Esteve-Matalí et al. BMC Family Practice (2020) 21:135 https://doi.org/10.1186/s12875-020-01207-9 RESEARCH ARTICLE Open Access Do primary and secondary care doctors have a different experience and perception of cross-level clinical coordination? Results of a cross-sectional study in the Catalan National Health System (Spain) Laura Esteve-Matalí1,2* , Ingrid Vargas1, Elvira Sánchez3, Isabel Ramon4, Pere Plaja5 and María-Luisa Vázquez1 Abstract Background: Clinical coordination across care levels is a priority for health systems around the world, especially for those based on primary health care. The aim of this study is to analyse the degree of clinical information and clinical management coordination across healthcare levels in the Catalan national health system experienced by primary (PC) and secondary care (SC) doctors and explore the associated factors. Methods: Cross-sectional study based on an online survey using the self-administered questionnaire COORDENA-CAT. Data collection: October–December 2017. Study population: PC and SC (acute and long term) doctors of the Catalan national health system. Participation rate was 21%, with a sample of 3308 doctors. Outcome variables: cross-level clinical information coordination, clinical management coordination, and perception of cross-level coordination within the area. Explanatory variables: socio-demographic, employment characteristics, attitude towards job, type of area (according to type of hospital and management), interactional factors, organizational factors and knowledge of existing coordination mechanisms. Stratification variable: level of care. Descriptive and multivariate analysis by logistic regression. (Continued on next page) * Correspondence: lesteve@consorci.org 1 Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Barcelona, Spain 2 Department for Paediatrics, Obstetrics and Gynaecology, Preventive Medicine, Universitat Autònoma de Barcelona, Catalonia, Spain Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Esteve-Matalí et al. BMC Family Practice (2020) 21:135 Page 2 of 14 (Continued from previous page) Results: The degree of clinical coordination experienced across levels of care was high for both PC and SC doctors, although PC doctors experienced greater exchange and use of information and SC doctors experienced greater consistency of care. However, only 32.13% of PC and 35.72% of SC doctors found that patient care was coordinated across care levels within their area. In both levels of care, knowing the doctors of the other level, working in an area where the same entity manages SC and majority of PC, and holding joint clinical case conferences were factors positively associated with perceiving high levels of clinical coordination. Other associated factors were specific to the care level, such as being informed of a patient’s discharge from hospital for PC doctors, or trusting in the clinical skills of the other care level for SC doctors. Conclusions: Interactional and organizational factors are positively associated with perceiving high levels of clinical coordination. Introducing policies to enhance such factors can foster clinical coordination between different health care levels. The COORDENA questionnaire allows us to identify fields for improvement in clinical coordination. Keywords: Clinical coordination across care levels, Integrated care, Health systems research, Questionnaire Background Clinical coordination is an important component of Over recent decades, clinical coordination has become a care coordination, along with administrative coordin- challenge as well as a priority for health systems around ation, or coordination of patient access across the con- the world, especially for those based on primary health tinuum of services according to their needs [16]. Care care, such as the Spanish national health system (NHS). coordination requires not only the coordination of care High specialization, rapid technological innovations and activities (clinical coordination) but also the coordin- new forms of organizing health services imply the in- ation of key support functions and activities (such as fi- volvement of multiple services and providers in patient nancial management, strategic planning, human care, a situation which particularly affects chronic pa- resources policies, etc.) across the operating units that tients or with comorbidities [1, 2]. make up the health services network [17]. Better coordination between levels of care is expected to Available qualitative and quantitative studies have improve the quality of health services and increase efficiency, identified different types of factors that can influence effectiveness and access to health services [3–7]. Given the clinical coordination: organizational factors, such as the importance of coordination, many strategies at micro-, management model or the availability of coordination meso- and macro-level have been developed in order to im- mechanisms [18–21] and factors related to professionals, prove collaboration between health care providers [4, 8, 9]. such as attitude towards coordination or knowing the Despite the interest and increase in publications, re- doctors of the other care level [18–21]. Clinical coordin- search on clinical coordination is limited by a lack of ation can be analysed through service-based indicators consensus on definitions across disciplines [10]. This or from the perspective of health professionals using study is based on a conceptual framework on care co- quantitative or qualitative methods [12]. ordination across care levels that addresses the different Most of the evidence available on clinical coordination types and dimensions of clinical coordination as well as at both the international and national level is limited to its related factors [11]. Clinical coordination is defined a specific pathology, focused on only one dimension of as the harmonious connection of the different health coordination (mainly information transfer across levels), services needed to provide care to a patient throughout or on one coordination mechanism or strategy (mainly the care continuum in order to achieve a common ob- electronic medical record) [22–25]. In general, the main jective without conflicts [12, 13]. Two interrelated types clinical coordination problem studied is poor informa- can be distinguished [14, 15]: tion transfer and difficulties in communicating with the other care level [26, 27]. Although the perspective of a) Clinical information coordination, which refers to doctors is relevant to the design of strategies to improve the appropriate transfer and use of patient clinical clinical coordination [28], there are few studies available information between providers. based on surveys of doctors and they rarely contemplate b) Clinical management coordination, which refers to the factors associated with coordination [29, 30]. More- the provision of care in a sequential and over, doctors from different levels of care, who are ex- complementary way by the different services and pected to collaborate on the patient care, might healthcare levels involved. It encompasses three experience clinical coordination differently, according to dimensions: consistency of care, adequate patient their needs and expectations, and therefore offer a differ- follow-up and accessibility between levels of care. ent perspective on the same phenomenon. Quantitative Esteve-Matalí et al. BMC Family Practice (2020) 21:135 Page 3 of 14 studies that comprehensively analyse clinical coordin- doctors of the Catalan NHS by self-administration of the ation, its determinants and the contribution of coordin- questionnaire COORDENA-CAT [19]. The areas of study ation mechanisms from the perspective of primary and were defined on the basis of primary healthcare areas and secondary care doctors are extremely scarce. their referral hospitals (acute and long-term care). In the Spanish NHS, in which primary health care acts as the gate-keeper and coordinator of patient care across Study population and sample the different healthcare levels, clinical coordination is The study population consisted of PC and SC doctors that still an unresolved issue [28, 31, 32], so it is crucial to had been working for at least one year in the organization, foster collaboration between doctors from different had direct contact with patients and whose daily practice levels of care. In the Spanish region of Catalonia, the involved contact with doctors of the other care level (i.e. NHS is characterized by a split of the financing and through the patient referral process). A total of 15,813 provision functions. The provision of services is the re- doctors from 41 areas of the public national health system sponsibility of a number of contracted providers; a large in Catalonia were invited to participate. The final sample public entity, the Catalan Health Institute (Institut Cat- was 3308 doctors (1141 from PC and 2167 from SC) from alà de la Salut), and a number of public consortia, muni- 32 healthcare areas. The participation rate was 21%. cipal foundations and some private foundations (mostly non-profit but also some for profit), which make up the Questionnaire Integrated Healthcare System for Public Use (Sistema The COORDENA questionnaire was originally designed Sanitari Integral d’Utilització Pública de Catalunya) [33]. in Latin America, based on the theoretical framework This diversity has generated a variety of management underlying this study [11] and an extent scientific litera- models of primary (PC) and secondary care (SC) pro- ture review, and it was tested, piloted and validated. The viders across the healthcare areas of the national health COORDENA-CAT questionnaire, the online version of system. According to the degree of management integra- the COORDENA questionnaire used in this study, was tion of PC/SC providers, the healthcare areas can be adapted to the Catalan NHS context and validated [37]. classified in: 1) areas in which a single entity manages It is divided into three main parts: the first, which is the SC and majority of PC centres (joint management); 2) focus of this paper, measures doctors’ experience of clin- one entity manages SC and some primary care centres, ical information and clinical management coordination while the rest are managed by other entities (partially in- across care levels and their general perception of coord- tegrated); 3) different entities manage SC and PC (non- ination within the area, by means of a Likert scale and integrated) [34, 35]. The coexistence of management one open-ended question on their reasons for that per- models offers an interesting landscape for health services ception. The second measures their knowledge and ex- research. perience in the use of coordination mechanisms across Clinical coordination in Catalonia has been previously care levels, and the third refers to the factors that might analysed by means of qualitative studies [18, 20, 21, 36] influence clinical coordination. which showed limits in cross-level coordination related to factors regarding the system, health professionals or Data collection organizational factors. More comprehensive evidence is Data was collected from October to December 2017. In- needed on clinical coordination in its different types and vitations were sent to the institutional doctors’ e-mails, dimensions, as well as a greater focus on the general by their own institutions. Each invitation contained a population, from the perspective of primary and second- link, randomly generated that gave anonymous access to ary care doctors [37]. the questionnaire. In addition to the invitation sent by e- mail, and following reminders after one and two weeks, Methods doctor participation was encouraged using different Aim strategies such as informative sessions in their centres, The aim of this study, which forms part of a wider re- posters and news posts on the intranet of their institu- search project [37], is to analyse the degree of clinical in- tions, strategies that were tested on the pilot study of formation and clinical management coordination across the questionnaire [37]. healthcare levels in the Catalan NHS experienced by pri- mary and secondary care doctors and explore the associ- Variables ated factors. The outcome variables of clinical coordination across levels were a) coordination of clinical information between Study design and areas of study levels: transfer and use of information (three items); b) co- A cross-sectional study was carried out based on an online ordination of clinical management: consistency of care survey of primary care (PC) and secondary care (SC) (four items), adequate follow up (four items) and Esteve-Matalí et al. BMC Family Practice (2020) 21:135 Page 4 of 14 accessibility between levels (three items); and c) general interactional factors; sixth, organizational factors and perception of the coordination of patient care in the area lastly, knowledge of existing coordination mechanisms (one item) and the underlying reasons. Outcome variables in the area. This allowed us to ascertain the impact of are described in Tables 3 and 4. Level of care was a strati- different types of variables on adjusting the model. Mul- fication variable. ticollinearity between the explanatory variables was The explanatory variables used to explore factors asso- assessed by a correlation matrix as well as by testing the ciated with perceiving high levels of clinical coordination variance inflation factor (VIF), which was found to be in- were a) sociodemographic: sex, age, country of birth and significant (below 1.5) in both final models. The fitness medical speciality; b) employment characteristics: years of the models was assessed with the Hosmer-Lemeshow working as a doctor, years working in the organization test, which gave p-values over 0.05 indicating the good- and type of contract; c) attitude towards job: satisfaction ness of fit of the models. The statistical software used with their job in the organization d) type of area: type of was STATA 15. management of PC and SC and type of hospital; e) inter- Finally, a content analysis was performed for an open- actional factors between doctors: knowing the doctors of ended question on reasons for the general perception of the other care level, trusting in their clinical skills, per- clinical coordination between care levels within the area. ceiving that they influence the practice of doctors of the The answers were coded and classified into categories. Fre- other level, and identifying the PC doctor as the coord- quencies were calculated stratified by PC and SC doctors. inator of patient care across levels; f) organizational fac- tors: perceiving that the organization’s management Results facilitates coordination, existence of objectives aimed at Characteristics of the sample coordination in the organization, having enough time to With regard to sociodemographic characteristics, the ma- dedicate to coordination during working hours, and jority of doctors in the sample in both care levels were visits of secondary care doctors to primary care centres; women (68.99% PC; 52.05% SC), and the highest propor- g) knowledge of existing coordination mechanisms in the tion were 41–55 years of age (51.21% PC; 43.90% SC). Most area: shared electronic medical record (EMR) of the were trained in a medical speciality: almost all PC doctors organization, joint clinical case conferences between pri- (98.76%), as family doctors, and 67.30% of SC (Table 1). mary and secondary care doctors, virtual consultations In terms of employment characteristics, the highest through EMR or e-mail, consultations via phone, shared proportion of doctors had 11 to 20 years’ work experi- protocols, care pathways or clinical guidelines, case man- ence (34.06% PC; 32.88% SC), and a little less experience agers or liaison nurses, and informing primary care doc- working in the organization, 6 to 15 years (30.94% PC; tors when their patients are discharged from hospital. 37.15% SC). The majority had a permanent contract Explanatory variables are described in Tables 1 and 2. (96.31% PC; 88.10% SC) (Table 1). With regard to attitude, most doctors were satisfied with Analysis their job, but SC doctors (86.17%) slightly more so than PC Univariate and bivariate analyses were performed to de- doctors (82.24%). With respect to the type of area, 41.81% scribe the experience and perception of clinical coordin- of PC and 45.22% of SC doctors worked in an organization ation across levels (outcome variables) and the potentially where the same entity manages SC and the majority of PC; associated factors (explanatory variables), stratified by level and 67.48% of PC and 50.16% of SC doctors worked in of care. Chi-square tests were performed to determine sta- areas with local and regional hospitals (Table 1). tistically significant differences between PC and SC doctors. In terms of interactional factors, less than half (44.02% Logistic regression models for each level of care were PC; 36.32% SC) reported knowing the doctors of the other generated in order to explore the factors associated with care level, but the great majority (97.20% PC; 83.70% SC) the general perception of high coordination across care reported trusting in their clinical skills. Finally, the major- levels within the area. Robust covariance adjustments – ity, but fewer PC (66.19%) than SC (85.56%) doctors, per- employing type of area according to the type of manage- ceived that the care they provide influences the practice of ment of PC and SC – were used to account for the doctors of the other level (Table 2). correlated observations due to clustering. Raw and ad- Regarding organizational factors, 67.44% of PC and justed odds ratios (OR) at the 95% confidence interval 53.88% of SC doctors found that their organization’s man- (CI 95%) were calculated. To reach the final models, the agement facilitates coordination across levels (Table 2). explanatory variables were introduced by groups on a The degree of knowledge of the cross-level coordination forward stepwise way, keeping the significant and theor- mechanisms available in the area was relatively high, espe- etically relevant ones in the model: first, sociodemo- cially for the shared EMR of the centre (87.60% PC; graphic; second, employment characteristics; third, 91.23% SC), although percentages differed between PC attitude towards job; fourth, type of area; fifth, doctors’ and SC doctors. The least accessible coordination Esteve-Matalí et al. BMC Family Practice (2020) 21:135 Page 5 of 14 Table 1 Description of the sample by level of care: sociodemographic, employment characteristics and type of area Total PC SC (N = 3308) (N = 1141) (N = 2167) n (%) n (%) n (%) p Sociodemographic characteristics Sex < 0.001 Male 1214 (42.12) 307 (31.01) 907 (47.94) Female 1668 (57.88) 683 (68.99) 985 (52.06) Age < 0.001 25–40 years 701 (25.46) 180 (18.97) 521 (28.88) 41–55 years 1278 (46.42) 486 (51.21) 792 (43.90) 56–70 years 774 (28.11) 283 (29.82) 491 (27.22) Country of birth 0.345 Spain 2469 (87.37) 858 (88.18) 1611 (86.94) Other 357 (12.63) 115 (11.82) 242 (13.06) Medical speciality < 0.001 Clinical speciality 2163 (78.37) 954 (98.76)* 1209 (67.39) Surgical speciality 265 (9.60) 0 (0) 265 (14.77) Medical and surgical speciality 332 (12.03) 12 (1.24) 320 (17.84) Employment characteristics Years working as a doctor < 0.001 0 to 10 years 378 (13.54) 88 (9.11) 290 (15.89) 11 to 20 years 929 (33.29) 329 (34.06) 600 (32.88) 21 to 30 years 805 (28.84) 318 (32.92) 487 (26.68) 31 to 45 years 679 (24.33) 231 (23.91) 448 (24.55) Years working in the organization < 0.001 1 to 5 years 406 (14.62) 78 (8,13) 328 (18.05) 6 to 15 years 972 (35) 297 (30.94) 675 (37.15) 16 to 25 years 769 (27.69) 338 (35.21) 431 (23.72) 26 to 45 years 630 (22.69) 247 (25.73) 383 (21.08) Type of contract a) < 0.001 Permanent 2630 (90.94) 965 (96.31) 1665 (88.10) Temporary 262 (9.06) 37 (3.69) 225 (11.90) Type of contract b) 0.233 Full-time 2660 (91.88) 929 (92.71) 1731 (91.44) Part-time 235 (8.12) 73 (7.29) 162 (8.56) Attitude towards job Satisfaction with the job in the organization 0.008 Yes 2193 (84.80) 741 (82.24) 1452 (86.17) No 393 (15.20) 160 (17.76) 233 (13.83) Type of area Area according to type of management of PC and SC 0.001 One entity manages SC and majority of PC 1457 (44.04) 477 (41.81) 980 (45.22) One entity manages SC and minority of PC 892 (26.96) 354 (31.03) 538 (24.83) Different entities manage SC and PC 959 (28.99) 310 (27.17) 649 (29.95) Esteve-Matalí et al. BMC Family Practice (2020) 21:135 Page 6 of 14 Table 1 Description of the sample by level of care: sociodemographic, employment characteristics and type of area (Continued) Total PC SC (N = 3308) (N = 1141) (N = 2167) n (%) n (%) n (%) p Area according to type of hospital < 0.001 Local or regional hospitals 1857 (56.14) 770 (67.48) 1087 (50.16) Regional high-resolution hospitals 810 (24.49) 222 (19.46) 588 (27.13) High-technology hospitals 641 (19.38) 149 (13.06) 492 (22.70) * Family doctors Table 2 Interactional and organizational factors and knowledge of coordination mechanisms, by level of care Total PC SC (N = 3308) (N = 1141) (N = 2167) n (%) n (%) n (%) p Interactional factors between doctors I know the doctors of the other care level who see my patients personallya 1103 (39.06) 442 (44.02) 661 (36.32) < 0.001 I trust in the clinical skills of the doctors of the other level who see my patientsa 2429 (88.62) 971 (97.20) 1458 (83.70) < 0.001 a My daily practice influences the practice of the doctors of the other level 1834 (78.61) 554 (66.19) 1280 (85.56) < 0.001 In practice, primary care doctors are responsible for coordinating the patient on 2189 (81.92) 950 (95.19) 1239 (74.01) < 0.001 their way through the different levels of carea Organizational factors My organization’s management facilitates coordination between primary and 1492 (59.18) 665 (67.44) 827 (53.88) < 0.001 secondary care doctorsa My organization sets objectives that are aimed at coordination between care levelsa 1370 (55.20) 540 (56.72) 830 (54.25) 0.228 The time I can dedicate to coordinating with doctors of the other level during 380 (13.90) 136 (13.67) 244 (14.03) 0.792 my working day is sufficient a As a secondary care doctor, do you do patient consultations in a primary care centre?a 386 (21.44) Knowledge of the coordination mechanisms available in the area The electronic medical records that you use in your centre allows you to share 2623 (89.92) 918 (87.60) 1705 (91.23) 0.002 information between primary and secondary (hospital, long-term) careb In your centre, you can hold virtual consultations through the EMR between primary 1795 (72.55) 841 (83.18) 954 (65.21) < 0.001 and secondary care doctorsb In your centre, you can hold consultations via e-mail between primary and 1885 (75.98) 792 (79.52) 1093 (73.60) 0.001 secondary care doctorsb In your centre, you can hold consultations via phone between primary and 2085 (79.73) 700 (71.72) 1385 (84.50) < 0.001 secondary care doctorsb In your centre, you hold joint clinical case conferences between primary and 1226 (43.50) 696 (66.60) 530 (29.91) < 0.001 secondary care doctors for the discussion of casesb In your centre, you have at your disposal shared protocols, care pathways 1847 (74.99) 940 (92.16) 907 (62.86) < 0.001 or clinical practice guidelines between primary and secondary careb There are case managers or liaison nurses at your centreb 2031 (80.28) 876 (87.43) 1155 (75.59) < 0.001 a Primary care doctors are informed when their patients are discharged from the hospital 1105 (43.61) 677 (64.05) 428 (28.98) < 0.001 a Results correspond to the categories always and very often b Results correspond to the category yes Esteve-Matalí et al. BMC Family Practice (2020) 21:135 Page 7 of 14 mechanism among both PC and SC doctors was joint clin- Primary and secondary care doctors’ perception of clinical ical case conferences (66.60% PC; 29.91% SC). There was coordination between levels in the area and underlying a notable difference between care levels in access to reasons standardization mechanisms such as shared protocols, Regarding the general perception of coordination across care pathways or clinical practice guidelines (92.16% PC; healthcare levels, only around a third of doctors (32.13% 62.86% SC) (Table 2). PC; 35.72% SC) reported that patient care is usually co- ordinated between primary and secondary care within Primary and secondary care doctors’ experience of clinical their area (Table 4). The results of the open-ended ques- information and clinical management coordination tion showed that reasons for this perception were similar between levels among doctors of both care levels (Fig. 1). The most fre- With regard to the coordination of clinical information quent reasons given for perceiving high coordination across levels of care, the majority of doctors from both (Fig. 1a) were that there was fluid communication and care levels reported frequent exchange and use of the in- direct communication mechanisms (phone, e-mail or formation required for patient care, with higher frequency virtual consultations; 23% PC; 22% SC); shared EMR among PC doctors. A higher proportion of PC doctors re- (20% PC; 18% SC); strategies that promote direct contact ported that the patient’s clinical information is usually and knowledge exchange (such as joint clinical case con- shared between levels of care (70.09% PC; 59.39% SC); ferences; 8% PC; 16% SC) and coordination with some that the information shared is as required for the care of centres/specialities (27% PC; 12% SC). Accordingly, the the patient (76.92% PC; 69.56% SC) and that this informa- most frequent reasons given for considering coordin- tion is frequently used (84.90% PC; 80.06%SC) (Table 3). ation to be poor (Fig. 1b) were related to a lack of com- The three dimensions of clinical management coordin- munication or direct contact (22% PC; 32% SC) and a ation showed relatively high frequencies in both care lack of coordination mechanisms (14% for both levels). levels, with some differences (Table 3). The reasons included limited time to dedicate to coord- Regarding consistency of care, most doctors reported ination (8% PC; 16% SC). usually agreeing with the treatments prescribed by doc- tors of the other care level (74.16% PC; 80.09% SC) and not experiencing contradictions or duplications in the Factors associated to primary and secondary care treatments prescribed by the other care level (61.05% doctor’s perception of high patient care coordination PC; 74.18% SC). However, only 11.99% of PC and between levels 14.82% of SC doctors reported establishing a treatment The item on general perception of the coordination of plan together for patients who require it. patient care in the area, “I think that in this area patient For patient follow-up between levels, as expected, care is coordinated between primary and secondary care more PC doctors (99.07% PC; 74.29% SC) reported that doctors”, was used to explore the associated factors PC doctors usually refer their patients to secondary care (Table 5), showing some concordance but also some dif- when appropriate and, vice versa, more SC doctors ferences between PC and SC doctors. Factors positively (87.36% SC; 76.65% PC) reported that SC doctors refer associated with perceiving high levels of coordination for the patients back to primary care when appropriate. both PC and SC doctors were interactional: knowing the Similarly, a smaller proportion of PC doctors (39.38% doctors of the other level, perceiving that their own PC; 69.94% SC) reported that SC doctors make recom- practice influences the other level; and organizational: mendations to PC doctors, while a higher proportion of perceiving that the organization’s management facilitates PC doctors (55% PC; 35.52% SC) reported that PC doc- coordination, working in an area where one entity man- tors contact SC doctors to resolve queries on the follow- ages SC and the majority of PC, and having access to up of patients. joint clinical case conferences. Lastly, in terms of accessibility across levels of care, a In the specific case of PC doctors, other factors found notable minority of PC doctors reported that the patient to be associated with perceiving high coordination were does not usually have to wait long for an appointment job-related attitude: being satisfied with their job in the upon standard (1.58% PC; 33.43% SC) or urgent (17.58% organization; and organizational: working in areas with PC; 69.15% SC) referral to SC. Conversely, 81.84% of PC local/regional hospitals, and being informed of their pa- doctors and 30.91% of SC doctors reported that the pa- tients’ hospital discharge. Specifically for SC doctors, fur- tient does not have to wait long to be seen on being sent ther associated factors were: less work experience as a back to PC. However, it should be stressed that for the doctor, trusting in the clinical skills of PC doctors, hav- latter item, around 50% of SC doctors responded “I don’t ing enough time for coordination during working hours, know”, this being the only item in which this answer cat- and access to shared protocols, pathways or clinical egory was chosen with notable frequency. practice guidelines (Table 5). Esteve-Matalí et al. BMC Family Practice (2020) 21:135 Page 8 of 14 Table 3 Primary and secondary care doctors’ experience of high levels of clinical coordination Total PC SC (N = 3308) (N = 1141) (N = 2167) n (%) n (%) n (%) p Coordination of clinical information between levels of care Primary and secondary care doctors share information on the care 1959 (63.11) 757 (70.09) 1202 (59.39) < 0.001 of patients we have in commona The information we share is as required for the care of these patientsa 2224 (72.14) 830 (76.92) 1394 (69.56) < 0.001 Primary and secondary care doctors use the information that we sharea 2489 (81.77) 911 (84.90) 1578 (80.06) 0.001 Coordination of clinical management: Consistency of care between levels We agree with the treatments prescribed or directions given to the patients 2357 (77.99) 792 (74.16) 1565 (80.09) < 0.001 by doctors of the other levela There are no contraindications and/or duplications in the treatments prescribed 2100 (69.54) 652 (61.05) 1448 (74.18) < 0.001 by primary and secondary care doctorsa Primary and secondary care doctors establish a treatment plan together for 422 (13.82) 129 (11.99) 293 (14.82) 0.030 patients that require thisa We do not repeat the tests that doctors have already carried out at the other 2182 (71.45) 768 (71.98) 1414 (71.16) 0.635 level (analysis, imaging)a Coordination of clinical management: Adequate follow-up between levels Primary care doctors refer the patients to secondary care when appropriatea 2493 (83.13) 1060 (99.07) 1433 (74.29) < 0.001 Secondary care doctors send the patients back to primary care for follow-up 2484 (83.55) 811 (76.65) 1673 (87.36) < 0.001 when appropriatea Secondary care doctors make recommendations to the primary care doctor on 1780 (59.10) 421 (39.38) 1359 (69.94) < 0.001 the follow-up of patients (diagnosis, treatment, other guidelines)a Primary care doctors resolve any queries on the follow-up of patients with the 1249 (42.63) 588 (55.00) 661 (35.52) < 0.001 secondary care doctorsa Coordination of clinical management: Accessibility between levels of care On being referred in the standard way to secondary care, the patient does not 611 (21.43) 17 (1.58) 594 (33.43) < 0.001 wait a long time to be seena On being referred urgently to secondary care, the patient does not wait a 1440 (49.33) 189 (17.58) 1251 (69.15) < 0.001 long time to be seena On being sent back to primary care, the patient does not wait a long time 1540 (76.24) 870 (81.84) 670 (30.91) < 0.001 to be seena a Results correspond to the categories always and very often Discussion secondary care doctors, allowing us to analyse critical elements This study is the first attempt to comprehensively analyse clin- for improvement. The degree of clinical coordination experi- ical coordination between care levels in a national health sys- enced across levels of care was relatively high, although doctors’ tem, taking into account the different types and dimensions of experiences differed according to care level: while PC doctors clinical coordination and the experience of primary and experienced better coordination of clinical information, SC Table 4 Primary and secondary care doctors’ general perception of high levels of coordination between healthcare levels Total PC SC (N = 3308) (N = 1141) (N = 2167) n (%) n (%) n (%) p General perception of coordination between healthcare levels I think that in this area patient care is coordinated between primary and secondary care doctorsa 1012 (34.43) 339 (32.13) 673 (35.72) 0.049 a Results correspond to the categories always and very often Esteve-Matalí et al. BMC Family Practice (2020) 21:135 Page 9 of 14 Fig. 1 Reasons for the perception of clinical coordination within the area, by level of care. a) Reasons for considering care to be coordinated within the area. b) Reasons for considering care not to be coordinated within the area doctors experienced greater consistency of care. However, the care was high, despite there being several areas for im- general perception of patient care coordination within the provement. Doctors reported a relatively high degree of healthcare area was low in both groups, in contrast to the clinical information coordination – higher than in other findings of previous qualitative studies [20]. Factors associated contexts [19] – which is coherent with various strategies with this perception were mostly interactional and and information coordination mechanisms that have organizational, with differences among levels of care. been implemented in Catalonia in recent years, such as EMR or virtual consultations [35, 38]. That said, consid- Primary and secondary care doctors experienced high ering these measures, it is still lower than expected, es- clinical coordination between levels, with direct pecially among SC doctors, which might be due to them communication for patient follow-up and accessibility as not yet having developed the habit of regularly using the the major areas needing improvement shared EMR. Moreover, reported access to joint clinical In general terms, the clinical information and clinical case conferences was particularly low in both care levels, management coordination experienced across levels of but especially for SC doctors, revealing limited direct Esteve-Matalí et al. BMC Family Practice (2020) 21:135 Page 10 of 14 Table 5 Factors associated with perception of high levels of clinical coordination, by level of care Factors Primary Care Secondary Care Raw OR (95% IC) Adj. OR (95% IC) Raw OR (95% IC) Adj. OR (95% IC) Sex Female 1 1 1 1 Male 1.04 (0.78–1.39) 1.02 (0.69–1.50) 0.94 (0.77–1.14) 1.12 (0.82–1.54) Country of birth Spain 0.63 (0.42–0.95) 0.85 (0.44–1.62) 1.21 (0.90–1.64) 1.19 (0.73–1.94) Other 1 1 1 1 Years working as a doctor 0 to 10 years 1 1 1 1 11 to 20 years 0.80 (0.49–1.32) 0.82 (0.31–2.20) 0.62 (0.46–0.83) 0.49 (0.27–0.89) 21 to 30 years 0.79 (0.48–1.30) 0.83 (0.32–2.13) 0.92 (0.68–1.25) 0.82 (0.43–1.57) 31 to 45 years 0.74 (0.44–1.24) 0.62 (0.24–1.60) 0.63 (0.58–0.94) 0.50 (0.32–0.80) Satisfaction with the job in the organization Yes 3.62 (2.25–5.83) 2.59 (2.09–3.21) 4.15 (2.78–6.19) No 1 1 1 I know the doctors of the other care level who see my patients personally Often/Always 3.51 (2.66–4.64) 2.22 (1.58–3.10) 3.79 (3.08–4.67) 2.67 (1.64–4.43) Rarely/Never 1 1 1 1 I trust in the clinical skills of the doctors of the other level who see my patients Often/Always 2.84 (0.98–8.29) 3.57 (2.54–5.01) 1.61 (1.18–2.19) Rarely/Never 1 1 1 My daily practice influences the practice of the doctors of the other level Often/Always 2.30 (1.64–3.22) 1.72 (1.29–2.30) 3.06 (2.11–4.43) 2.08 (1.36–3.18) Rarely/Never 1 1 1 1 My organization’s management facilitates coordination between primary and secondary care doctors Often/Always 4.43 (3.12–6.30) 2.56 (1.80–3.63) 5.15 (4.07–6.52) 3.59 (2.36–5.46) Rarely/Never 1 1 1 1 The time I can dedicate to coordinating with doctors of the other level during my working day is sufficient Often/Always 1.87 (1.28–2.71) 3.97 (2.97–5.31) 2.20 (1.90–2.56) Rarely/Never 1 1 1 Area according to type of management of PC and SC One entity manages SC and majority of PC 1 1 1 1 One entity manages SC and minority of PC 0.73 (0.54–0.99) 0.76 (0.71–0.82) 0.77 (0.61–0.98) 0.78 (0.70–0.87) Different entities manage SC and PC 0.70 (0.51–0.97) 0.64 (0.58–0.72) 1.17 (0.94–1.46) 1.05 (0.95–1.16) Area according to type of hospital Local and regional hospitals 1 1 1 1 Regional high-resolution hospitals 1.14 (0.82–1.58) 1.15 (0.90–1.47) 1.19 (0.96–1.48) 1.14 (0.56–2.34) High-technology hospitals 0.75 (0.49–1.13) 0.54 (0.49–0.60) 0.78 (0.61–0.99) 1.03 (0.69–1.55) Joint clinical case conferences between primary and secondary care doctors for the discussion of cases Yes 2.46 (1.81–3.34) 1.97 (1.32–2.94) 3.26 (2.63–4.05) 1.50 (1.39–1.62) No 1 1 1 1 Esteve-Matalí et al. BMC Family Practice (2020) 21:135 Page 11 of 14 Table 5 Factors associated with perception of high levels of clinical coordination, by level of care (Continued) Factors Primary Care Secondary Care Raw OR (95% IC) Adj. OR (95% IC) Raw OR (95% IC) Adj. OR (95% IC) Shared protocols, care pathways or clinical practice guidelines between primary and secondary care Yes 3.99 (1.97–8.11) 3.77 (2.91–4.88) 2.42 (1.63–3.58) No 1 1 1 Primary care doctors are informed when their patients are discharged from the hospital Often/Always 3.12 (2.30–4.25) 3.14 (2.53–3.89) 2.52 (1.99–3.19) Rarely/Never 1 1 1 communication and feedback between care levels. In Interactional and organizational factors are associated fact, lack of communication or direct contact was the with the perception of clinical coordination between main reason for considering care not to be coordinated levels within the area for both PC and SC doctors. Mutual feedback is crucial Although PC and SC doctors tend to experience high clin- for the follow-up of patients, especially in complex cases ical information and clinical management coordination, involving high levels of uncertainty, for which their general perception of clinical coordination within standardization mechanisms such as shared protocols or their healthcare area is relatively low. Their most fre- clinical practice guidelines are less effective [39]. So des- quently reported reasons for considering care not to be pite the progress made in the use of health information coordinated were lack of communication or direct contact technology, improvement in direct communication and lack of coordination mechanisms. across the care continuum is still needed [30, 40], par- Most factors associated with perceiving high levels of co- ticularly in situations of high levels of uncertainty. ordination are common to both PC and SC doctors, mean- With regard to clinical management coordination, we ing that such factors could be addressed across the whole should highlight the high level of agreement with the healthcare network, regardless of level of care. These factors treatments prescribed by the other level and adequate- are mostly interactional and organizational factors, in keep- ness of referrals and back-referrals, which are consistent ing with the results of other authors [45, 46]. Communica- with the reported high degree of trust in the clinical tion, knowing each other and good relationships between skills of doctors of the other level. This reflects the doctors of different care levels are at the core of clinical co- strengths of primary care in the Spanish NHS, in con- ordination determinants [18]. In this study, interactional trast to other healthcare settings where SC doctors have factors associated with perceiving high levels of coordin- low levels of trust in PC doctors’ clinical skills [19]. ation were: knowing the doctors of the other level, trusting Nevertheless, only a small proportion of doctors from in their clinical skills and believing that their own practice both levels of care reported making recommendations had an influence on the other level, in keeping with studies and resolving queries with each other regularly, and this conducted in other contexts [19] and with relational theory, limited direct contact seems to also be reflected in PC which underlines knowing each other and mutual respect and SC doctors rarely establishing treatment plans to- as key factors for coordination [47]. gether for complex patients, a result also described in The positive association of joint clinical case confer- previous qualitative studies [20], suggesting that such de- ences for both levels of care confirms the importance of cisions are not taken jointly despite the importance and knowing each other and the need for direct communica- need for it [18, 20, 41]. tion mechanisms. In previous qualitative studies [21] clin- In terms of accessibility between levels of care, as antici- ical case conferences have also emerged as a mechanism pated and in line with the evidence [20, 42], waiting times that promotes coordination. In fact, the coordination for referrals to SC (urgent and standard) were reported to mechanisms found to contribute most to clinical coordin- be too long, especially by PC doctors. Long waiting times ation are feedback mechanisms based on mutual adjust- between levels have implications for quality of care and ment, which include shared EMR, joint clinical case adequate follow-up by PC doctors [43, 44]. Interestingly conferences, virtual consultations and telephone [21]. The enough, while a high proportion of PC doctors reported presence of direct communication coordination mecha- acceptable waiting times on the patient’s return to PC, half nisms such as phones, e-mail, or virtual consultations did of the SC doctors did not know how long waiting times not emerge as significant associated factors in the statis- were for this transition, demonstrating a lack of interest tical models, but were highly emphasised by doctors as a that contradicts expectations for coordinated care reason for perceiving high levels of clinical coordination, provision. in addition to access to shared EMR. Esteve-Matalí et al. BMC Family Practice (2020) 21:135 Page 12 of 14 Besides coordination mechanisms, other organizational identified related to the lack of direct communication conditions are also relevant in improving coordination. between PC and SC doctors to make recommendations, A common factor associated with perceiving high levels resolve queries and establish common treatment plans of clinical coordination for doctors of both levels of care, for patients, and limited accessibility between levels of also pointed out in the scientific literature [48], is for an care. This study reveals the important role that mutual organization’s management to facilitate coordination, feedback and direct communication play in fostering not only by implementing coordination mechanisms but clinical coordination across healthcare levels, both for also by creating the adequate conditions for their use, PC and SC doctors. It is therefore necessary to extend such as ensuring there is enough time available to use the existing mechanisms or even to implement new ones them [49], another factor positively associated with the which enhance mutual feedback between doctors of dif- perception of clinical coordination among SC doctors. In ferent levels of care. It is also important to tackle other fact, lack of time is one of the most frequent reasons given organizational factors, such as building time into the by SC doctors for a low perception of coordination, which schedule to use such mechanisms. is also consistent with the literature [18–21, 50]. Further studies are needed to assess the relevance of Finally, healthcare areas where the same entity man- coordination mechanisms based on the management ages SC and majority of PC are also positively associated model of the area where they are implemented, as well with perceiving a high degree of clinical coordination for as to explore the difficulties in their use in the Catalan doctors of both levels of care. There is evidence suggest- context. Moreover, future research should shed more ing that management integration across the entire care light on the relationship between high levels of clinical continuum (through aligning economic interests, budget coordination and quality of care. policies, clinical objectives, human resources, etc.) is most likely to promote clinical coordination [18, 46, 51]. Abbreviations NHS: National Health System; PC: Primary Care; SC: Secondary Care; Further studies should be performed to comparatively EMR: Electronic medical record; HC3: Electronic medical record of Catalonia; analyse clinical coordination according to management OR: Odds Ratio; CI: Confidence Interval; VIF: Variance Inflation Factor model, particularly in a NHS context. Acknowledgements We highly appreciate the contributions to the project of the members who, Limitations together with the authors of the paper, constitute the Grup d’Avaluació de The main limitation of this study is the potential selec- la Integració Assistencial (GAIA): Lluís Colomés (Grup SAGESSA), Francesc tion bias resulting from the voluntary, self-administered Cots (Parc de Salut Mar), Mercè Abizanda (Parc Sanitari Pere Virgili), Jordi Coderch (Serveis Salut Integrats Baix Empordà), Elena Medarde (Consorci nature of the questionnaire and having no information Sanitari de Terrassa), Àngels Avecilla (Badalona Serveis Assistencials), Marta on doctors’ reasons for refusing to participate when they Banqué (Consorci Sanitari de l’Anoia), Rami Qanneta (Gestió i Prestació de did so. However, we can confirm the representativeness Serveis de Salut), Yolanda Lejardi (Institut Català de la Salut), Palmira Borràs, Verónica Espinel, Aida Oliver and Andrea Miranda (Consorci de Salut i Social of the sample when comparing some characteristics (sex, de Catalunya). age, level of care) with the available data on doctors working in the NHS in Catalonia. On the other hand, Authors’ contributions the online self-administered nature of the questionnaire MLV and IV were responsible for the design and supervision of the study. LEM analysed and interpreted the data and was the major contributor in is also a strength, since it makes it easier to reach doc- writing the manuscript. MLV, IV, ES, PP and IR coordinated data collection, tors and it is simpler, faster and less expensive to con- participated in its interpretation and were contributors in writing the duct than face-to-face surveys [37]. Participation was manuscript. All authors read and approved the final manuscript. similar or even higher than reported by other online sur- Funding veys of doctors [52, 53]. Project partially funded by Instituto de Salud Carlos III and Fondo Europeo de Desarrollo Regional (PI15/0021). The funding body did not participate in Conclusions the design of the study, collection, analysis, interpretation of data or in writing the manuscript. This is the first study that comprehensively analyses clinical coordination across care levels in a national Availability of data and materials health system. The application of the COORDENA The datasets generated and/or analysed in this study are not publicly questionnaire, which can be adapted to other contexts, available because individual privacy could be compromised, but are available allowed us to identify fields for improvement in clinical from the corresponding author on reasonable request. coordination and to provide policy makers with evi- Ethics approval and consent to participate dence, and could be used to periodically monitor clinical Ethical approval for the study was granted by the ethical committee of Parc coordination performance in health services. de Salut Mar and Bellvitge Hospital. The basis for participation was voluntary, In Catalonia, in general terms, PC and SC doctors ex- after reading and signing an informed consent in order to access the questionnaire. A random coding system ensured the anonymity of the perienced a high level of clinical information and clinical participants. Confidentiality and protection of data were guaranteed. management coordination. The major problems Participants also had the right to withdraw from the survey at any moment. Esteve-Matalí et al. BMC Family Practice (2020) 21:135 Page 13 of 14 Consent for publication associated factors. A cross-sectional study in public healthcare networks of Not applicable. six Latin American countries. Soc Sci Med. 2017;182:10–9. 20. Aller MB, Vargas I, Coderch J, Calero S, Cots F, Abizanda M, et al. Doctors’ Competing interests opinions on clinical coordination between primary and secondary care in The authors declare that they have no competing interests. the Catalan healthcare system. Gac Sanit. 2019;33(1):66–73. 21. Aller MB, Vargas I, Coderch J, Vázquez ML. 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