title: The performance of integrated health care networks in continuity of care: a qualitative multiple case study of COPD patients.
abstract: BACKGROUND
  Integrated health care networks (IHN) are promoted in numerous countries as a response to fragmented care delivery by providing a coordinated continuum of services to a defined population. However, evidence on their effectiveness and outcome is scarce, particularly considering continuity across levels of care; that is the patient's experience of connected and coherent care received from professionals of the different care levels over time. The objective was to analyse the chronic obstructive pulmonary disease (COPD) patients' perceptions of continuity of clinical management and information across care levels and continuity of relation in IHN of the public health care system of Catalonia.
  
  
  METHODS
  A qualitative multiple case study was conducted, where the cases are COPD patients. A theoretical sample was selected in two stages: (1) study contexts: IHN and (2) study cases consisting of COPD patients. Data were collected by means of individual, semi-structured interviews to the patients, their general practitioners and pulmonologists and review of records. A thematic content analysis segmented by IHN and cases with a triangulation of sources and analysists was carried out.
  
  
  RESULTS
  COPD patients of all networks perceived that continuity of clinical management was existent due to clear distribution of roles for COPD care across levels, rapid access to care during exacerbations and referrals to secondary care when needed; nevertheless, patients of some networks highlighted too long waiting times to non-urgent secondary care. Physicians generally agreed with patients, however, also indicated unclear distribution of roles, some inadequate referrals and long waiting times to primary care in some networks. Concerning continuity of information, patients across networks considered that their clinical information was transferred across levels via computer and that physicians also used informal communication mechanisms (e-mail, telephone); whereas physicians highlighted numerous problems of the information system, thus the need to use informal communication channels. Finally, regarding continuity of relation, patients of some networks pointed out high turnover of personnel - being frequently seen by locum doctors or assigned to new physicians - which hindered the development of a trusting relationship.
  
  
  CONCLUSIONS
  Study findings suggest a generally perceived adequate performance of IHN in continuity of care but also the existence of a series of difficulties related to all continuity types. Results can provide opportunities to improving the care process of COPD patients but also of patients with other conditions who receive care across the primary and secondary care level.
authors.affiliation: Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Barcelona, Spain.
authors.forename: Sina
authors.initials: S
authors.lastname: Waibel
authors.affiliation: Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Barcelona, Spain.
authors.forename: Ingrid
authors.initials: I
authors.lastname: Vargas
authors.affiliation: Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Barcelona, Spain.
authors.forename: Marta-Beatriz
authors.initials: MB
authors.lastname: Aller
authors.affiliation: Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Barcelona, Spain.
authors.forename: Renata
authors.initials: R
authors.lastname: Gusmão
authors.affiliation: Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Barcelona, Spain.
authors.forename: Diana
authors.initials: D
authors.lastname: Henao
authors.affiliation: Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Barcelona, Spain.
authors.forename: M Luisa
authors.initials: ML
authors.lastname: Vázquez
keywords: chronic obstructive pulmonary disease; clinical information continuity; clinical management continuity; continuity of patient care; integrated delivery systems; patient–physician relationship; qualitative research