Doctors' experience of coordination across care levels and associated factors. A cross-sectional study in public healthcare networks of six Latin American countries.

Improving coordination between primary care (PC) and secondary care (SC) has become a policy priority in recent years for many Latin American public health systems looking to reinforce a healthcare model based on PC. However, despite being a longstanding concern, it has scarcely been analyzed in this region. This paper analyses the level of clinical coordination between PC and SC experienced by doctors and explores influencing factors in public healthcare networks of Argentina, Brazil, Chile, Colombia, Mexico and Uruguay. A cross-sectional study was carried out based on a survey of doctors working in the study networks (348 doctors per country). The COORDENA questionnaire was applied to measure their experiences of clinical management and information coordination, and their related factors. Descriptive analyses were conducted and a multivariate logistic regression model was generated to assess the relationship between general perception of care coordination and associated factors. With some differences between countries, doctors generally reported limited care coordination, mainly in the transfer of information and communication for the follow-up of patients and access to SC for referred patients, especially in the case of PC doctors and, to a lesser degree, inappropriate clinical referrals and disagreement over treatments, in the case of SC doctors. Factors associated with a better general perception of coordination were: being a SC doctor, considering that there is enough time for coordination within consultation hours, job and salary satisfaction, identifying the PC doctor as the coordinator of patient care across levels, knowing the doctors of the other care level and trusting in their clinical skills. These results provide evidence of problems in the implementation of a primary care-based model that require changes in aspects of employment, organization and interaction between doctors, all key factors for coordination.

Patient perceptions of continuity of health care and associated factors. Cross-sectional study in municipalities of central Colombia and north-eastern Brazil.

Despite the fragmentation of healthcare provision being considered one of the main obstacles to attaining effective health care in Latin America, very little is known about patients' perceptions. This paper analyses the level of continuity of health care perceived by users and explores influencing factors in two municipalities of Colombia and Brazil, by means of a cross-sectional study based on a survey of a multistage probability sample of people who had suffered at least one health problem within the previous three months (2163 in Colombia; 2167 in Brazil). An adapted and validated version of the CCAENA© (Questionnaire of care continuity across levels of health care) was applied. Logistic regression models were generated to assess the relationship between perceptions of the different types of health care continuity and sociodemographic characteristics, health needs, and organizational factors. The results show lower levels of continuity across care levels in information transfer and care coherence and higher levels for the ongoing patient-doctor relationship, albeit with differences between the two countries. They also show greater consistency of doctors in the Brazilian study areas, especially in primary care. Consistency of doctors was not only positively associated with the patient-doctor ongoing relationship in the study areas of both countries, but also with information transfer and care coherence across care levels. The study area and health needs (the latter negatively for patients with poor self-rated health and positively for those with at least one chronic condition) were associated with all types of continuity of care. The influence of the sex or income varied depending on the country. The influence of the insurance scheme in the Colombian sample was not statistically significant. Both countries should implement policies to improve coordination between care levels, especially regarding information transfer and job stability for primary care doctors, both key factors to guarantee quality of care.

[Adaptation and validation of the CCAENA(©) scale for the measurement of continuity of care between healthcare levels in Colombia and Brazil]. / Adaptación y validación de la escala CCAENA(©) para evaluar la continuidad asistencial entre niveles de atención en Colombia y Brasil.

OBJECTIVE: To adapt and to validate the scale of the questionnaire Continuity of Care between Care Levels (CCAENA(©)) in the context of the Colombian and Brazilian health systems. METHODS: The study consisted of two phases: 1) adaptation of the CCAENA(©) scale to the context of each country, which was tested by two pretests and a pilot test, and 2) validation by means of application of the scale in a population survey in Colombia and Brazil. The following psychometric properties were analyzed: construct validity (exploratory factor analysis), internal consistency (Cronbach's alpha and item-rest correlations), the multidimensionality of the scales (Spearman correlation coefficients), and known group validity (chi-square test). RESULTS: Of the 21 items of the original scale, 14 were selected and reformulated based on a statement with response options of agreement to a question with frequency response options. Factor analysis showed that items could be grouped into three factors: continuity across healthcare levels, the patient-primary care provider relationship, and the patient-secondary care provider relationship. Cronbach's alpha indicated good internal consistency (>0.80 in all the scales). The correlation coefficients suggest that the three factors could be interpreted as separated scales (<0.70) and had adequate ability to differentiate between groups. CONCLUSION: The adapted version of the CCAENA(©) shows adequate validity and reliability in both countries, maintaining a high equivalence with the original version. It is a useful and feasible tool to assess the continuity of care between healthcare levels from the users' perspective in both contexts.

[Determinants of the use of different healthcare levels in the General System of Social Security in Health in Colombia and the Unified Health System in Brazil]. / Determinantes del uso de distintos niveles asistenciales en el Sistema General de Seguridad Social en Salud y Sistema Único de Salud en Colombia y Brasil.

OBJECTIVE: To compare the use of different healthcare levels, and its determinants, in two different health systems, the General System of Social Security in Health (GSSSH) and the Unified Health System (UHS) in municipalities in Colombia and Brazil. METHODS: A cross-sectional study was carried out, based on a population survey in two municipalities in Colombia (n=2163) and two in Brazil (n=2155). Outcome variables consisted of the use of primary care services, outpatient secondary care services, and emergency care in the previous 3 months. Explanatory variables were need and predisposing and enabling factors. Bivariate and multivariate logistic regression analyses were performed by healthcare level and country. RESULTS: The determinants of use differed by healthcare level and country: having a chronic disease was associated with a greater use of primary and outpatient secondary care in Colombia, and was also associated with the use of emergency care in Brazil. In Colombia, persons enrolled in the contributory scheme more frequently used the services of the GSSSH than persons enrolled with subsidized contributions in primary and outpatient secondary care and more than persons without insurance in any healthcare level. In Brazil, the low-income population and those without private insurance more frequently used the UHS at any level. In both countries, the use of primary care was increased when persons knew the healthcare center to which they were assigned and if they had a regular source of care. Knowledge of the referral hospital increased the use of outpatient secondary care and emergency care. CONCLUSIONS: In both countries, the influence of the determinants of use differed according to the level of care used, emphasizing the need to analyze healthcare use by disaggregating it by level of care.

Barriers in access to healthcare in countries with different health systems. A cross-sectional study in municipalities of central Colombia and north-eastern Brazil.

There are few comprehensive studies available on barriers encountered from the initial seeking of healthcare through to the resolution of the health problem; in other words, on access in its broad domain. For Colombia and Brazil, countries with different healthcare systems but common stated principles, there have been no such analyses to date. This paper compares factors that influence access in its broad domain in two municipalities of each country, by means of a cross-sectional study based on a survey of a multistage probability sample of people who had had at least one health problem within the last three months (2163 in Colombia and 2155 in Brazil). The results reveal important barriers to healthcare access in both samples, with notable differences between and within countries, once differences in sociodemographic characteristics and health needs are accounted for. In the Colombian study areas, the greatest barriers were encountered in initial access to healthcare and in resolving the problem, and similarly when entering the health service in the Brazilian study areas. Differences can also be detected in the use of services: in Colombia greater geographical and economic barriers and the need for authorization from insurers are more relevant, whereas in Brazil, it is the limited availability of health centres, doctors and drugs that leads to longer waiting times. There are also differences according to enrolment status and insurance scheme in Colombia, and between areas in Brazil. The barriers appear to be related to the Colombian system's segmented, non-universal nature, and to the involvement of insurance companies, and to chronic underfunding of the public system in Brazil. Further research is required, but the results obtained reveal critical points to be tackled by health policies in both countries.

Inequities in access to health care in different health systems: a study in municipalities of central Colombia and north-eastern Brazil.

INTRODUCTION: Health system reforms are undertaken with the aim of improving equity of access to health care. Their impact is generally analyzed based on health care utilization, without distinguishing between levels of care. This study aims to analyze inequities in access to the continuum of care in municipalities of Brazil and Colombia. METHODS: A cross-sectional study was conducted based on a survey of a multistage probability sample of people who had had at least one health problem in the prior three months (2,163 in Colombia and 2,167 in Brazil). The outcome variables were dichotomous variables on the utilization of curative and preventive services. The main independent variables were income, being the holder of a private health plan and, in Colombia, type of insurance scheme of the General System of Social Security in Health (SGSSS). For each country, the prevalence of the outcome variables was calculated overall and stratified by levels of per capita income, SGSSS insurance schemes and private health plan. Prevalence ratios were computed by means of Poisson regression models with robust variance, controlling for health care need. RESULTS: There are inequities in favor of individuals of a higher socioeconomic status: in Colombia, in the three different care levels (primary, outpatient secondary and emergency care) and preventive activities; and in Brazil, in the use of outpatient secondary care services and preventive activities, whilst lower-income individuals make greater use of the primary care services. In both countries, inequity in the use of outpatient secondary care is more pronounced than in the other care levels. Income in both countries, insurance scheme enrollment in Colombia and holding a private health plan in Brazil all contribute to the presence of inequities in utilization. CONCLUSIONS: Twenty years after the introduction of reforms implemented to improve equity in access to health care, inequities, defined in terms of unequal use for equal need, are still present in both countries. The design of the health systems appears to determine access to the health services: two insurance schemes in Colombia with different benefits packages and a segmented system in Brazil, with a significant private component.