The rationale for integrated care deployment to chronic patients in Ecuador and proposals to act locally: results from a mixed method study

Abstract

Introduction: Integrated care (IC) has potential to improve health care experience and treatment adherence by properly coordinated and stratified care. We aimed to: (i) assess the patients’ perception about the degree of integrality in their care, (ii) identify potential predictors for risk assessment; and, (iii) assess clinicians’ and patients’ expectations about the involvement of general practitioners (GP) specialists in chronic care. Methods: mixed methods study. Cross sectional study: Two subsets of chronic patients (total n=416) attended by three public health care centres in Portoviejo – Ecuador were studied. In first subset (n=111) we searched for independent associations between sociodemographic and clinical variables with perception of integrality in their care by Patient Assessment of Care for Chronic Conditions (PACIC) instrument. In second subset (n=305), we searched for independent associations between clinical data –collected by “the passport to a healthy lifestyle”–, BMI, diagnoses, and self-rated health with: (i) representations of illness by the Brief Illness Perception Questionnaire (BIPQ) questionnaire, and (ii) any hospitalization in last year. Qualitative research: Two focus groups, focused on finding out expectations of future involvement of GP specialists in chronic care, subsequent transcription and discursive analyses were performed. Results: Patients were, mostly, female, median age of 59 years old, low educated, married, unemployed, and without social security. First subset: median (P25 to P75) PACIC score was 4 (3.2 to 4.8) points, ageing, male sex and longer duration of the disease were associated with a lower PACIC score. Second subset: ageing, low education, and unemployment were associated with lower BIPQ score. Abnormal BMI, fair to poor self-rated health, and multimorbidity were associated to any hospitalization in last year (aOR=2.8, 95%CI: 1.0 to 8.0; aOR=2.3, 95%CI: 1.0 to 5.9; and, aOR=2.5, 95%CI: 1.1 to 5.8, respectively). Physicians and patients considered that there is scarce or poor integrality in chronic care and that IC is necessary; further, involvement of GP specialists is seen as it would improve chronic care. Discussion: Cross sectional approach does not let to properly establish predictors of adverse outcomes, but our results suggest there is potential for practical risk assessment. Massive recruitment of GP specialists is a well-perceived strategy by patients and physicians, but subsequent IC deployment in Ecuador requires further structural changes. Conclusions and lessons learned: Fragmented care is provided to patients in Portoviejo. We provide a rationale for recruiting GP specialists and subsequent IC adoption. Ageing and social factors contribute to a poorer understanding of the disease, which deserves special attention by healthcare workers. BMI, number of diseases, and self-rated health are potential predictors for risk assessment – an IC core component–; in that regard, “the passport” could be a contribution to the adoption of IC. Limitations: The convenience sampling could exclude high risk patients; nevertheless, it is estimated that public health centres cover 60% of the population; further, given that low educated patients were included, we believe that high risk stratum was properly represented. Suggestions for future research: Longitudinal follow-up of a large sample of Ecuadorian patients is desirable to corroborate proposed risk predictors.

Keywords

• integrated care
• chronic patients
• risk assessment and stratification
• primary care
• general practitioners