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.

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.

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 Latin American 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 clinical management continuity. Descriptive analyses were conducted, and Poisson regression models with robust variance were fitted to estimate changes. With differences between countries, the results showed improvements in cross-level continuity of clinical information (transfer of clinical information) and clinical management continuity (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.

[Knowledge and use of clinical coordination mechanisms in healthcare networks in Latin America]. / Conocimiento y uso de mecanismos de coordinación clínica de servicios de salud de Latinoamérica.

OBJECTIVE: To analyze the level of knowledge and use, and the characteristics of use, of care coordination mechanisms in public healthcare networks of six Latin America countries. METHOD: Cross-sectional study based on a survey using the COORDENA® questionnaire with primary and secondary care doctors (348 doctors/country) of public healthcare networks in Argentina, Brazil, Chile, Colombia, Mexico and Uruguay (May-October 2015). Analyzed variables: degree of knowledge and use of information coordination (referral/reply letter, discharge report, phone, e-mail) and of clinical management coordination (shared clinical guidelines, joint meetings) mechanisms. Descriptive analyses were conducted. RESULTS: Knowledge of clinical information coordination mechanisms was high in both care levels and analyzed networks as was the use of referral/reply letter. There was greater variability in the use of discharge reports (from 40.0% in Brazil to 79.4% in Mexico) and, except for Argentina, a low reception reported by primary care doctors stands out (12.3% in Colombia and 55.1% in Uruguay). In contrast, knowledge of clinical management coordination mechanisms was limited, especially among secondary care doctors. It is noteworthy, however, that adherence to clinical guidelines was high (from 83.1% in Mexico to 96.8% in Brazil), while participation in joint meetings varied widely (from 23.7% in Chile to 76.2% in Brazil). The difficulties reported in the use of the mechanisms are related to structural and organizational factors. CONCLUSIONS: The limited knowledge and use of coordination mechanisms shows insufficient diffusion and implementation. Strategies to increase its use are needed, including the related factors.

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.