Linking Manager's, Health Provider's and Patient's Assessment of Chronic Illness Care in Primary and Secondary Level of Care in Brazil
Authors: A Barcelo , E Amaral , Galil A Garcia de Siqueira , BM Costa , R de Paula , FAB Colugnati 
Published: February 2022

Background: Twenty years after the first publication of the landmark Chronic Care Model by Wagner and collaborators, it still guides interventions and evaluation aiming to improve patient chronic disease outcomes. Chronic care can be influenced by stakeholders who are user of the collected data, but health providers and patient have also a major impact on the success or failure of intervention aiming to improve quality of care. The Assessment of Chronic Illness Care (ACIC) and Patient Assessment of Chronic Illness Care (PACIC) are tools that have been used with success to evaluate care for a number of chronic diseases from the point of view of providers and patients respectively. In Brazil, chronic diseases are the leading cause of mortality accounting for more than 70% of deaths. Diabetes and cardiovascular diseases accounted for 13% and 5% of discounted disability-adjusted life years (DALYs) in 2007. Aim: The objective of this study was to evaluate care for diabetes and hypertension from the point of view of the patient, providers, and managers in primary and secondary care clinics of the city of Juiz de For a, Minas Gerais, Brazil. Material and Methods: Three different tools were used to evaluate care, named the Assessment of Chronic Illness Care (ACIC) and the Patient Assessment of Chronic Illness Care (PACIC) both designed and tested by the MacColl Institute for Health Improvement as well as the questionnaire Chronic Care Structure Survey designed by the Pan American Health Organization and based on the Physician Practice Connection and Readiness Survey (PPC-RS). In the evaluation participated 1,664 patients with diabetes or hypertension, as well as 323 health providers from public primary and secondary care clinics. Patients and providers were interviewed using ACIC and PACIC; and the CCSS was completed by medical managers from each clinic. Clinical data from patients were abstracted from electronic records. Results: Scores for all the three questionnaires were scaled to 100 percentage points. The evaluation of the structure for chronic care scored 49 and 94 percentage points for primary and secondary care respectively. All PACIC and ACIC scores for primary care clinics were lower than scores for the secondary care clinic. Patients and providers rated care at 45 and 48, and 73 and 68 percentage points for primary and secondary care clinics. The secondary care clinic was evaluated with very high scores by patients and providers. Among the activities explored by the PACIC questionnaire, patient considered the lowest score for activation, followed by care coordination for both primary and secondary care clinics; while providers considered that the weakest aspects were the Health Care Organization. This research showed that using the PACIC, ACIC and CCSS were helpful understanding capacity and identifying chronic care areas for improvement in primary and secondary care settings. The capacity and clinic outcomes of the secondary care clinic proved to be better than the one exhibited by the primary care clinics for the management of diabetes and hypertension.