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Neill R, Zia N, Ashraf L, Khan Z, Pryor W, Bachani AM. Integration measurement and its applications in low- and middle-income country health systems: a scoping review. BMC Public Health 2023; 23:1876. [PMID: 37770887 PMCID: PMC10537146 DOI: 10.1186/s12889-023-16724-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 09/08/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND Despite growing interest in and commitment to integration, or integrated care, the concept is ill-defined and the resulting evidence base fragmented, particularly in low- and middle-income countries (LMICs). Underlying this challenge is a lack of coherent approaches to measure the extent of integration and how this influences desired outcomes. The aim of this scoping review is to identify measurement approaches for integration in LMICs and map them for future use. METHODS Arksey and O'Malley's framework for scoping reviews was followed. We conducted a systematic search of peer-reviewed literature measuring integration in LMICs across three databases and screened identified papers by predetermined inclusion and exclusion criteria. A modified version of the Rainbow Model for Integrated Care guided charting and analysis of the data. RESULTS We included 99 studies. Studies were concentrated in the Africa region and most frequently focused on the integration of HIV care with other services. A range of definitions and methods were identified, with no single approach for the measurement of integration dominating the literature. Measurement of clinical integration was the most common, with indicators focused on measuring receipt of two or more services provided at a single point of time. Organizational and professional integration indicators were focused on inter- and intra-organizational communication, collaboration, coordination, and continuity of care, while functional integration measured common information systems or patient records. Gaps were identified in measuring systems and normative integration. Few tools were validated or publicly available for future use. CONCLUSION We identified a wide range of recent approaches used to measure integration in LMICs. Our findings underscore continued challenges with lack of conceptual cohesion and fragmentation which limits how integration is understood in practice.
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Affiliation(s)
- Rachel Neill
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins International Injury Research Unit, Health Systems Program, 615 N. Wolfe Street Suite E8527, Baltimore, MD, 21205, USA.
| | - Nukhba Zia
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins International Injury Research Unit, Health Systems Program, 615 N. Wolfe Street Suite E8527, Baltimore, MD, 21205, USA
| | - Lamisa Ashraf
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins International Injury Research Unit, Health Systems Program, 615 N. Wolfe Street Suite E8527, Baltimore, MD, 21205, USA
| | - Zainab Khan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins International Injury Research Unit, Health Systems Program, 615 N. Wolfe Street Suite E8527, Baltimore, MD, 21205, USA
| | - Wesley Pryor
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, 3010, Australia
| | - Abdulgafoor M Bachani
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins International Injury Research Unit, Health Systems Program, 615 N. Wolfe Street Suite E8527, Baltimore, MD, 21205, USA
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Vargas I, Mogollón-Pérez AS, Eguiguren P, Samico I, Bertolotto F, López-Vázquez J, Amarilla DI, De Paepe P, Vázquez ML. Lessons learnt from the process of designing care coordination interventions through participatory action research in public healthcare networks of six Latin American countries. Health Res Policy Syst 2023; 21:39. [PMID: 37264416 DOI: 10.1186/s12961-023-00985-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 04/27/2023] [Indexed: 06/03/2023] Open
Abstract
BACKGROUND The participation of health professionals in designing interventions is considered vital to effective implementation, yet in areas such as clinical coordination is rarely promoted and evaluated. This study, part of Equity-LA II, aims to analyse the design process of interventions to improve clinical coordination, taking a participatory-action-research (PAR) approach, in healthcare networks of Argentina, Brazil, Chile, Colombia, Mexico and Uruguay. This participatory process was planned in four phases, led by a local steering committee (LSC): (1) dissemination of problem analysis results and creation of professionals' platform, (2) selection of problems and intervention (3) intervention design and planning (4) adjustments after evaluation of first implementation stage. METHODS A descriptive qualitative study based on documentary analysis, using a topic guide, was conducted in each intervention network. Documents produced regarding the intervention design process were selected. Thematic content analysis was conducted, generating mixed categories taken from the topic guide and identified from data. Main categories were LSC characteristics, type of design process (phases, participants' roles, methods) and associated difficulties, coordination problems and interventions selected. RESULTS LSCs of similar composition (managers, professionals and researchers) were established, with increasing membership in Chile and high turnover in Argentina, Colombia and Mexico. Following results dissemination and selection of problems and interventions (more participatory in Chile and Colombia: 200-479 participants), the interventions were designed and planned, resulting in three different types of processes: (1) short initial design with adjustments after first implementation stage, in Colombia, Brazil and Mexico; (2) longer, more participatory process, with multiple cycles of action/reflection and pilot tests, in Chile; (3) open-ended design for ongoing adaptation, in Argentina and Uruguay. Professionals' time and the political cycle were the main barriers to participation. The clinical coordination problem selected was limited communication between primary and secondary care doctors. To address it, through discussions guided by context and feasibility criteria, interventions based on mutual feedback were selected. CONCLUSIONS As expected in a flexible PAR process, its rollout differed across countries in participation and PAR cycles. Results show that PAR can help to design interventions adapted to context and offers lessons that can be applied in other contexts.
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Affiliation(s)
- Ingrid Vargas
- Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Avenida Tibidabo 21, 08022, Barcelona, Spain.
| | - Amparo-Susana Mogollón-Pérez
- Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Cra 24 No. 63C-69, Quinta Mutis, 11001, Bogotá, Colombia
| | - Pamela Eguiguren
- Escuela de Salud Pública Dr. Salvador Allende Gossens, Facultad de Medicina, Universidad de Chile, Avenida Independencia, 939, Santiago de Chile, Chile
| | - Isabella Samico
- Instituto de Medicina Integral Prof. Fernando Figueira-IMIP, Rua Dos Coelhos No. 300, Boa Vista, 50070-550, Recife, Brasil
| | - Fernando Bertolotto
- Facultad de Enfermería, Universidad de la República, Avenida 18 de Julio 124, 11200, Montevideo, Uruguay
| | - Julieta López-Vázquez
- Instituto de Salud Pública, Universidad Veracruzana, Avenida Dr. Luis Castelazo Ayala S/N. Col. Industrial Ánimas, 91190, Xalapa, Veracruz, México
| | - Delia-Inés Amarilla
- Centro de Estudios Interdisciplinarios, Universidad Nacional de Rosario, Rosario, Argentina
| | - Pierre De Paepe
- Public Sector Care Unit, Department of Public Health, Prince Leopold Institute of Tropical Medicine, Nationalestraat 155, 2000, Antwerp, Belgium
| | - María-Luisa Vázquez
- Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Avenida Tibidabo 21, 08022, Barcelona, Spain
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Espinel-Flores V, Tiburcio-Lara G, Vargas I, Eguiguren P, Mogollón-Pérez AS, Ferreira-de-Medeiros-Mendes M, López-Vázquez J, Bertolotto F, Amarilla D, Vázquez ML. Relational Continuity of Chronic Patients with Primary and Secondary Care Doctors: A Study of Public Healthcare Networks of Six Latin American Countries. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13008. [PMID: 36293587 PMCID: PMC9602030 DOI: 10.3390/ijerph192013008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/05/2022] [Accepted: 10/07/2022] [Indexed: 06/16/2023]
Abstract
Despite relational continuity (RC) with the doctor being key to care quality for chronic patients, particularly in fragmented healthcare systems, like many in Latin America (LA), little is known about RC and its attributes, particularly regarding specialists. Aim: We aim to analyse chronic patients' perceptions of RC with primary (PC) and secondary (SC) care doctors, and record changes between 2015 and 2017 in the public healthcare networks of six LA countries. An analysis of two cross-sectional studies applying the CCAENA questionnaire to chronic patients (N = 4881) was conducted in Argentina, Brazil, Chile, Colombia, Mexico, and Uruguay. The dependent variables of RC with PC and SC doctors were: consistency, trust, effective communication, and synthetic indexes based on RC attributes. Descriptive and multivariate analyses were performed. Although the RC index was high in 2015, especially in PC in all countries, and at both levels in Argentina and Uruguay, low perceived consistency of PC and SC doctors in Colombia and Chile and of SC doctors in Mexico revealed important areas for improvement. In 2017 the RC index of SC doctors increased in Chile and Mexico, while SC doctors' consistency in Colombia decreased. This study reveals important gaps in achieving RC with doctors, particularly in SC, which requires further structural and organisational reforms.
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Affiliation(s)
- Verónica Espinel-Flores
- Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Avinguda Tibidabo 21, ES08022 Barcelona, Spain
| | - Gabriela Tiburcio-Lara
- Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Avinguda Tibidabo 21, ES08022 Barcelona, Spain
| | - Ingrid Vargas
- Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Avinguda Tibidabo 21, ES08022 Barcelona, Spain
| | - Pamela Eguiguren
- Escuela de Salud Pública Dr. Salvador Allende Gossens, Universidad de Chile, Independencia 939, Santiago de Chile, Chile
| | - Amparo-Susana Mogollón-Pérez
- Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Cra 24 No. 63C-69, Quinta Mutis, Bogotá 11001, Colombia
| | - Marina Ferreira-de-Medeiros-Mendes
- Grupo de Estudos de Gestão e Avaliação em Saúde, Instituto de Medicina Integral Professor Fernando Figueira, Rua Dos Coelhos No. 300, Boa Vista, Recife 50070-550, Brazil
| | - Julieta López-Vázquez
- Instituto de Salud Pública, Universidad Veracruzana, Av. Dr. Luis Castelazo Ayala s/n Col. Industrial Ánimas, Xalapa 91190, Mexico
| | - Fernando Bertolotto
- Facultad de Enfermería, Universidad de la República, Avenida 18 de Julio 124, Montevideo 11200, Uruguay
| | - Delia Amarilla
- Maestría en Salud Pública, Centro de Estudios Interdisciplinarios, Universidad Nacional de Rosario, Maipú 1065, Rosario 2000, Argentina
| | - María-Luisa Vázquez
- Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Avinguda Tibidabo 21, ES08022 Barcelona, Spain
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Guerra S, Martelli PJDL, Dubeux LS, Marques P, Samico IC. [Coordination of clinical management between levels: the views of physicians in primary and specialized care in Recife, Pernambuco State, Brazil]. CAD SAUDE PUBLICA 2022; 38:e00262921. [PMID: 35649101 DOI: 10.1590/0102-311xpt262921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 02/15/2022] [Indexed: 11/22/2022] Open
Abstract
This study analyzed the views of physicians towards coordination of clinical management between different levels of care. This was a cross-sectional quantitative study using data from a survey of 182 physicians in primary healthcare (PHC) and specialized care in Recife, Pernambuco State, Brazil, in 2017. The results revealed significant differences in the physicians' experience. Considering referrals, the majority (81.32%) felt that PHC physicians referred patients to specialized care when necessary, and the proportion was higher in PHC physicians themselves (92.73%). As for agreement, two-thirds of PHC physicians (67.27%) reported that they agreed with the treatment prescribed by the specialist, while only 33.86% of the specialists agreed with the PHC physician. Concerning clinical responsibility, 89.09% of PHC physicians reported that they were clinically responsible for the patient, compared to only 43.31% of the specialists. As for recommendations, most of the interviewees (63.19%) felt that the specialists did not issue recommendations, and this proportion was higher among PHC physicians (81.82%). For waiting time, the majority (82.42%) felt that patients waited too long for appointments in specialized care, and the proportion was higher among PHC physicians (98.18%) than among specialists (75.59%). Only 16.36% of PHC physicians felt that waiting time was too long in PHC, compared to 38.58% of the medical specialists. The study's results are consistent with similar studies and highlight the need to strengthen coordination between levels of care to achieve effective integration in healthcare networks.
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Affiliation(s)
- Sofia Guerra
- Grupo de Estudos em Gestão e Avaliação em Saúde, Instituto de Medicina Integral Prof. Fernando Figueira, Recife, Brasil
| | | | - Luciana Santos Dubeux
- Grupo de Estudos em Gestão e Avaliação em Saúde, Instituto de Medicina Integral Prof. Fernando Figueira, Recife, Brasil
| | - Pedro Marques
- Grupo de Estudos em Gestão e Avaliação em Saúde, Instituto de Medicina Integral Prof. Fernando Figueira, Recife, Brasil
| | - Isabella Chagas Samico
- Grupo de Estudos em Gestão e Avaliação em Saúde, Instituto de Medicina Integral Prof. Fernando Figueira, Recife, Brasil
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León-Arce HG, Chávez Chávez J, Mogollón-Pérez AS, Vargas I, Vázquez ML. Implementing joint training sessions of general practitioners and specialists aimed at improving clinical coordination in Colombia: Contributions from participatory action research. J Health Serv Res Policy 2022; 27:261-268. [PMID: 35603753 DOI: 10.1177/13558196221094676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To analyse the contribution of participatory action research (PAR) in designing and implementing joint training sessions as a means to improve clinical coordination in a public health care network in Bogotá, Colombia. METHODS A qualitative, descriptive-interpretative study using semi-structured individual interviews and focus groups with 40 professionals (GPs, specialists, members of the local steering committee (LSC) and network middle managers) involved in designing and implementing joint training sessions to improve cross-level clinical coordination. The intervention consisted of two forms of joint training sessions for GPs and specialists, implemented through two PAR cycles. RESULTS The PAR approach in designing and implementing joint training sessions led to greater awareness of clinical coordination problems and helped adapting sessions to the local health care context. Study participants highlighted the role of LSC leadership during the PAR process and the importance of ensuring the necessary resources for adopting the intervention. Limited institutional support and differences between joint training sessions affected doctors' participation and reduced the time available to conduct the sessions. The use of a reflexive method was essential in enhancing doctors' participation, along with session duration, the facilitator's role and session content. CONCLUSIONS The study provides evidence regarding the contribution of a PAR process to designing and implementing joint training sessions for improving clinical coordination. The findings can inform similar approaches in other health systems.
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Affiliation(s)
- Heisel G León-Arce
- Junior researcher at the School of Medicine and Health Sciences, 25807Universidad del Rosario, Bogotá, Colombia.,PhD Student, Department of Paediatrics, Obstetrics & Gynaecology and Preventative Medicine, Universitat Autònoma de Barcelona, Spain
| | - Josefina Chávez Chávez
- Junior researcher at the School of Medicine and Health Sciences, 25807Universidad del Rosario, Bogotá, Colombia
| | | | - Ingrid Vargas
- Senior researcher, Health Policy and Health Services Research Group Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Barcelona, Spain
| | - María-Luisa Vázquez
- Head, Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Barcelona, Spain
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Vázquez ML, Miranda-Mendizabal A, Eguiguren P, Mogollón-Pérez AS, Ferreira-de-Medeiros-Mendes M, López-Vázquez J, Bertolotto F, Vargas I. Evaluating the effectiveness of care coordination interventions designed and implemented through a participatory action research process: Lessons learned from a quasi-experimental study in public healthcare networks in Latin America. PLoS One 2022; 17:e0261604. [PMID: 35020735 PMCID: PMC8754346 DOI: 10.1371/journal.pone.0261604] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 12/06/2021] [Indexed: 11/27/2022] Open
Abstract
Background Despite increasing recommendations for health professionals to participate in intervention design and implementation to effect changes in clinical practice, little is known about this strategy’s effectiveness. This study analyses the effectiveness of interventions designed and implemented through participatory action research (PAR) processes in healthcare networks of Brazil, Chile, Colombia, Mexico and Uruguay to improve clinical coordination across care levels, and offers recommendations for future research. Methods The study was quasi-experimental. Two comparable networks, one intervention (IN) and one control (CN), were selected in each country. Baseline (2015) and evaluation (2017) surveys of a sample of primary and secondary care doctors (174 doctors/network/year) were conducted using the COORDENA® questionnaire. Most of the interventions chosen were based on joint meetings, promoting cross-level clinical agreement and communication for patient follow-up. Outcome variables were: a) intermediate: interactional and organizational factors; b) distal: experience of cross-level clinical information coordination, of clinical management coordination and general perception of coordination between levels. Poisson regression models were estimated. Results A statistically significant increase in some of the interactional factors (intermediate outcomes) -knowing each other personally and mutual trust- was observed in Brazil and Chile INs; and in some organizational factors -institutional support- in Colombia and Mexico. Compared to CNs in 2017, INs of Brazil, Chile, Colombia and Mexico showed significant differences in some factors. In distal outcomes, care consistency items improved in Brazil, Colombia and Uruguay INs; and patient follow-up improved in Chile and Mexico. General perception of clinical coordination increased in Brazil, Colombia and Mexico INs. Compared to CNs in 2017, only Brazil showed significant differences. Conclusions Although more research is needed, results show that PAR-based interventions improved some outcomes regarding clinical coordination at network level, with differences between countries. However, a PAR process is, by definition, slow and gradual, and longer implementation periods are needed to achieve greater penetration and quantifiable changes. The participatory and flexible nature of interventions developed through PAR processes poses methodological challenges (such as defining outcomes or allocating individuals to different groups in advance), and requires a comprehensive mixed-methods approach that simultaneously evaluates effectiveness and the implementation process to better understand its outcomes.
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Affiliation(s)
- María-Luisa Vázquez
- Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Barcelona, Spain
| | - Andrea Miranda-Mendizabal
- Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Barcelona, Spain
- School of Medicine and Health Sciences, International University of Catalonia (UIC), Sant Cugat del Vallès, Spain
| | - Pamela Eguiguren
- Escuela de Salud Pública Dr. Salvador Allende Gossens, Facultad de Medicina, Universidad de Chile, Santiago de Chile, Chile
| | | | | | | | | | - Ingrid Vargas
- Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Barcelona, Spain
- * E-mail:
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Understanding How to Improve the Use of Clinical Coordination Mechanisms between Primary and Secondary Care Doctors: Clues from Catalonia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18063224. [PMID: 33804691 PMCID: PMC8003988 DOI: 10.3390/ijerph18063224] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 03/10/2021] [Accepted: 03/11/2021] [Indexed: 01/27/2023]
Abstract
Clinical coordination between primary (PC) and secondary care (SC) is a challenge for health systems, and clinical coordination mechanisms (CCM) play an important role in the interface between care levels. It is therefore essential to understand the elements that may hinder their use. This study aims to analyze the level of use of CCM, the difficulties and factors associated with their use, and suggestions for improving clinical coordination. A cross-sectional online survey-based study using the questionnaire COORDENA-CAT was conducted with 3308 PC and SC doctors in the Catalan national health system. Descriptive bivariate analysis and logistic regression models were used. Shared Electronic Medical Records were the most frequently used CCM, especially by PC doctors, and the one that presented most difficulties in use, mostly related to technical problems. Some factors positively associated with frequent use of various CCM were: working full-time in integrated areas, or with local hospitals. Interactional and organizational factors contributed to a greater extent among SC doctors. Suggestions for improving clinical coordination were similar between care levels and related mainly to the improvement of CCM. In an era where management tools are shifting towards technology-based CCM, this study can help to design strategies to improve their effectiveness.
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