Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Avenida Tibidabo 21, 08022, Barcelona, Spain.
Escuela de Salud Pública Dr. Salvador Allende Gossens, Facultad de Medicina, Universidad de Chile, Avenida Independencia, 939, Santiago de Chile, Chile.
BMC Health Serv Res. 2020 Oct 12;20(1):941. doi: 10.1186/s12913-020-05781-7.
Finding new strategies for care integration has become a policy priority for many fragmented health systems in Latin America. Although the implementation of interventions through a participatory action research (PAR) approach is considered to be more effective in achieving organizational change, its application is scarce. This study, part of the research project Equity-LA II, aims to analyze the impact of PAR interventions on care coordination across levels, and key aspects for their sustainability and transferability, from the stakeholder viewpoint in healthcare networks of Brazil, Chile, Colombia, Mexico and Uruguay. Different interventions were designed and implemented through a PAR process to improve communication and clinical agreement between primary care and secondary care doctors: joint meetings to discuss clinical cases and/or training; shared care guidelines; offline virtual consultations; a referral and reply letter; and an induction program.
A qualitative, descriptive-interpretative study was conducted in the healthcare network of each country. Focus groups and semi-structured individual interviews were conducted with a criterion sample of participants: local steering committee (29) and professional platform members (28), other health professionals (49) and managers (28). Thematic content analysis was conducted, segmented by country and type of intervention.
Informants highlighted that joint meetings based on reflexive methods contributed substantially to improving contextually relevant elements of clinical management coordination - communication in patient follow-up, clinical agreement, appropriateness of referrals - and also administrative coordination. The meetings, alongside the PAR process, also helped to improve interaction between professionals - knowing each other personally and mutual trust - thus fostering willingness to collaborate. The PAR approach, moreover, served to spread awareness of the coordination problems and need for intervention, encouraging greater commitment and interest in participating. No noteworthy contributions were identified in remaining interventions due to low uptake. A necessary condition for the sustainability and replicability was that PAR process had to be used appropriately in a favourable context.
Evidence is provided on the substantial contribution of interventions to improving locally relevant clinical coordination elements and professional interaction when implemented through an adequate PAR process (in terms of time, method and participation levels), a necessary condition for their sustainability and replicability.
为许多拉丁美洲支离破碎的卫生系统发现新的护理整合策略已成为政策优先事项。尽管通过参与式行动研究（PAR）方法实施干预措施被认为在实现组织变革方面更有效，但这种方法的应用却很少。这项研究是 Equity-LA II 研究项目的一部分，旨在从利益相关者的角度分析通过 PAR 干预措施对跨越各级的护理协调的影响，以及其可持续性和可转移性的关键方面，在巴西、智利、哥伦比亚、墨西哥和乌拉圭的医疗保健网络中。通过 PAR 过程设计和实施了不同的干预措施，以改善初级保健和二级保健医生之间的沟通和临床协议：讨论临床病例和/或培训的联席会议；共同护理指南；离线虚拟咨询；转诊和回复信；以及入职计划。
在每个国家的医疗保健网络中进行了定性、描述性-解释性研究。使用标准样本的参与者进行了焦点小组和半结构化个人访谈：地方指导委员会（29 人）和专业平台成员（28 人）、其他卫生专业人员（49 人）和管理人员（28 人）。通过国家和干预类型进行主题内容分析。
信息提供者强调，基于反思方法的联席会议极大地促进了改善临床管理协调方面的相关因素 - 患者随访中的沟通、临床协议、转诊的适当性 - 以及行政协调。这些会议，以及 PAR 过程，还有助于改善专业人员之间的互动 - 相互了解和相互信任 - 从而促进合作的意愿。此外，PAR 方法还提高了对协调问题和干预需求的认识，鼓励更多的承诺和参与意愿。由于采用率低，其他干预措施没有发现显著贡献。可持续性和可复制性的必要条件是，PAR 过程必须在有利的环境中得到适当应用。
提供了证据表明，通过适当的 PAR 过程（在时间、方法和参与水平方面）实施干预措施，对改善当地相关的临床协调要素和专业互动具有重要贡献，这是其可持续性和可复制性的必要条件。
