Improving coordination between primary care (PC) and secondary care (SC) has become a policy priority in recent years for many Latin American public health systems looking to reinforce a healthcare model based on PC. However, despite being a longstanding concern, it has scarcely been analyzed in this region. This paper analyses the level of clinical coordination between PC and SC experienced by doctors and explores influencing factors in public healthcare networks of Argentina, Brazil, Chile, Colombia, Mexico and Uruguay. A cross-sectional study was carried out based on a survey of doctors working in the study networks (348 doctors per country). The COORDENA questionnaire was applied to measure their experiences of clinical management and information coordination, and their related factors. Descriptive analyses were conducted and a multivariate logistic regression model was generated to assess the relationship between general perception of care coordination and associated factors. With some differences between countries, doctors generally reported limited care coordination, mainly in the transfer of information and communication for the follow-up of patients and access to SC for referred patients, especially in the case of PC doctors and, to a lesser degree, inappropriate clinical referrals and disagreement over treatments, in the case of SC doctors. Factors associated with a better general perception of coordination were: being a SC doctor, considering that there is enough time for coordination within consultation hours, job and salary satisfaction, identifying the PC doctor as the coordinator of patient care across levels, knowing the doctors of the other care level and trusting in their clinical skills. These results provide evidence of problems in the implementation of a primary care-based model that require changes in aspects of employment, organization and interaction between doctors, all key factors for coordination.

IntroductionAlthough fragmentation in the provision of healthcare is considered an important obstacle to effective care, there is scant evidence on best practices in care coordination in Latin America. The aim is 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.Methods and analysisA 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 after intervention (α=0.05; β=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 and disseminationThis study complies with international and national legal stipulations on ethics. Conditions of the study procedure were approved by each country's ethical committee. A variety of dissemination activities are implemented addressing the main stakeholders. Registration No.257 Clinical Research Register of the Santa Fe Health Department, Argentina.

An adequate use of referral and reply letters—the main form of communication between primary care (PC) and out-patient secondary care (SC)—helps to avoid medical errors, test duplications and delays in diagnosis. However, it has been little studied to date in Latin America. The aim is to determine the level and characteristics of PC and SC doctors’ use of referral and reply letters and to explore influencing factors in public healthcare networks of Argentina, Brazil, Chile, Colombia, Mexico and Uruguay. A cross-sectional study was conducted through a survey of PC and SC doctors working in public healthcare networks (348 doctors per country). The COORDENA questionnaire was applied to measure the frequency of use and receipt of referral and reply letters, quality of contents, timeliness and difficulties in using them. Descriptive analyses were conducted and a multivariate logistic regression model was generated to assess the relationship between frequent use and associated factors. The great majority of doctors claim that they send referral letters to the other level. However, only half of SC doctors (a higher proportion in Chile and Mexico) report that they receive referral letters and <20% of PC doctors receive a reply from specialists. Insufficient recording of data is reported in terms of medical history, tests and medication and the reason for referral. The factor associated with frequent use of the referral letter is doctors’ age, while the use of reply letters is associated with identifying PC doctors as care coordinators, knowing them and trusting in their clinical skills, and receiving referral letters. Significant problems are revealed in the use of referral and reply letters which may affect quality of care. Multifaceted strategies are required that foster a direct contact between doctors and a better understanding of the PC-based model.

Objectives. To report the surveillance of COVID-19 pandemic in Chile and analyse the response to public health interventions implemented from 3 March to 30 June 2020 and to assess the risks of collapse of the health care system. Methods. We analysed the effective reproductive number, underreporting of cases, burden of critical beds, case fatality ratio and number of diagnostic RT-PCR for SARS-CoV-2. Results. After an accelerated onset, the COVID-19 pandemic seemed to be relatively controlled in Chile (late April 2020), with reproductive numbers close to 1.00. However, at this time, the load of infected patients was high, with an important number of underreported cases; the diagnostic effort was still limited and heterogeneous across regions. After 1 May up to 30 June a marked exponential increase in the number of cases was observed with a peak on June 14. In this last period the occupation of intensive care unit beds increased to saturation level (89% nationally; 95% in the Metropolitan Region). Conclusions. Our findings suggest that the implemented public health interventions have been initially effective in decreasing the spread of the pandemic. Premature decisions to relax these interventions may have resulted in a rebound in cases with a rapid saturation of the health care system.

Healthcare coordination is considered key to improving care quality. Although participatory action research (PAR) has been used effectively to bridge the gap between evidence and practice in other areas, little is known about the key success factors of its use in healthcare organizations. This article analyses the factors influencing the implementation of PAR interventions to improve clinical coordination from the perspective of actors in public healthcare networks of Brazil, Chile, Colombia, Mexico and Uruguay. A qualitative, descriptive-interpretative study was conducted in each country’s healthcare network. Focus groups and semi-structured individual interviews were conducted to a criterion sample of: local steering committee (LSC) (29), professional platform (PP) (28), health professionals (49) and managers (28). Thematic content analysis was conducted, segmented by country and themes. The PAR process led by the LSC covered the return of baseline results, selection of problems and interventions and design, implementation and adjustment of the intervention, with PP. Interventions were implemented to improve communication and clinical agreement between primary and secondary care. Results reveal that contextual factors, the PAR process and the intervention’s content influenced their implementation, interacting across time. First, institutional support providing necessary resources, and professionals’ and managers’ willingness to participate, emerge as contextual pivotal factors, influenced by other factors related to: the system (alignment with policy and political cycle), networks (lack of time due to work overload and inadequate working conditions) and individuals (not knowing each other and mutual mistrust). Second, different characteristics of the PAR process have a bearing, in turn, on institutional support and professionals’ motivation: participation, flexibility, consensual decision-making, the LSC’s leadership and the facilitating role of researchers. Evidence is provided that implementation through an adequate PAR process can become a factor of motivation and cohesion that is crucial to the adoption of care coordination interventions, leading to better results when certain contextual factors converge.