M. Luisa Vázquez

Coordination and continuity across care levels in the Catalan national health system: differing perceptions of physicians and users?

Introduction : Care coordination has become a priority in most health systems, as patients increasingly receive care from several professionals in different settings, particularly those with chronic conditions and multi-morbidities. Fragmented care produces difficulties in access to care, poor technical quality, discontinuity of care and inefficiency. Care coordination is the harmonious connection of the different services needed to provide care to a patient throughout the care continuum in order to achieve a common objective without producing conflicts. Continuity of care, in turn, is how patients experience care coordination. Perceptions of physicians and user have rarely been analyzed in a comprehensive manner. The objective is to analyze comparatively physicians’ perceptions of coordination and patients’ perceptions of continuity across care levels in different areas of the Catalan national health system. Methods : Descriptive-interpretative qualitative study. A three-stage theoretical sample was selected: (i) study contexts: healthcare areas in Catalonia with different services management models (selecting Baix Emporda, Girona and Ciutat Vella in Barcelona); (ii) GP and specialists (including different specialities providing outpatient, inpatient and emergency care) having been employed in the study areas for at least 1.5 years; (iii) users ≥ 18 years of age who were attended to at both care levels for the same condition. Data were collected by means of individual semi-structured interviews with GPs (26), specialists (24) and patients (49). Interviews were recorded and transcribed. Data were segmented by informant and study area. A thematic content analysis was carried out with a mixed generation of categories and triangulation of analysts. Results : Physicians and patients in all study areas perceived the existence of coordination and continuity across levels, especially referring to information transfer and consistency of medical indications, treatments and tests. Nevertheless, limitations were also identified, some of which varied between healthcare areas and informant groups. Main differences of perceptions of physicians of the different study areas related to referrals and accessibility across care levels. First, concerning coordination/continuity of information, both informant groups perceived its existence, described by the transfer of information across care levels via a shared medical history system and its uptake. Physicians across the areas pointed out that, as a result of information sharing, the care provision across levels was consistent and follow-up at the other care level facilitated. For its part, patients indicated that they were spared from carrying test results and commenting on antecedents or preceding visits. However, physicians also reported some limitations of information transfer, e.g. missing reason for referrals or recommendations for follow-up. Whilst GPs indicated insufficient uptake of information by some specialists, patients highlighted limited use by emergency and locum doctors. Second, concerning consistency of care, both informant groups perceived that physicians generally provided the same diagnosis and treatment to the patient and that incompatibilities of medications were rare. Moreover, few test duplications were reported by physicians and patients. According to physicians, consistency was achieved particularly through the coordination of information across levels and direct communication to respond to questions about diagnosis and treatment and to reach consensus. In addition, physicians reported that care is generally provided at the appropriate care level and according to patient needs, which was similar to patients’ accounts indicating the receipt of care at right level and when necessary. Nevertheless, some specialists reported that referrals to their care level were inadequate and some GPs of Ciutat Vella and Girona highlighted that in some occasions necessary secondary care was not provided (too early emergency and impatient discharge and referral rejections). A few patients of all healthcare areas expressed absent referral resulting in the patient seeking private care and a perceived loss of time and resources. Finally, concerning accessibility across levels, both informant groups perceived adequate waiting times for urgent specialized care. However, according to some GPs, waiting times were too long for non-urgent secondary care after a referral and in Girona for some specific tests, resulting in diagnostic and therapeutic delays. Occasionally, some patients reported interruptions in the diagnostic process and treatment due to long waiting times for non-urgent secondary care. Discussion : Physicians and patients generally perceived that coordination and continuity across care levels existed in the study areas. However, some interruptions were also identified, such as the insufficient uptake of information or long waiting times for non-urgent secondary care. Results further suggest similar perceptions in all areas, as well as congruent reports by physicians and patient, with a few specific differences in highlighted problems. Conclusion : Coordination and continuity across care levels appears to exist in the areas studied, with certain exceptions that highlight where there is room for improvement.