money (79.2%) compared to face-to-face visits. Most patients felt supported by the medical team (89.1%) and kept the prescriptions updated (84.8%). The physicians reported resolutive appointments in 92.2% of cases, despite longer time to reach the patients and subsequent calls to complement missing information. Satisfaction and patient–provider relationship were maintained during the study, but the choice for virtual appointment for the next appointment fell from 78.7% to 34.8% after 6 months. Coronavirus disease 2019 (COVID-19) was confirmed in 13% of patients, mostly mild and moderate manifestations.

Conclusion:

Telemedicine is a tool for medical care in underserved populations, feasible even in low-income countries. This study suggests that it is difficult to sustain exclusive remote care for more than 6 months. The method could be adopted interchangeably with in-person consultations in acromegalic patients with stable disease.

Background

Telemedicine is a viable strategy that can expand access and bring medical attention to patients with disabilities and multisystemic health conditions. It is also an important tool to offer access to education and medical research, especially for students and doctors working in geographically isolated regions.¹ These technologies allow patients to receive care remotely through virtual applications, which offers opportunities for patients who face impediments that limit their access to care, live in rural or underserved areas, or have rare diseases and need a distant specialist.^1
–3 Recently, an exceptional situation of restriction in elective outpatient consultations has been established to prevent the exposure of patients with chronic diseases to the risk of contamination by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in medical hospital settings.

The internet has incorporated several security technologies and databases on the web and has become a proper telemedicine environment with few computational requirements.⁴ Nevertheless, there is a concern about risks to privacy and confidentiality, the limitations of electronically mediated interactions for physical examinations, and the potential for disruption of the patient–physician relationship.^4,5

Virtual medical assistance must guarantee physicians ethical responsibilities, respect patient privacy and confidentiality, and provide competent and continuous care, as recommended by the American Medical Association's (AMA) Council on Ethical and Judicial Affairs (CEJA) on ethical practice in telehealth and telemedicine.⁶ Coronavirus disease 2019 (COVID-19) is rapidly transforming the telemedicine landscape, with a massive mobilization of health care providers onto diverse platforms, providing remote medical assistance to susceptible patients.⁷

The recently published Clinical Practice Guidance for the Management of Pituitary Tumors during COVID-19 Pandemic recommends remote care, avoiding face-to-face contact, informing the patients about pituitary apoplexy risks, adrenal insufficiency, tumor growth, and close monitoring of these complications.^8,9

Patients with pituitary tumors present symptoms related to mass effect, hormone hypersecretion, or hypopituitarism and require frequent medical evaluations.⁸ In the COVID era, these patients do not have easy access to radiological, neuro-ophthalmologic, and hormone profile monitoring nor to elective neurosurgeries. Patients need continuous contact with the medical team, and social isolation measures make access to the hospital environment difficult for elective consultations.

Patients with acromegaly usually have comorbidities that potentially increase the risk of SARS-CoV-2 complications, like hypertension, osteoarticular impairments, diabetes mellitus, and secondary adrenal insufficiency; patients should be closely monitored and informed about their disease's impact on the prognosis of COVID-19.⁸ In addition, hypothalamic and pituitary tissues express angiotensin converting enzyme - 2 (ACE2) and could also be viral targets, and tissue damage can occur directly or via immune-mediated hypophysitis.¹⁰ The therapeutic approach is multimodal, generally life-long, and entails a high cost. Telemedicine can provide patients with easy access to the medical team and educational opportunities.

For the consolidation of telemedicine, it is important to have multiprofessional-specialized centers to provide accessible tools for the patients' education and assistance. This work aims to systematize several aspects of endocrinological teleassistance and develop and implement remote and multiprofessional care in a pilot study in acromegalic patients. The feasibility, efficacy, and satisfaction of patients and the medical team of virtual care were tested during the COVID-19 pandemic.

Objectives

Implement a telemedicine model of care in a group of patients with somatotropic pituitary tumors.

Evaluate the feasibility, efficacy, and sustainment of and patient and physician satisfaction with virtual consultations.

Propose facility modifications so that patients can travel less to obtain prescriptions and receive medication.

Methods

The Neuroendocrine Unit of the Brasilia University Hospital (HUB) meets the criteria of Pituitary Tumor Centers of Excellence (PTCOE)¹¹ for the treatment of complex diseases at the tertiary and quaternary levels of health care, such as neuroendocrine and pituitary tumors. Before COVID-19, the Endocrinology Unit had never offered telemedicine, and this is a pilot study in a cohort of patients diagnosed with acromegaly in regular medical assistance in our service.

Local Policies and Economic Aspects

In Brazil, acromegaly treatment is provided for free through the public health care system and is defined by published Clinical Protocols and Therapeutic Guidelines.¹² Only first-generation somatostatin analogs and cabergoline are available in the Brazilian Unified Health System (SUS). The estimated high costs of pharmacological therapy demand a robust social protection system to prevent inequity in access to medicines.¹³ To have access to a supply of drugs, the patient needs to accomplish several steps: (1) have a medical evaluation; (2) obtain the printed prescription; (3) take it to the central high-cost public pharmacy; and (4) receive the medicine and bring it back to the hospital to receive the injection.

Barriers to social isolation

Patients need to travel long distances to receive medications, laboratory work, and medical assistance. Regarding our published data using geographical information system, the mean distance between home and the drug dispensing center was 15 km, and more than 40 km from home to achieve referral medical center;^14,15

The majority of patients use public transportation; and

Need to move through multiple sectors of the health service, such as pharmacy, ambulatory, or nurse assistance.

Barriers for the medical team

One of the most critical barriers to the medical team concerned the methods to access the patients;

Contacting family when the telephone or computer does not belong to the patient;

Number of attempts by the medical team to access the patient;

Difficulties in accessing internet platforms from public hospitals; and

Long duration of the teleconsultation.

Service remodeling solutions proposed in this study

Virtual meetings scheduled individually;

Blood sampling performed by the laboratory at home;

Abolishing printed prescriptions and provisioning of electronic files directly to central pharmacy; and

High-cost drugs (somatostatin analogs and cabergoline) delivered directly to the patient's home.

Study Design

This prospective longitudinal study evaluated patients' and physicians' perceptions of telemedicine during two time points (1) baseline and (2) after 6 months. The inclusion criteria were a previous diagnosis of acromegaly and regular appointments at the Neuroendocrine Unit. The exclusion criteria for telemedicine were acute illness, inability to hear or speak, no access to a telephone or computer, and severe neurologic or psychiatric diseases. The medical team contacted the patients who met the inclusion criteria, and all individuals who agreed to participate gave proper informed consent. During the first telephone call, patients were informed that the medical team would safeguard all medical information and would guarantee privacy. Appointments corresponded to the same time previously scheduled for an in-person consultation. According to patients' preference and access, the remote consultations were performed from March to November 2020 on different platforms. The most used tools were Teams, Skype, WhatsApp, and FaceTime, all authorized by the Federal Council of Medicine in Brazil and regulated by the Brazilian Law 13,989/2020 for telemedicine.

The digital visit consisted of systematization of relevant social and clinical information, documentation of possible complications, and digital renewal of prescriptions. Socioeconomic status was measured by analysis of patients' information concerning education, income, and occupation. All assistance was recorded in the Management Application for University Hospitals (AGHU). At baseline, clinical evaluation was performed, and patients were submitted to laboratory work, with blood sampling occurring at home. The laboratory results were shared with patients by e-mail. A printed prescription was sent to patients' addresses, and an electronic prescription was sent directly to the central pharmacy. Medicine was delivered directly to the patients' homes.

Forty-eight hours after the digital visit, an electronic survey was sent to patients and physicians. After 3 months, another telephone contact was performed and, when necessary, the medical team reevaluated the patients in an in-person consultation. Six months after the first virtual meeting, patients had a second round of virtual clinical evaluation, laboratory work, and updated prescriptions. After 48 h, the second electronic survey was sent to patients and physicians. Informative texts and warnings about COVID-19 were available for the patients (Fig. 1).

Fig. 1.

Workflow for patient's assessment for telehealth.

Surveys

We used a questionnaire-based survey that was sent via e-mail or WhatsApp to all patients and physicians. Patients with no access to the internet received their questionnaire through a relative's electronic address. Patients were asked to complete the survey 48 h after the first telemedicine appointment. A different questionnaire evaluated physician's perceptions of telemedicine at the same time. The questionnaires consisted of three parts: accessibility, satisfaction with a virtual medical evaluation, and outcomes. Following the second virtual clinical evaluation, a survey was sent and included in the outcomes section questions regarding COVID-19 infection in patients or contacts. The satisfaction questionnaires were adapted from Telehealth Usability Questionnaire (TUQ) rated by a five-point Likert scale, with higher scores reflecting more positive outcomes.¹⁶

Patients Surveys

Evaluation of quality of patient–physician interaction

Consisted of four questions, questioning the facility to connect to and start the virtual appointment; quality of internet connection; and if it was possible to see, hear, speak to a physician easily.

Evaluation of patients' satisfaction with telemedicine

This section integrated questions concerning patients' acceptance to telemedicine and included (1) an evaluation degree of satisfaction with the virtual meeting; (2) patient's impressions about financial and time savings with virtual meetings; (3) if the relationship with the doctor was comparable to a face-to-face consultation; (4) likelihood of using telemedicine again; or (5) if the patient prefers to have a conventional in-person appointment with his physician.

Evaluation of Outcomes of the Disease

The evaluation of outcomes achieved in acromegaly control during the pandemic consisted of questions asking whether the patient (1) had blood samples collected; (2) was able to send the results to the medical team, (3) kept prescriptions up-to-date; (4) received medications, and (5) used medications prescribed during the pandemic period. In the second questionnaire, questions concerning exposure or infection by COVID-19 were included.

Physicians Survey

This questionnaire consisted of eight questions that evaluated (1) accessibility, regarding the number of phone call attempts to access the patient, duration of virtual meetings, and whether the query generated additional phone calls or e-mails, related or not to the clinical condition; (2) satisfaction of medical team with telemedicine; and (3) if treatment goals were achieved in a way comparable to face-to-face consultations.

Ethical Aspects

All patients signed informed consent, and Ethics Committee approved this study of the Faculty of Health Sciences of University of Brasilia, CAAE 36461020.4.0000.0030.

Results

Characteristics of the Sample

We evaluated a cohort of 78 patients, 65% were female, 57.5% of white ethnicity, 20% brown, and 22.5% black. The median age of patients was 63 years (19–78). None of these patients had private health insurance, and all were supported by the Brazilian SUS, which is entirely public. The socioeconomic levels of our patients, measured as a combination of education, income, and occupation, were medium-high (15%), medium (34.5%), and low (52.3%). Patients' level of education varied; 20% were illiterate, and 31.1% had less than 7 years of schooling (Table 1).

Table 1.

Level of Education and Socioeconomic Status

LEVEL OF EDUCATION (YEARS OF SCHOOLING^a)	%
Illiterate (<2)	20
Elementary School (2–4)	8.9
Incomplete High School (5–7)	2.2
Complete High School (>8)	40
College (>15)	28.9

SOCIOECONOMIC CLASSIFICATION	%
Medium-high	15
Skilled employees^b
Medium	32
Elementary workers^c
Retirees and pensioners
Low
Precarious self-employed^d	20
Domestic workers	18
Unemployed	15

Average number of years of formal education, excluding years spent repeating individual grades.

Economic activity related to formal education.

Service sector, building industry, garbage collection.

Work without an established settlement for their economic activity.

First Virtual Medical Appointment

The illiterate patients or patients with no access to the internet were interviewed by telephone (35.8%) with the aid of children or grandchildren. From the total cohort, 24.5% did not have a phone, and 62% of families owned only one computer, sharing the equipment with other family members. To schedule the first telemedicine appointment, we contacted 57% of patients with a single call, but the number of phone call attempts to access the patients ranged from 2 (16%), 3 (12%), 4 (9%), and 5 (6%). The medical evaluation was performed using telephone calls for 27% of patients, or internet platforms such as WhatsApp or FaceTime in 44.5%, Teams in 19.3%, and Skype in 9.2%. Telephone calls were the first choice for aged and illiterate patients (p < 0.01). Only two aged patients had difficulties with hearing related to mild sensory hearing loss. The average duration of video consultations was 28.5 and 19.6 min for phone calls.

Evaluation of clinical aspects, renewal of prescriptions, request for laboratory tests, and scheduling a follow-up appointment were performed. A digital prescription was sent to the patient and the pharmacy. Laboratory samples were scheduled and collected at the patient's home. Medicine (somatostatin analogs and cabergoline) were delivered at home by the Specialized Pharmaceutical Assistance from the Secretary of Health of the Federal District. Some educational videos concerning comorbidities and therapeutic approaches of acromegaly were made available to interested patients.

Patients survey

Forty-eight hours after the telemedicine consultation, all patients received a questionnaire. Ninety-six percent of patients sent back filled forms to the researchers. In the first part of the survey, patients described the accessibility to connecting and starting virtual appointments; quality of internet collection; and if it was possible to see, hear, speak to physician easily. The responses were categorized as completely disagree, indifferent, completely agree.

The patients expressed satisfaction with convenience (91.1%), decreased wait time (85.1%), and saving money with transportation (79.2%) compared to previous face-to-face visits. Most patients felt supported by the medical team (89.1%) and kept the prescriptions updated (84.8%). If the pandemic continues, 78.7% of patients indicated that they would do the next consultation by telemedicine within the next 6 months (Fig. 2). Older individuals, patients with lower education levels or with less access to computers were helped by family members; no differences were observed in adherence or reliability of responses of these individuals, compared to the other participants.

Fig. 2.

Patients' survey at baseline, answered after 48 h from the first telemedicine appointment.

Physicians perceptions after the first telemedicine appointment

Physicians completed an electronic questionnaire for each consultation performed. Difficulties in connectivity and multiple phone call attempts to access the patients were reported. Only 13.2% of patients started the virtual appointment in the first attempt, 18.4% after the second assay, 44.7% after the third assay, and 23.7% in the fourth attempt. The quality of internet connection, sound, and video were considered as excellent in 52%, 47.4%, and 42.7% of consults, respectively. The medical team considered the time spent on the virtual approach superior to in face-to-face meetings in 68.4% of cases.

The remote consultations were resolutive in 92.2%, and 15.8% of patients were referred to presential evaluation. Physicians reported that the absence of physical examination did not impact the effectiveness of the medical evaluation in 89.4% of cases.

The information provided by the patients was considered reliable in 81.1% of consults. Teleconsultations led to subsequent virtual contacts in the next 72 h in 70.3% of cases, generally complementing missing data related to the medical condition (48.6%). However, in 18.9% of cases, second or third approaches were considered as inappropriate by the physician, involving social media or subjects not related to a medical condition.

The doctors felt that they were welcomed by the patients in 89.5% of cases, and intervention by the end of the medical consultation is described in Figure 3. The updated prescriptions and laboratory test requests were provided in digital and printed versions were sent by mail.

Fig. 3.

Clinical management after virtual consultation.

Second Virtual Medical Appointment

Six months after the first teleconsultation, the second appointment for remote follow-up was scheduled. All 78 patients were contacted, and only two patients did not attend the meeting because they were hospitalized for severe COVID symptoms.

The second survey was filled and sent back in 97.3% of cases. Comparing patient satisfaction reported in the first and second surveys, the internet connection was more straightforward than at the first meeting (p < 0.01), and the patient's perception about physician–patient relationship and convenience had improved. However, 65% of patients related a preference for face-to-face meetings, and only 34.8% of patients would choose telemedicine for the next appointment in the second survey (Figs. 4 and 5).

Fig. 4.

Patients survey after 6 months, answered 48 h from the second telemedicine appointment.

Fig. 5.

Comparison of patient's satisfaction with telemedicine at baseline and after 6 months of the pandemic.

Treatment and Monitoring of Acromegaly

Considering the relevant aspects regarding access and adherence to treatment and monitoring of acromegaly, 95.2% of patients kept their prescriptions updated. Only 22.2% delayed the injection of somatostatin analogs during the quarantine phase imposed during the pandemic. During this period, 75% of the patients were able to do laboratory tests and send them to the doctor via the internet. These results were comparable to adherence observed in conventional face-to-face consultations over the last 10 years, as previously published by our group.^13
–15

In the survey applied after the second virtual visit, 52.4% of patients reported the desire to schedule a face-to-face consultation within the next 3 months.

COVID-19 Infection in Acromegalic Patients and Family

In this study, 45.5% of the patients reported relatives or close contacts infected by SARS-CoV-2 by the second appointment. About 18.2% of infected relatives lived in the same household as the acromegalic patient. Neighbors and coworkers corresponded to 13.5% of infected contacts, and 83.3% of reported contacts presented mild disease, but hospital stay was necessary in 16.6% and respiratory support in 8% of cases.

Considering the sample of 78 patients, 18 (23%) presented symptoms suggestive of COVID-19. The most common suspected symptoms were fever (72%), myalgia (64%), anosmia (53%), dyspnea (34%), and diarrhea (15%). These patients were tested for SARS-CoV-2 by different methods (real time protein chain reaction 17.4%, total antibodies 8.7%, and rapid screening tests 4.3%), but only 10 patients (12.8%) had a confirmed COVID-19 infection.

Of the 10 patients with a confirmed COVID-19 infection, 4 presented severe disease. One, aged 78 years, with severe pulmonary impairment, deceased after 14 days of intensive care. The second patient, aged 48 years, presented 75% of pulmonary impairment, with recovery after 21 days of hospital stay. The third patient, 72 years old, presented pituitary apoplexy with adrenal insufficiency, required corticotherapy and enoxaparin. The fourth patient, 63 years old, had diabetes as a comorbidity and presented acute renal insufficiency, requiring hemodialysis for 2 months. The other six patients showed mild disease, with fever, tiredness, and gastrointestinal (GI) symptoms (diarrhea, nausea, and vomiting).

Discussion

This study was innovative and allowed the implementation of telemedicine at the Neuroendocrinology Unit of the University Hospital of Brasilia. Our acromegalic patients had virtual consultations in an exceptional situation so they would not be exposed to other potentially infected people, following the recent recommendations.⁸ Elderly patients or those with a lower education level preferred phone calls or attended the appointment with the help of friends or relatives, which had the added benefit of allowing family to be more involved in understanding disease prognosis and treatment.

The use of video visits may improve communication, but requires internet access and technology navigation, which can highlight health care disparities.¹⁷ Effective communication is a pillar of the physician–patient relationship and compassionate medical practice, but virtual care includes the inability to utilize body language and barriers to traditional physical examination.¹⁸ These challenges may be essential obstacles to good medical practice. To attain good virtual care, the principles of professionalism, empathy, respect, and virtual physical examination should be applied.^18,19

Despite the low social and educational level of our patient cohort, we observed a very high adherence to the alternative of virtual appointments, and 96% of the survey questionnaires were sent back to the medical team within 24 h of being sent. The high acceptance of telemedicine in this cohort can be explained by the fact that only previously diagnosed patients in routine follow-up and treatment in our service were included. The interpersonal relationship between the medical team and patients was previously established in-person and allowed patient-centered virtual care. One limitation of this study is the absence of a matched control group, submitted to in-person consultations. Considering the exceptionality conferred by the pandemic, telemedicine became the only accessible option to maintain adequate medical assistance. That being said, the adherence in the study group was similar to that observed in face-to-face consultations carried out in previous years^13
–15 and the medical effectiveness of the remote medical assistance seemed to be comparable to the conventional protocol in our service.

In our study, remodeling the health service structure was fundamental for the feasibility of telemedicine, allowed the avoidance of public transportation, integrated pharmacy and clinical teams, permitted home delivery of medicines, and simplified access to medical care. A crucial aspect in low- and middle-income countries is the reported financial savings when the patient does not need to pay for transportation to make multiple trips to different levels of health care and the reduction of absenteeism at work. Telemedicine can eliminate logistic barriers and increase access to clinical care.^20

–23

In the first virtual survey filled after the first consultation, patients expressed satisfaction with the convenience, reduction in time spent to achieve the medical assistance, and saving money with transportation of telemedicine compared to previous face-to-face visits. Most patients felt supported by the medical team and kept their prescriptions updated.

Despite these advantages, there was a relevant difference in the patient's choice for the next virtual appointment after 6 months of the first telemedicine meeting. Only 34.8% of patients would choose to maintain virtual consultations for long periods, relating a preference for face-to-face meetings, which represents a drastic reduction in patient´s engagement along the social isolation imposed by the pandemics.

Several factors that may have influenced the choice for in-person consultation in long-term follow-up: (1) most of our patients had a low level of education or were illiterate, needing family support to make the teleconsultation. This aspect was observed in other studies in underserved populations, where technological disparities, lack of computer literacy, or access to reliable internet to complete the video consultation successfully were found.²⁴ (2) The sample of patients with acromegaly is composed mostly of elderly patients, which prefer phone calls. Some authors have also described difficulties in acceptance of using electronic media to communicate with the patient instead of telephone calls,²⁵ even though recent reviews have demonstrated that video conferencing is feasible, acceptable, and can effectively be used in older adults.²⁶ Virtual care includes the inability to utilize body language and barriers to traditional physical examination. (3) The hospital team did not provide technological support to our patients. Most of them learned alone or with the help of friends or family, which imposes difficulties on the use of computers or other devices. Other authors suggested that the possibility of staff members being able to explain and train patients to use the technological resources may increase patient favorability toward teleconsultation. Such an intervention, however, may not be suitable for certain seniors who may be uncomfortable with technology or who do not have the necessary readiness to change to participate.²⁷ (4) Most of acromegalic patients have some physical disability due to the presence of comorbidities and complications of the disease, such as visual impairment related to tumoral compression of optic chiasma, acral enlargement, and restriction of fine movements, which hinders the use of small electronic devices. In a previously telehealth-naive clinic, however, some authors have shown successful implementation of telehealth for a diverse orthopedic population with low mobility.²⁸

The physicians' perceptions of remote consultations were accessed by a web link survey, filled in, and sent back within 48 h after each consultation. The experience in our sample was positive, and the meetings were resolutive in most cases, requiring an in-person evaluation in less than 16% of cases. The absence of a physical examination did not impact the final care in our patient sample, which may be related to the fact that we only included patients with a known diagnosis of acromegaly, in long-term clinical follow-up in our service, in which the empathy and physician–patient relationships were previously established.

All the medical team was unfamiliar with telemedicine before the pandemic. The main disadvantages reported by physicians were the longer time spent trying to contact the patients, the inability to access records, and the subsequent virtual contacts necessary to complement information or laboratory tests. Our data are in accordance with other authors, and we agree that telemedicine can be used for selected groups of patients in the post-COVID-19 era.²⁹

During the first 6 months of virtual monitoring, 10 (13%) of acromegalic patients reported COVID-19. Most of the cases were mild and moderate, but four confirmed cases required hospitalization. Telemedicine improved communication between patients and the medical team allowed immediate notification of symptoms and confirmed PCR tests. Another great advantage was better contact and proximity with patients' families during the course of the infection in outpatients.

Our data suggest that the sustainability of exclusive telemedicine for long periods of time is very difficult, and we highlight the need for better training of assistance teams for using the different platforms, for the achievement of the main objectives of good medical practice, including empathy, compassion, and ethics.³⁰

Telemedicine is a very important tool for maintaining essential health services during the pandemic, but can become a sustainable resource for educational initiatives and patient-centered care.^22
–24 Telemedicine innovations should be designed to increase the quality of care, with safety, effectiveness, efficiency, and comparable to face-to-face visits.³¹

Conclusion

Telemedicine can complement traditional ambulatory and hospital-based practices, creating an opportunity to implement remote follow-up and patient-centered care. Wherever feasible, less costly solutions that take advantage of telemedicine's capabilities should be incorporated into the future to reduce risks of health care disruption. In the nonurgent care setting, the forced transition to video visits have demonstrated its feasibility, satisfaction, and its value in promoting social distancing, concerning an important tool in low-incoming countries. Our study suggests that telemedicine could be adopted interchangeably with in-person consultations in acromegalic patients with stable disease.

Footnotes

Acknowledgments

The authors acknowledge Dr. Diogo de Amorim Barros and Silas Dino de Sousa from Management of the Specialized Pharmaceutical Assistance from Secretary of Health of the Federal District, for accepting electronic prescriptions and being responsible for the feasibility of home delivery of medications; Dr. Silvio de Paiva Fonseca, from Sabin Medicina Diagnóstica for making feasible the blood sampling at home; The National Council of Scientific Research (CNPq) for supporting Prof. Luciana Ansaneli Naves. We thank to Sabin Medicina Diagnóstica and Instituto Sabin for nonprofit laboratorial analysis of this cohort of patients. The authors thank Gabriela Naves Rosa for editing all figures.

Authors' Contributions

L.A.N. contributed to the study design, clinical responsibilities, and writing and reviewing the report. I.N.R. contributed to the conceptualization of the study, data collection, and writing and collecting the forms. T.A.d.S.L., L.B.S., L.F.C., and L.A.C. contributed to writing and reviewing the text. All authors approved the article.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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