Secondary Care Doctors Research Articles

Anxiety levels during COVID 19 pandemic in primary and secondary doctors in UK

AimsThe study aims to examine the severity of anxiety in primary and secondary doctors in the UK during first wave of COVID-19 pandemic.MethodAn online General Anxiety Disorder-7 (GAD7) survey was distributed during the first wave of COVID-19 pandemic (April-May 2020) to doctors in primary and secondary care in the UK. Seven closed-ended questions were included in the questionnaire. Respondents were to indicate how frequently they experienced specific issues in the previous fortnight: Feeling nervous, anxious, or on edge; being unable to stop or control worrying; worrying too much generally; trouble relaxing; being so restless that it's hard to sit still; becoming easily annoyed or irritable, feeling afraid of something awful happening. Participants were required to tick one of four choices for each of the seven parameters - not at all (0), several days (1), more than half the days (2) and nearly every day (3). A person with minimal or no anxiety will score less than 5. The survey was anonymous and circulated in professional online doctors' forums. Participation was voluntary and no incentives were given.Result273 completed surveys were received; 120 doctors were in primary care and 153 were in secondary care. Average GAD7 score was 6.4 in primary care and 7.9 in secondary care. 57% of primary care doctors and 66% of secondary care doctors reported score of 5 or more, representing at least mild anxiety symptoms. 22% doctors in primary care and 31% doctors in secondary care reported GAD7 score of 10 or more, indicating moderate to severe anxiety. One in ten doctors in both primary and secondary care reported severe anxiety due to the ongoing COVID-19 pandemic.ConclusionThe finding of more anxiety in secondary care doctors might be because general practitioners could resort early in the pandemic to remote consultations along with inadequacy of resources, greater exposure to suffering/deaths of patients and colleagues in hospital and perceived risk of catching COVID-19 infection.Results are limited due to relatively low numbers and it would be useful to replicate this study on a larger scale. Doctors are less likely to acknowledge their mental health difficulties due to stigma associated with mental health.Many employers have psychological support systems in place for their staff, but it is questionable if affected individuals are willing to receive this support. This paper; therefore, calls for creating open anonymous platforms for professionals to get access to appropriate support to address their anxiety.

Medical malpractice in Norway: frequency and distribution of disciplinary actions for medical doctors 2011\u20132018

BackgroundPhysicians who perform unsafe practices and harm patients may be disciplined. In Norway, there are five types of disciplinary action, ranging from a warning for the least serious examples of malpractice to loss of licence for the most serious ones. Disciplinary actions always involve medical malpractice. The aims of this study were to investigate the frequency and distribution of disciplinary actions by the Norwegian Board of Health Supervision for doctors in Norway and to uncover nation-wide patient safety issues.MethodsWe retrospectively investigated all 953 disciplinary actions for doctors given by the Board between 2011 and 2018. We categorized these according to type of action, recipient’s profession, organizational factors and geographical location of the recipient. Frequencies, cross tables, rates and linear regression were used for statistical analysis.ResultsRural general practitioners received the most disciplinary actions of all doctors and had their licence revoked or restricted 2.1 times more frequently than urban general practitioners. General practitioners and private specialists received respectively 98.7 and 91.0 disciplinary actions per 1000 doctors. Senior consultants and junior doctors working in hospitals received respectively 17.0 and 6.4 disciplinary actions per 1000 doctors. Eight times more actions were received by primary care doctors than secondary care doctors. Doctors working in primary care were given a warning 10.6 times more often and had their licence revoked or restricted 4.6 times more often than those in secondary care.ConclusionThe distribution and frequency of disciplinary actions by the Norwegian Board of Health Supervision clearly varied according to type of health care facility. Private specialists and general practitioners, especially those working in rural clinics, received the most disciplinary actions. These results deserve attention from health policy-makers and warrant further studies to determine the factors that influence medical malpractice. Moreover, the supervisory authorities should assess whether their procedures for reacting to malpractice are efficient and adequate for all types of physicians working in Norway.

Understanding How to Improve the Use of Clinical Coordination Mechanisms between Primary and Secondary Care Doctors: Clues from Catalonia.

Clinical coordination between primary (PC) and secondary care (SC) is a challenge for health systems, and clinical coordination mechanisms (CCM) play an important role in the interface between care levels. It is therefore essential to understand the elements that may hinder their use. This study aims to analyze the level of use of CCM, the difficulties and factors associated with their use, and suggestions for improving clinical coordination. A cross-sectional online survey-based study using the questionnaire COORDENA-CAT was conducted with 3308 PC and SC doctors in the Catalan national health system. Descriptive bivariate analysis and logistic regression models were used. Shared Electronic Medical Records were the most frequently used CCM, especially by PC doctors, and the one that presented most difficulties in use, mostly related to technical problems. Some factors positively associated with frequent use of various CCM were: working full-time in integrated areas, or with local hospitals. Interactional and organizational factors contributed to a greater extent among SC doctors. Suggestions for improving clinical coordination were similar between care levels and related mainly to the improvement of CCM. In an era where management tools are shifting towards technology-based CCM, this study can help to design strategies to improve their effectiveness.

Practice-based small group learning (PBSGL) with mixed groups of general practitioners and secondary care doctors: a qualitative study

ABSTRACT General practitioners (GPs) and secondary care doctors share a common background of learning together whilst at medical school but their learning paths diverge after specialist qualification. Reconnect is an initiative in NHS Grampian in Scotland which offered a variety of shared activities, including learning, to both groups of medical practitioners. One learning activity was of Practice-Based Small Group Learning (PBSGL) which has proved popular with primary care clinicians. Groups drawn from both health care sectors were started and met over a five month pilot period. A qualitative research method was chosen to identify the perceptions and experiences of participants. They were interviewed in one-to-one telephone interviews. Interviews were audio-recorded, transcribed and analysed using grounded theory methods. Two PBSGL groups were formed with a total of 13 members. One group met twice in the pilot period and the other group met only once. Nine participants were interviewed and four main themes emerged from analysis of the data. Reasons for participation were often related to a desire to improve working relationships between the two sectors and to increase understanding. Practitioners learned about how working conditions and team working affected the working lives of the other sector. Participants found the logistics of arranging further meetings challenging and considered they had a lack of shared learning time together. Considerations to the future of the project were positive but this contrasted with the few meetings that had taken place.

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

BackgroundFinding 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.MethodsA 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.ResultsInformants 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.ConclusionsEvidence 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.

Changes in knowledge and use of clinical coordination mechanisms between care levels in healthcare networks of Colombia.

Clinical coordination mechanisms (CCMs) have become key tools in healthcare networks for improving coordination between primary care (PC) and secondary care (SC) and are particularly relevant in health systems with highly fragmented healthcare provision. However, their implementation has been little studied to date in Latin America and particularly in Colombia. This study analyses the level of knowledge and use of CCMs between care levels and their changes between 2015 and 2017 in two public healthcare networks in Bogotá, Colombia. Comparison of two cross-sectional studies based on surveys among PC and SC doctors working in their networks (174 doctors per network/year). The COORDENA questionnaire was used for measuring knowledge concerning CCMs and the frequency of use and difficulties involved in using referral/reply letters (R/RLs) and hospital discharge reports (HDRs). Descriptive bivariate analysis and Poisson regression models with robust variance were used for analysing differences between networks and years. The results for both networks and years revealed greater knowledge and use of information coordination mechanisms than those regarding clinical management coordination (though their knowledge increased in 2017). Although widely known and used, significant problems regarding infrequent and late receipt of RLs and HDRs in PC as well as the poor quality of their contents limits their effective use, which may affect the quality of care. Strategies are required to improve CCMs use.

Competencies to promote collaboration between primary and secondary care doctors: an integrative review

BackgroundIn a society where ageing of the population and the increasing prevalence of long-term conditions are major issues, collaboration between primary and secondary care is essential to provide continuous, patient-centred care. Doctors play an essential role at the primary-secondary care interface in realising ‘seamless’ care. Therefore, they should possess collaborative competencies. However, knowledge about these collaborative competencies is scarce. In this review we explore what competencies doctors need to promote collaboration between doctors at the primary-secondary care interface.MethodsWe conducted an integrative literature review. After a systematic search 44 articles were included in the review. They were analysed using a thematic analysis approach.ResultsWe identified six themes regarding collaborative competencies: ‘patient-centred care: a common concern’, ‘roles and responsibilities’, ‘mutual knowledge and understanding’, ‘collaborative attitude and respect’, ‘communication’ and ‘leadership’. In every theme we specified components of knowledge, skills and attitudes as found in the reviewed literature. The results show that doctors play an important role, not only in the way they collaborate in individual patient care, but also in how they help shaping organisational preconditions for collaboration.ConclusionsThis review provides an integrative view on competencies necessary for collaborative practice at the primary-secondary care interface. They are part of several domains, showing the complexity of collaboration. The information gathered in this review can support doctors to enhance and learn collaboration in daily practice and can be used in educational programmes in all stages of medical education.

Effectiveness of interventions related to continuity of health care in five Latin America countries

Abstract Background Evaluation of interventions to improve continuity of care across care levels is scarce in Latin America. The Aim to analyse the impact of implemented interventions on the perception of continuity of care of chronic patients in public health care networks of five LA countries (Brazil, Chile, Colombia, Mexico, and Uruguay). Methods Quasi-experimental study (controlled before and after design). Comparable networks, one intervention (IN) and one control (CN) were selected in each country. Baseline (2015) and evaluation (2017) surveys were conducted applying CCAENA questionnaire® to a sample of patients with chronic conditions (392/network; 784/country/year). Result variables: information continuity (exchange of clinical information) and clinical management continuity (repetition of exams, accessibility of primary care (PC) and secondary care (SC), perception of agreement between PC and SC doctors and of collaboration between PC and SC doctors. Descriptive analysis were conducted, and chi-square test was calculated to determine significant changes. Results An increase in the perception of continuity of information between care levels was observed in the IN of all countries, but Colombia. Clinical management continuity: decrease in the repetition of exams and increase in accessibility of consultation with the specialist in all countries but Mexico. The accessibility of PC doctor decreased in the IN in all countries. No differences in the perception of agreement between PC and SC doctors regarding diagnosis, treatment and recommendations were found. The perception of collaboration between PC and SC doctors increased in the five countries. Conclusions Consistent with expected results, the level of perceived information continuity and clinical management continuity increased in the IN, with differences between countries. Further multivariate analyses will be conducted to explore the differences between the IN and CN. Key messages Provides a cross-country comparison of the perception of continuity of care in patients with chronic conditions. Contributes to fill the knowledge gap on the effectiveness of participatory interventions improving continuity of care.

Does management integration improve cross-level clinical coordination? Experience of Catalonia

Abstract Background Cross-level clinical coordination is a priority for health systems. Evidence suggests that management integration may improve clinical coordination. This study aims to evaluate clinical coordination according to the type of management integration of the area in the Catalan health system. Methods Cross-sectional study based on the online questionnaire COORDENA-CAT (October-December 2017). Study population: primary and secondary care (acute and long term) doctors of the public Catalan health system. Sample: 3.308 doctors. Outcome variables: experience and perception of clinical coordination across care levels, knowledge and use of coordination mechanisms and related factors. Explanatory variables: area according to type of management (integrated, semi-integrated and non-integrated), demographic, employment characteristics and attitude towards work. Descriptive and multivariate analysis by robust Poisson regression. Results Better clinical coordination was observed in integrated areas compared to those semi-integrated, mostly in information transfer (PR 0.80 (95%CI 0.74-0.87)) and adequate follow-up of the patient (PR 0.89 (95%IC 0.82-0.97)). No differences were observed between integrated and non-integrated areas. General perception of coordination was higher in integrated areas than in semi-integrated and non-integrated areas (PR 0.73 (95%CI 0.63-0.84) and PR 0.85 (95%CI 0.75-0.97) respectively). Some organizational and interactional factors and the knowledge and use of coordination mechanisms showed also better results in integrated areas. There were common fields for improvement like accessibility between care levels. Conclusions No differences between integrated and non-integrated areas reveal that management integration is not enough condition to improve clinical coordination. Differences with semi-integrated areas suggest that coordination efforts should be equitable among all the providers of the territory to avoid inequalities in quality of care. Key messages Management integration does not determine clinical coordination. Cooperation formulas are needed between all territory providers that allow to fix common strategies to improve clinical coordination.

Clinical coordination across care levels according to medical specialty in the Catalan health system

Abstract Background In primary care-based national health systems, cross-level clinical coordination is a priority, as it contributes to quality of care and efficiency. Studies show that clinical coordination may vary depending on doctoŕs specialty. The study's aim was to determine the differences in experience and perception of clinical coordination and their related factors according to the doctor's specialty in the Catalan health system Methods Cross-sectional study, based on an on-line survey applying the COORDENA-CAT questionnaire to 1666 secondary care doctors. Descriptive and multivariate analysis were used to compare five groups of specialties (potentially decentralised, hospital-based, internal-medicine/geriatrics, gynaecology, and paediatrics), for experience, perception and factors related to clinical coordination. Results Clinical coordination experience was relatively high in all groups, with differences when comparing with decentralised specialties; hospital-based specialties and internal medicine/geriatrics presented lower care consistency and follow up across levels, while gynaecology and paediatrics showed higher accessibility. General perception of coordination was low, being worse in hospital-based specialties (PR:0.80,95%CI0.72-0.89) and better in gynaecology (PR:1.36,95%CI1.18-1.56). Moreover, hospital-based specialties reported lower use of coordination mechanisms and less interaction with doctors from the other level (PR:0.42,95%CI0.23-0.72), than gynaecology (PR:2.04, 95%CI1.22-3.45). Conclusions Doctors' experience and perception of clinical coordination was lower among hospital-based specialties and internal medicine/geriatrics and higher in gynaecology and paediatrics. These differences may be explained by complexity, coordination needs, level of specialty decentralisation or related factors. Further research is needed to understand such differences and consider the coordination needs of each specialty to improve cross-level clinical coordination. Key messages Differences between specialities might be explain by the complexity, level of specialty decentralisation or factors related to clinical coordination. Clinical coordination needs of each specialty should be deeply explored to improve cross-level clinical coordination.

Primary medical care continuity and patient mortality: a systematic review.

A 2018 review into continuity of care with doctors in primary and secondary care concluded that mortality rates are lower with higher continuity of care. This association was studied further to elucidate its strength and how causative mechanisms may work, specifically in the field of primary medical care. Systematic review of studies published in English or French from database and source inception to July 2019. Original empirical quantitative studies of any design were included, from MEDLINE, Embase, PsycINFO, OpenGrey, and the library catalogue of the New York Academy of Medicine for unpublished studies. Selected studies included patients who were seen wholly or mostly in primary care settings, and quantifiable measures of continuity and mortality. Thirteen quantitative studies were identified that included either cross-sectional or retrospective cohorts with variable periods of follow-up. Twelve of these measured the effect on all-cause mortality; a statistically significant protective effect of greater care continuity was found in nine, absent in two, and in one effects ranged from increased to decreased mortality depending on the continuity measure. The remaining study found a protective association for coronary heart disease mortality. Improved clinical responsibility, physician knowledge, and patient trust were suggested as causative mechanisms, although these were not investigated. This review adds reduced mortality to the demonstrated benefits of there being better continuity in primary care for patients. Some patients may benefit more than others. Further studies should seek to elucidate mechanisms and those patients who are likely to benefit most. Despite mounting evidence of its broad benefit to patients, relationship continuity in primary care is in decline - decisive action is required from policymakers and practitioners to counter this.

The quality of e-fit notes issued in secondary care.

Few data are available on the pattern of use of fit notes issued in secondary care settings. To evaluate the pattern and quality of e-fit notes issued in an NHS Trust. Anonymized data on patients admitted to Guy's and St Thomas' NHS Foundation Trust (London, UK) who had an e-fit note issued from 1 January to 31 August 2017 were analysed using descriptive statistical methods. Thematic analysis was used to group the free-text comments into distinct categories and themes. A total of 815 fit notes were issued during the study period. A total of 659 (81%) fit notes advised that patients were 'not fit' for work, whilst 156 (19%) advised that they 'may be fit' for work. The specialty with the highest proportion of patients assessed as may be fit was plastic surgery 46/104 (44%), whilst the lowest was ear, nose and throat surgery 0/57 (0%). The majority 151/156 (97%) of fit notes which advised that patients may be fit for work used the tick-box sections on the fit note to recommend work modifications. Of the free-text comments in section 4 of the 'may be fit' e-fit notes issued, 91/114 (80%) were related to the functional ability of patients. Our study suggests that doctors in secondary care are more willing to use the 'may be fit' option on the fit note than primary care practitioners. Most fit notes, which advised that a patient may be fit for work, suggested workplace modifications.

Care continuity across levels of care perceived by patients with chronic conditions in six Latin-American countries

ObjectiveTo 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. MethodCross-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. ResultsAlthough 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. ConclusionsMain 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.

Do primary and secondary care doctors have a different experience and perception of cross-level clinical coordination? Results of a cross-sectional study in the Catalan National Health System (Spain)

BackgroundClinical coordination across care levels is a priority for health systems around the world, especially for those based on primary health care. The aim of this study is to analyse the degree of clinical information and clinical management coordination across healthcare levels in the Catalan national health system experienced by primary (PC) and secondary care (SC) doctors and explore the associated factors.MethodsCross-sectional study based on an online survey using the self-administered questionnaire COORDENA-CAT. Data collection: October–December 2017. Study population: PC and SC (acute and long term) doctors of the Catalan national health system. Participation rate was 21%, with a sample of 3308 doctors. Outcome variables: cross-level clinical information coordination, clinical management coordination, and perception of cross-level coordination within the area. Explanatory variables: socio-demographic, employment characteristics, attitude towards job, type of area (according to type of hospital and management), interactional factors, organizational factors and knowledge of existing coordination mechanisms. Stratification variable: level of care. Descriptive and multivariate analysis by logistic regression.ResultsThe degree of clinical coordination experienced across levels of care was high for both PC and SC doctors, although PC doctors experienced greater exchange and use of information and SC doctors experienced greater consistency of care. However, only 32.13% of PC and 35.72% of SC doctors found that patient care was coordinated across care levels within their area. In both levels of care, knowing the doctors of the other level, working in an area where the same entity manages SC and majority of PC, and holding joint clinical case conferences were factors positively associated with perceiving high levels of clinical coordination. Other associated factors were specific to the care level, such as being informed of a patient’s discharge from hospital for PC doctors, or trusting in the clinical skills of the other care level for SC doctors.ConclusionsInteractional and organizational factors are positively associated with perceiving high levels of clinical coordination. Introducing policies to enhance such factors can foster clinical coordination between different health care levels. The COORDENA questionnaire allows us to identify fields for improvement in clinical coordination.

Competencies for collaboration between general practitioners and medical specialists: a qualitative study of the patient perspective

ObjectivesTo explore the patient view of competencies essential for doctors to provide good collaboration at the primary–secondary care interface.DesignWe used a qualitative research approach. Focus groups with patients were conducted...

Exploring UK doctors' attitudes towards online patient feedback: Thematic analysis of survey data.

IntroductionPatients are increasingly using online platforms to give feedback about their health-care experiences. Online feedback has been proposed as a way to drive transformative change in the health service through informing choice and improving quality. Attitudes held by health-care professionals influence the uptake of new technologies. Understanding these attitudes is essential in exploring the potential of online patient feedback as a standard feedback mechanism. This study explores the content of free-text comments left by doctors responding to a survey with the aim of understanding their attitudes towards online feedback.MethodsA cross-sectional online questionnaire was completed by 1001 UK primary and secondary-care doctors. Doctors were given the opportunity to leave a free-text comment about online patient feedback. Doctors’ attitudes towards online patient feedback were identified and explored using thematic analysis. Descriptive statistics and chi-square tests were used to examine demographic differences between those doctors who left a comment and those who did not.ResultsThematic analysis identified five key interrelated themes: anonymity, confidentiality, representativeness, moderation/regulation of online feedback and platform type. The characteristics of those leaving a comment very closely matched those of the entire survey sample.ConclusionAcross the comments, the most prominent finding was a general scepticism and caution towards online feedback, with most of the key themes relating to the perceived limitations and challenges. Further work exploring ways of addressing and verifying online comments without breaching confidentiality could provide valuable information to health systems seeking to drive improvement through patient online feedback.

Associated factors to the perception of clinical coordination in the Catalan national health system

Abstract Background Clinical coordination across levels of care is a priority for health systems. The aim is to analyse the factors associated to a high perception of clinical coordination of primary (PC) and secondary care (SC) doctors of the Catalan national health system (NHS). Methods Cross-sectional study based on the self-administered online questionnaire COORDENA-CAT. Data collection: October-December 2017. Study population: PC and SC (acute and long term) doctors of the public Catalan NHS that had been working for at least one year in the organization, had direct contact with patients and related with doctors of the other level of care. The participation rate was 20.5%, with a sample of 3308 doctors. Outcome variable: perception of clinical coordination across levels of care. Explanatory variables: socio-demographic, employment characteristics, attitude towards work, type of area (according to type of hospital and managing entity), interactional factors, organizational factors and knowledge of existing coordination mechanisms. Stratification variable: level of care. Descriptive and multivariate analysis by logistic regression. Results Only 32.13% of PC doctors and 35.72% of SC doctors found that patient care was coordinated across care levels within their area. In both levels of care, knowing the doctor of the other level; finding that their practice influences the other care level; finding that the organization’s management facilitates coordination; working in an area where the same entity manages SC and majority of PC and to hold joint clinical case conferences are factors positively associated to a high perception of clinical coordination. Besides, there are other positively associated factors exclusive for each level of care. Conclusions Several common interactional and organizational factors are positively associated to a high perception of care coordination. Introducing policies to enhance such factors can foster care coordination in the Catalan NHS. Key messages This study found out factors associated to clinical coordination across care levels in each level. It helps to develop specific coordination policies by level of care to address those factors.

Effectiveness of participatory interventions in improving clinical coordination in Latin America

Abstract Background Evaluation of interventions to improve clinical coordination across care levels is scarce in Latin America. Aim to evaluate the effectiveness of interventions implemented through participatory action research in improving clinical coordination between care levels in public healthcare networks of Brazil, Chile, Colombia, Mexico and Uruguay. Methods Quasi-experimental study (controlled before and after design). Comparable networks, one intervention (IN) and one control (CN), were selected in each country. Baseline (2015) and evaluation (2017) surveys were conducted applying COORDENA® questionnaire to a sample of primary (PC) and secondary (SC) care doctors (174 doctors/network/year). Designed interventions promoted clinical agreement and communication across levels for patients’ follow-up. Outcome variables: a) intermediate: interactional and organizational factors; b) final: experience of clinical management coordination (care consistency and patients’ follow-up) and general perception of coordination between levels. Poisson regression models were estimated. Results Intermediate: interactional factors -personal knowledge and trust on the other care level-increased significantly in Brazil’ and Chile’ INs; and organizational factors -managers’ support- in the INs of Colombia and Mexico. Comparing to CN in 2017, INs of Brazil, Chile, Colombia and Mexico showed significant differences in some factors. Final: care consistency items -agreement over the treatments- improved in the INs of Brazil, Colombia and Uruguay; and patients’ follow-up in the INs of Chile and Mexico. General perception of clinical coordination increased in the INs of Brazil, Colombia and Mexico. Compared to CN in 2017, only Brazil showed significant differences. Conclusions Improvements in intermediate and final care coordination results, consistent with expected results, were observed in all the INs. Reduced implementation time and some process and context factors may have limited their impact. Key messages First study assessing the effectiveness of participatory interventions in improving clinical coordination between care levels in public healthcare networks of Latin America. Results showed changes in the intermediate and final clinical coordination results in the intervention networks. Longer implementation and evaluation times are expected to achieve greater impact.

Teaching family medicine online: the experience in Cyprus.

Cyprus has an underdeveloped primary care system.1 As in many other countries in the Middle East, family medicine has never grown from its roots so the first point of contact for patients remains secondary care doctors, with paediatricians and obstetrician-gynaecologists providing care for their respective groups. Yet those physicians working as family doctors are eager to pursue postgraduate training, gain due accreditation and ultimately raise the contribution of family medicine to the nation’s health care. To meet this demand in the region, the University of Nicosia Medical School launched a postgraduate family medicine course in 2014. It already had experience of teaching an international undergraduate course in English in collaboration with St George’s Hospital Medical School in London and an MD programme developed by the University. Setting up an international academic programme with on-the-job training raised unique challenges. The …

Conocimiento y uso de mecanismos de coordinación clínica de servicios de salud de Latinoamérica

ObjectiveTo 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. MethodCross-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. ResultsKnowledge 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. ConclusionsThe limited knowledge and use of coordination mechanisms shows insufficient diffusion and implementation. Strategies to increase its use are needed, including the related factors.