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Avaliação da coordenação da atenção entre níveis assistenciais às doenças crónicas não transmissíveis em um município do Estado de Pernambuco, Brasil
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A fragmentação dos serviços de saúde representa um dos principais obstáculos para atingir cuidados efetivos em muitos países, incluindo o Brasil. Essas dificuldades são mais evidentes na atenção às pessoas com doenças crônicas e múltiplas enfermidades, que requerem atenção contínua, multiprofissional e com diferentes níveis assistenciais. Esta pesquisa teve como objetivo avaliar a coordenação da atenção entre níveis assistenciais aos pacientes com doenças crônicas não transmissíveis em um município do estado de Pernambuco, Brasil. O estudo é um recorte da pesquisa multicêntrica Equity-LA II. Com abordagem de métodos mistos, o estudo avaliativo foi desenvolvido no município de Caruaru, Pernambuco, Brasil. No inquérito foram entrevistados 180 médicos (58 Atenção Primária à Saúde- APS e 122 Atenção Especializada - AE), que trabalhavam na rede há mais de três meses. As variáveis relacionaram se à coordenação da informação, gestão clínica, conhecimento e uso de mecanismos e fatores que influenciam. Os dados foram analisados utilizando programa SPSS 23.0. De caráter descritivo interpretativo, a investigação qualitativa foi conduzida por meio de 24 entrevistas semiestruturadas com médicos, apoiadores institucionais, gerentes e gestores. O tamanho final da amostra foi definido pela saturação da informação. Realizou-se análise temática de conteúdo, segmentado por grupo de informante e temas. Os resultados demonstraram que médicos da APS e AE reconhecem a importância da informação trocada entre os níveis para cuidado ao paciente. No entanto, a maioria considerou não haver troca de informações. Há consenso entre equipe de gestão e profissionais sobre a deficiência de acesso ágil e oportuno à informação, destacando-se a inexistência de mecanismos adequados e falta de diálogo entre profissionais. Especialistas questionam a adequação clínica dos encaminhamentos da APS, relacionando-os com a baixa resolubilidade desse nível de atenção. Não existe consenso quanto ao papel do responsável clínico como coordenador do processo de atenção. Os mecanismos de coordenação são subutilizados e quando utilizados apresentam divergências entre níveis. Os mecanismos mais utilizados foram o telefone, bilhetes e os protocolos do Ministério da Saúde. Já as sessões clínicas conjuntas foram os menos conhecidos e utilizados. Chama atenção a baixa utilização dos formulários de Referência e Contrarreferência, principal mecanismo de articulação entre níveis no sistema de saúde brasileiro. De modo geral, médicos da APS utilizam mais os mecanismos que os especialistas. A falta de confiança e reconhecimento do especialista em relação aos generalistas representa um problema. Tais resultados evidenciam que a coordenação da informação e da gestão clínica, bem como o conhecimento e uso dos seus mecanismos, mostraram-se insuficientes para uma adequada coordenação entre níveis assistenciais. O pouco conhecimento e a ausência de colaboração mútua contribuem para fragmentação das práticas e do cuidado, repercutem negativamente na qualidade da atenção e dificultam a edificação do modelo de atenção em rede. A análise permitiu aprofundar o olhar para complexidade das relações entre os atores e como podem influenciar a coordenação. Ao perceber tensões e fragilidades comunicacionais, torna-se premente introduzir estratégias multifacetadas que instituam espaços para diálogos, onde se promovam articulação entre APS e AE. A identificação desses entraves pode dar subsídios ao planejamento e avaliação de futuras intervenções.
Fragmentation of health services is one of the main obstacles to meet effective care in many countries, including Brazil. These difficulties are more evident in the attention to people with chronic diseases and multiple ailments that require continuous multiprofessional attention, and different care levels. This research aimed to evaluate the coordination of care between levels of care to patients with chronic noncommunicable diseases in a city in the state of Pernambuco, Brazil. The study is a cut-off from the multicentric Equity-LA II research. The evaluative study, with a mixed methods approach, was developed in the city of Caruaru, Pernambuco, Brazil. In the survey, 180 physicians (58 Primary Health Care - PHC and 122 Specialized Care - AE), who had been working in the network for more than three months, were interviewed. The variables were related to information coordination, clinical management, knowledge and use of influenced mechanisms and factors. Data were analyzed using SPSS 23.0 software. Qualitative research, with descriptive-interpretive nature, was conducted through 24 semi-structured interviews with physicians, institutional supporters, managers and administrators. The final sample size was defined by the saturation of the information. Thematic content analysis was carried out, segmented by informant group and themes. The results showed that PHC and AE physicians recognize the importance of information exchanged between levels for patient care. However, most considered that there was no exchange of information. There is a consensus between the management team and professionals about the lack of agile and timely information access, highlighting the absence of adequate mechanisms and lack of dialogue among professionals. Specialists question the clinical adequacy of the referrals of PHC, relating them to the low resolubility of this level of attention. There is no consensus as to the role of the responsible clinical doctor as coordinator of the care process. Coordination mechanisms are underutilized and when used they have divergences between levels. The most used mechanisms were the telephone and tickets, the protocols of the Ministry of Health and the joint clinical sessions were the least known and used. It is worth noting the low use of reference and counter-referral forms, the main mechanism of articulation between levels in the Brazilian health system. In general, PHC doctors use more mechanisms than specialists. The lack of confidence and recognition of the specialist in relation to the generalists represents a problem. These results highlight that the coordination of information and clinical management, as well as the knowledge and use of their mechanisms, have proved insufficient for an adequate coordination between care levels. The little knowledge and lack of mutual collaboration contributes to the fragmentation of practices and care, negatively affects the quality of care and makes it difficult to build the network care model. The analysis allowed to deepen the look at the complexity of the relations between the actors and how they can influence the coordination. When perceiving tensions and communicational fragilities it becomes urgent to introduce multifaceted strategies that establish spaces for dialogues that promote articulation between PHC and AE. Identifying these barriers can give grants to the planning and evaluation of future interventions.
Fragmentation of health services is one of the main obstacles to meet effective care in many countries, including Brazil. These difficulties are more evident in the attention to people with chronic diseases and multiple ailments that require continuous multiprofessional attention, and different care levels. This research aimed to evaluate the coordination of care between levels of care to patients with chronic noncommunicable diseases in a city in the state of Pernambuco, Brazil. The study is a cut-off from the multicentric Equity-LA II research. The evaluative study, with a mixed methods approach, was developed in the city of Caruaru, Pernambuco, Brazil. In the survey, 180 physicians (58 Primary Health Care - PHC and 122 Specialized Care - AE), who had been working in the network for more than three months, were interviewed. The variables were related to information coordination, clinical management, knowledge and use of influenced mechanisms and factors. Data were analyzed using SPSS 23.0 software. Qualitative research, with descriptive-interpretive nature, was conducted through 24 semi-structured interviews with physicians, institutional supporters, managers and administrators. The final sample size was defined by the saturation of the information. Thematic content analysis was carried out, segmented by informant group and themes. The results showed that PHC and AE physicians recognize the importance of information exchanged between levels for patient care. However, most considered that there was no exchange of information. There is a consensus between the management team and professionals about the lack of agile and timely information access, highlighting the absence of adequate mechanisms and lack of dialogue among professionals. Specialists question the clinical adequacy of the referrals of PHC, relating them to the low resolubility of this level of attention. There is no consensus as to the role of the responsible clinical doctor as coordinator of the care process. Coordination mechanisms are underutilized and when used they have divergences between levels. The most used mechanisms were the telephone and tickets, the protocols of the Ministry of Health and the joint clinical sessions were the least known and used. It is worth noting the low use of reference and counter-referral forms, the main mechanism of articulation between levels in the Brazilian health system. In general, PHC doctors use more mechanisms than specialists. The lack of confidence and recognition of the specialist in relation to the generalists represents a problem. These results highlight that the coordination of information and clinical management, as well as the knowledge and use of their mechanisms, have proved insufficient for an adequate coordination between care levels. The little knowledge and lack of mutual collaboration contributes to the fragmentation of practices and care, negatively affects the quality of care and makes it difficult to build the network care model. The analysis allowed to deepen the look at the complexity of the relations between the actors and how they can influence the coordination. When perceiving tensions and communicational fragilities it becomes urgent to introduce multifaceted strategies that establish spaces for dialogues that promote articulation between PHC and AE. Identifying these barriers can give grants to the planning and evaluation of future interventions.
Descrição
Palavras-chave
Saúde pública Avaliação em saúde Níveis de atenção em saúde Doenças crónicas Comunicação em saúde Gestão clínica Atenção integral à saúde