Abstract
Background
Given the problems generated by health care fragmentation, the coordinated provision of health care has become a priority, particularly in Latin America. This communication ...analyses the strategies for improving clinical coordination proposed by primary and secondary care doctors from public health service networks in six countries of the region (Argentina, Brazil, Chile, Colombia, Mexico and Uruguay), and their changes between 2015 and 2017.
Methods
Two cross-sectional survey-based studies (2015 and 2017) were analysed with application of the COORDENA questionnaire to a total of 4311 primary and secondary care doctors from two public health service networks in each country. A descriptive analysis was carried out, stratified by country and year, of the suggestions proposed in the open question ‘What do you propose to improve clinical coordination between primary and secondary care doctors in the network?
Results
In all countries, the introduction or improvement of strategies and mechanisms that facilitate interaction and mutual knowledge between professionals at different care levels were highlighted, especially joint meetings, direct communication mechanisms (such as telephone and/or e-mail) and strategies to strengthen the use of the referral and counter-referral sheet. Less frequently, other organisational strategies aimed at strengthening the primary care model, improving access to secondary care and coordinating the management level of the network, were also suggested.
Conclusions
The results contribute to generate recommendations for the improvement of clinical coordination in health systems, based on the suggestions of doctors, a perspective that is not usually considered in the design and implementation of interventions in health services. The need to promote strategies based on mutual feedback in the design of public health policies stands out.
Key messages
• The design of effective interventions aimed at improving coordination requires doctors’ participation.
• Strategies based on mutual feedback and communication should be promoted by healthcare organisations to improve clinical coordination.
Abstract
Background
Despite the effectiveness of Participatory Action Research (PAR) in reducing the gap between evidence and practice, its use to improve care integration is rare. The aim is to ...analyze the factors influencing the implementation of PAR interventions to improve clinical coordination in public health services networks of Brazil, Chile, Colombia, Mexico and Uruguay.
Methods
A qualitative, descriptive-interpretative study was conducted in participating healthcare networks of each country. Focus groups and individual semi-structured interviews were conducted to a criteria sample of participants: members of Local Steering Committee (LSC)(29), professionals’ platform (PP)(28), other professionals (49) and managers(28). Thematic content analysis was performed, segmented by country and themes.
Results
Findings reveal that contextual factors, the PAR process and interventions’ content were determinants in the implementation, interacting over time, and differing among experiences. On the one hand, institutional support (providing the necessary resources) together with the interest of professionals and managers in participating, emerged as influencing factors influenced by other factors related to: the system (alignment with policies; electoral cycle), networks (lack of time due to work overload; precarious employment conditions) and individuals (limited mutual knowledge and mistrust). On the other, some characteristics of the PAR process facilitated institutional support and motivation: professionals’ participation in all activities, design flexibility and shared decision-making - also present when interventions were based on mutual adjustment - the LSC’s leadership and the facilitating role of the research team.
Conclusions
Evidence is provided that when some contextual elements converge the implementation of interventions through PAR processes can turn into a factor of motivation and cohesion, determinant for the adoption of clinical coordination interventions.
Key messages
Contributes to fill the knowledge gap in factors influencing the implementation of PAR interventions in healthcare.
Provides a framework for analysis and recommendations for their implementation.
En este libro se presenta una parte de los resultados del proyecto internacional de investigación “Impacto en la equidad de acceso y la eficiencia de las redes integradas de servicios de salud en ...Colombia y Brasil (Equity-LA)”, financiado por la Unión Europea y en el que participaron seis instituciones de cuatro países, dos europeos (España y Bélgica) y dos latinoamericanos (Colombia y Brasil). La investigación se diseñó con el propósito de mejorar la comprensión sobre el impacto de la implementación de las redes integradas de servicios de salud en el acceso, la coordinación, la eficiencia y la equidad de acceso, en diferentes contextos de Latinoamérica. El estudio además de evidencia, generó nuevas preguntas, que dieron lugar al proyecto Equity LA II (www.equity-la.eu), actualmente en desarrollo, también financiado por la Unión Europea, que profundiza en sus resultados y amplía el análisis a cuatro países más de América Latina: Argentina, Chile, México y Uruguay. Los resultados contenidos en esta obra se refieren a los aspectos de acceso, coordinación, continuidad y calidad de la atención en las redes de servicios de salud, que se analizan mediante un estudio de casos, basado en estudios cualitativos y cuantitativos y cuyos datos se recogieron entre 2009 y 2012.
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.
Regional-based Integrated Healthcare Networks (IHNs) have been promoted in Brazil to overcome the fragmentation due to the health system decentralization to the municipal level; however, evaluations ...are scarce. The aim of this article is to analyse the content of IHN policies in force in Brazil, and the factors that influence policy implementation from the policymakers' perspective.
A two-fold, exploratory and descriptive qualitative study was carried out based on (1) content analysis of policy documents selected to meet the following criteria: legislative documents dealing with regional-based IHNs; enacted by federal government; and in force, (2) semi-structured individual interviews were conducted to a theoretical sample of policymakers at federal (eight), state (five) and municipal levels (four). Final sample size was reached by saturation of information. An inductive thematic analysis was conducted.
The results show difficulties in the implementation of IHN policies due to weaknesses that arise from the policy design and the performance of the three levels of government. There is a lack of specificity as to the criteria and tools for configuring and financing IHNs that need to be agreed upon between involved governments. For their part, policymakers emphasize the difficulty of establishing agreements in a health system with disincentives for collaboration between municipalities. The allocation of responsibilities that are too complex for the capacity and size of the municipalities, the abandonment of essential functions such as network planning by states and the strategic role by the Ministry, the 'invasion' of competences among levels of government and high political turnover are also highlighted.
The implementation of regional-based IHN policy in Brazil is hampered by the decentralized organization of the health system to the municipal level, suggesting the need to centralize certain functions to regional structures or states and to define better the role of the government levels involved.
Objetivo Contribuir al conocimiento sobre el acceso a los servicios en Colombia tras la reforma del sistema de salud, exponiendo los principales resultados y vacios en las investigaciones. Metodos Se ...realizo una revision sistematica de la bibliografia, a traves de la busqueda exhaustiva y analisis de articulos originales publicados entre 1994 y 2009. Se incluyeron 27 investigaciones cuantitativas y cualitativas que cumplian los criterios de seleccion. El analisis se enmarco en los modelos teoricos de Aday y Andersen y Gold, que diferencian entre acceso potencial y realizado y consideran las caracteristicas de la poblacion, proveedores y aseguradoras que influyen en la utilizacion. Resultados Los analisis explicativos de la utilizacion de los servicios de salud a partir de modelos de determinantes resultan escasos y parciales (limitados a areas geograficas, patologias o colectivos especificos). Pocos estudios profundizan en factores de contexto -politicas y caracteristicas 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 regimen subsidiado- y, en cambio, senalan la existencia de importantes barreras relacionadas con factores poblacionales (aseguramiento, renta y educacion) y caracteristicas de los servicios (accesibilidad geografica, organizativas y calidad). Conclusiones La revision muestra limitaciones importantes en el analisis del acceso en Colombia que indican la necesidad de reorientar la evaluacion 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. Palabras Clave: Accesibilidad a los servicios de salud, prestacion de atencion de salud, Colombia, literatura de revision como asunto (fuente: DECS, BIREME). 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. Key Words: Health service accessibility, healthcare provision, Colombia, review literature (source: MeSH, NLM).
Asociación entre la antropometría materna y el producto de la gestación Martin Carrillo, S.; Pérez Guillén, A.; Armenia Hernández Hernández, R. ...
Nutrición hospitalaria : organo oficial de la Sociedad Española de Nutrición Parenteral y Enteral,
10/2010, Letnik:
25, Številka:
5
Journal Article
Odprti dostop
Objetivo: evaluar la asociación entre el estado nutricional antropométrico materno durante su tercer trimestre de gravidez con el estado nutricional antropométrico del neonato. Método: Se evaluaron ...98 binomios madre-recién nacido atendidos en el Hospital Público Universitario de Caracas y en el Hospital Privado de Clínicas Caracas, Venezuela. Las variables maternas fueron: peso pregestacional, peso gestacional, talla, circunferencia media del brazo (CMB), circunferencia de pantorrilla y pliegue del tríceps y se construyeron los indicadores antropométricos: índice de masa corporal pregestacional (IMCpg) y gestacional (IMCg), así como indicadores de composición corporal: área grasa (AG) y muscular del brazo (AM). En el recién nacido, se evaluó: peso, talla, índice ponderal (IP), y evaluación clínica del estado nutricional del neonato (ECEN). Resultados: El IMCg mostró una de las mejores correlaciones y con significancia estadística con el IP del neonato (r=0,22) observando este mismo resultado la CMB materno con el IP (r=0,21) y el puntaje de ECEN (r=0,22). En cuanto a los indicadores de composición corporal materno, únicamente se encontró correlación positiva y estadísticamente significativas entre el AM y el puntaje ECEN (r = 0,24) y el AG con el IP (r = 0,20). Conclusión: La CMB materna podría constituir una variable indicativa del estado nutricional del neonato y se recomienda la incorporación temprana en el monitoreo rutinario del control prenatal.
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