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.

Experiencias subjetivas del personal de salud durante la emergencia sanitaria en Uruguay / Experiences of health personnel during the health emergency in Uruguay / Vivências subjetivas dos trabalhadores de saúde na emergência sanitária en Uruguay

La emergencia sanitaria COVID-19 impactó en los/as trabajadores de salud, dejando en evidencia: el malestar subjetivo y altos índices de ansiedad y depresión. El objetivo del presente trabajo es analizar las experiencias y vivencias de trabajadores/as de la salud durante la pandemia. La misma se realizó a partir del análisis de las respuestas obtenidas en la pregunta abierta del formulario autoadministrado del proyecto Héroes Uruguay. La población objetivo fue el personal de los servicios de salud integrados al Sistema Nacional Integrado de Salud en los tres niveles de atención. Las respuestas fueron agrupadas y categorizadas en base a su frecuencia. La categoría condiciones de trabajo fue la temática más mencionada, seguida de organización del trabajo y vivencias. Realizamos otra categorización sobre los sentidos subjetivos durante la pandemia, nueve categorías son las frecuentes, siendo el 86% de los sentidos subjetivos: ansiedad y estrés, miedo, cansancio, no apoyo social y sobrecarga son los más mencionados. Los resultados muestran que la mayoría de las respuestas remite a las condiciones y a la organización del trabajo, se trata de dimensiones claves en la salud del trabajador, en su entorno, y en los procesos de asistencia al paciente y su familia. Este estudio nos permite afirmar la importancia a nivel organizacional y de políticas de salud, de generar entornos laborales seguros y saludables. La emergencia sanitaria generada por el COVID 19, expuso y agudizó la tensión de los sistemas sanitarios y su impacto en la salud y bienestar del personal.

The COVID-19 health emergency impacted health workers, revealing: subjective discomfort and high rates of anxiety and depression. The objective of this work is to analyze the experiences of health workers during the pandemic. It was carried out from the analysis of the answers obtained in the open question of the self-administered form of the Héroes Uruguay project. The target population was the staff of the health services integrated into the National Integrated Health System at the three levels of care. The responses were grouped and categorized based on recurring themes. The working conditions category was the most mentioned theme, followed by work organization and experiences. We carry out another categorization of the subjective senses during the pandemic, nine categories are the most frequent, with 86% of the subjective senses: anxiety and stress, fear, tiredness, lack of social support and overload are the most mentioned. The results show that most of the answers refer to the conditions and organization of work, these are key dimensions in the worker's health, in his environment, and in the patient assisted and his family. This study allows us to affirm the importance at the organizational and health policy level of generating safe and healthy work environments. The health emergency generated by COVID 19 exposed and exacerbated the tension in health systems and its impact on the health and well-being of personnel.

A emergência sanitária da COVID-19 impactou os trabalhadores da saúde, revelando: desconforto subjetivo e altos índices de ansiedade e depressão. O objetivo deste trabalho é analisar as vivências dos trabalhadores da saúde durante a pandemia. Foi realizada a partir da análise das respostas obtidas na questão aberta do formulário autoaplicável do projeto Héroes Uruguai. A população alvo foram os trabalhadores dos serviços de saúde integrados no Sistema Único de Saúde Integrado nos três níveis de cuidados. As respostas foram agrupadas e categorizadas com base em temas recorrentes. A categoria condições de trabalho foi o tema mais citado, seguido de organização do trabalho e experiências. Realizamos outra categorização dos sentidos subjetivos durante a pandemia, nove categorias são as mais frequentes, com 86% dos sentidos subjetivos: ansiedade e estresse, medo, cansaço, falta de apoio social e sobrecarga são os mais citados. Os resultados mostram que a maioria das respostas se refere às condições e organização do trabalho, dimensões fundamentais na saúde do trabalhador, em seu ambiente, e no paciente assistido e sua família. Este estudo permite afirmar a importância a nível organizacional e da política de saúde de gerar ambientes de trabalho seguros e saudáveis. A emergência de saúde gerada pelo COVID 19 expôs e exacerbou a tensão nos sistemas de saúde e seu impacto na saúde e bem-estar do pessoal.

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.

Care continuity across levels of care perceived by patients with chronic conditions in six Latin-American countries / La continuidad de la atención entre niveles percibida por pacientes con enfermedades crónicas en seis países latinoamericanos

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. (AU)

Objetivo: Analizar la continuidad asistencial entre niveles de atención percibida por pacientes con enfermedades crónicas en redes sanitarias públicas de seis países latinoamericanos (Argentina, Brasil, Chile, Colombia, México y Uruguay) y explorar los factores asociados. Método: Estudio transversal mediante una encuesta realizada a una muestra aleatoria de pacientes crónicos en los centros de atención primaria de las redes de estudio (784 por país) utilizando el Cuestionario de Continuidad Asistencial Entre Niveles de Atención (CCAENA©). Los pacientes presentaban al menos una afección crónica y habían utilizado dos niveles de atención en los 6 meses anteriores a la encuesta por el mismo motivo. Se realizaron un análisis descriptivo y una regresión logística multivariante. Resultados: Aunque existen diferencias notables entre las redes analizadas, los resultados muestran que los pacientes crónicos perciben discontinuidades significativas en el intercambio de información clínica entre médicos de atención primaria y secundaria, y en el acceso a la atención secundaria tras una derivación, así como, en menor medida, en la coherencia clínica entre niveles. La continuidad de relación con los médicos de atención primaria y secundaria, y la transferencia de información, se asocian de manera positiva con la continuidad asistencial en ambos niveles; ningún factor individual se asocia sistemáticamente con la continuidad asistencial. Conclusiones: Las principales discontinuidades percibidas se relacionan con la transferencia de información y el acceso a la atención secundaria después de una derivación. El estudio indica la importancia de los factores organizativos para mejorar la calidad de la atención de los pacientes crónicos. (AU)

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.

Qualitative research training to nursing teaching personnel: achievements and challenges / Capacitação de professores de enfermagem em pesquisa qualitativa: conquistas e desafios / Capacitación de docentes de enfermería en investigación cualitativa: logros y desafios

ABSTRACT Objective: describe the experience of the proposal, process and results of a training program on qualitative research for nursing teachers based on the constructivist pedagogic model. Method: implementation of a course at a Nursing School in Uruguay from November 3, 2016 to October 12, 2017, in which thirty-nine teachers participated voluntarily. The description of the experience presented in this article is based on the assessment of the course made through participant observation, surveys and a dialogue session with the participants in which the results of the course were discussed. Results: through the implementation of the course, several achievements were accomplished, as well as challenges detected. We would like to highlight the interest received from the course managers and participants in the subject, the nine new research projects, the creation of a bibliographic material, videos and recordings repository, as well as the financial resource mobilization. The challenges were mainly structural and organizational; such as the limited time the participants had to do research and work in teams, the trouble to adopt a critical approach and difficulties with the communication systems. Conclusion: this article contributes to fill the existing gap in qualitative research teaching, and invites to reconsider iniciatives regarding the training of health personnel in the countries of the region, mainly through constructivist and participative models.

RESUMO Objetivo: descrever o relato de uma experiência sobre a proposta, o processo e os resultados de um programa de formação em pesquisa qualitativa, dirigido a professores de enfermagem, baseado no modelo pedagógico construtivista. Método: de 3 de novembro de 2016 a 12 de outubro de 2017entre 3/11/2016 e 12/10/2017 implementamos um curso, em uma faculdade de enfermagem no Uruguai, do qual participaram de forma voluntária 39 professores. O relato da experiência que apresentamos é baseado na avaliação do curso, que foi feito por meio da observação participante, questionários e uma sessão de diálogo com os alunos, na qual se discutiram os resultados do curso. Resultados: a implementação do curso permitiu alcançar conquistas e vislumbrar desafios. Destaca-se o interesse dos gerentes e participantes no tema, contando com nove projetos de pesquisa, um repositório com material bibliográfico, vídeos e gravações, além da mobilização de recursos financeiros. Os desafios foram estruturais e organizacionais; dentre eles, o pouco tempo das participantes para pesquisar ou trabalhar em equipe, dificuldades para adotar uma perspectiva crítica e problemas com os sistemas de comunicação. Conclusão: este trabalho visa a preencher uma lacuna existente sobre o ensino da pesquisa qualitativa, convidando a repensar iniciativas tendentes à formação do pessoal da saúde nos países da região, principalmente desde modelos construtivistas e participativos.

RESUMEN Objetivo: describir el relato de experiencia sobre la propuesta, el proceso y los resultados de un programa de formación en investigación cualitativa dirigido a docentes de enfermería basado en el modelo pedagógico constructivista. Método: entre 3 de octubre de 2016 a 12 de noviembre de 2017, implementamos un curso en una facultad de enfermería en Uruguay, en el que participaron de forma voluntaria 39 docentes. El relato de la experiencia que se presenta se basa en la evaluación del curso, que se hizo por medio de observación participante, cuestionarios y una sesión de dialogo con los alumnos en la que se discutieron los resultados del curso. Resultados: la implementación del curso permitió alcanzar logros y entrever desafíos. Se destaca el interés de los gestores y participantes en el tema, el contar con nueve proyectos de investigación, un repositorio con material bibliográfico, videos y grabaciones, así como la movilización de recursos financieros. Los desafíos fueron estructurales y organizativos; entre ellos, el poco tiempo de las participantes para investigar o trabajar en equipo, dificultades para adoptar una perspectiva crítica y problemas con los sistemas de comunicación. Conclusión: este trabajo abona a llenar una laguna existente sobre la enseñanza de la investigación cualitativa, invitando a repensar iniciativas tendientes a la formación del personal de la salud en los países de la región, principalmente desde modelos constructivistas y participativos.

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.

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

OBJETIVO: Analizar el nivel de conocimiento y uso, y las características del uso, de los mecanismos de coordinación clínica entre niveles de atención en redes de servicios de salud de seis países de Latinoamérica. MÉTODO: Estudio transversal mediante encuesta, usando el cuestionario COORDENA®, a médicos de atención primaria y especializada (tamaño estimado: 348 médicos/país) de redes sanitarias públicas de Argentina, Brasil, Chile, Colombia, México y Uruguay (mayo-octubre 2015). Variables analizadas: conocimiento y uso de mecanismos de coordinación de la información (hoja de referencia/contrarreferencia-interconsulta [HRCR], informe de alta hospitalaria, teléfono, correo electrónico) y de la gestión clínica (guías de práctica clínica y reuniones conjuntas). Se realizó un análisis descriptivo. RESULTADOS: El conocimiento de los mecanismos de coordinación de la información es alto en ambos niveles de atención en las redes analizadas, así como también el uso de la HRCR. Existe mayor variabilidad en el envío del informe de alta hospitalaria (del 40,0% en Brasil al 79,4% en México) y, excepto en Argentina, destaca su baja recepción por los médicos de atención primaria (12,3% en Colombia y 55,1% en Uruguay). En cambio, el conocimiento de los mecanismos de coordinación de la gestión clínica es limitado, en especial entre los médicos de atención especializada. Llama la atención la alta adherencia a las guías de práctica clínica (del 83,1% en México al 96,8% en Brasil), mientras que la participación en reuniones conjuntas varía ampliamente (del 23,7% en Chile al 76,2% en Brasil). Las dificultades para la utilización de los mecanismos se refieren a factores estructurales y organizativos. CONCLUSIONES: El conocimiento y el uso limitados de los mecanismos de coordinación parecen reflejar su escasa difusión e implementación. Son necesarias estrategias que promuevan su uso, interviniendo sobre los factores determinantes

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

[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.

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.

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

INTRODUCTION: Although fragmentation in the provision of healthcare is considered an important obstacle to effective care, there is scant evidence on best practices in care coordination in Latin America. The aim is to evaluate the effectiveness of a participatory shared care strategy in improving coordination across care levels and related care quality, in health services networks in six different healthcare systems of Latin America. METHODS AND ANALYSIS: A controlled before and after quasi-experimental study taking a participatory action research approach. In each country, two comparable healthcare networks were selected--intervention and control. The study contains four phases: (1) A baseline study to establish network performance in care coordination and continuity across care levels, using (A) qualitative methods: semi-structured interviews and focus groups with a criterion sample of health managers, professionals and users; and (B) quantitative methods: two questionnaire surveys with samples of 174 primary and secondary care physicians and 392 users with chronic conditions per network. Sample size was calculated to detect a proportion difference of 15% and 10%, before and after intervention (α=0.05; ß=0.2 in a two-sided test); (2) a bottom-up participatory design and implementation of shared care strategies involving micro-level care coordination interventions to improve the adequacy of patient referral and information transfer. Strategies are selected through a participatory process by the local steering committee (local policymakers, health care network professionals, managers, users and researchers), supported by appropriate training; (3) Evaluation of the effectiveness of interventions by measuring changes in levels of care coordination and continuity 18 months after implementation, applying the same design as in the baseline study; (4) Cross-country comparative analysis. ETHICS AND DISSEMINATION: This study complies with international and national legal stipulations on ethics. Conditions of the study procedure were approved by each country's ethical committee. A variety of dissemination activities are implemented addressing the main stakeholders. Registration No.257 Clinical Research Register of the Santa Fe Health Department, Argentina.