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

Abstract

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

Conhecimento e uso de mecanismos para articulação clínica entre níveis em duas redes de atenção à saúde de Pernambuco, Brasil

“…No Brasil, várias políticas auxiliam na implementação dos mecanismos. O sistema de referência e contrarreferência, por exemplo, é considerado como um dos elementos-chave para a efetividade das RAS, e o Ministério da Saúde ressaltou o papel deste mecanismo e dos protocolos compartilhados para a integração entre os níveis de atenção e o aumento da resolubilidade da atenção básica 3,11,12 . A implementação dos mecanismos está relacionada com o sistema de saúde e com fatores políticos, econômicos e organizacionais.…”

“…A implementação dos mecanismos está relacionada com o sistema de saúde e com fatores políticos, econômicos e organizacionais. Por isso, a gestão deve incentivar o uso e reforçar estratégias para a utilização na conduta clínica 11,12 . Porém, estudos sobre mecanismos que promovam a coordenação e continuidade da atenção entre níveis ainda são escassos e as evidências sobre este tema são limitadas, principalmente na América Latina 11,12,13,14 .…”

“…Cobertura da Estratégia Saúde da Família, 2016. http://dab.saude.gov.br/portaldab/historico_cobertura_sf.php, acessado em 20/Ago/2016). Tais redes foram selecionadas baseando-se nos seguintes critérios: ter uma rede de serviços contínua, incluindo a atenção básica e atenção especializada; ter serviços com área e população delimitada; contemplar áreas de médio/baixo nível socioeconômico; e contar com profissionais que aceitassem participar da pesquisa 12 .…”

“…Para tanto, adotou-se um poder de 80% (β = 0,20) e um nível de 95% de confiança (α = 0,05). Para atingir a amostra, todos os médicos das redes (que cumpriam os critérios de seleção) foram convidados a participar da pesquisa, com um percentual de recusa de 6,6% na rede de Caruaru e 13,4% em Recife (DS III e VII) 12 .…”

Improving performance of long‐term care networks at their initial stage: an empirical study of factors affecting results

“…Vàzquez et al (: 7) proposed a list of potential mechanisms which could foster integration in healthcare network services. These mechanisms were a specification of the “network management” factors identified in the performance management literature and consisted in: “the placement of care managers and liaison professionals, the implementation of in‐service supervision and individual coaching, the development of multidisciplinary working groups to enhance communication between health professionals, the fostering of informal channels of communication, and an adequate use of clinical information systems”.…”