Doctors' opinions on clinical coordination between primary and secondary care in the Catalan healthcare system.

OBJECTIVE: To analyse doctors' opinions on clinical coordination between primary and secondary care in different healthcare networks and on the factors influencing it. METHODS: A qualitative descriptive-interpretative study was conducted, based on semi-structured interviews. A two-stage theoretical sample was designed: 1) healthcare networks with different management models; 2) primary care and secondary care doctors in each network. Final sample size (n = 50) was reached by saturation. A thematic content analysis was conducted. RESULTS: In all networks doctors perceived that primary and secondary care given to patients was coordinated in terms of information transfer, consistency and accessibility to SC following a referral. However, some problems emerged, related to difficulties in acceding non-urgent secondary care changes in prescriptions and the inadequacy of some referrals across care levels. Doctors identified the following factors: 1) organizational influencing factors: coordination is facilitated by mechanisms that facilitate information transfer, communication, rapid access and physical proximity that fosters positive attitudes towards collaboration; coordination is hindered by the insufficient time to use mechanisms, unshared incentives in prescription and, in two networks, the change in the organizational model; 2) professional factors: clinical skills and attitudes towards coordination. CONCLUSIONS: Although doctors perceive that primary and secondary care is coordinated, they also highlighted problems. Identified factors offer valuable insights on where to direct organizational efforts to improve coordination.

Cost-effectiveness of Continuous Positive Airway Pressure Treatment in Moderate-Severe Obstructive Sleep Apnea Syndrome. / Análisis coste-efectividad del tratamiento con presión positiva continua de la vía aérea en el síndrome de apnea-hipopnea durante el sueño (SAHS) moderado-grave.

INTRODUCTION: The socioeconomic impact of obstructive sleep apnea-hypopnea syndrome (OSAHS) is considerable. The aim of this study was to evaluate the cost-effectiveness of treating OSAHS with continuous positive airway pressure (CPAP) and the impact of CPAP compliance. METHODS: This was a retrospective, case-crossover study of 373 patients with OSAHS receiving CPAP. We compared changes in costs, Epworth score and health-related quality of life (EQ-5D questionnaires) between the year before treatment and the year after treatment. The incremental cost-effectiveness ratio (ICER) for the first year of treatment was estimated, and projections were made for the second year, using different effectiveness and cost scenarios. RESULTS: The visual analog scale score for the EQ-5D questionnaire increased by 5 points and the Epworth score fell by 10 points during the year of CPAP treatment. Mean gain in quality-adjusted life years (QALY) was 0.05 per patient per year (P<.001): 0.07 among compliers and -0.04 among non-compliers. ICER was €51,147/QALY during the first year of CPAP treatment and €1,544/QALY during the second year. CONCLUSION: CPAP treatment in patients with moderate-severe OSAHS improves the quality of life of compliant patients, and is cost-effective as of the second year.

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.

A tool for assessing continuity of care across care levels: an extended psychometric validation of the CCAENA questionnaire.

BACKGROUND: The CCAENA questionnaire was developed to assess care continuity across levels from the patients' perspective. The aim is to provide additional evidence on the psychometric properties of the scales of this questionnaire. METHODS: Cross-sectional study by means of a survey of a random sample of 1500 patients attended in primary and secondary care in three health care areas of the Catalan health care system. Data were collected in 2010 using the CCAENA questionnaire. To assess psychometric properties, an exploratory factor analysis was performed (construct validity) and the item-rest correlations and Cronbach's alpha were calculated (internal consistency). Spearman correlation coefficients were calculated (multidimensionality) and the ability to discriminate between groups was tested. RESULTS: The factor analysis resulted in 21 items grouped into three factors: patient-primary care provider relationship, patient-secondary care provider relationship and continuity across care levels. Cronbach's alpha indicated good internal consistency (0.97, 0.93, 0.80) and the correlation coefficients indicated that dimensions can be interpreted as separated scales. Scales discriminated patients according to health care area, age and educational level. CONCLUSION: The CCAENA questionnaire has proved to be a valid and reliable tool for measuring patients' perceptions of continuity. Providers and researchers could apply the questionnaire to identify areas for health care improvement.

A comprehensive analysis of patients' perceptions of continuity of care and their associated factors.

OBJECTIVE: To determine the patients' perceived degree of continuity of care between primary and secondary care and to identify contextual and individual factors that influence patients' perceptions of continuity of care. DESIGN: Cross-sectional study by means of a survey of patients attended to in primary and secondary care. SETTING: Three health-care areas of the Catalonian public health-care system. PARTICIPANTS: A random sample of 1500 patients. MAIN OUTCOME MEASURES: Relational, informational and managerial continuity of care measured by means of Likert scales, using the CCAENA questionnaire. RESULTS: Overall, 93.8 and 83.8% of patients perceived an ongoing relationship with primary and secondary care physicians, respectively (relational continuity), 71.2% perceived high levels of information transfer (informational continuity) and 90.7% perceived high levels of consistency of care (managerial continuity). Patients from health-care areas where primary and secondary care were managed by a single organization and the elderly tended to perceive higher levels of all three types of continuity. Foreign-born patients were less likely to perceive relational continuity with primary care physicians; those with higher educational levels were less likely to perceive high levels of informational continuity and patients with worse health status were less likely to report high levels of managerial and relational continuity with secondary care physicians. CONCLUSIONS: Study results suggest high levels of perceived continuity of care, especially for relational and managerial continuity. The adopted comprehensive approach proves to be useful to properly understand the phenomenon because perceptions and associated factors vary according to the type of continuity.

Factors associated to experienced continuity of care between primary and outpatient secondary care in the Catalan public healthcare system.

OBJECTIVE: To analyze patient's reported elements of relational, informational and managerial (dis)continuity between primary and outpatient secondary care and to identify associated factors. METHODS: Cross-sectional study by means of a survey of a random sample of 1500 patients attended in primary and secondary care for the same condition. The study settings consisted of three health areas of the Catalan health system. Data were collected in 2010 using the CCAENA questionnaire, which identifies patients' experiences of continuity of care. Descriptive analyses and multivariable logistic regression models were carried out. RESULTS: Elements of continuity of care were experienced by most patients. However, elements of discontinuity were also identified: 20% and 15% were seen by more than one primary or secondary care physician, respectively. Their secondary care physician or both professionals were identified as responsible for their care by 40% and 45% of users, respectively. Approximately 20% reported a lack of information transfer. Finally, 72% of secondary care consultations were due to primary care referral, whilst only 36% reported a referral back to primary care. Associated factors were healthcare setting, age, sex, perceived health status and disease duration. CONCLUSION: Users generally reported continuity of care, although elements of discontinuity were also identified, which can be partially explained by the healthcare setting and some individual factors. Elements of discontinuity should be addressed to better adapt care to patients' needs.

[Design and validation of a questionnaire to measure continuity between care levels from the user's perspective]. / Diseño y validación de un cuestionario para medir la continuidad asistencial entre niveles desde la perspectiva del usuario: CCAENA.

OBJECTIVES: To design and validate an instrument that measures continuity between levels of care from the user's perspective to be applied in any healthcare system providing a continuum of care. METHODS: 1) A questionnaire for the measurement of continuity of care was designed, based on a literature review, and 2) the questionnaire was validated using an expert group, two pretests and a pilot test to a sample of 200 healthcare users. We assessed the questionnaire's comprehensibility, content validity and interviewer burden, as well as the reliability and construct validity of the scale. RESULTS: The instrument encompasses three types of continuity (management, information and relational) and is divided in two complementary parts. The first part addresses the patients' care pathways and the continuity of care for a particular episode that occurred in the last 3 months. The second part measures patients' perception of the continuity between levels of care. The experts agreed that all dimensions of continuity were represented and the interviewees found the questionnaire easy to understand. The mean time required to apply the instrument was 33.9 min. Cronbach's alpha was acceptable (>0.7) in all subscales except one, which was then removed. The multiple correspondence analyses showed associations among theoretically related items. CONCLUSIONS: The questionnaire (CCAENA) seems to be an useful, valid and reliable instrument to assess comprehensively continuity between levels of care from the user's perspective. Further information about the questionnaire's psychometric properties will be obtained by applying it to a larger population.