Abstract:

The article analyzes the coordination of information and clinical management between levels of care in physicians’ experience and explores related labor and organizational factors and attitudes towards the work and interaction. This is a cross-sectional study with application of the COORDENA-BR questionnaire to a sample of 64 primary health care (PHC) physicians and 56 specialized care (SC) from the public system in a medium-sized Brazilian city. The results show limited linkage of care in the Healthcare Network (RAS), with differences between PHC and SC. There is no exchange of information on diagnosis, treatment, or tests. Physicians in PHC agree more on the treatments prescribed by the specialists than vice versa, but repetition of tests is not frequent. PHC physicians refer patients to SC when necessary. Most medical specialists do not refer patients for follow-up consultations in PHC when necessary and do not give orientation to PHC physicians, who in turn fail to resolve their doubts with SC. Both PHC and specialties report long waiting times for specialist consultations. Temporary employment contracts are more common in PHC. Consultation time was considered too short for coordination between the two. Most physicians do not plan to change jobs, despite their heavy dissatisfaction with wages and work. Physicians do not know each other personally, and specialists do not identify physicians in PHC as the coordinators of care. Policies and measures to guarantee structural conditions to improve access, working conditions, and more favorable mutual adaptation need to be implemented systemically to the set of services in the Brazilian Unified National Health System (SUS).

Keywords:
Health Care Levels; Comprehensive Health Care; Integrality in Health; Health Evaluation

Introduction

Primary health care (PHC)-oriented health systems are expected to coordinate patient care throughout the care continuum ¹1. Starfield B. Atenção primária de saúde: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: Organização das Nações Unidas para a Educação, a Ciência e a Cultura/Ministério da Saúde; 2002.^,22. Organização Pan-Americana da Saúde. Renovação da atenção primária em Saúde nas Américas: documento de posicionamento da Organização Pan-Americana da Saúde/Organização Mundial da Saúde. Washington DC: Organização Pan-Americana da Saúde; 2007.. The search for integrated care is a fundamental component of health system reforms. It is central to addressing the challenges of an aging population and, especially, a higher burden of chronic diseases, which often require the care of several providers and services over time ³3. European Union. Tools and methodologies to assess integrated care in Europe. Luxembourg: Publications Office of the European Union; 2017.. Care coordination emerges as one of the results of care integration and can be defined as the connection of all services and actions related to patient care, so that they harmonize and achieve a common, conflict-free goal ⁴4. Longest BB, Young G. Coordination and communication. In: Shortell SM, Kaluzny A, editors. Health care management. 4th Ed. New York: Delmar; 2000. p. 210-43., regardless of their location.

In a systemic logic, overcoming fragmentation and achieving continuing care, integrated networks of health services, based on the strengthening of PHC as a gateway and organizer of flows to other services, has been a strategy adopted in several health systems ²2. Organização Pan-Americana da Saúde. Renovação da atenção primária em Saúde nas Américas: documento de posicionamento da Organização Pan-Americana da Saúde/Organização Mundial da Saúde. Washington DC: Organização Pan-Americana da Saúde; 2007.. In Latin America, most countries, from the 2000s onwards, promoted care model reforms based on a comprehensive PHC proposal ⁵5. Giovanella L, Almeida PF. Atenção primária integral e sistemas segmentados de saúde na América do Sul. Cad Saúde Pública 2017; 33 Suppl 2:e00118816.. However, establishing Healthcare Networks (RAS in portuguese) and intrinsic to PHC in assuming care coordination between care levels ⁶6. World Health Organization. Primary health care. Now more than ever. The World Health Report 2008. Geneva: World Health Organization; 2008.^,77. Almeida PF, Medina MG, Fausto MCR, Giovanella L, Bousquat A, Mendonça MHM. Coordenação do cuidado e Atenção Primária à Saúde no Sistema Único de Saúde. Saúde Debate 2018; 42 (spe1):244-60. remains a challenge.

Care coordination can be analyzed from different perspectives. In Brazil, one of the most widespread and used concepts refers to vertical coordination, which occurs between the levels of care in the health system; and horizontal coordination, which takes place at the same level of care, whether within the PHC or specialized care (SC), and in the territory, through intersectoral relationships ⁷7. Almeida PF, Medina MG, Fausto MCR, Giovanella L, Bousquat A, Mendonça MHM. Coordenação do cuidado e Atenção Primária à Saúde no Sistema Único de Saúde. Saúde Debate 2018; 42 (spe1):244-60.. In the country, the difficulty in achieving better coordination has been attributed to the hardships in ensuring integration between care levels, whether due to the low use of information and communication technologies, the lack of definition of care flows in the RAS, or the insufficient specialized rearguard therapy, a significant bottleneck in the Brazilian Unified National Health System (SUS) ⁷7. Almeida PF, Medina MG, Fausto MCR, Giovanella L, Bousquat A, Mendonça MHM. Coordenação do cuidado e Atenção Primária à Saúde no Sistema Único de Saúde. Saúde Debate 2018; 42 (spe1):244-60.^,88. Spedo SM, Pinto NRS, Tanaka OY. O difícil acesso a serviços de média complexidade do SUS: o caso da cidade de São Paulo, Brasil. Physis (Rio J.) 2010; 20:953-72..

A wide range of definitions for care coordination is available in the literature. Based on the definition by Longest & Young ⁴4. Longest BB, Young G. Coordination and communication. In: Shortell SM, Kaluzny A, editors. Health care management. 4th Ed. New York: Delmar; 2000. p. 210-43., Aller et al. ⁹9. Aller MB, Vargas I, Waibel S, Coderch-Lassaletta J, Sánchez-Pérez I, Llopart JR, et al. Factors associated to experienced continuity of care between primary and outpatient secondary care in the Catalan public healthcare system. Gac Sanit 2013; 27:207-13. and Vázquez et al. ¹⁰10. Vázquez ML, Vargas I, Unger JP, De Paepe P, Mogollón-Pérez AS, Samico I, et al. Evaluating the effectiveness of care integration strategies in different healthcare systems in Latin America: the EQUITY-LA II quasi-experimental study protocol. BMJ Open 2015; 5:e007037. identify three care coordination types between levels: information, clinical management, and administrative, and we shall focus on the first two. Clinical information coordination involves the transfer and use of patient information between different services and care levels. Clinical management coordination is expressed in the sequential and complementary provision of care and covers three dimensions: care coherence, interlevel monitoring of users, and accessibility between care levels. Administrative coordination refers to the administrative activities necessary for access between care levels (such as administrative circuits, central regulation, and definition of flows).

Interventions can be implemented at the macro (policies to promote the RAS, payment systems), meso (organization of health networks), and micro (coordination mechanisms and instruments) levels ¹⁰10. Vázquez ML, Vargas I, Unger JP, De Paepe P, Mogollón-Pérez AS, Samico I, et al. Evaluating the effectiveness of care integration strategies in different healthcare systems in Latin America: the EQUITY-LA II quasi-experimental study protocol. BMJ Open 2015; 5:e007037. to achieve greater clinical coordination. Such strategies can improve the exchange of information, increase care consistency and accessibility between levels, avoid unnecessary repetitions of tests, and long waiting times for specialized visits ¹⁰10. Vázquez ML, Vargas I, Unger JP, De Paepe P, Mogollón-Pérez AS, Samico I, et al. Evaluating the effectiveness of care integration strategies in different healthcare systems in Latin America: the EQUITY-LA II quasi-experimental study protocol. BMJ Open 2015; 5:e007037.^,1111. Vázquez ML, Vargas I, Garcia-Subirats I, Unger JP, De Paepe P, Mogollón-Pérez AS, et al. Doctors' experience of coordination across care levels and associated factors. A cross-sectional study in public healthcare networks of six Latin American countries. Soc Sci Med 2017; 182:10-9.. Organizational factors (availability, time during and after consultations to use coordination mechanisms) and other factors related to attitude towards work (job satisfaction) and interaction between professionals (trust, knowledge, and considering the PHC physician responsible for the coordination function) may favor or constrain care coordination ¹¹11. Vázquez ML, Vargas I, Garcia-Subirats I, Unger JP, De Paepe P, Mogollón-Pérez AS, et al. Doctors' experience of coordination across care levels and associated factors. A cross-sectional study in public healthcare networks of six Latin American countries. Soc Sci Med 2017; 182:10-9..

In the SUS, studies analyzing care coordination from the perspective of PHC physicians, who are primarily responsible for screening the demand to other levels of care, are also less frequent, and SC physicians who receive and share the care of referred users, such as those performed by Vázquez et al. ¹¹11. Vázquez ML, Vargas I, Garcia-Subirats I, Unger JP, De Paepe P, Mogollón-Pérez AS, et al. Doctors' experience of coordination across care levels and associated factors. A cross-sectional study in public healthcare networks of six Latin American countries. Soc Sci Med 2017; 182:10-9., Jesus et al. ¹²12. Jesus RPFS, Santo ACGE, Mendes MFM, Samico IC. Percepção dos profissionais sobre a coordenação entre níveis de atenção à saúde em dois municípios pernambucanos de grande porte. Interface (Botucatu) 2018; 22:423-34. and Oliveira et al. ¹³13. Oliveira CRF, Samico IC, Mendes MFM, Vargas I, Vázquez ML. Conhecimento e uso de mecanismos para articulação clínica entre níveis em duas redes de atenção à saúde de Pernambuco, Brasil. Cad Saúde Pública 2019; 35:e00119318.. The need for interlevel collaboration is increasingly related to the provision of safe and quality care, although organizational (time unavailability, lack of structures, rules, and communication resources), professional barriers (different characteristics and personal, social, and communication values) are recognized, among other that challenge a more articulated performance ¹⁴14. Schot E, Tummers L, Noordegraaf M. Working on working together. A systematic review on how healthcare professionals contribute to interprofessional collaboration. J Interprof Care 2020; 34:332-42.. Knowing the experience and perception of professionals who share the care of users in the RAS can favor implementing arrangements that encourage a professional culture more receptive to cooperation and dialogue. This paper aims to analyze PHC and SC physicians’ experience and perceptions about information coordination and clinical management between care levels and explore factors related to work, organization, attitude towards work, and interactive factors.

Methods

Study design and location

It is a cross-sectional based survey with the application of the COORDENA-BR questionnaire to PHC and SC physicians from the SUS network in a medium-sized municipality in the Northeast Region (approximately 340,000 inhabitants in 2019), Brazil. The primary network consisted of 42 basic health units (UBS) equipped with 44 teams from the Family Health Strategy (FHS) and 7 traditional UBS, with PHC coverage of 60% (47% FHS and 13% traditional UBS) ¹⁵15. Secretaria de Atenção Primária à Saúde, Ministério da Saúde. Informação e gestão da atenção básica (e-Gestor). http://egestorab.saude.gov.br (acessado em 18/Mai/2019).
http://egestorab.saude.gov.br... . A medical specialties center was selected among the services of the specialized municipal network, which concentrated most of the specialized visits (angiology, anesthesia, cardiology, surgery, dermatology, endocrinology, gastroenterology, hematology, mastology, nephrology, neurology, oncology, otorhinolaryngology, orthopedics, pneumology, proctology, rheumatology, and urology); an outpatient mental health clinic; a rehabilitation clinic (orthopedics and angiology); and two traditional UBS, where some specialists (gynecologists/obstetricians and pediatric hematologist) worked as referrals for PHC. Individual private providers and specialized units that did not receive a direct referral from PHC were excluded.

Study population and sample

According to information from the municipal management, the study population consisted of all PHC physicians (FHS and traditional UBS) and specialists from municipal services who received regular referrals at the onset of the field (June 2019). A total of 120 of the 136 operational physicians (88.2%) were interviewed. Interviewed subjects and losses, according to their service, are described in Table 1.

Instrument

We used the COORDENA-BR questionnaire (http://www.equity-la.eu/upload/seccions/files/COORDENA_BR%282%29.pdf), for data collection, which was adapted, translated into Portuguese, and validated. It is based on the theoretical model for assessing coordination between care levels developed by Vázquez et al. ¹⁰10. Vázquez ML, Vargas I, Unger JP, De Paepe P, Mogollón-Pérez AS, Samico I, et al. Evaluating the effectiveness of care integration strategies in different healthcare systems in Latin America: the EQUITY-LA II quasi-experimental study protocol. BMJ Open 2015; 5:e007037. and Vargas et al. ¹⁶16. Vargas I, Mogollón-Pérez AS, De Paepe P, Ferreira Silva MR, Unger J-P, Vázquez M-L. Barriers to healthcare coordination in market-based and decentralized public health systems: a qualitative study in healthcare networks of Colombia and Brazil. Health Policy Plan 2016; 31:736-48.. The instrument was digitized using the Kobo Toolbox 1.4.8 software (https://downloadapk.net/down_KoBoCollect.4511263.html), available on tablets, Samsung brand, model Galaxy Tab A.

The complete questionnaire addresses: (1) experience of coordinating information and clinical management between care levels, their respective dimensions, and general perception of coordination; (2) professional interaction factors related to coordination between levels; (3) knowledge and use of coordination mechanisms; (4) suggestions for improving coordination; (5) organizational, work factors and attitudes related to coordination between levels; (6) sociodemographic data of the respondents. The data obtained in sections 1, 2, and 5 of COORDENA-BR will be analyzed in this paper.

Data collection

Face-to-face interviews were conducted from June to October 2019 at the physicians’ respective workplaces, with an average duration of 26.6 minutes, audio-recorded on a device for transcription and categorization of open-ended questions to apply the questionnaire. We employed direct monitoring of field activities and evaluated the completion of all questionnaires in the database to ensure the quality of data collection and reliability.

Variables and data analysis

This study analyzed variables related to the coordination of clinical information and clinical management between PHC and SC, which make up the COORDENA-BR (Box 1), and working conditions (type of professional relationship, remuneration, weekly workload, working time, experience in the workplace, and additional work in the private sector), organizational (sufficient visit time for clinical coordination); attitude towards work (pretending to change jobs in the next six months, satisfaction with salary and work) and relational or interactional (trust in clinical skills, personally familiar with the physician at the other level, and considering the PHC physician as responsible for coordination). The Likert scale (always, often, sometimes, very few times, and never; totally agree, agree, neither agree, nor disagree, disagree, and strongly disagree) and dichotomous answers (yes/no) were used for the answers. Variables were submitted to a descriptive analysis using absolute (n) and relative (%) frequencies according to the care level. Some variables of interest were dichotomized for better comparison. The answers “always, often” and “totally agree, agree” were considered “yes”, whereas “sometimes, very few times, and never” and “neither agree, nor disagree, disagree, and strongly disagree” as “no”. The data were processed using the Stata program, version 15.0 (https://www.stata.com). Differences between proportions were assessed through Pearson’s chi-square test and Fisher’s exact test.

The study was approved by the Ethics Research Committee of the Federal University of Bahia (UFBA), under opinion n. 3.334.464 and CAAE: 09503419.1.0000.5556, with the consent of the municipality.

Results

Sample characteristics

Most physicians interviewed were male (56.7%), with most female in PHC (54.7%). PHC professionals were aged between 25 and 34 years old (40.6%) and the majority of SC physicians were between 35 and 49 years old (60.7%), had more time since graduating, and were public university graduates (55.4%). In PHC, 62.5% of physicians were private college graduates, and around 59.4% had no medical residency yet, with only four professionals in the process of completing their residency in Family and Community Medicine (Table 2).

Coordination experience between care levels

Only 4.2% of the PHC and SC physicians stated a frequent exchange of clinical information (diagnosis, treatment, and tests) of users whose care was shared, although most (83.9%) considered it necessary, especially among PHC professionals (93.6%), compared to SC professionals (72.5%) (p = 0.008). A higher percentage of specialists (80%) reported that physicians considered clinical information when shared (Table 3).

Concerning the coordination of clinical management between care levels, significant differences were observed between PHC and SC physicians’ experience regarding the coherence of the care provided. Approximately one-third of the specialists (30.4%) said he agreed with the PHC physicians’ treatments, and, on the contrary, most of the PHC physicians said he agreed with SC’s treatments (70.3%) (p < 0.001). Even so, about 72.5% of physicians reported that there were no contradictions between the treatments prescribed at the two care levels, with a higher frequency among PHC physicians (82.8%), when compared to the experience of SC physicians (60.7%) (p = 0.010). A low percentage of physicians at both levels (11.7%) considered that tests were repeated in the usual way. Almost all PHC physicians (95.3%) reported referring users to the specialist when necessary, the proportion of SC physicians who considered the necessary PHC referrals was lower (53.6%) (p < 0.001) (Table 3).

Most physicians at both levels (65%) said that there were no follow-up visit in PHC after seeing the specialist, a higher percentage among SC physicians (71.4%) than PHC physicians (59.4%) (p = 0.003). Recommendations and guidelines for PHC were very infrequent (15%), with 25% of experts reporting that they were performed and only 6.3% of PHC physicians had this perception (p = 0.004). Likewise, a deficient proportion of professionals (6.7%) reported that PHC physicians consulted specialists to clarify concerns regarding users’ follow-up (Table 3).

As for accessibility between care levels, approximately half of the physicians (55%) considered that the patients had access to specialized visits by the SUS, mostly among specialists (76.8%), and only a third of PHC physicians (35.9%) (p < 0.001). As for the specialized visits, both PHC professionals (93.7%) and SC professionals (75%) affirmed that waiting time for a visit was long, with significant differences (p = 0.004). Only 6.3% of the PHC physicians and 16.1% of the specialists considered that the waiting time for service at the PHC was long after a specialized visit (p < 0.001), and 21.4% of the SC physicians did not know or did not respond. Finally, only a small minority (7.5%) of physicians at both levels said that the care provided in the network by PHC and SC physicians was articulate (Table 3).

Work, organizational, attitude towards work and interaction factors related to clinical coordination between care levels

Temporary employment relationships were more frequent among PHC professionals (67.2%) (p < 0.001). In this case, it was highlighted that 37.5% were Brazilian physicians of the More Doctor Program in force at the time. Among the specialists, a higher percentage of statutory workers was observed (42.9%), and all employees were salaried (p < 0.001). PHC physicians had a higher workload of dedication to the service than specialists. Most specialists also worked in the private sector (92.9%), in contrast to PHC physicians (48.4%) (p < 0.001). Most specialists (62.5%) had four or more seniority years in the workplace, while this percentage was 43.7% among PHC physicians (Table 4).

As for the organizational factors, only 17.2% of the PHC physicians considered the time of the visit sufficient to exercise clinical coordination activities and 39.3% among specialists (p = 0.007) (Table 4).

Regarding the attitude towards work, most specialists (92.9%) and PHC physicians (78.1%) did not intend to change jobs (p = 0.024), although dissatisfaction with wages was high (60.8%), mainly in SC (71.4%) (p = 0.026) and work in general (82.5%), also higher among specialist physicians (85.7%) (Table 4).

Regarding interaction or relational factors, most PHC physicians (70.3%) considered themselves the professional responsible for monitoring users in their care trajectory, and only 17.9% of specialists (p < 0.001) recognized this function. Almost all respondents (90%) did not personally know physicians at the other level. The percentage of 73.4% of the PHC physicians stated that they trusted the clinical skills of the specialists and about 53.6% (p = 0.024) of the specialists stated that they trusted the PHC professionals (Table 4).

Discussion

In Brazil, the care coordination attribute has been holding a central place in the organization of the SUS and PHC, especially with the expanded FHS, given the need to provide comprehensive and integrated care. The main actions and policies sought to strengthen FHS’s position in the care network, promote the integration between levels and interfaces with care regulation, and strengthen horizontal integration with other care devices in the territory ⁷7. Almeida PF, Medina MG, Fausto MCR, Giovanella L, Bousquat A, Mendonça MHM. Coordenação do cuidado e Atenção Primária à Saúde no Sistema Único de Saúde. Saúde Debate 2018; 42 (spe1):244-60.. Even so, the limited nature of such initiatives and the huge loco-regional diversity of the implanted experiences are recognized. This study’s results indicate limited coordination of information and clinical management between care levels and a general perception of PHC and SC physicians that there is no articulation of the care provided in the RAS. It is expressed through an experience with insufficient communication between the levels of care, due to the scarce exchange of clinical information between physicians about users, whose care is shared at different levels. In addition, it is evidenced, also, by a low agreement among the professionals in relation to the treatments indicated, mainly, by the medical specialists, which, consequently, brings serious losses for the follow-up of the users between the levels of care. Accessibility difficulties between care levels are also recognized.

Regarding the coordination of clinical information ¹⁰10. Vázquez ML, Vargas I, Unger JP, De Paepe P, Mogollón-Pérez AS, Samico I, et al. Evaluating the effectiveness of care integration strategies in different healthcare systems in Latin America: the EQUITY-LA II quasi-experimental study protocol. BMJ Open 2015; 5:e007037.^,1717. Aller M-B, Vargas I, Coderch J, Vázquez M-L. Doctors' opinion on the contribution of coordination mechanisms to improving clinical coordination between primary and outpatient secondary care in the Catalan national health system. BMC Health Serv Res 2017; 17:842., the results indicate no frequent exchange of information about patients shared between PHC and SC and are more unfavorable when compared to another similar investigation in a different national scenario ¹¹11. Vázquez ML, Vargas I, Garcia-Subirats I, Unger JP, De Paepe P, Mogollón-Pérez AS, et al. Doctors' experience of coordination across care levels and associated factors. A cross-sectional study in public healthcare networks of six Latin American countries. Soc Sci Med 2017; 182:10-9.. There is a better experience, especially in PHC, regarding the need for clinical information for the care process and, at both levels, the valorization of information, when shared. Such evidence highlight the need and a favorable outlook for the implementation of mutual adaptation clinical mechanisms (feedback-based). These mechanisms facilitate communication and information exchange between professionals for shared care planning using tools, such as direct communication (phone, e-mail), shared information systems (shared electronic medical record), and incentives to use referral counter-referral forms ¹⁸18. Terraza Núñez R, Vargas Lorenzo I, Vázquez Navarrete ML. La coordinación entre niveles asistenciales: una sistematización de sus instrumentos y medidas. Gac Sanit 2006; 20:485-95..

There were disagreements about inadequate treatments and referrals, especially in the experience of SC physicians, a result similar to that of other studies ¹¹11. Vázquez ML, Vargas I, Garcia-Subirats I, Unger JP, De Paepe P, Mogollón-Pérez AS, et al. Doctors' experience of coordination across care levels and associated factors. A cross-sectional study in public healthcare networks of six Latin American countries. Soc Sci Med 2017; 182:10-9.^,1212. Jesus RPFS, Santo ACGE, Mendes MFM, Samico IC. Percepção dos profissionais sobre a coordenação entre níveis de atenção à saúde em dois municípios pernambucanos de grande porte. Interface (Botucatu) 2018; 22:423-34.^,1919. Garcia-Subirats I, Vargas I, Mogollón-Pérez AS, De Paepe P, Silva MR, Unger JP, et al. Barriers in access to healthcare in countries with different health systems. A cross-sectional study in municipalities of central Colombia and north-eastern Brazil. Soc Sci Med 2014; 106:204-13.. Possible issues in the quality of referrals promote the travel of companions and patients and favor the inappropriate use of specialized services, increasing waiting times, and aggravating difficulties in accessing the therapeutic rearguard ¹²12. Jesus RPFS, Santo ACGE, Mendes MFM, Samico IC. Percepção dos profissionais sobre a coordenação entre níveis de atenção à saúde em dois municípios pernambucanos de grande porte. Interface (Botucatu) 2018; 22:423-34.^,2020. Almeida PF, Santos AM. Primary health care: care coordinator in regionalized networks? Rev Saúde Pública 2016; 50:80.. Also, discordant therapeutic plans can generate a perception of discontinuity and insecurity regarding the quality of care, which is considered an expression of the lack of care coherence ¹⁶16. Vargas I, Mogollón-Pérez AS, De Paepe P, Ferreira Silva MR, Unger J-P, Vázquez M-L. Barriers to healthcare coordination in market-based and decentralized public health systems: a qualitative study in healthcare networks of Colombia and Brazil. Health Policy Plan 2016; 31:736-48.^,2121. Giovanella L. Redes integradas, programas de gestão clínica e generalista coordenador: análise das reformas recentes do setor ambulatorial na Alemanha. Ciênc Saúde Colet 2011; 16 Suppl 1:1081-96..

More favorable and concordant results were found regarding test non-repetition, one of the positive effects of clinical coordination ²²22. Vázquez ML, Vargas I, Unger JP, Mogollón A, Silva MR, De Paepe P. Integrated health care networks in Latin America: toward a conceptual framework for analysis. Rev Panam Salud Pública 2009; 26:360-7., perhaps partly explained by the professionals’ recognition of insufficient specialized resources in the RAS. This structural factor mitigates access to these SUS procedures and often generates users’ direct purchase of services from private providers ¹⁹19. Garcia-Subirats I, Vargas I, Mogollón-Pérez AS, De Paepe P, Silva MR, Unger JP, et al. Barriers in access to healthcare in countries with different health systems. A cross-sectional study in municipalities of central Colombia and north-eastern Brazil. Soc Sci Med 2014; 106:204-13.^,2323. Galvão JR, Almeida PF, Santos AM, Bousquat A. Percursos e obstáculos na Rede de Atenção à Saúde: trajetórias assistenciais de mulheres em região de saúde do Nordeste brasileiro. Cad Saúde Pública 2019; 35:e00004119..

The results of patient follow-up between care levels were quite negative, with greater intensity in the experience of SC physicians. Professionals recognize the lack of communication: on the one hand, no recommendations or guidelines are sent to PHC, and, on the other hand, PHC physicians do not usually clarify concerns about the users’ follow-up with their SC peers. Studies point to an association between the fact that the physician, regardless of his role, recognizes the first level professional as the care coordinator and the establishment of a more responsible and collaborative relationship to articulate care between levels ¹¹11. Vázquez ML, Vargas I, Garcia-Subirats I, Unger JP, De Paepe P, Mogollón-Pérez AS, et al. Doctors' experience of coordination across care levels and associated factors. A cross-sectional study in public healthcare networks of six Latin American countries. Soc Sci Med 2017; 182:10-9.^,2424. Vargas I, Garcia-Subirats I, Mogollón-Pérez AS, Ferreira-de-Medeiros-Mendes M, Eguiguren P, Cisneros AI, et al. Understanding communication breakdown in the outpatient referral process in Latin America: a cross-sectional study on the use of clinical correspondence in public healthcare networks of six countries. Health Policy Plan 2018; 33:494-504., which, again, reinforces the need for measures to strengthen the central position of PHC in the network, its professional and social legitimacy in the SUS ²⁵25. Almeida PF, Fausto MC, Giovanella L. Fortalecimento da atenção primária à saúde: estratégia para potencializar a coordenação dos cuidados. Rev Panam Salud Pública 2011; 29:84-95., while ensuring the availability of mechanisms that facilitate formal and informal communication between professionals.

Problems with accessibility to SC, with long waiting times, were mentioned more expressly by PHC physicians who, as responsible for the referral of users and longitudinal monitoring, end up playing the role of observing the barriers of access to other levels ²⁶26. Cecílio LC, Andreazza R, Carapinheiro G, Araújo EC, Oliveira LA, Andrade MG, et al. A Atenção Básica à Saúde e a construção das redes temáticas de saúde: qual pode ser o seu papel? Ciênc Saúde Colet 2012; 17:2893-902.. In a study in a health region, Silva et al. ²⁷27. Silva CR, Carvalho BG, Cordoni Júnior L, Nunes EFPA. Dificuldade de acesso a serviços de média complexidade em municípios de pequeno porte: um estudo de caso. Ciênc Saúde Colet 2017; 22:1109-20. show that specialized consultations for vascular surgery, proctology, geriatrics, endocrinology, and neurology were evaluated as non-existent or as a care void, followed by a set of other specialties (ophthalmology, orthopedics, otorhinolaryngology) whose supply was insufficient. Such findings reinforce that the scarcity or even lack of specialized care is a major bottleneck and structural problem of SUS ⁸8. Spedo SM, Pinto NRS, Tanaka OY. O difícil acesso a serviços de média complexidade do SUS: o caso da cidade de São Paulo, Brasil. Physis (Rio J.) 2010; 20:953-72.^,2727. Silva CR, Carvalho BG, Cordoni Júnior L, Nunes EFPA. Dificuldade de acesso a serviços de média complexidade em municípios de pequeno porte: um estudo de caso. Ciênc Saúde Colet 2017; 22:1109-20.. Also, long waiting times for visits with specialists lead to delayed diagnosis and impair the proper treatment of patients ¹¹11. Vázquez ML, Vargas I, Garcia-Subirats I, Unger JP, De Paepe P, Mogollón-Pérez AS, et al. Doctors' experience of coordination across care levels and associated factors. A cross-sectional study in public healthcare networks of six Latin American countries. Soc Sci Med 2017; 182:10-9., contributing to physicians’ dissatisfaction with work ²⁸28. Gittell JH, Weinberg D, Pfefferle S, Bishop C. Impact of relational coordination on job satisfaction and quality outcomes: a study of nursing homes. Hum Resour Manag J 2008; 18:154-70., which is an issue to be observed by SUS administrations.

Regarding working conditions, in the studied scenario, PHC physicians have more unstable relationships, characterized by fixed-term contracts and scholarships (More Doctors Program or residency), which influences the turnover of professionals at this level of care ²⁹29. Giovanella L, Mendonça MH, Fausto MC, Almeida PF, Bousquat A, Lima JG, et al. A provisão emergencial de médicos pelo Programa Mais Médicos e a qualidade da estrutura das unidades básicas de saúde. Ciênc Saúde Colet 2016; 21:2697-708.. In the national scenario, the resurgence of ultra-neoliberal policies with weakened labor rights makes it even more challenging to face the turnover, which also implies the loss of trained professionals. The establishment of more stable links with permanent contracts, among other factors, is associated with more positive coordination experiences ¹⁶16. Vargas I, Mogollón-Pérez AS, De Paepe P, Ferreira Silva MR, Unger J-P, Vázquez M-L. Barriers to healthcare coordination in market-based and decentralized public health systems: a qualitative study in healthcare networks of Colombia and Brazil. Health Policy Plan 2016; 31:736-48..

Vázquez et al. ¹¹11. Vázquez ML, Vargas I, Garcia-Subirats I, Unger JP, De Paepe P, Mogollón-Pérez AS, et al. Doctors' experience of coordination across care levels and associated factors. A cross-sectional study in public healthcare networks of six Latin American countries. Soc Sci Med 2017; 182:10-9.indicate that job satisfaction and salary influence the perception of care coordination. Although PHC and SC physicians were dissatisfied with their work, almost all specialists did not intend to change jobs, perhaps because they maintained more stable relationships, long stay in municipal health services and concomitant work in the private network. In any case, the intention to stay seems to be a positive aspect for investments in professional qualification through continuing education, valuing, and improving organizational and work conditions, associated with policies for stabilizing labor bonds.

Regarding organizational conditions, sufficient time available during the consultation positively influences perceptions about coordination ¹¹11. Vázquez ML, Vargas I, Garcia-Subirats I, Unger JP, De Paepe P, Mogollón-Pérez AS, et al. Doctors' experience of coordination across care levels and associated factors. A cross-sectional study in public healthcare networks of six Latin American countries. Soc Sci Med 2017; 182:10-9.. Professionals consider the visit time to be insufficient for coordinating activities. Tremendous care pressure is imposed on PHC physicians, as they meet the programmed demand (case of specialists) and the walk-in demand, among other activities arising from the territorial inclusion ³⁰30. Girardi SN, Carvalho CL, Pierantoni CR, Costa JO, Stralen AC, Lauar TV, et al. Avaliação do escopo de prática de médicos participantes do Programa Mais Médicos e fatores associados. Ciênc Saúde Colet 2016; 21:2739-48.^,3131. Franco CM, Almeida PF, Giovanella L. A integralidade das práticas dos médicos cubanos no Programa Mais Médicos na cidade do Rio de Janeiro, Brasil. Cad Saúde Pública 2018; 34:e00102917.. PHC physicians’ functions have expanded, absorbing care previously provided at other levels ³²32. Bodenheimer T. Coordinating care: a perilous journey through the health care system. N Engl J Med 2008; 358:1064-71. and, in the Brazilian case, incorporating actions and programs that have been decentralized ³³33. Facchini LA, Tomasi E, Dilélio AS. Qualidade da Atenção Primária à Saúde no Brasil: avanços, desafios e perspectivas. Saúde Debate 2018; 42 (spe1):208-23., without proper training in Family and Community Medicine, the gold standard for acting at this care level. Such factors can hinder coordination activities that require proper completion of reference guides and medical records, contacting specialists, among other activities, which are not usually paid by performance-based payment schemes. In this sense, coordination actions will not develop spontaneously without guaranteeing organizational conditions and incentive schemes ³²32. Bodenheimer T. Coordinating care: a perilous journey through the health care system. N Engl J Med 2008; 358:1064-71..

Regarding relational factors, physicians from the same RAS do not know each other personally, as specialists do not recognize the role of coordinator of their PHC peer, and many do not trust their clinical skills, a result that is synergistic to others found in this study and which indicate compromised longitudinal follow-up, more appropriately conducted by physicians of the first level ¹1. Starfield B. Atenção primária de saúde: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: Organização das Nações Unidas para a Educação, a Ciência e a Cultura/Ministério da Saúde; 2002.. The scarce or inexistent mechanisms that favor direct contact between professionals and turnover allows understanding the issue ¹¹11. Vázquez ML, Vargas I, Garcia-Subirats I, Unger JP, De Paepe P, Mogollón-Pérez AS, et al. Doctors' experience of coordination across care levels and associated factors. A cross-sectional study in public healthcare networks of six Latin American countries. Soc Sci Med 2017; 182:10-9.. Also, confidence in the professionals’ skills at the other level contributes to a greater receptivity for shared information ¹¹11. Vázquez ML, Vargas I, Garcia-Subirats I, Unger JP, De Paepe P, Mogollón-Pérez AS, et al. Doctors' experience of coordination across care levels and associated factors. A cross-sectional study in public healthcare networks of six Latin American countries. Soc Sci Med 2017; 182:10-9..

As a limitation of the study, analyses of associations between perceptions about coordination and organizational, labor, and relational factors were not carried out, considering the description and thorough analysis of physicians’ experience regarding coordination practices. While losses were negligible, one of the challenges for carrying out studies involving physicians is adherence and availability for participation, requiring repeated returns of the researcher to health services. It is noteworthy that the study used an instrument applied in national and international scenarios, which by revealing the experience and perception of PHC and SC physicians, allows a broad understanding of the coordination of care between levels, which is based on an inter-professional interlevel relationship as one of its pillars and identifies many areas that can be improved.

Final considerations

It is necessary to recognize that the daily sharing of information is not part of the work processes of PHC and SC physicians, and is a field that should be improved. This study indicates that the place held by PHC in the SUS does not yet enable exercising coordination of care between levels in the HCN, which, in turn, face difficulties that have not been overcome with underfunding that hinders access to the therapeutic rearguard services. How would it be possible for PHC to be the care coordinator if other professionals do not recognize it in this place? In the country, public policies that value PHC and its professionals have not kept pace with expanding the ESF ³⁴34. Batista SR, Almeida MM, Trindade TG. Medicina de Família e Comunidade na Atenção Primária à Saúde no Brasil. In: Mendonça MHM, Matta GC, Gondim R, Giovanella L, editores. Atenção primária à saúde no Brasil: conceitos, práticas e pesquisa. Rio de Janeiro: Editora Fiocruz; 2018. p. 313-36.. Simultaneously, promoting greater permanence and joint training of professionals could facilitate knowledge of the health care flows and specificities of the RAS, favoring inter-professional interlevel relationships, and the mutual recognition of work processes. The results suggest that the rhetoric of care coordination remains restricted to PHC and is not part of the modus operandi of the RAS, with many inhibiting factors. Policies and actions to ensure more favorable structural conditions for improving access, work, and mutual adaptation need to be implemented systematically, reinforcing the premise that the coordination of care is reliant on arrangements that promote conditions and encourage collaboration between the SUS workers and services.

Acknowledgments

P. F. Almeida is a productivity fellowships of the Brazilian National Research Council (CNPq) and is grateful for the support for carrying out studies on the topic.

References

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History