Evaluating the effectiveness of care integration strategies in different healthcare systems in Latin America: the EQUITY-LA II quasi-experimental study protocol

Integration measurement and its applications in low- and middle-income country health systems: a scoping review

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.

Lessons learnt from the process of designing care coordination interventions through participatory action research in public healthcare networks of six Latin American countries

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.

Improving equity in access to early diagnosis of cancer in different healthcare systems of Latin America: protocol for the EquityCancer-LA implementation-effectiveness hybrid study

INTRODUCTION

Healthcare fragmentation, a main cause for delay in cancer diagnosis and treatment, contributes to high mortality in Latin America (LA), particularly among disadvantaged populations. This research focuses on integrated care interventions, which have been limitedly implemented in the region. The objective is to evaluate the contextual effectiveness of scaling-up an integrated care intervention to improve early diagnosis of frequent cancers in healthcare networks of Chile, Colombia and Ecuador.

METHODS AND ANALYSIS

This research is two pronged: (A) quasi-experimental design (controlled before and after) with an intervention and a control healthcare network in each LA country, using an implementation-effectiveness hybrid approach to assess the intervention process, effectiveness and costs; and (B) case study design to analyse access to diagnosis of most frequent cancers. Focusing on the most vulnerable socioeconomic population, it develops in four phases: (1) analysis of delays and barriers to early diagnosis (baseline); (2) intervention adaptation and implementation (primary care training, fast-track referral pathway and patient information); (3) intracountry evaluation of intervention and (4) cross-country analysis. Baseline and evaluation studies adopt mixed-methods qualitative (semistructured individual interviews) and quantitative (patient questionnaire survey) methods. For the latter, a sample size of 174 patients with cancer diagnosis per healthcare network and year was calculated to detect a proportions difference of 15%, before and after intervention (α=0.05; β=0.2) in a two-sided test. A participatory approach will be used to tailor the intervention to each context, led by a local steering committee (professionals, managers, policy makers, patients and researchers).

ETHICS AND DISSEMINATION

This study complies with international and national legal stipulations on ethics. It was approved by each country's ethical committee and informed consent will be obtained from participants. Besides the coproduction of knowledge with key stakeholders, it will be disseminated through strategies such as policy briefs, workshops, e-tools and scientific papers.

Relational Continuity of Chronic Patients with Primary and Secondary Care Doctors: A Study of Public Healthcare Networks of Six Latin American Countries

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.

[Coordination of clinical management between levels: the views of physicians in primary and specialized care in Recife, Pernambuco State, Brazil]

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.

Implementing joint training sessions of general practitioners and specialists aimed at improving clinical coordination in Colombia: Contributions from participatory action research

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.

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

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.

Construção participativa da modelização das ações educacionais da estratégia de Planificação da Atenção à Saúde: subsídios para avaliação da efetividade

A estratégia de Planificação da Atenção à Saúde configura-se como um potente dispositivo de reorganização dos processos de trabalho nas redes de atenção à saúde e vem sendo implementada pelo conselho nacional de secretários de saúde desde 2013, em 25 regiões de saúde de 11 estados brasileiros, ofertando um conjunto de ações educacionais aos profissionais do sistema único de saúde. Este estudo objetiva descrever o processo de construção participativa e consenso da modelização das ações educacionais, para subsidiar a avaliação da efetividade da estratégia. A construção da modelização foi realizada por meio da consulta a 18 informantes-chave, selecionados intencionalmente pela sua proximidade com o planejamento e a execução das ações educacionais. Os informantes analisaram individualmente a modelização inicialmente proposta, declarando seu grau de concordância acerca do conteúdo e fornecendo sugestões e comentários, os quais foram analisados pelos pesquisadores. O percentual mínimo de concordância total previamente estabelecido de 75% foi obtido ao final de três rodadas de consulta. Importantes sugestões foram realizadas ao longo das rodadas, evidenciando os elementos prioritários para subsidiar a avaliação da efetividade da estratégia. Os percentuais finais de concordância total da modelização variaram entre 76,5% e 100%, de acordo com o componente, demonstrando que a modelização construída participativamente pode ser considerada satisfatória. Essa construção pode estimular pesquisas a respeito de estratégias que busquem qualificar a resposta do sistema de saúde, por meio do desenvolvimento de competências, habilidades e atitudes de seus profissionais.

Continuidade da gestão clínica entre níveis assistenciais: experiências dos usuários de uma rede municipal de saúde

Este estudo analisa as experiências dos usuários sobre a continuidade da gestão clínica entre níveis assistenciais. Trata-se de um estudo transversal, quantitativo, que utiliza dados de um inquérito realizado com 407 usuários de uma rede pública de saúde de Recife, Pernambuco, Brasil, nos anos de 2017 e 2018. As experiências sobre a continuidade da gestão clínica foram exploradas a partir de duas dimensões: coerência da atenção e acessibilidade entre níveis assistenciais. Os usuários apresentaram opiniões mais positivas sobre a coerência da atenção que sobre a acessibilidade. Quanto à coerência da atenção, a maioria dos usuários referiu que os médicos da atenção primária e da especializada concordam entre si quanto a diagnóstico, tratamento e recomendações, e que o médico da atenção primária encaminha ao especialista quando necessário. Apenas 43% dos usuários relataram existir colaboração entre os médicos para resolução dos seus problemas de saúde. Quanto à acessibilidade, a maioria dos usuários (77,2%) referiu um longo tempo de espera para a consulta com o especialista e menos da metade (48,9%) referiu demora para atendimento na atenção primária. Os resultados deste estudo coincidem com outras investigações e evidenciam a necessidade de fomentar estratégias para alcançar uma integração efetiva das redes assistenciais e assim conferir ao usuário uma maior continuidade dos cuidados em saúde.

Assessing the Impact of Clinical Coordination Interventions on the Continuity of Care for Patients With Chronic Conditions: Participatory Action Research in Five Latin American Countries

Although fragmentation in the provision of services is considered an obstacle to effective health care, there is scant evidence on the impact of interventions to improve care coordination between primary care and secondary care in terms of continuity of care -i.e. from the patient perspective- particularly in Latin America (LA). Within the framework of the Equity-LA II project, interventions to improve coordination across care levels were implemented in five LA countries (Brazil, Chile, Colombia, Mexico and Uruguay) through a participatory action research (PAR) process. This paper analyses the impact of these PAR interventions on the cross-level continuity of care of chronic patients in public healthcare networks. A quasi-experimental study was performed with measurements based on two surveys of a sample of patients with chronic conditions (392 per network; 800 per country). Both the baseline (2015) and evaluation (2017) surveys were conducted using the CCAENA questionnaire. In each country, two comparable public healthcare networks were selected, one intervention and one control. Outcomes were cross-level continuity of information and of clinical management. Descriptive analyses were conducted and Poisson regression models with robust variance fitted to estimate changes. With differences between countries, the results showed improvements in cross-level continuity of clinical information (transfer of clinical information) and of clinical management (care coherence). These results are consistent with those of previous studies on the effectiveness of the interventions implemented in each country in improving care coordination in Brazil, Chile, and Colombia. Differences between countries are probably related to particular contextual factors and events that occurred during the implementation process. This supports the notion that certain context and process factors are needed to improve continuity of care. The results provide evidence that, although the interventions were designed to enhance care coordination and aimed at health professionals, patients report improvements in continuity of care.

Interventions to Improve Clinical Coordination between Levels: Participatory Experience in a Public Healthcare Network in Xalapa, Mexico

INTRODUCTION

Coordination of care can be improved through an intervention or a combination of several ones. In addition, it is recommended to encourage the active involvement of professionals in the design, implementation and assessment of coordination mechanisms.

OBJECTIVE

To analyse the factors that influence the implementation of participatively designed interventions and their effects on clinical coordination between levels of care in a public healthcare network of health services in Xalapa, Veracruz, Mexico.

METHODS

A qualitative, descriptive-interpretative study, for which individual interviews and discussion groups with a criterion sample of participants: Local Steering Committee and the Professional Platform. A content analysis, with mixed category generation and segmentation by intervention and topics, was carried out. According to the problem analysis, participants designed two sequential interventions: offline virtual consultation, and joint training meetings on maternal health and chronic diseases.

RESULTS

Respondents perceived a differentiated impact on clinical coordination according to intervention: greater in the case of joint maternal health trainings and limited for the chronic diseases meetings, as they were the offline virtual consultation was rarely used.

CONCLUSION

The involvement of professionals in designing the interventions, as well as institutional support and reflexive methods for training, all decisively improved clinical coordination between levels.

Treatment outcome and readmission risk among women in women-only versus mixed-gender drug treatment programs in Chile

Introduction:

Traditional treatment programs for substance use disorder (SUD) tend to be male-dominated environments, which can negatively affect women’s access to treatment and related outcomes. Women’s specific treatment needs have led some providers to develop women-only SUD treatment programs in several countries. In Chile, women-only programs were only fully implemented in 2010. We compared treatment outcomes and readmission risk for adult women admitted to state-funded women-only versus mixed-gender SUD treatment programs in Chile.

Methods:

We used a registry-based retrospective cohort design of adult women in women-only (N = 8200) and mixed-gender (N = 13,178) SUD treatment programs from 2010 to 2019. The study obtained data from the National Drug and Alcohol Service from Chile. We used a multistate model to estimate the probabilities of experiencing treatment completion, discharge without completion (i.e., patient-initiated discharge and administrative discharge), or readmission, as well as the likelihood of being readmitted, conditioned on prior treatment outcome. We adjusted models for multiple baseline characteristics (e.g., substance use, socioeconomic).

Results:

Overall, 24% of women completed treatment and 54% dropped out of treatment. The proportion of patient-initiated discharges within the first three month was larger in women-only than in mixed-gender programs (19% vs. 12%). In both programs, women who completed treatment were more likely to experience readmission at three months, and one and three years. In the long term, women in the women-only programs were more likely to complete treatment than women in mixed-gender programs (34% vs. 23%, respectively). The readmission probability was higher among women who previously completed treatment than those who had a discharge without completion (40% vs 21% among women in women-only programs; 38% vs. 19% among women in mixed-gender programs, respectively); no differences occurred in the risk of readmission between women-only and mixed-gender programs.

Conclusions:

In terms of treatment outcomes and readmission risk, women-only programs had similar results to mixed-gender programs in Chile. The added value of these specialized programs should be addressed in further research.

Coordenação do cuidado no Consultório na Rua no município do Rio de Janeiro: romper barreiras e construir redes

RESUMO O objetivo do artigo foi caracterizar arranjos e ações de coordenação do cuidado desenvolvidos pelo Consultório na Rua (CnaR). Foi realizado estudo qualitativo a partir de observação participante e entrevistas com profissionais do CnaR e serviços de referência em um município de grande porte. A coordenação do cuidado foi analisada nas dimensões horizontal e vertical. Os resultados mostram que a coordenação horizontal é fortalecida pelo acolhimento, pela presença e insistência da equipe em estar nas ruas, em reunir-se formal e informalmente, pela plasticidade da agenda e pelos diversos agenciamentos para garantia da estada dos usuários em outros espaços dentro e fora do setor saúde. O desenvolvimento de ações intersetoriais enfrenta diferentes concepções das políticas e do direito à saúde entre os órgãos governamentais. A coordenação entre níveis é ainda mais frágil pela fragmentação dos serviços, ausência de comunicação profissional, exigência de documentos, desresponsabilização dos demais serviços e precariedade dos vínculos laborais que impediam a tessitura de relações duradouras na rede. Iniciativas de coordenação do cuidado pelo CnaR reafirmam seu papel estratégico na composição de redes, negociações, tensões e desconfortos que pode provocar ao reconduzir, ainda que de forma parcial, excluídos ao campo da cidadania e do direito à saúde.

Experience with coordination of care between primary care physicians and specialists and related factors

The article analyzes the coordination of information and clinical management between levels of care in physicians' experience and explores related labor and organizational factors and attitudes towards the work and interaction. This is a cross-sectional study with application of the COORDENA-BR questionnaire to a sample of 64 primary health care (PHC) physicians and 56 specialized care (SC) from the public system in a medium-sized Brazilian city. The results show limited linkage of care in the Healthcare Network (RAS), with differences between PHC and SC. There is no exchange of information on diagnosis, treatment, or tests. Physicians in PHC agree more on the treatments prescribed by the specialists than vice versa, but repetition of tests is not frequent. PHC physicians refer patients to SC when necessary. Most medical specialists do not refer patients for follow-up consultations in PHC when necessary and do not give orientation to PHC physicians, who in turn fail to resolve their doubts with SC. Both PHC and specialties report long waiting times for specialist consultations. Temporary employment contracts are more common in PHC. Consultation time was considered too short for coordination between the two. Most physicians do not plan to change jobs, despite their heavy dissatisfaction with wages and work. Physicians do not know each other personally, and specialists do not identify physicians in PHC as the coordinators of care. Policies and measures to guarantee structural conditions to improve access, working conditions, and more favorable mutual adaptation need to be implemented systemically to the set of services in the Brazilian Unified National Health System (SUS).

[Barriers and factors associated with the use of coordination mechanisms between levels of care in Mexico]

The aim was to analyze the level and characterize the use of clinical coordination mechanisms between levels of care, and their associated factors, in two public networks of health services in Mexico. A cross-sectional study was carried out using the COORDENA questionnaire to primary and specialized care physicians in the state of Veracruz. Differences were found between networks and levels of care, according to the mechanism. In both, the referral/counter-referral is mostly used to channel the patient to another level, mainly by primary care physicians. A high reception of referrals by specialists was identified, but few counterreferences in primary care. Being a man and recognizing the primary care physician, as responsible for monitoring the patient in his/her healthcare career, were factors associated with the frequent sending of the counter-referral by specialists. The discharge report is used in both networks to send clinical information to the other level, with more sending by specialist doctors, but with less reception in primary care. In both networks, the follow-up to the recommendations of the mechanisms to standardize clinical care was greater by primary care physicians than specialized ones. The use of coordination mechanisms between levels of care is deficient and limited, with greater use of mechanisms to transfer information than for clinical management. The need to implement strategies that consider the participation of professionals is evident, to favor local adaptation, appropriation and improve their use.

Understanding How to Improve the Use of Clinical Coordination Mechanisms between Primary and Secondary Care Doctors: Clues from Catalonia

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.

[Communicational relations between healthcare professionals and their influence on coordination of care]

The study aims to understand the influence of communicational relations among healthcare professionals in the coordination of care between levels. This is a qualitative study with data from the international multicenter study Equity-LA II, with dialectic hermeneutics as the theoretical reference. The authors listened to the audios from 15 interviews with professionals (7 physicians from primary care and 5 from specialized care, and 3 institutional supporters from primary care) in a municipal network in the Agreste region of the state of Pernambuco, Brazil, in 2016. The mixed categories were submitted to content analysis. The analysis revealed a lack of recognition, by nearly all of the professionals, of primary care as the organizational backbone for care, and the perception of coordination revealed obstacles related to disconnects in establishing dialogical relations. Knowledge of the physician's role in primary care is incomplete, and its praxis is viewed with distrust by specialists, while the reciprocal is not true. There was a visibly non-dialogical interpersonal relationship, based on asymmetric relations reflected in the specialist's authoritarian stance and that of inferiority of primary care physicians. The basis for the communicative action relates to pretensions of validity rather than of power, which is external to language, and impedes the discussion of reasons and arguments. There was little disposition for dialogue and reciprocal recognition between the parties involved, with interdiction of a communicative situation in which there is symmetry of participation. The results revealed communicational weaknesses, thus requiring strategies that allow achieving communicative understanding among the professionals and promoting satisfactory patient follow-up between levels of care.

[Evaluation of the collaboration between Primary and Hospital Care in order to improve inappropriate prescription]

INTRODUCTION AND OBJECTIVES

To evaluate the implementation of a collaborative experience between Primary (PC) and Hospital Care (HC) aimed at reducing potentially inappropriate prescribing (PIP) in patients with polypharmacy.

MATERIALS AND METHODS

Collaborative experience including a controlled before-after intervention study, carried out in the Donostialdea Integrated Health Organization (IHO), with Bilbao Basurto IHO as control group, Osakidetza, Basque Health Service. Participant were 227 PC physicians and physicians from 7 hospital services, and patients with 5 or more drugs meeting at least one PIP criteria. The intervention consisted of communication and knowledge between professionals, PC-HC consensus, training, identification of patients at risk, medication review, evaluation and feed-back. The collaboration process (agreements, consensus documents, training activities) and the change in the prevalence of PIP in polymedicated patients (using computerised health records) were evaluated.

RESULTS

A total of 21 PIP criteria and 6 recommendation documents were agreed. An analysis was performed on 15,570 PIP from OSI Donostialdea and 24,866 from the control group. The prevalence of PIP in polymedicated patients was reduced by -4.53% (95% CI: -4.71 to -4.36, P< .0001) in comparison with the control group. The before-after differences were statistically significant across the 7 services.

CONCLUSIONS

PC-HC collaboration is feasible and, along with other intervention components, reduces inappropriate polypharmacy in the context of a recently integrated healthcare organisation. The collaboration process is complex and requires continuous monitoring, policy involvement, leadership that encourages health professional participation, and intensive use of information systems.

Medical heuristics and action-research: professionalism versus science

BACKGROUND

Professional knowledge aims at improving practice. It reduces uncertainty in decision-making, improves effectiveness in action and relevance in evaluation, stimulates reflexivity, and subjects practice to ethical standards. Heuristics is an approach to problem-solving, learning, and discovery employing a practical methodology that, although not optimal, is sufficient for achieving immediate goals. This article identifies the desirable, heuristic particularities of research in professional, medical practice; and it identifies what distinguishes this research from scientific research.

MAIN TEXT

We examine the limits of biomedical and sociological research to produce professional knowledge. Then, we derive the heuristic characteristics of professional research from a meta-analysis of two action-research projects aimed at securing access to essential generic drugs in Senegal and improving physicians' self-assessment and healthcare coordination in Belgium. To study healthcare, biomedical sciences ignore how clinical decisions are implemented. Decisions are built into an articulated knowledge system, such as (clinical) epidemiology, where those studied are standardisable - while taking care of patients is an idiosyncratic, value-based, person-to-person process that largely eludes probabilistic methodologies. Social sciences also reach their limits here because descriptive, interpretative methods cannot help with gesture and speech quality, while the management of the patient's suffering and risks makes each of them unique. Research into medical professionalism is normative as it is intended to formulate recommendations. Scientific data and descriptions are useful to the practitioner randomly, only from the similarities in the environment of the authors and their readers. Such recommendations can be conceived of as strategies, i.e., multi-resource and multi-stage action models to improve clinical and public health practice. Action learning and action-research are needed to design and implement these strategies, because their complexity implies trial and error. To validate a strategy, repeated experiences are needed. Its reproducibility assumes the description of the context. To participate in medical action-research, the investigator needs professional proficiency - a frequent difficulty in academic settings.

CONCLUSION

Some criteria to assess the relevance of publicly funded clinical and public health research can be derived from the difference between scientific and professional knowledge, i.e. the knowledge gained with real-life experience in the field.

Do primary and specialized care physicians know and use coordination mechanisms?

OBJECTIVES:

To analyze if primary and specialized care physicians know and use care coordination mechanisms between healthcare levels.

METHODS:

Cross-sectional survey study, with the application of the COORDENA-BR instrument to primary and specialized care physicians in a public heathcare network, medium-sized municipality, from June to October 2019. The questionnaire addresses knowledge, frequency of sending and receiving, purpose, characteristics and difficulties in using feedback or mutual adaptation and standardization mechanisms to promote coordination of care service between healthcare levels.

RESULTS:

Feedback instruments such as referral and reply letters, hospital discharge report and WhatsApp are widely known by professionals of both levels, without significant differences. Clinical sessions and protocols are not well-known, especially in specialized care, which supposes a low usage of standardization mechanisms to a better coordination between the healthcare levels. Despite being well-known and easy, traditional feedback instruments such as referral and reply letters are not widely used. Fewer physicians knew the protocols, mainly in specialized care. They pointed difficulties in their application, such as insufficient exams and unavailable supplies in the healthcare network. Clinical sessions were unknown and registered low participation frequency. Care overload, low institutionalization and time constraints were barriers identified for the incorporation of care coordination mechanisms in the work process in primary and specialized care, in addition to those related to the provision of health services in the network.

CONCLUSION:

We conclude the fragmentation of the system and care can be faced in the complementarity of measures that make it possible to know the mechanisms, develop professional skills, institutionalize and promote organizational conditions for the effective use of coordination mechanisms throughout the healthcare network.

Can care coordination across levels be improved through the implementation of participatory action research interventions? Outcomes and conditions for sustaining changes in five Latin American countries

BACKGROUND

Finding new strategies for care integration has become a policy priority for many fragmented health systems in Latin America. Although the implementation of interventions through a participatory action research (PAR) approach is considered to be more effective in achieving organizational change, its application is scarce. This study, part of the research project Equity-LA II, aims to analyze the impact of PAR interventions on care coordination across levels, and key aspects for their sustainability and transferability, from the stakeholder viewpoint in healthcare networks of Brazil, Chile, Colombia, Mexico and Uruguay. Different interventions were designed and implemented through a PAR process to improve communication and clinical agreement between primary care and secondary care doctors: joint meetings to discuss clinical cases and/or training; shared care guidelines; offline virtual consultations; a referral and reply letter; and an induction program.

METHODS

A qualitative, descriptive-interpretative study was conducted in the healthcare network of each country. Focus groups and semi-structured individual interviews were conducted with a criterion sample of participants: local steering committee (29) and professional platform members (28), other health professionals (49) and managers (28). Thematic content analysis was conducted, segmented by country and type of intervention.

RESULTS

Informants highlighted that joint meetings based on reflexive methods contributed substantially to improving contextually relevant elements of clinical management coordination - communication in patient follow-up, clinical agreement, appropriateness of referrals - and also administrative coordination. The meetings, alongside the PAR process, also helped to improve interaction between professionals - knowing each other personally and mutual trust - thus fostering willingness to collaborate. The PAR approach, moreover, served to spread awareness of the coordination problems and need for intervention, encouraging greater commitment and interest in participating. No noteworthy contributions were identified in remaining interventions due to low uptake. A necessary condition for the sustainability and replicability was that PAR process had to be used appropriately in a favourable context.

CONCLUSIONS

Evidence is provided on the substantial contribution of interventions to improving locally relevant clinical coordination elements and professional interaction when implemented through an adequate PAR process (in terms of time, method and participation levels), a necessary condition for their sustainability and replicability.

Understanding the factors influencing the implementation of participatory interventions to improve care coordination. An analytical framework based on an evaluation in Latin America

Healthcare coordination is considered key to improving care quality. Although participatory action research (PAR) has been used effectively to bridge the gap between evidence and practice in other areas, little is known about the key success factors of its use in healthcare organizations. This article analyses the factors influencing the implementation of PAR interventions to improve clinical coordination from the perspective of actors in public healthcare networks of Brazil, Chile, Colombia, Mexico and Uruguay. A qualitative, descriptive-interpretative study was conducted in each country's healthcare network. Focus groups and semi-structured individual interviews were conducted to a criterion sample of: local steering committee (LSC) (29), professional platform (PP) (28), health professionals (49) and managers (28). Thematic content analysis was conducted, segmented by country and themes. The PAR process led by the LSC covered the return of baseline results, selection of problems and interventions and design, implementation and adjustment of the intervention, with PP. Interventions were implemented to improve communication and clinical agreement between primary and secondary care. Results reveal that contextual factors, the PAR process and the intervention's content influenced their implementation, interacting across time. First, institutional support providing necessary resources, and professionals' and managers' willingness to participate, emerge as contextual pivotal factors, influenced by other factors related to: the system (alignment with policy and political cycle), networks (lack of time due to work overload and inadequate working conditions) and individuals (not knowing each other and mutual mistrust). Second, different characteristics of the PAR process have a bearing, in turn, on institutional support and professionals' motivation: participation, flexibility, consensual decision-making, the LSC's leadership and the facilitating role of researchers. Evidence is provided that implementation through an adequate PAR process can become a factor of motivation and cohesion that is crucial to the adoption of care coordination interventions, leading to better results when certain contextual factors converge.

Changes in knowledge and use of clinical coordination mechanisms between care levels in healthcare networks of Colombia

Clinical coordination mechanisms (CCMs) have become key tools in healthcare networks for improving coordination between primary care (PC) and secondary care (SC) and are particularly relevant in health systems with highly fragmented healthcare provision. However, their implementation has been little studied to date in Latin America and particularly in Colombia. This study analyses the level of knowledge and use of CCMs between care levels and their changes between 2015 and 2017 in two public healthcare networks in Bogotá, Colombia. Comparison of two cross-sectional studies based on surveys among PC and SC doctors working in their networks (174 doctors per network/year). The COORDENA questionnaire was used for measuring knowledge concerning CCMs and the frequency of use and difficulties involved in using referral/reply letters (R/RLs) and hospital discharge reports (HDRs). Descriptive bivariate analysis and Poisson regression models with robust variance were used for analysing differences between networks and years. The results for both networks and years revealed greater knowledge and use of information coordination mechanisms than those regarding clinical management coordination (though their knowledge increased in 2017). Although widely known and used, significant problems regarding infrequent and late receipt of RLs and HDRs in PC as well as the poor quality of their contents limits their effective use, which may affect the quality of care. Strategies are required to improve CCMs use.

Care continuity across levels of care perceived by patients with chronic conditions in six Latin-American countries

OBJECTIVE

To analyse the care continuity across levels of care perceived by patients with chronic conditions in public healthcare networks in six Latin American countries (Argentina, Brazil, Chile, Colombia, Mexico and Uruguay), and to explore associated factors.

METHOD

Cross-sectional study by means of a survey conducted to a random sample of chronic patients in primary care centres of the study networks (784 per country) using the questionnaire Cuestionario de Continuidad Asistencial Entre Niveles de Atención (CCAENA)©. Patients had at least one chronic condition and had used two levels of care in the 6 months prior to the survey for the same medical condition. Descriptive analysis and multivariable logistic regression were carried out.

RESULTS

Although there are notable differences between the networks analysed, the results show that chronic patients perceive significant discontinuities in the exchange of clinical information between primary care and secondary care doctors and in access to secondary care following a referral; as well as, to a lesser degree, regarding clinical coherence across levels. Relational continuity with primary care and secondary care doctors and information transfer are positively associated with care continuity across levels; no individual factor is systematically associated with care continuity.

CONCLUSIONS

Main perceived discontinuities relate to information transfer and access to secondary care after a referral. The study indicates the importance of organisational factors to improve chronic patients' quality of care.

Do primary and secondary care doctors have a different experience and perception of cross-level clinical coordination? Results of a cross-sectional study in the Catalan National Health System (Spain)

BACKGROUND

Clinical coordination across care levels is a priority for health systems around the world, especially for those based on primary health care. The aim of this study is to analyse the degree of clinical information and clinical management coordination across healthcare levels in the Catalan national health system experienced by primary (PC) and secondary care (SC) doctors and explore the associated factors.

METHODS

Cross-sectional study based on an online survey using the self-administered questionnaire COORDENA-CAT.

DATA COLLECTION

October-December 2017.

STUDY POPULATION

PC and SC (acute and long term) doctors of the Catalan national health system. Participation rate was 21%, with a sample of 3308 doctors.

OUTCOME VARIABLES

cross-level clinical information coordination, clinical management coordination, and perception of cross-level coordination within the area. Explanatory variables: socio-demographic, employment characteristics, attitude towards job, type of area (according to type of hospital and management), interactional factors, organizational factors and knowledge of existing coordination mechanisms. Stratification variable: level of care. Descriptive and multivariate analysis by logistic regression.

RESULTS

The degree of clinical coordination experienced across levels of care was high for both PC and SC doctors, although PC doctors experienced greater exchange and use of information and SC doctors experienced greater consistency of care. However, only 32.13% of PC and 35.72% of SC doctors found that patient care was coordinated across care levels within their area. In both levels of care, knowing the doctors of the other level, working in an area where the same entity manages SC and majority of PC, and holding joint clinical case conferences were factors positively associated with perceiving high levels of clinical coordination. Other associated factors were specific to the care level, such as being informed of a patient's discharge from hospital for PC doctors, or trusting in the clinical skills of the other care level for SC doctors.

CONCLUSIONS

Interactional and organizational factors are positively associated with perceiving high levels of clinical coordination. Introducing policies to enhance such factors can foster clinical coordination between different health care levels. The COORDENA questionnaire allows us to identify fields for improvement in clinical coordination.

The thinking and acting of health professionals on the coordination between the assistance levels of the health care network

The study aims to understand the thinking and acting of health professionals about the coordination between levels of care. Qualitative research from an international multicenter study Equity-LA II. Audios were retrieved from eleven interviews of doctors/nurses of two levels of care in Recife, 2014. A content analysis of the theoretical framework of coordination was performed in the light of the hermeneutic approach. Most professionals knew the duties of coordination, without identifying its execution. The primary care physician was not recognized as responsible for the clinic, nor for his role by the specialist physician, while the primary care physician resented it. Failures in the use/completion of reference/counter-reference mechanisms and organizational barriers emerged. The unavailability for the "conversation game" and "fusionality" was evidenced in the lack of recognition of authority in the authoritative character of the primary care physician by that of the specialized, feeling of less value for that and technicist and specialized posture in everyone's practice. The coordination in on professionals' view revealed the "there-to-be-understood" condition that needs to be launched in the "game of comprehension" to build dialogical practices focused on integral care.

Percepción sobre la coordinación de la atención: el caso de las redes de servicios de salud de Xalapa y Veracruz, México, en el periodo 2014-2016

Una limitada coordinación asistencial impide garantizar una atención integrada, eficiente y de calidad. El objetivo del estudio fue explorar la percepción de profesionales de salud sobre la coordinación entre niveles de atención y los factores que la influyen. Se realizó un estudio cualitativo mediante el análisis de contenido de 54 entrevistas semiestructuradas y 11 grupos focales con personal de dos redes de servicios de salud en Xalapa y Veracruz, México. Los entrevistados refirieron dificultades para el seguimiento de los pacientes, desacuerdos respecto a los criterios de referencia, barreras de acceso a la atención especializada, baja calidad de los formatos de referencia, escasa recepción de los formatos de contrarreferencia y dificultades para seguir los circuitos de referencia. Atribuyeron estos problemas a la insuficiencia de recursos, la cobertura limitada del Seguro Popular, la sobrecarga de trabajo, falta de supervisión, deficiente formación de los médicos generales y limitada comunicación entre profesionales. Estos resultados coinciden con otros estudios en la región, por lo que se señala la necesidad de reforzar los mecanismos basados en la normalización, introducir estrategias basadas en la adaptación mutua y modificar rasgos de la estructura y cultura organizacional para lograr una coordinación de la atención efectiva, que contribuya a la integración de las redes.

Care coordination in two of Bogota’s public healthcare networks: A cross-sectional study among doctors

Introduction

Care coordination is a priority concern for healthcare systems. In Colombia, there is a lack of information on the topic. This study analysed how doctors of two Bogotá’s public healthcare networks perceived coordination between healthcare levels and what factors are associated with their perception.

Methods

A cross-sectional study using the COORDENA-CO questionnaire to a sample of 363 doctors (network-1 = 181; network-2 = 182) in 2015. The questionnaire asks about types and dimensions of care coordination: information and clinical management, with items in a Likert scale, as well as conditions regarding health system, organisational and doctors’ conditions. Descriptive statistics and logistic regression analysis were performed.

Results

The doctors’ perception of a high level of coordination did not exceed 25.4%. On coordination of information, limited transfer of clinical information was found. Concerning clinical management, there were limited care coherence, deficits in patient follow-up and lengthy waiting times for specialised care. A high perception of coordination were associated with being female, being over 50 years old, being a specialist, having less than one year’s working experience, working less than 20 h per week at the centre, forming part of network-1, having time available for performing coordination tasks, having job satisfaction and not identifying limitations imposed by healthcare insurers.

Discussion

There was limited perception of coordination, in its different dimensions and types with some differences between networks. The results support the importance of guaranteeing job satisfaction, ensuring sufficient time to coordination-related activities and intervening in the restrictions imposed by healthcare insurers to improve care coordination.

[Factors influencing the use of mechanisms for coordinating healthcare levels in Colombia]

OBJECTIVE

To analyse the factors influencing the use of mechanisms for the clinical coordination of two Colombian public healthcare networks' healthcare levels in Bogotá from the main social actors' perspective.

METHOD

This was a descriptive-interpretative, qualitative study of two public healthcare networks. Discussion groups and semi-structured interviews were used for collecting information. The approach involved two-stage theoretical sampling of a selection of centres operating at different healthcare levels and a selection of informants, including managers (n=19), healthcare employees (n=23) and administrative staff (n=20). Content analysis involved adopting a mixed method approach for generating categories, segmented by network, informant group and topic.

RESULTS

Both networks had few mechanisms for enabling the clinical coordination of healthcare levels; information transfer mechanisms predominated and clinical management coordination mechanisms only dealt with maternal-perinatal care. Organisational factor-related complications were found regarding their use: lack of time, staff turnover, administrative use and technological deficiency. Employee/staff-related difficulties were due to lack of interest. These factors directly affected coordination with limited information transfer, patient follow-up and healthcare quality (diagnosis and treatment delays).

CONCLUSIONS

The results highlighted the limited use of clinical coordination mechanisms in both public healthcare networks studied here, with problems in their use. Changes are required that affect directly organisational factors (time for coordination and working conditions) and professional factors (attitudes towards collaborative work).

O Complexo Regulador em Saúde do Distrito Federal, Brasil, e o desafio da integração entre os níveis assistenciais

Resumo A integração entre os níveis de atenção é um desafio contínuo mesmo em sistemas de saúde consolidados e de alta performance. A reestruturação do sistema público de saúde do Distrito Federal, baseado no fortalecimento da Atenção Primária à Saúde (APS), na reconfiguração da atenção especializada (ambulatorial e hospitalar) e de sua rede de urgência e emergência, trouxe como desafio a necessidade de integração entre esses níveis. Fez-se necessária a criação de um dispositivo que desempenhasse o papel de “gatekeeper” conduzindo o acesso equânime, transparente e seguro para a atenção especializada e hospitalar. Neste sentido, foi estruturado o Complexo Regulador em Saúde do Distrito Federal (CRDF) e suas Centrais de Regulação (CR), orientados para a execução de um processo regulatório de acesso para os serviços de internação hospitalar, ambulatorial (procedimentos e consultas especializadas), cirurgias eletivas, alta complexidade, transporte sanitário, urgências e transplantes de pacientes do Distrito Federal e de fora dele. Este artigo descreve o processo de implantação e de implementação do CRDF e de suas CR, de forma a refletir sobre as potencialidades e desafios de seu papel enquanto instrumento de integração entre os níveis assistenciais de saúde.

[Awareness and use of mechanism for clinical coordination between levels in two health care networks in Pernambuco State, Brasil]

This article assesses awareness and use of mechanisms for clinical coordination between service levels in two health care networks in the Pernambuco State, Brasil. It is a descriptive, cross-sectional, survey-based study. We interviewed 381 doctors from the public primary health care and specialized health care networks in the cities of Caruaru and Recife (Sanitary Districts III and VII). We used a structured questionnaire (COORDENA) in order to assess awareness, frequency and characteristics of the use of the following mechanisms: referral and reply letters, discharge summary, phone and notes (mutual adaptation mechanisms), Health Ministry protocols and joint clinical sessions (standardization mechanisms). We analyzed the data using simple frequencies, means and percentages. In general, primary health care doctors are more familiar with the mechanisms, and use them more frequently, than specialized health care doctors. In the comparison between networks, Recife had better results. Referral and reply letters were the most used (61.4%) and joint clinical sessions were the least used (8.6%), in addition to the existence of informal mechanisms (phone 58%, notes 56.6%, WhatsApp 2.6%). Underutilization of mechanisms, divergences in information sent and received between primary health care and specialized health care professionals and inadequate mechanism use suggest communication failures among professionals and service levels. The findings reveal a need for investments that enable awareness, communication and collaboration between professionals, contributing to a better coordination between the different services levels.

Understanding communication breakdown in the outpatient referral process in Latin America: a cross-sectional study on the use of clinical correspondence in public healthcare networks of six countries

An adequate use of referral and reply letters—the main form of communication between primary care (PC) and out-patient secondary care (SC)—helps to avoid medical errors, test duplications and delays in diagnosis. However, it has been little studied to date in Latin America. The aim is to determine the level and characteristics of PC and SC doctors’ use of referral and reply letters and to explore influencing factors in public healthcare networks of Argentina, Brazil, Chile, Colombia, Mexico and Uruguay. A cross-sectional study was conducted through a survey of PC and SC doctors working in public healthcare networks (348 doctors per country). The COORDENA questionnaire was applied to measure the frequency of use and receipt of referral and reply letters, quality of contents, timeliness and difficulties in using them. Descriptive analyses were conducted and a multivariate logistic regression model was generated to assess the relationship between frequent use and associated factors. The great majority of doctors claim that they send referral letters to the other level. However, only half of SC doctors (a higher proportion in Chile and Mexico) report that they receive referral letters and <20% of PC doctors receive a reply from specialists. Insufficient recording of data is reported in terms of medical history, tests and medication and the reason for referral. The factor associated with frequent use of the referral letter is doctors’ age, while the use of reply letters is associated with identifying PC doctors as care coordinators, knowing them and trusting in their clinical skills, and receiving referral letters. Significant problems are revealed in the use of referral and reply letters which may affect quality of care. Multifaceted strategies are required that foster a direct contact between doctors and a better understanding of the PC-based model.

Integração de rede e coordenação do cuidado: o caso do sistema de saúde do Chile

Resumo O artigo analisa a implementação de redes integradas de serviços de saúde (RISS) e de estratégias para a coordenação do cuidado pela APS no sistema de saúde do Chile em seu segmento público. Foram realizadas entrevistas semiestruturadas com “policymakers” do sistema público de saúde e academia, complementado por análise documental e revisão bibliográfica. O país destaca-se pela institucionalização de instrumentos de coordenação do cuidado amplamente reconhecidos como mapas de derivação, médico gestor de demanda, prontuários eletrônicos e, sobretudo, definição de protocolos, sob forte liderança do Ministério da Saúde e condução pelos gestores dos “Servicios de Salud”, espaço regional de construção das RISS. Contudo, identificam-se camadas de segmentação e fragmentação no interior do subsistema público com a manutenção da livre-eleição para consultas especializadas e duplas filas de espera – uma para os procedimentos com garantias explícitas de acesso e outra para os demais. A experiência chilena demonstra a necessidade de maior protagonismo da APS para que seja capaz de assumir a condução das RISS. No país, as redes parecem orbitar ao redor de grandes e potentes hospitais. Elementos do contexto mais amplo do sistema de saúde também condicionam avanços e impasses no desenvolvimento das estratégias analisadas.

Recording a diagnosis of stroke, transient ischaemic attack or myocardial infarction in primary healthcare and the association with dispensation of secondary preventive medication: a registry-based prospective cohort study

OBJECTIVES

The aim of this study was to explore whether recording in primary care of a previously recorded hospital diagnosis was associated with increased patient utilisation of recommended medications.

DESIGN

Registry-based prospective cohort study.

SETTING AND PARTICIPANTS

19 072 patients with a hospital discharge diagnosis of transient ischaemic attack (TIA), stroke or acute coronary syndrome from hospitals in Stockholm County 2010-2013 were included in the study.

MAIN OUTCOME MEASURE

The outcome of the study was medication dispensation as a marker of adherence to recommended medications. Adherence was defined as having had at least two filled prescriptions in the third year following hospital discharge.

RESULTS

Recording a diagnosis was associated with higher utilisation of all recommended medications with the exception of antihypertensives in patients with TIA. The differences between the groups with and without a recorded diagnosis remained after adjusting for age, sex, index year and visits to private practitioners. Dispensation of antithrombotics was high overall, 80%-90% in patients without a recorded diagnosis and 90%-94% for those with a diagnosis. Women with recorded ischaemic stroke/TIA/acute coronary syndrome were dispensed more statins (56%-71%) than those with no recorded diagnosis (46%-59%). Similarly, 68%-83% of men with a recorded diagnosis were dispensed statins (57%-77% in men with no recorded diagnosis). The rate of diagnosis recording spanned from 15% to 47% and was especially low in TIA (men 15%, women 16%).

CONCLUSION

Recording a diagnosis of TIA/stroke or acute coronary syndrome in primary care was found to be associated with higher dispensation of recommended secondary preventive medications. Further study is necessary in order to determine the mechanisms underlying our results and to establish the utility of our findings.

Improving performance of long-term care networks at their initial stage: an empirical study of factors affecting results

Until now very little research has been carried out on the performance of health and human services networks in evolution. In particular, previous studies mainly referred to "centrally governed services networks" in the US context. According to Provan and Kenis (2008), these networks are "lead organization-governed", and are different from the "participant-governed" model or the "network administrative organization (NAO)" solution. We focused our attention on the Apulia region care services networks (Italy). In the last few years, the governance of these networks has passed from the "participant-governed" model to the NAO approach. We examined how the integration mechanisms work in this type of networks, and if there were challenges to tackle in order to improve their overall performance. These networks were examined at their initial stage, exactly when their governance model moved to a more integrated solution. We collected survey data from 17 health and human services networks out of 45 (38%). The research is carried out by means of statistical methods (OLS). The analysis is cross sectional. The implementation of "rational/technocratic" factors is important but not sufficient to enhance collaboration. The integration at the "professional level" should be kept in mind. In particular, the role of network (case) managers is paramount. Copyright © 2016 John Wiley & Sons, Ltd.

Patients' Perceptions of Endodontic Treatment as Part of Public Health Services: A Qualitative Study

Evaluations by patients constitute an important part of the process of improving health services. This study examined patients' perceptions of secondary dental care in three cities in Minas Gerais, Brazil based on the endodontic treatment received. Data were collected using semi-structured interviews (addressing access, treatment and results) and a field diary (direct observations and report of professionals). The interviews were audiotaped, fully transcribed, and analyzed using content analysis. Two principal themes were identified: access to service and quality of service. The difficulties in accessing service were associated with the insufficient number of professionals to meet the high demand for endodontic treatment, problems in referring from primary to secondary care and geographic barriers. Service quality was related to the presence/absence of pain and anxiety that patients experienced, the time and number of sessions required to complete treatment, how patients were treated by dentists, and whether those patients would recommend the service to other patients. Access to endodontic treatment was a problem emphasized by users, and satisfaction with the quality of the service was more related to how patients were treated than to the technical competence of the dentist.

Development and testing of indicators to measure coordination of clinical information and management across levels of care

BACKGROUND

Coordination across levels of care is becoming increasingly important due to rapid advances in technology, high specialisation and changes in the organization of healthcare services; to date, however, the development of indicators to evaluate coordination has been limited. The aim of this study is to develop and test a set of indicators to comprehensively evaluate clinical coordination across levels of care.

METHODS

A systematic review of literature was conducted to identify indicators of clinical coordination across levels of care. These indicators were analysed to identify attributes of coordination and classified accordingly. They were then discussed within an expert team and adapted or newly developed, and their relevance, scientific soundness and feasibility were examined. The indicators were tested in three healthcare areas of the Catalan health system.

RESULTS

52 indicators were identified addressing 11 attributes of clinical coordination across levels of care. The final set consisted of 21 output indicators. Clinical information transfer is evaluated based on information flow (4) and the adequacy of shared information (3). Clinical management coordination indicators evaluate care coherence through diagnostic testing (2) and medication (1), provision of care at the most appropriate level (2), completion of diagnostic process (1), follow-up after hospital discharge (4) and accessibility across levels of care (4). The application of indicators showed differences in the degree of clinical coordination depending on the attribute and area.

CONCLUSION

A set of rigorous and scientifically sound measures of clinical coordination across levels of care were developed based on a literature review and discussion with experts. This set of indicators comprehensively address the different attributes of clinical coordination in main transitions across levels of care. It could be employed to identify areas in which health services can be improved, as well as to measure the effect of efforts to improve clinical coordination in healthcare organizations.