Marta-Beatriz Aller

Acceso a los servicios de salud de la población inmigrante en España

Fundamentos: Una importante proporcion de poblacion en Espana es inmigrante y la evidencia internacional senala su acceso inadecuado a los servicios de salud. El objetivo es conocer el acceso a la atencion de la poblacion inmigrante en Espana. Metodos: Revision bibliografica de los articulos originales (1998-2012) sobre acceso y utilizacion de los servicios de la poblacion inmigrante en Espana registrados en Medline y MEDES. Se identificaron 319 articulos de los que se seleccionaron 20. Se utilizo el modelo de Aday y Andersen para el analisis. Resultados: Entre los articulos seleccionados, 13 estudios cuantitativos analizaron diferencias en la utilizacion de los servicios entre inmigrantes y autoctonos y 7 determinantes del acceso en inmigrantes. En lineas generales estos muestran menor utilizacion de la atencion especializada, mayor de las urgencias y no se observaron diferencias entre grupos en atencion primaria. Los 5 estudios cuantitativos sobre determinantes se centraron en las caracteristicas de la poblacion (sexo, edad, nivel de estudios y posesion de seguro privado) sin observarse un patron claro. Los 2 estudios cualitativos analizaron factores relacionados con los servicios de salud y encontraron barreras en el acceso, como la provision de informacion o los requisitos para obtener la tarjeta sanitaria. Conclusiones: El acceso a la atencion en inmigrantes ha sido limitadamente abordado, con aproximaciones diferentes y los factores relacionados con la oferta, escasamente analizados. No se observa un patron de utilizacion, las diferencias dependen de la clasificacion de los inmigrante segun origen y nivel asistencial. No obstante, en inmigrantes se observa menor utilizacion de la atencion especializada y mayor de las urgencias, asi como determinantes del acceso distintos a la necesidad.BACKGROUND An important proportion of the population in Spain is immigrant and the international literature indicates their inadequate access to health services. The objective is to contribute to improving the knowledge on access to health care of the immigrant population in Spain. METHODS Review of original papers published (1998-2012) on access to health services of the immigrant population in Spain published in Medline and MEDES. Out of 319 studies, 20 were selected, applying predefined criteria. The results were analyzed using the Aday and Andersen framework. RESULTS Among the publications, 13 quantitative studies analysed differences in health care use between the immigrant and the native population, and 7 studied determinants of access of immigrants. Studies showed less use of specialized care by immigrants, higher use of emergency care and no differences in the use of primary care between groups. Five quantitative articles on determinants of access focused on factors related to the immigrant population (sex, age, educational level and holding private health insurance), but without observing clear patterns. The two qualitative studies analyzed factors related to health services, describing access to healthcare barriers such as the limited provision of information or the requirements for personal health card. CONCLUSION Access to health care in immigrants has been scarcely studied, using different approaches and the barely analysed factors related to the services. No clear patterns were observed, as differences depend on the classification of migrants according to country of origin and the level of care. However, studies showed less use of specialized care by immigrants, higher use of emergency care and the existence of determinants of access different to their needs.

Development and testing of indicators to measure coordination of clinical information and management across levels of care

BackgroundCoordination across levels of care is becoming increasingly important due to rapid advances in technology, high specialisation and changes in the organization of healthcare services; to date, however, the development of indicators to evaluate coordination has been limited. The aim of this study is to develop and test a set of indicators to comprehensively evaluate clinical coordination across levels of care.MethodsA systematic review of literature was conducted to identify indicators of clinical coordination across levels of care. These indicators were analysed to identify attributes of coordination and classified accordingly. They were then discussed within an expert team and adapted or newly developed, and their relevance, scientific soundness and feasibility were examined. The indicators were tested in three healthcare areas of the Catalan health system.Results52 indicators were identified addressing 11 attributes of clinical coordination across levels of care. The final set consisted of 21 output indicators. Clinical information transfer is evaluated based on information flow (4) and the adequacy of shared information (3). Clinical management coordination indicators evaluate care coherence through diagnostic testing (2) and medication (1), provision of care at the most appropriate level (2), completion of diagnostic process (1), follow-up after hospital discharge (4) and accessibility across levels of care (4). The application of indicators showed differences in the degree of clinical coordination depending on the attribute and area.ConclusionA set of rigorous and scientifically sound measures of clinical coordination across levels of care were developed based on a literature review and discussion with experts. This set of indicators comprehensively address the different attributes of clinical coordination in main transitions across levels of care. It could be employed to identify areas in which health services can be improved, as well as to measure the effect of efforts to improve clinical coordination in healthcare organizations.

Available tools to comprehensively assess continuity of care from the patients’ perspective

[2] Aller MB, Vargas I, V azquez ML. Available tools to comprehensively assess continuity of care from the patients’ perspective. J Clin Epidemiol 2012;65:578e9. [3] Letelier MJ, Aller MB, Henao D, S anchez-P erez I, Vargas I, Coderch de Lassaletta J, et al. Design and validation of a questionnaire to measure continuity between care levels from the user’s perspective. Gac Sanit 2010;24:339e46. [4] Uijen AA, Schers HJ, Schellevis FG, Mokkink HGA, van Weel C, van den Bosch WJHM. Measuring continuity from the patient perspective: psychometric properties of the Nijmegen Continuity Questionnaire. [in press].

Doctors’ opinion on the contribution of coordination mechanisms to improving clinical coordination between primary and outpatient secondary care in the Catalan national health system

BackgroundClinical coordination is considered a health policy priority as its absence can lead to poor quality of care and inefficiency. A key challenge is to identify which strategies should be implemented to improve coordination. The aim is to analyse doctors’ opinions on the contribution of mechanisms to improving clinical coordination between primary and outpatient secondary care and the factors influencing their use.MethodsA qualitative descriptive study in three healthcare networks of the Catalan national health system. A two-stage theoretical sample was designed: in the first stage, networks with different management models were selected; in the second, primary care (n = 26) and secondary care (n = 24) doctors. Data were collected using semi-structured interviews. Final sample size was reached by saturation. A thematic content analysis was conducted, segmented by network and care level.ResultsWith few differences across networks, doctors identified similar mechanisms contributing to clinical coordination: 1) shared EMR facilitating clinical information transfer and uptake; 2) mechanisms enabling problem-solving communication and agreement on clinical approaches, which varied across networks (joint clinical case conferences, which also promote mutual knowledge and training of primary care doctors; virtual consultations through EMR and email); and 3) referral protocols and use of the telephone facilitating access to secondary care after referrals. Doctors identified organizational (insufficient time, incompatible timetables, design of mechanisms) and professional factors (knowing each other, attitude towards collaboration, concerns over misdiagnosis) that influence the use of mechanisms.DiscussionMechanisms that most contribute to clinical coordination are feedback mechanisms, that is those based on mutual adjustment, that allow doctors to exchange information and communicate. Their use might be enhanced by focusing on adequate working conditions, mechanism design and creating conditions that promote mutual knowledge and positive attitudes towards collaboration.

Factors influencing coordination and continuity across care levels in the Catalan Health Care System

Background 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 is related to how patients experience the coordination of services. The objective is to identify factors influencing care coordination and continuity across care levels …