Do primary and specialized care physicians know and use coordination mechanisms?

Mendes, Lívia dos Santos; Almeida, Patty Fidelis de

doi:10.11606/s1518-8787.2020054002475

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Original Article • Rev. Saúde Pública 54 • 2020 • https://doi.org/10.11606/s1518-8787.2020054002475 copy

Do primary and specialized care physicians know and use coordination mechanisms?

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

OBJECTIVES:

To analyze if primary and specialized care physicians know and use care coordination mechanisms between healthcare levels.

METHODS:

Cross-sectional survey study, with the application of the COORDENA-BR instrument to primary and specialized care physicians in a public heathcare network, medium-sized municipality, from June to October 2019. The questionnaire addresses knowledge, frequency of sending and receiving, purpose, characteristics and difficulties in using feedback or mutual adaptation and standardization mechanisms to promote coordination of care service between healthcare levels.

RESULTS:

Feedback instruments such as referral and reply letters, hospital discharge report and WhatsApp are widely known by professionals of both levels, without significant differences. Clinical sessions and protocols are not well-known, especially in specialized care, which supposes a low usage of standardization mechanisms to a better coordination between the healthcare levels. Despite being well-known and easy, traditional feedback instruments such as referral and reply letters are not widely used. Fewer physicians knew the protocols, mainly in specialized care. They pointed difficulties in their application, such as insufficient exams and unavailable supplies in the healthcare network. Clinical sessions were unknown and registered low participation frequency. Care overload, low institutionalization and time constraints were barriers identified for the incorporation of care coordination mechanisms in the work process in primary and specialized care, in addition to those related to the provision of health services in the network.

CONCLUSION:

We conclude the fragmentation of the system and care can be faced in the complementarity of measures that make it possible to know the mechanisms, develop professional skills, institutionalize and promote organizational conditions for the effective use of coordination mechanisms throughout the healthcare network.

DESCRIPTORS:
Intersectoral Collaboration; Comprehensive Health Care; Health Care Levels; Health Services Administration

Type of service			Number of physicians	Number of losses	Number of respondents
PHC	FHS	Countryside	16	2	14
	FHS	Urban area	28	2	26
	Total of FHS physicians		44	4	40
	Total of BHC physicians		26	2	24
Total of PHC physicians			70	6	64
SC	Specialized medical center		52	9	43
	Mental health outpatient clinic		5	-	5
	Rehabilitation clinic		2	-	2
	BHC		7	1	6
Total of specialists			66	10	56
Total			136	16	120

Characteristics		PHC (n = 64) n (%)	SC (n = 56) n (%)	Total (n = 120) n (%)
Gender
	Female	35 (54.7)	17 (30.4)	52 (43.3)
	Male	29 (45.3)	39 (69.6)	68 (56.7)
Age (years)
	25–34	26 (40.6)	11 (19.6)	37 (30.8)
	35–49	22 (34.4)	34 (60.7)	56 (46.7)
	> 50	16 (25.0)	11 (19.6)	27 (22.5)
Nationality
	Brazilian	64 (100.0)	56 (100.0)	120 (100.0)
Training time (years)
	≤ 2	15 (23.4)	0 (0.0)	15 (12.5)
	3–10	26 (40.6)	15 (26.8)	41 (34.2)
	11–20	7 (10.9)	24 (42.8)	31 (25.8)
	> 20	16 (25.0)	17 (30.4)	33 (27.5)
Education institution
	Public	24 (37.5)	31 (55.4)	55 (45.8)
	Private	40 (62.5)	25 (44.6)	65 (54.2)
Medical specialization
	No Medical Residency	38 (59.4)	1 (1.8)	39 (32.5)
	Medical clinic	9 (14.1)	0 (0.0)	9 (7.0)
	Pediatrics	7 (10.9)	5 (8.9)	12 (10.0)
	Obstetrics and gynecology	3 (4.7)	6 (10.7)	9 (7.0)
	Others	7 (10.9)	44 (78.6)	51 (42.5)
Working hours per week
	20–32	42 (65.6)	45 (80.4)	87 (72.5)
	≥ 40	22 (34.4)	11 (19.6)	33 (27.5)
Works in the private sector
	Yes	31 (48.4)	52 (92.9)	83 (69.2)
	No	33 (51.6)	4 (7.1)	37 (30.8)

		PHC (n = 64) n (%)	SC (n = 56) n (%)	Total (n = 120) n (%)	p
Existence of the instrument
Referral form and reply letters
	Yes	55 (85.9)	41 (73.2)	96 (80.0)	0.082
	No	9 (14.1)	15 (26.8)	24 (20.0)
Hospital discharge report
	Yes	50 (78.1)	51 (91.1)	101 (84.2)	0.053
	No	14 (21.9)	5 (8.9)	19 (15.8)
MH and municipal protocols shared between levels
	Yes	42 (65.6)	22 (39.3)	64 (53.3)	0.004
	No	22 (34.4)	34 (60.7)	56 (46.7)
Joint clinical sessions between PHC and SC physicians
	Yes	29 (45.3)	9 (16.1)	38 (31.7)	0.001
	No	35 (54.7)	47 (83.9)	82 (68.3)
Institutional phone line
	Yes	41 (64.1)	51 (91.1)	92 (76.7)	< 0.001
	No	23 (35.9)	5 (8.9)	28 (23.3)
Telehealth
	Yes	35 (54.7)	5 (8.9)	40 (33.3)	< 0.001
	No	29 (45.3)	51 (91.1)	80 (66.7)
Electronic medical record
	Yes	29 (45.3)	6 (10.7)	35 (29.2)	< 0.001
	No	35 (54.7)	50 (89.3)	85 (70.8)
WhatsApp:
	Yes	56 (87.5)	54 (96.4)	110 (91.7)	0.102
	No	8 (12.5)	2 (3.6)	10 (8.3)
Frequency^a a Questions answered only by professionals that knew about the existence of the instrument.
Referral form and reply letters sending^b b The referral form sending was answered by the PHC physicians and the reply letters form sending by the SC physicians.		n = 55	n = 41	n = 96	0.038
	High	24 (43.6)	8 (19.5)	32 (33.3)
	Low	22 (40.0)	21 (51.2)	43 (44.8)
	Never	9 (16.4)	12 (29.3)	21 (21.9)
Referral form and reply letters receiving^c b The referral form receiving was answered by the PHC physicians and the reply letters form sending by the SC physicians.		n = 55	n = 41	n = 96	0.012
	High	2 (3.6)	7 (17.1)	9 (9.4)
	Low	26 (47.3)	24 (58.5)	50 (52.1)
	Never	27 (49.1)	10 (24.4)	37 (38.5)
Hospital discharge report receiving		n = 50	n = 51	n = 101	-
	High	22 (44.0)	-	-
	Low	25 (50.0)	-	-
	Never	3 (6.0)	-	-
Use of MH and municipal protocols shared between levels		n = 42	n = 22	n = 64	0.006
	High	39 (92.8)	14 (63.6)	53 (82.9)
	Low	2 (4.8)	2 (9.1)	4 (6.2)
	Never	1 (2.4)	6 (27.3)	7 (10.9)
Participation joint clinical sessions between PHC and SC physicians		n = 29	n = 9	n = 38	0.002
	High	19 (65.5)	1 (11.1)	20 (52.6)
	Low	10 (34.5)	6 (66.7)	16 (42.1)
	Never	0 (0.0)	2 (22.2)	2 (5.3)
WhatsApp Use		n = 56	n = 54	n = 110	0.259
	High	7 (12.5)	2 (3.7)	9 (8.2)
	Low	22 (39.3)	22(40.7)	44 (40.0)
	Never	27 (48.2)	30 (55.6)	57 (51.8)

			PHC n (%)	SC n (%)	Total n (%)
Purpose^a a n defined by the number of professionals that presented some frequency of using or receiving the instrument, according to Table 3. ^b b Categorized open questions.
Referral form and reply letters			n = 46	n = 29	n = 75
	Information exchange		38 (82.6)	28 (96.5)	66 (88.0)
	Patient referral		10 (21.7)	1 (3.4)	11 (14.7)
	PHC monitoring		2 (4.3)	9 (31.0)	11 (14.7)
	Streamline access to the specialist		4 (8.7)	0 (0.0)	4 (5.3)
	Bureaucracy		2 (4.3)	1 (3.4)	3 (4.0)
Hospital discharge report			n = 47	-	-
	Information exchange		35 (74.5)	-	-
	PHC monitoring		17 (36.2)	-	-
Shared protocols			n = 41	n = 16	n = 57
	Service guidance		19 (46.3)	9 (56.2)	28 (49.1)
	Care standardization		19 (46.3)	7 (43.7)	26 (45.6)
	Care quality		6 (14.6)	1 (6.2)	7 (12.3)
	Cost reduction		1 (2.4)	2 (12.5)	3 (5.3)
	Articulation favoring		3 (7.3)	0 (0.0)	3 (5.3)
	Unnecessary referral prevention		3 (7.3)	0 (0.0)	3 (5.3)
	Bureaucracy		1 (2.4)	0 (0.0)	1 (1.7)
Clinical sessions			n = 29	n = 7	n = 36
	Improve knowledge		17 (58.6)	3 (42.8)	20 (55.5)
	Conduct unification		13 (44.8)	4 (57.1)	17 (47.2)
	Case discussion		5 (17.2)	4 (57.1)	9 (25.0)
	Experience exchange		3 (10.3)	3 (42.8)	6 (16.7)
WhatsApp			n = 29	n = 24	n = 53
	Ease/speed		17 (58.6)	21 (87.5)	38 (71.7)
	Information exchange		11 (37.9)	13 (54.2)	24 (45.3)
	Streamline access to the specialist		6 (20.7)	1 (4.2)	7 (13.2)
Use characteristics
Referral form and reply letters^a a n defined by the number of professionals that presented some frequency of using or receiving the instrument, according to Table 3.
	Referral form and reply letters sending method		n = 46	n = 29	n = 75
		Via patient	37 (80.4)	28 (96.6)	65 (86.7)
		Via regulation center	9 (19.6)	1 (3.4)	10 (13.3)
	Referral and reply letters form receiving method		n = 28	n = 31	n = 59
		Via patient	27 (96.4)	29 (93.5)	56 (94.9)
		Via regulation center	1 (3.6)	2 (6.5)	3 (5.1)
	Information contained in the referral^c c Multiple choice questions that admitted more than one answer.		-	n = 31	-
		Treatments	-	20 (64.5)	-
		Diagnosis	-	20 (64.5)	-
		Personal information	-	29 (93.5)	-
		Clinical history	-	24 (77.4)	-
		Exams	-	18 (58.0)	-
		Reason for referral	-	31 (100.0)	-
	Information contained in the reply letters^c c Multiple choice questions that admitted more than one answer.		n = 28	-	-
		Treatments	25 (89.3)	-	-
		Diagnosis	26 (92.9)	-	-
		Personal information	19 (67.9)	-	-
		Clinical history	18 (64.3)	-	-
		Exams	17 (60.7)	-	-
	Reply letters attends the referral reason.		n = 28	-	-
		High	16 (57.1)	-	-
		Low	10 (35.7)	-	-
		Never	2 (7.2)	-	-
	The reply letters is received in a timely manner to make decisions.		n = 28	-	-
		High	9 (32.1)	-	-
		Low	15 (53.6)	-	-
		Never	4 (14.3)	-	-
Hospital discharge report^a a n defined by the number of professionals that presented some frequency of using or receiving the instrument, according to Table 3.
	Receive information in a timely manner to make decisions.		n = 47	-	-
		High	16 (34.0)	-	-
		Low	29 (61.7)	-	-
		Never	2 (4.3)	-	-
	Hospital discharge report receiving method		n = 47	-	-
		Via patient	47 (100.0)	-	-
	Information received in the hospital discharge report^c c Multiple choice questions that admitted more than one answer.		n = 47	-	-
		Pharmacological treatment	47 (100.0)	-	-
		Diagnosis	47 (100.0)	-	-
		Reason of hospitalization	46 (97.9)	-	-
		Procedure performed	47 (100.0)	-	-
		Exam results	40 (85.1)	-	-
		Follow-up indications	30 (63.8)	-	-
Shared protocols^d d n defined by the number of professionals that knew the existence of the instrument, according to Table 3.
Participates in training on the use of shared protocols			n = 42	n = 22	n = 64
	High		27 (64.3)	8 (36.4)	35 (54.7)
	Low		15 (35.7)	14 (63.6)	29 (45.3)
	Never		0 (0.0)	0 (0.0)	0 (0.0)
Clinical sessions^d d n defined by the number of professionals that knew the existence of the instrument, according to Table 3.
The institution provides time to participate in clinical sessions			n = 29	n = 9	n = 38
	Yes		20 (69.0)	4 (44.5)	24 (63.2)
	Sometimes		6 (20.7)	2 (22.2)	8 (21.0)
	No		3 (10.3)	1 (11.1)	4 (10.5)
	My area of expertise is not included		0 (0.0)	2 (22.2)	2 (5.3)
	Content		n = 29	n = 7	n = 36
		Adequate	27 (93.1)	7 (100.0)	34 (94.4)

		PHC n (%)	SC n (%)	Total n (%)	p
Difficulties
Referral form and reply letters		n = 55	n = 41	n = 96	0.916
	Yes	18 (32.7)	13 (31.7)	31 (32.3)
	No	37 (67.3)	28 (68.3)	65 (67.7)
Hospital discharge report		n = 50	-	-	-
	Yes	13 (26.0)	-	-
	No	37 (74.0)	-	-
Shared protocols		n = 42	n = 22	n = 64	0.586
	Yes	18 (42.9)	11 (50.0)	29 (45.3)
	No	24 (57.1)	11 (50.0)	35 (54.7)
Clinical sessions		n = 29	n = 9	n = 38	0.436
	Yes	10 (34.5)	5 (55.6)	15 (39.5)
	No	19 (65.5)	4 (44.4)	23 (60.5)

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[1] Correspondence: Patty Fidelis de Almeida, Instituto de Saúde Coletiva, Universidade Federal Fluminense, Rua Marquês do Paraná, 303 3° andar 24030-900 Niterói, RJ, Brasil. E-mail: pattyfidelis@id.uff.br