Equity-centered digital health implementation: stratified patient-reported outcomes and usability of nurse-assisted teleconsultation in Brazil’s unified health system

Background: Digital health has the potential to expand access to care for chronic diseases. However, poorly designed interventions can exacerbate existing inequities. Evidence from universal public health systems in low- and middle-income countries remains scarce, particularly regarding the usability and acceptability of teleconsultation among populations at high risk of digital exclusion. We evaluated equity-stratified patient-reported outcomes and usability of nurse-assisted teleconsultation for type 2 diabetes within Brazil’s Unified Health System (SUS). Methods: We performed a pre-specified secondary analysis of the TELECONSULTA trial (N = 278), comparing nurse-assisted video teleconsultation delivered in primary care units with standard in-person specialist care. Seven satisfaction domains were assessed using dichotomized patient-reported outcomes. Usability was measured using the Telehealth Usability Questionnaire. Digital vulnerability was stratified into three categories based on educational attainment. Risk ratios were estimated with false discovery rate correction. Interaction tests explored effect modification by digital-risk strata. Results: Teleconsultation was associated with a 48% relative reduction in sleep dissatisfaction compared with in-person care (p = 0.047). Overall satisfaction was similar. Dissatisfaction with sexual health (~29%) and physical activity (~30%) persisted in both groups. High digital-risk participants reported no overall dissatisfaction with teleconsultation (0% vs 9.1% in-person). Usability was uniformly high across all educational levels. One hundred percent of participants rated teleconsultation as “easy to use”. Interaction tests showed no evidence of widening inequities. Conclusions: Nurse-assisted, primary care-embedded teleconsultation preserved patient experience and achieved equitable usability among digitally vulnerable populations within a universal public health system. The findings demonstrate that equity-centered design can prevent digital exclusion. Persistent dissatisfaction in sexual health and physical activity underscores the need for broader system redesign beyond consultation modality. These findings provide actionable design principles for equity-centered digital health policies in universal health systems, supporting scalable teleconsultation models that prevent the widening of digital divides.