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  • Periodic Report Summary 3 - EQUITY-LA II (The impact of alternative care integration strategies on Health Care Networks’ performance in different Latin American health systems)

Periodic Report Summary 3 - EQUITY-LA II (The impact of alternative care integration strategies on Health Care Networks’ performance in different Latin American health systems)

Project Context and Objectives:
Introduction: Health services fragmentation is considered to be one of the main obstacles to attaining effective healthcare outcomes in many Latin American health systems. It produces difficulties in access to care, poor technical quality, discontinuity of care and inefficiency. Nevertheless, there is scant evidence on best practices in care coordination in Latin America. The project will build on the previous Equity-LA project (FP7-Health-2007-B) by expanding the scope of the research in Colombia and Brazil and incorporating other Latin American countries – Chile, Mexico, Argentina and Uruguay – thus representing a large array of health systems and health services networks.
General objective: 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.
Specific objectives:
- To analyse the performance of health services networks with respect to coordination and quality of care and associated factors in each particular context
- To design, implement and benchmark a set of organizational interventions aimed at improving care coordination and quality of care with a focus on health works and patients with chronic conditions
- To test the effectiveness and limitations of the various interventions in improving coordination and quality of care in the health services networks, and to identify the factors that determine their applicability in different contexts
- To develop tools to translate evidence on best practices of care integration into innovative and effective policies for a better organization of health services networks in Latin America
Methods and analysis: A 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 alter intervention (alpha=0.05; beta=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: This study complies with international and national legal stipulations on ethics. Conditions of the study procedure were approved by each country’s ethical committee.
Project Results:
These reporting periods include finalization of WP1 Theoretical framework and research tools, WP2 Base-line study and WP3 Design and implementation of interventions, beginning of WP4 Evaluation of interventions and continuation of WP6 “Capacity building and dissemination of research results” and WP7 “Project management and coordination”.
In WP1, the common theoretical framework, research plan and tools for the qualitative data were elaborated, the study areas (intervention and control healthcare networks) selected and the context analysis finalized. Capacity building was initiated.
In WP2, the qualitative (individual interviews and focus groups with healthcare personnel and, users) and quantitative (questionnaire surveys to doctors and users) data collection and analysis for the base-line was finished. Quantitative research tools (COORDENA for care coordination and CCAENA for continuity of care) were elaborated, adapted to the language and context of each country, pre-tested and piloted, with the support of Beneficiary 1 (CSC). The sample size was calculated, the selection process discussed. Support manuals for data collection, entry and analysis and data bases were elaborated by Beneficiary 1. Descriptive analysis was finalized. Research capacity building of junior researchers continued, including in-situ support by Beneficiary 1.
WP3 was the design, implementation and monitoring of the interventions to improve care coordination across care levels that had been designed by means of a participatory process based on the discussion of problems regarding coordination and continuity of care in the healthcare networks, previously identified in the base-line study (WP2). Most were micro-level interventions based on feedback focusing on improving communication between PC and SC doctors (face-to face or on-line joint clinical/training sessions, off-line communication system) but also their clinical skills, together with an induction program, clinical agreements for care across levels and improvements in the referral/back referral system. Beneficiary 1 provided permanent support (feed-back and documents) and Beneficiary 2 compiled report on the intervention design and implementation plan. Research capacity building of junior researchers continued and capacity building of health professionals was a strong component and received the support of Beneficiary 1.
In WP4 the theoretical framework for the evaluation of interventions’ process and effectiveness was elaborated and the instruments used in the base-line surveys (COORDENA and CCAENA) adapted to capture specific elements related to the intervention. Specifics topic guides were developed for the qualitative evaluation by Beneficiary 1. The fieldwork was almost finished (400 doctors and 800 patients per country) and preliminary analysis were conducted. The qualitative evaluation started. Research capacity building continued throughout the WP, by the direct involvement of junior researchers in all the activities, closely supervised by senior researchers, in situ-scientific support by Beneficiary 1.
In WP6, the capacity building of the LSC and dissemination of the project and its results continues in different forms: the project dissemination strategy, logotype and leaflets and website regularly updated; articles; presentations to policy makers and relevant stakeholders, communications to national and international conferences, organising seminars, introducing results and methods in different training courses of the involved Latin-American partners, news in newsletters-
In WP7, Beneficiary 1 guided and supervised management tasks and ensured communication and information exchange between partners via telephone, e-mail and the Intranet of the project website and regular virtual meetings (teleconferences) and seven international workshops (face-to-face meetings) were organized with the participation of all Beneficiaries to discuss the project progress and prepare upcoming research activities.
Potential Impact:
The expected results of this research project will support national and international decision-makers by providing evidence of best practices in care integration in different health systems in Latin America, with particular reference to two chronic diseases (diabetes and chronic obstructive pulmonary disease (COPD). It will also contribute to advancing the state of the art by generating new knowledge on the impact of health care network reforms on coordination across care levels and, ultimately, quality of care. A dissemination strategy was developed to ensure that the findings are used to inform policy and practice and disseminated to the greater public. The following mechanisms for the management of newly generated knowledge will be considered: (1) for dissemination among the academic communities, short reports and research papers in free access peer-reviewed national and international journals and other relevant publications, as well as participation in national and international conferences; (2) to ensure that results inform policymaking: (A) a best practices report on care integration in the region and policy guidelines; (B) round tables, meetings and workshops to present key findings and policy recommendations to local and national interest groups in the six Latin American countries; (C) building networks of key contacts (academic, governmental, non-governmental, civil society, including users’ organisations, etc) in the participating countries and other countries in Latin America and elsewhere, and with international agencies, such as the PAHO, World Bank, WHO, EC, etc; and (D) coordinating with pre-established networks.
The study will further contribute to capacity building in three domains: (1) capacity building of policymakers for the planning, management and organisation of health systems by involving key stakeholders from the beginning of the project and generating evidence-based tools for the development of policy and research dissemination; (2) strengthening of research capacity of all involved institutions in health system research through the specific training of junior researchers and the exchange of knowledge and experiences among senior researchers; and (3) improvement of health professionals’ knowledge and skills in coordination across care levels and quality of care through in-service training programmes.
A conservative estimation indicates that, so far, around 15,000 people have been directly involved (researchers, policy makers, health professionals and managers members of different committees, doctors and users as informants) and around 3000,000 between users and doctors of the participating networks are potential direct beneficiaries of the interventions. Those estimates do not include other impacts, such as the project methods and results being part of the National healthcare Network programmatic Plan for 2018 in Chile (national level dissemination), or the intervention having been scaled-up to the State level in Mexico, by the State Health Secretariat.
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