Factores que influyen en el uso de mecanismos de coordinación entre niveles asistenciales en Colombia / Factors influencing the use of mechanisms for coordinating healthcare levels in Colombia

Objetivo: Analizar los factores que inciden en la utilización de mecanismos de coordinación clínica entre niveles de atención en dos redes de servicios de salud de Bogotá (Colombia), desde la perspectiva de los actores principales. Método: Estudio cualitativo, descriptivo-interpretativo, en dos redes de servicios de salud públicas, mediante entrevistas individuales semiestructuradas y grupos de discusión. Se realizó un muestreo teórico en dos etapas: 1) selección de centros de diferentes niveles de atención y 2) selección de informantes: directivos/as (n=19), profesionales de salud (n=23) y administrativos/as (n=20). Se realizó un análisis de contenido, con generación mixta de categorías y segmentación por red, grupos de informantes y temas. Resultados: En ambas redes se identificaron pocos mecanismos de coordinación clínica entre niveles, con predominio de los mecanismos de transferencia de información, y como mecanismos de coordinación de gestión clínica solo los dedicados a atención maternal-perinatal. Emergieron problemas uso relacionados con factores organizativos (falta de tiempo, rotación del personal, uso administrativo, déficit tecnológico) y de los/las profesionales (desinterés), con consecuencias sobre la coordinación (limitada transferencia de información y seguimiento de la atención) y la calidad de la atención (retrasos en diagnósticos y tratamientos). Conclusiones: Los resultados indican una limitada implementación de mecanismos de coordinación clínica en general, con problemas en su uso. Se requieren cambios sobre factores organizativos (tiempo para la coordinación y condiciones de trabajo) y de los/las profesionales (actitudes hacia el trabajo colaborativo). (AU)

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). (AU)

[Factors influencing the use of mechanisms for coordinating healthcare levels in Colombia]. / Factores que influyen en el uso de mecanismos de coordinación entre niveles asistenciales en 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).

Coordinación de la atención entre niveles y sus factores asociados en dos subredes de la red municipal de salud de la ciudad de Rosario, Argentina / Coordenação de cuidados entre os níveis e fatores associados em dois sub-redes da rede municipal de saúde da cidade de Rosario, Argentina / Coordination of care between levels and their associated factors in two subnets of the municipal health network in the city of Rosario, Argentina

Objetivo: evaluar la coordinación de atención entre niveles y factores que influyen a partir de experiencia de médicos de primer y segundo nivel en subredes del sistema público Municipalidad de Rosario. Método: Estudio transversal, encuestas presenciales a médicos de Primer (AP) y Segundo (AE) nivel. Análisis univariado y bivariado. Resultados: similares en subredes. Bajo intercambio de información, pero alta valoración. Remisión oportuna entre niveles; prevalece entre AP existencia de acuerdos de indicaciones de médicos de AE. No se repiten estudios. AP es responsable del seguimiento del paciente, AE envía a pacientes al primer nivel post consulta, AE hacen recomendaciones a AP y AP consultan dudas a AE. La minoría percibe atención coordinada. Factores que influyen: edad, nivel de atención, antigüedad de trabajo, red de atención, tiempo/paciente, tiempo para coordinación en consulta, satisfacción salarial y confianza en habilidades clínicas. Conclusiones: rasgos comunes con particularidades producto de la construcción de redes locales.

The objective was to evaluate care coordination between levels and influential factors from the experience of Primary Care (PC) and Secondary Care (SC) level doctors in subnets of the public system in the city of Rosario. Methods: Cross sectional study, based on face-to-face surveys to doctors of first and second care levels. Univariate and bivariate analysis. Results: similar in both subnets. Low information exchange, but highly valued. Adequate remission between levels, agreements among PC with SC's recommendations. Studies are not repeated. PC doctor is responsible for the patient's follow up; SC doctor sends patients for a follow up consultation with PC doctor, SC makes recommendations to PC and PC asks doubts to SC. A minority perceives coordinated care. Age, care level, seniority at work, care network, time/patient, coordination time in consultation, satisfaction with salary, and confidence on clinical abilities are influential factors. Conclusions: common features with particularities due to the construction of local networks.

O objetivo foi avaliar a coordenação do atendimento entre níveis e fatores que influenciam a partir da experiência de médicos de primeiro e segundo nível em sub-redes do sistema público do município de Rosário. O método foi um estudo transversal, enquetes presenciais a médicos do primeiro (AP) e segundo (AE) nível. Análise univariada e bivariada. Resultados: semelhantes em sub-redes. Baixa troca de informações, mas alta valorização. Transmissão oportuna entre os níveis; a existência de acordos de indicações de médicos de EA prevalece entre aqueles de AP. Nenhum estudo é repetido. AP é responsável pelo acompanhamento do paciente. AE envia pacientes para o primeiro nível após consulta, AE faz recomendações para dúvidas de AP, e AP consulta dúvidas para AE. A minoria percebe atenção coordenada. Fatores que influenciam: idade, nível de cuidados, antigüidade no serviço, rede de cuidados, tempo / paciente, tempo de coordenação da consulta, satisfação salarial e confiança nas habilidades clínicas. Conclusões: características comuns com particularidades decorrentes da construção de redes locais.

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

Objetivo: Adaptar y validar la escala del Cuestionario de Continuidad Asistencial Entre Niveles de Atención (CCAENA©) en el contexto de los sistemas de salud colombiano y brasileño. Métodos: El estudio consistió en dos fases: 1) adaptación de la escala CCAENA© al contexto de cada país mediante dos pretests y una prueba piloto; y 2) validación mediante la aplicación de la escala en una encuesta poblacional en Colombia y Brasil. Se analizaron las siguientes propiedades psicométricas: validez de constructo (análisis factorial), consistencia interna (alfa de Cronbach; correlaciones ítem-resto), multidimensionalidad de las escalas (coeficientes de correlación de Spearman) y análisis de grupos conocidos (test de ji al cuadrado). Resultados: Se seleccionaron 14 de los 21 ítems de la escala original y se reformularon pasando de una afirmación con opciones de respuesta de acuerdo a una pregunta con opciones de respuesta de frecuencia. El análisis factorial mostró que los ítems se agrupan en tres factores: continuidad entre niveles asistenciales, continuidad de relación con el proveedor de atención primaria y continuidad de relación con el proveedor de atención especializada. El alfa de Cronbach indicó una buena concordancia interna (>0,80 en todas las escalas). Los coeficientes de correlación indican que los tres factores pueden interpretarse como escalas separadas (<0,70) y presentan una adecuada capacidad de diferenciar entre grupos. Conclusiones: La versión adaptada del CCAENA© muestra adecuadas validez y fiabilidad en ambos países, manteniendo una alta equivalencia con la versión original. Es una herramienta útil y viable para evaluar la continuidad asistencial entre niveles asistenciales desde la perspectiva del usuario en ambos contextos (AU)

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 (AU)

[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.

Acceso a los servicios de salud de la población inmigrante en España / Immmigrant´s access to health care in Spain: a review

Fundamentos: Una importante proporción de población en España es inmigrante y la evidencia internacional señala su acceso inadecuado a los servicios de salud. El objetivo es conocer el acceso a la atención de la población inmigrante en España. Métodos: Revisión bibliográfica de los artículos originales (1998- 2012) sobre acceso y utilización de los servicios de la población inmigrante en España registrados en Medline y MEDES. Se identificaron 319 artículos de los que se seleccionaron 20. Se utilizó el modelo de Aday y Andersen para el análisis. Resultados: Entre los artículos seleccionados, 13 estudios cuantitativos analizaron diferencias en la utilización de los servicios entre inmigrantes y autóctonos y 7 determinantes del acceso en inmigrantes. En líneas generales estos muestran menor utilización de la atención especializada, mayor de las urgencias y no se observaron diferencias entre grupos en atención primaria. Los 5 estudios cuantitativos sobre determinantes se centraron en las características de la población (sexo, edad, nivel de estudios y posesión de seguro privado) sin observarse un patrón claro. Los 2 estudios cualitativos analizaron factores relacionados con los servicios de salud y encontraron barreras en el acceso, como la provisión de información o los requisitos para obtener la tarjeta sanitaria. Conclusiones: El acceso a la atención en inmigrantes ha sido limitadamente abordado, con aproximaciones diferentes y los factores relacionados con la oferta, escasamente analizados. No se observa un patrón de utilización, las diferencias dependen de la clasificación de los inmigrante según origen y nivel asistencial. No obstante, en inmigrantes se observa menor utilización de la atención especializada y mayor de las urgencias, así como determinantes del acceso distintos a la necesidad (AU)

Background: An important proportion of the population in Spain is immigrant and the international literature indicates their inadequate access to health services. The objective is to contribute to improving the knowledge on access to health care of the immigrant population in Spain. Methods: Review of original papers published (1998-2012) on access to health services of the immigrant population in Spain published in Medline and MEDES. Out of 319 studies, 20 were selected, applying predefined criteria. The results were analyzed using the Aday and Andersen framework. Results:Among the publications, 13 quantitative studies analysed differences in health care use between the immigrant and the native population, and 7 studied determinants of access of immigrants. Studies showed less use of specialized care by immigrants, higher use of emergency care and no differences in the use of primary care between groups. Five quantitative articles on determinants of access focused on factors related to the immigrant population (sex, age, educational level and holding private health insurance), but without observing clear patterns. The two qualitative studies analyzed factors related to health services, describing access to healthcare barriers such as the limited provision of information or the requirements for personal health card. Conclusion: Access to health care in immigrants has been scarcely studied, using different approaches and the barely analysed factors related to the services. No clear patterns were observed, as differences depend on the classification of migrants according to country of origin and the level of care. However, studies showed less use of specialized care by immigrants, higher use of emergency care and the existence of determinants of access different to their needs (AU)

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 / 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

Objetivo. Analizar comparativamente la utilización de servicios de los distintos niveles asistenciales y sus determinantes, de dos sistemas de salud diferentes, Sistema General de Seguridad Social en Salud (SGSSS) y Sistema Único de Salud (SUS), en municipios de Colombia y Brasil. Métodos. Estudio transversal basado en encuesta poblacional en dos municipios de Colombia (n = 2163) y dos de Brasil (n = 2155). Variables resultado: utilización de los servicios de atención primaria, especializada y urgencias en los últimos 3 meses. Variables explicativas: necesidad, factores capacitantes y predisponentes. Análisis bivariado y regresiones logísticas multivariadas por nivel asistencial y país. Resultados. Los determinantes de la utilización varían según el nivel asistencial y el país. Padecer una enfermedad crónica se asocia a un mayor uso de atención primaria y especializada en Colombia, y además a las urgencias en Brasil. En Colombia, los afiliados al régimen contributivo utilizan más los servicios del SGSSS que los del subsidiado en atención primaria y especializada, o que los no asegurados en cualquier nivel; en Brasil, la población de baja renta y sin seguro privado hace un mayor uso del SUS en cualquier nivel de atención. En ambos países, conocer el centro de salud asignado y tener una fuente regular de atención incrementa el uso de la atención primaria y el conocimiento del hospital de referencia, el de especializada y urgencias. Conclusiones. La influencia de los determinantes del uso difiere según el nivel de atención utilizado en ambos países, por lo que se subraya la necesidad de analizarlo desagregando por nivel asistencial (AU)

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 (AU)

[Immigrants' access to health care in Spain: a review]. / Acceso a los servicios de salud de la población inmigrante en España.

BACKGROUND: An important proportion of the population in Spain is immigrant and the international literature indicates their inadequate access to health services. The objective is to contribute to improving the knowledge on access to health care of the immigrant population in Spain. METHODS: Review of original papers published (1998-2012) on access to health services of the immigrant population in Spain published in Medline and MEDES. Out of 319 studies, 20 were selected, applying predefined criteria. The results were analyzed using the Aday and Andersen framework. RESULTS: Among the publications, 13 quantitative studies analysed differences in health care use between the immigrant and the native population, and 7 studied determinants of access of immigrants. Studies showed less use of specialized care by immigrants, higher use of emergency care and no differences in the use of primary care between groups. Five quantitative articles on determinants of access focused on factors related to the immigrant population (sex, age, educational level and holding private health insurance), but without observing clear patterns. The two qualitative studies analyzed factors related to health services, describing access to healthcare barriers such as the limited provision of information or the requirements for personal health card. CONCLUSION: Access to health care in immigrants has been scarcely studied, using different approaches and the barely analysed factors related to the services. No clear patterns were observed, as differences depend on the classification of migrants according to country of origin and the level of care. However, studies showed less use of specialized care by immigrants, higher use of emergency care and the existence of determinants of access different to their needs.

[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.

Políticas sanitarias de ámbito estatal y autonómico para la población inmigrante en España

Objetivos: Analizar el contenido de las políticas sanitarias estatales y autonómicas dirigidas a inmigrantes en España. Material y métodos: Se realizó un estudio comparativo descriptivo de las políticas sanitarias para inmigrantes, estatales y autonómicas, mediante análisis de contenido. Se seleccionaron Andalucía, Comunidad Valenciana, Comunidad de Madrid y País Vasco por tener políticas específicas, proporción diferente de inmigrantes y evaluación de la política. Se seleccionaron planes estatales o autonómicos con intervenciones sanitarias dirigidas a inmigrantes. Se realizó un análisis de contenido cuyas dimensiones iniciales fueron: principios, objetivos, estrategias y evaluación. Posteriormente se clasificaron las estrategias según el ámbito de actuación.

[Continuity of care between levels perceived by users of the health system in Catalonia, Spain]. / La continuidad asistencial entre niveles percibida por usuarios del sistema de salud en cataluña.

BACKGROUND: Rapid technological advances, organizational changes in health services and the rise of complex chronic diseases mean that users receive care from a wide variety of providers, threatening continuity of care (CC). The aim is to analyse users' perception of CC, as well as their experienced elements of (dis)continuity in the Catalonian health services. METHODS: Cross-sectional study by means ofa questionnaire survey to a sample of 200 healthcare users attended by more than one level of care for the same condition in the previous 3 months. The survey was conducted in Barcelona and Baix Empordà, between March and June 2009. The applied questionnaire collected first, the users' trajectories within health services and second, their perception of CC using a scale. A descriptive data analysis was conducted. RESULTS: Important elements of relational continuity were identified (86.4 and 83.5% of users were attended in the last year, respectively, by the same physician of primary and secondary care). However, potential elements of discontinuity were identified relating to transfer of clinical information (29.1% and 21.3% of users perceived that secondary care professionals were unaware of their comorbidities and the results of medical tests ordered by physicians of primary care, respectively), coherence of care (levels of referral to primary care of 51.2 %) and accessibility between levels of care (37.8 and 17.6% considered long or excessive waiting time for secondary and primary care, respectively). CONCLUSIONS: The results point to aspects of care, as accessibility and information transfer between professionals that could act as barriers for continuity and would require improvements in the coordination strategies of the health providers.

Acceso a la atención en salud en Colombia / Access to health care in Colombia

Objetivo Contribuir al conocimiento sobre el acceso a los servicios en Colombia tras la reforma del sistema de salud, exponiendo los principales resultados y vacíos en las investigaciones. Métodos Se realizó una revisión sistemática de la bibliografía, a través de la búsqueda exhaustiva y análisis de artículos originales publicados entre 1994 y 2009. Se incluyeron 27 investigaciones cuantitativas y cualitativas que cumplían los criterios de selección. El análisis se enmarcó en los modelos teóricos de Aday y Andersen y Gold, que diferencian entre acceso potencial y realizado y consideran las características de la población, proveedores y aseguradoras que influyen en la utilización. Resultados Los análisis explicativos de la utilización de los servicios de salud a partir de modelos de determinantes resultan escasos y parciales (limitados a áreas geográficas, patologías o colectivos específicos). Pocos estudios profundizan en factores de contexto -políticas y características de proveedores y aseguradoras- o en la perspectiva de los actores sobre los factores que influyen en el acceso. Los estudios no parecen indicar un aumento del acceso realizado -salvo en el régimen subsidiado- y, en cambio, señalan la existencia de importantes barreras relacionadas con factores poblacionales (aseguramiento, renta y educación) y características de los servicios (accesibilidad geográfica, organizativas y calidad). Conclusiones La revisión muestra limitaciones importantes en el análisis del acceso en Colombia que indican la necesidad de reorientar la evaluación hacia el acceso realizado, e incorporar variables de contexto y la perspectiva de los actores para comprender mejor el impacto de la reforma en el uso de servicios.

Objectives Contributing towards improving knowledge about access to health services in Colombia following health-sector reform, highlighting the main results and gaps in research. Methods Original papers were systematically reviewed through a comprehensive search and analysis of original papers published between 1994 and 2009. After selection criteria had been applied, 27 papers were included in the review. Analysis was based on Aday Aday & Andersen and Gold's theoretical frameworks, distinguishing between potential and actual healthcare access and considering the characteristics of the population, health services and insurers influencing service use. Results There was little explanatory analysis of service use applying determinant models; this was also partial (limited to geographical areas, diseases or specific groups). Likewise, only a few studies analysed contextual factors influencing service use (health policies and health providers and insures) or social actors' perspectives. The available studies did not seem to indicate increased actual access (except for subsidised system users) but, on the contrary the existence of barriers relating to population (insurance coverage, income and education) and health service factors (geographic and organizational accessibility and quality of care). Conclusions This review led to identifying important limitations in the analysis of healthcare access in Colombia and highlighted the need for further research on actual access and the better incorporation of context variables and actors perspectives in understanding the impact of reform on health service use.

La continuidad asistencial entre niveles percibida por usuarios del sistema de salud en Cataluña / Continuity of care between levels perceived by users of the health system in catalonia, Spain

Fundamentos: Los avances tecnológicos, cambios organizativos de los servicios y el aumento de las enfermedades crónicas complejas favorecen que los usuarios del sistema de salud sean atendidos por un elevado número de proveedores, amenazando la continuidad asistencial (CA). El objetivo es analizar la valoración de la CA de los usuarios e identificar elementos de (dis)continuidad a partir de sus experiencias en los servicios de salud de Cataluña. Métodos: Estudio transversal, mediante encuesta a 200 usuarios que utilizaron dos niveles asistenciales en los últimos tres meses por un mismo motivo. La encuesta se realizó en Barcelona y Baix Empordà entre los meses de marzo y junio de 2009. Se aplicó un cuestionario que recoge la trayectoria de los usuarios en los servicios de salud y su valoración de la CA, mediante una escala. Se realizó un análisis descriptivo de los resultados. Resultados: Se identifican elementos de continuidad de relación (86,4% y el 83,5% fueron atendidos, respectivamente, por un único médico de atención especializada y de atención primaria en el último año). Por el contrario, se identifican elementos de discontinuidad en la transferencia de información clínica (29,1% y el 21,3% consideró que el médico de la atención especializada desconocía sus comorbilidades y las pruebas realizadas en la atención primaria, respectivamente), en la coherencia del cuidado (niveles de contrarreferencia de 51,2%) y en la accesibilidad entre niveles (37,8% y 17.6% consideraron largo o excesivo el tiempo de espera en atención especializada y primaria, respectivamente). Conclusiones: Se identifican aspectos de la provisión, como accesibilidad y transferencia de información entre profesionales, que podrían indicar barreras a la continuidad y la necesidad de introducir mejoras en las estrategias de coordinación asistencial de las organizaciones sanitarias(AU)

Background: Rapid technological advances, organizational changes in health services and the rise of complex chronic diseases mean that users receive care from a wide variety of providers, threatening continuity of care (CC). The aim is to analyse users’ perception of CC, as well as their experienced elements of (dis)continuity in the Catalonian health services. Methods: Cross-sectional study by means of a questionnaire survey to a sample of 200 healthcare users attended by more than one level of care for the same condition in the previous 3 months. The survey was conducted in Barcelona and Baix Empordà, between March and June 2009. The applied questionnaire collected first, the users’ trajectories within health services and second, their perception of CC using a scale. A descriptive data analysis was conducted. Results: Important elements of relational continuity were identified (86.4 and 83.5% of users were attended in the last year, respectively, by the same physician of primary and secondary care). However, potential elements of discontinuity were identified relating to transfer of clinical information (29.1% and 21.3% of users perceived that secondary care professionals were unaware of their comorbidities and the results of medical tests ordered by physicians of primary care, respectively), coherence of care (levels of referral to primary care of 51.2 %) and accessibility between levels of care (37.8 and 17.6% considered long or excessive waiting time for secondary and primary care, respectively). Conclusions: The results point to aspects of care, as accessibility and information transfer between professionals that could act as barriers for continuity and would require improvements in the coordination strategies of the health providers(AU)

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

ObjetivoDiseñar y validar un instrumento que permita evaluar la continuidad asistencial entre niveles desde la perspectiva de los usuarios, para ser aplicado en cualquier sistema de salud que provea un continuo de servicios.Métodos1) Diseño de un cuestionario para medir la continuidad asistencial, a partir de la revisión de la bibliografía; 2) validación del cuestionario mediante discusión con un grupo de expertos, dos pretests y una prueba piloto en una muestra de 200 usuarios. Se analizaron la comprensibilidad y la validez de contenido del cuestionario, la carga para el entrevistador y la fiabilidad y la validez de constructo de la escala.ResultadosEl cuestionario aborda los tres tipos de continuidad asistencial (gestión, información y relación) y está dividido en dos apartados complementarios. El primero reconstruye la trayectoria y continuidad para un episodio concreto durante los últimos tres meses. El segundo apartado mide la percepción general de los usuarios sobre la continuidad. Hubo acuerdo entre los expertos en que todas las dimensiones de la continuidad estaban representadas, y los encuestados lo consideraron de fácil comprensión. El tiempo medio de aplicación fue de 33,9min. El valor alfa de Cronbach fue aceptable (>0,7) en todas las subescalas excepto en una, que fue eliminada. Los análisis de correspondencias múltiples mostraron asociación entre aquellos ítems teóricamente relacionados.ConclusionesSe ha diseñado un cuestionario (CCAENA) útil, válido y fiable para evaluar la continuidad asistencial entre niveles de manera integral y desde la perspectiva de los usuarios. Su aplicación en una muestra mayor aportará información adicional acerca de sus propiedades psicométricas (AU)

ObjectivesTo 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.Methods1) 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.ResultsThe 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 33.9min. 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.ConclusionsThe 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 (AU)

[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.

Políticas sanitarias de ámbito estatal y autonómico para la población inmigrante en España / Health policies of national and regional level for the immigrant population in Spain

Objetivos Analizar el contenido de las políticas sanitarias estatales y autonómicas dirigidas a inmigrantes en España.MétodosSe realizó un estudio comparativo descriptivo de las políticas sanitarias para inmigrantes, estatales y autonómicas, mediante análisis de contenido. Se seleccionaron Andalucía, Comunidad Valenciana, Comunidad de Madrid y País Vasco por tener políticas específicas, proporción diferente de inmigrantes y evaluación de la política. Se seleccionaron planes estatales o autonómicos con intervenciones sanitarias dirigidas a inmigrantes. Se realizó un análisis de contenido cuyas dimensiones iniciales fueron: principios, objetivos, estrategias y evaluación. Posteriormente se clasificaron las estrategias según el ámbito de actuación.ResultadosLas políticas sanitarias dirigidas a inmigrantes se definen principalmente en los planes de inmigración. Los principios se basan en la igualdad de derechos en salud con la población autóctona, y los objetivos se dirigen a su consecución. Buena parte de las acciones están encaminadas a la mejora del acceso a la atención. Además, contemplan estrategias específicas para adaptación de los servicios, promoción de la salud, análisis de las necesidades y formación de los profesionales. Las políticas autonómicas siguen las directrices generales marcadas para todo el Estado, pero con acciones más concretas. Las evaluaciones de las políticas son muy limitadas.ConclusiónEl contenido de las políticas sanitarias, especialmente estatales, responden a aspectos importantes a considerar en la atención a la población inmigrante. Sin embargo, la ausencia de evaluaciones, junto a la persistencia de problemas en la atención e inequidades en el acceso, podría indicar una insuficiente implantación y requiere un seguimiento cuidadoso(AU)

ObjectivesTo analyze the content of health policies for the immigrant population developed by central and regional governments in Spain.MethodsA descriptive comparative study of central and regional healthcare policies for the immigrant population was conducted in Spain through content analysis. The selected regions were Andalusia, Valencia, Madrid and the Basque Country as these regions have specific policies, distinct proportions of immigrants and policy evaluations. National or regional health and immigration plans with health policies for immigrants were selected. Contents analysis was conducted of the following main dimensions: policy principles and objectives, strategies and results’ evaluation. Subsequently, strategies were categorized according to the area of intervention.ResultsHealthcare policies for the immigrant population are mainly included in national and regional immigration plans. The principles of these policies are based on equal rights to healthcare between the immigrant and native-born populations and the objectives aim to achieve this end. National objectives and actions address access to and adaptation of health services, health promotion, health needs assessment, and health personnel training in cultural competences. Regional policies follow the national guidelines but their actions are more specific. Policy evaluations are highly limited.ConclusionsThe content of the health policies, especially national policies, address major issues in meeting immigrants’ healthcare needs. However, the absence of assessments, together with persistent problems in the provision of care and inequalities in access, could indicate insufficient implementation and requires careful monitoring(AU)

[Health policies of national and regional level for the immigrant population in Spain]. / Políticas sanitarias de ámbito estatal y autonómico para la población inmigrante en España.

OBJECTIVES: To analyze the content of health policies for the immigrant population developed by central and regional governments in Spain. METHODS: A descriptive comparative study of central and regional healthcare policies for the immigrant population was conducted in Spain through content analysis. The selected regions were Andalusia, Valencia, Madrid and the Basque Country as these regions have specific policies, distinct proportions of immigrants and policy evaluations. National or regional health and immigration plans with health policies for immigrants were selected. Contents analysis was conducted of the following main dimensions: policy principles and objectives, strategies and results' evaluation. Subsequently, strategies were categorized according to the area of intervention. RESULTS: Healthcare policies for the immigrant population are mainly included in national and regional immigration plans. The principles of these policies are based on equal rights to healthcare between the immigrant and native-born populations and the objectives aim to achieve this end. National objectives and actions address access to and adaptation of health services, health promotion, health needs assessment, and health personnel training in cultural competences. Regional policies follow the national guidelines but their actions are more specific. Policy evaluations are highly limited. CONCLUSIONS: The content of the health policies, especially national policies, address major issues in meeting immigrants' healthcare needs. However, the absence of assessments, together with persistent problems in the provision of care and inequalities in access, could indicate insufficient implementation and requires careful monitoring.

[Access to health care in Colombia]. / Acceso a la atención en salud en Colombia.

OBJECTIVES: Contributing towards improving knowledge about access to health services in Colombia following health-sector reform, highlighting the main results and gaps in research. METHODS: Original papers were systematically reviewed through a comprehensive search and analysis of original papers published between 1994 and 2009. After selection criteria had been applied, 27 papers were included in the review. Analysis was based on Aday Aday & Andersen and Gold's theoretical frameworks, distinguishing between potential and actual healthcare access and considering the characteristics of the population, health services and insurers influencing service use. RESULTS: There was little explanatory analysis of service use applying determinant models; this was also partial (limited to geographical areas, diseases or specific groups). Likewise, only a few studies analysed contextual factors influencing service use (health policies and health providers and insures) or social actors' perspectives. The available studies did not seem to indicate increased actual access (except for subsidised system users) but, on the contrary the existence of barriers relating to population (insurance coverage, income and education) and health service factors (geographic and organizational accessibility and quality of care). CONCLUSIONS: This review led to identifying important limitations in the analysis of healthcare access in Colombia and highlighted the need for further research on actual access and the better incorporation of context variables and actors perspectives in understanding the impact of reform on health service use.

Necesidades de los profesionales de salud en la atención a la población inmigrante / Perceived needs of health personnel in the provision of healthcare to the immigrant population

ObjetivoAnalizar las necesidades de apoyo expresadas por el personal sanitario en la atención al colectivo inmigrante y aportar sugerencias de mejora.MétodosEstudio cualitativo, descriptivo, de carácter exploratorio y fenomenológico. Se llevaron a cabo entrevistas individuales semiestructuradas y grupos focales en una muestra teórica de informantes: directivos de proveedores (21) y profesionales de primaria y especializada (42). Se hizo un análisis narrativo del contenido con generación mixta de categorías y segmentación por grupo de informantes y temas.ResultadosEn el discurso de los informantes emergen con fuerza diversas necesidades de apoyo para la atención a la población inmigrante, con algunas voces discrepantes. Por un lado, para superar las barreras a la comunicación e información se requieren materiales en diversos idiomas y servicios de traducción, así como más tiempo por paciente. Por otro lado, para proveer atención a pacientes con culturas diversas se requiere formación centrada en aspectos culturales y de carácter práctico con aplicación inmediata. Además, para adaptar los recursos a la nueva situación, destaca la necesidad de introducir cambios en el sistema sanitario, liderados por el Departament de Salut.ConclusiónLas necesidades identificadas de apoyo para la comunicación, la información y la formación, así como de cambios en el sistema, indican que las intervenciones contempladas en el Plan Director de Inmigración en Salud no son debidamente implantadas, pero además se observan deficiencias estructurales y organizativas que deberían abordarse mediante políticas generales(AU)

ObjectiveTo analyze the needs perceived by health personnel in the provision of healthcare to the immigrant population and to provide suggestions for improvement.Methods A descriptive, exploratory and phenomenological qualitative study was carried out by means of semi-structured individual interviews and focus groups to a criterion sample of informants: healthcare managers (n=21) and health professionals (n=44) from primary and specialized care. A narrative content analysis was conducted by three analysts, segmented by groups of informants and themes, with mixed generation of categories.ResultsThe need for support in providing healthcare to the immigrant population strongly emerged in the informants’ discourses, with some discrepant voices. On the one hand, translated materials, translation services, and a greater length of time allocated per patient, were required to address communication and information barriers. On the other hand, specific training focusing on cultural aspects and practical tools for immediate implementation were needed to provide adequate care to patients from diverse cultural backgrounds. In addition, changes in the healthcare system, led by the Health Department, were requested to adapt resources to the new situation.ConclusionThe needs identified for support in communication, information and training, as well as changes in the system, reveal the insufficient implementation of the interventions contemplated in the Immigration and Health Plan. In addition, structural and organizational deficiencies were identified that should be addressed by general policies(AU)

Factores que influyen en la coordinación entre niveles asistenciales según la opinión de directivos y profesionales sanitarios / Factors influencing coordination among healthcare levels according to the opinion of healthcare managers and health professionals

ObjetivoAnalizar la coordinación entre niveles asistenciales desde la perspectiva de directivos y profesionales de organizaciones sanitarias integradas (OSI).MétodosEstudio cualitativo, descriptivo e interpretativo, mediante entrevistas individuales semiestructuradas, con muestreo teórico en dos etapas. En la primera se seleccionaron los contextos (las OSI) y en la segunda los informantes: directivos (n=18) y profesionales (n=23). Análisis de contenido, con generación mixta de categorías y segmentación por temas e informantes.ResultadosLa coordinación entre niveles es definida de diversas formas por los informantes, que coinciden en considerarla complicada, pero necesaria, para la mejora de la eficiencia. Comunicación, conocimiento y relación entre los profesionales emergen como factores determinantes centrales de la coordinación, sobre los que influyen los valores de los profesionales y la existencia de mecanismos apropiados en las instituciones. Ambos dependen de las condiciones estructurales y organizativas, principalmente de carácter interno, aunque también externas a las organizaciones, que determinan su desarrollo. Las estrategias de mejora propuestas se relacionan directamente con los factores identificados.ConclusionesLas opiniones sobre la coordinación asistencial reflejan la complejidad del término y la tradicional separación entre niveles asistenciales. Su mejora requiere acciones organizativas específicas que respondan a los determinantes, no sólo dentro de las organizaciones, sino también entre todos los proveedores de un territorio(AU)

ObjectiveTo analyze coordination among healthcare levels from the viewpoint of healthcare managers and health professionals in integrated healthcare systems (IHS).MethodsA qualitative, exploratory and descriptive study was conducted by means of individual semi-structured interviews to a criterion sample. We performed two-stage sampling: in the first stage, IHS were selected and in the second, managers (n=18) and professionals (n=23). A content analysis was carried out with mixed generation of categories, segmented by themes and informants.ResultsCoordination among healthcare levels was defined differently by the two groups of informants. However, the informants agreed that coordination was complicated but necessary to improve access to and the efficiency of the system. Factors central to achieving coordination were communication, knowledge and good relationships among professionals. These factors were influenced by professionals’ values and the existence of appropriate institutional coordination mechanisms. In turn, these elements depended mainly on internal but also external structural and organizational conditions, which determined the development of coordination. Improvement strategies were directly related to the factors identified.ConclusionsOpinions on healthcare coordination reflect not only the complexity of the concept, but also the traditional separation of healthcare levels. Improving coordination requires specific organizational interventions to address its determinants, not only within but also among all healthcare providers in an area(AU)