Objectives. To identify obstacles impeding the use of the reply letter by secondary level specialists in the municipality of Camaragibe, Pernambuco, Brazil, and to highlight possible solutions for improving communication at the interface between secondary level specialist care and primary care. Methods. Conducted in 2003, this qualitative study used semistructured interviews with 10 randomly selected secondary level specialists. The following specialties were represented: neurology, obstetrics,

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... gynecology, psychiatry, otolaryngology, and colposcopy. Interviews were semistructured, using an interview guide, based on the following seven categories: (1) profile of the specialist, (2) description of outpatient clinic services, (3) professional satisfaction, (4) assessment of the municipal health services, (5) assessment of the Family Health Program (Programa Saúde da Família), (6) description of the referral process, and (7) reply letter utilization. Results. Most of the specialists understood the importance of the reply letter and that this form of communication with the generalist would ensure continuity of care, avoid duplication of efforts or disorganized patient management, and would provide the generalist with the professional support required. However, the study found that most of the specialists do not routinely use the reply letter. In general, the specialists have their own criteria to reply or not to a referral, for example, whether the generalist "deserved" a reply, whether the patient will remain under their care, or whether the patient has a significant pathology. Reasons for low reply letter utilization rates among specialists were categorized into four broad themes: (1) workplace organization, (2) communication inhibition, (3) professional isolation, and (4) medical education. Conclusions. Despite a general understanding of its importance, specialists in Camaragibe had difficulty adopting the reply letter as a form of communication at the interface between primary and secondary care levels. The reply letter can be effective in improving communication at the interface, but the broad cultural, historical, and organizational features of secondary level specialists need to be considered in order to improve reply letter utilization. ABSTRACT The use of reply letters to improve communication at the interface between secondary level specialist care and primary care can impact positively on health system efficiency and ensure continuity of patient care. Bra-zil introduced the Family Health Program (FHP) (Programa Saúde da Família) in the 1990s to provide universal community-based primary care at the municipal level. However, there has been difficulty ensuring the functional letter utilization by secondary level specialists in a municipality in Brazil: a qualitative study. Rev Panam Salud Publica. 2007;21(2/3):96-110.