Models of care for musculoskeletal health: A cross-sectional qualitative study of Australian stakeholders' perspectives on relevance and standardised evaluation

Background: The prevalence and impact of musculoskeletal conditions are predicted to rapidly escalate in the coming decades. Effective strategies are required to minimise 'evidence-practice', 'burden-policy' and 'burden-service' gaps and optimise health system responsiveness for sustainable, best-practice healthcare. One mechanism by which evidence can be translated into practice and policy is through Models of Care (MoCs), which provide a blueprint for health services planning and delivery. While evidence supports the effectiveness of musculoskeletal MoCs for improving health outcomes and system efficiencies, no standardised national approach to evaluation in terms of their 'readiness' for implementation and 'success' after implementation, is yet available. Further, the value assigned to MoCs by end users is uncertain. This qualitative study aimed to explore end users' views on the relevance of musculoskeletal MoCs to their work and value of a standardised evaluation approach. Methods: A cross-sectional qualitative study was undertaken. Subject matter experts (SMEs) with health, policy and administration and consumer backgrounds were drawn from three Australian states. A semi-structured interview schedule was developed and piloted to explore perceptions about musculoskeletal MoCs including: i) aspects important to their work (or life, for consumers) ii) usefulness of standardised evaluation frameworks to judge 'readiness' and 'success' and iii) challenges associated with standardised evaluation. Verbatim transcripts were analysed by two researchers using a grounded theory approach to derive key themes. Results: Twenty-seven SMEs (n = 19; 70.4 % female) including five (18.5 %) consumers participated in the study. MoCs were perceived as critical for influencing and initiating changes to best-practice healthcare planning and delivery and providing practical guidance on how to implement and evaluate services. A 'readiness' evaluation framework assessing whether critical components across the health system had been considered prior to implementation was strongly supported, while 'success' was perceived as an already familiar evaluation concept. Perceived challenges associated with standardised evaluation included identifying, defining and measuring key 'readiness' and 'success' indicators; impacts of systems and context changes; cost; meaningful stakeholder consultation and developing a widely applicable framework. Conclusions: A standardised evaluation framework that includes a strong focus on 'readiness' is important to ensure successful and sustainable implementation of musculoskeletal MoCs

Entre incertitudes et reconnaissances : se construire avec le syndrome de Gilles de la Tourette

L'objectif de ce travail est de comprendre comment des personnes atteintes du syndrome de Gilles de la Tourette (SGT) peuvent vivre avec un tel syndrome et construire leur identité. Le SGT est défini comme un trouble neurologique relativement rare caractérisé par des tics moteurs et vocaux souvent associés à d'autres symptômes (tels les troubles de l'attention), variables d'un individu à l'autre et au cours du développement d'un individu. L'origine du syndrome est incertaine et il n'y a pas de traitement curatif. Afin d'appréhender les problèmes rencontrés par les personnes atteintes ainsi que leurs ressources, nous nous intéressons à leurs représentations du SGT et à leur parcours de vie, de même qu'au soutien social fourni par les associations de malades. Pour cela, nous avons effectué un travail ethnographique dans une association et mené des entretiens auprès de personnes atteintes. Nos données ont ensuite été analysées à la lumière de la littérature médicale sur le SGT et de la psychologie de la santé, que nous avons complétées par une perspective psychosociale et discursive. Nos résultats montrent que les incertitudes médico-scientifiques entourant le SGT n'empêchent pas les personnes atteintes de lui donner un sens et participent même à la construction de leurs représentations. Ces représentations varient chez une même personne et visent une double reconnaissance : celle de la personne et celle de la maladie. Cette double reconnaissance est recherchée par les personnes atteintes à cause du regard stigmatisant d'autrui qui les pousse à développer des stratégies pour contrôler leur syndrome. A un niveau collectif, elles adhèrent à une association de malades. Si l'association paraît leur apporter une aide effective, nos résultats montrent qu'elle participe aussi à la construction d'une identité tant sociale qu'individuelle, en permettant la comparaison à un autre semblable. -- The aim of this work is to understand how people suffering from Tourette's syndrome (TS) can live with it and construct their identity. TS is defined as a relatively rare neurological disorder characterised by motor and vocal tics, frequently associated with other disorders (such as attention déficit) that vary from one individual to another and during the development of an individual. The origin of the syndrome is uncertain and there is no curative treatment. In order to comprehend the problems faced by people suffering from TS and their resources, we are interested in their TS' représentations and their life history, as well as the social support provided by ill persons' associations. To this end, we carried out an ethnographical work in an association and conducted interviews with people suffering from TS. Our data were then analysed in the light of médical literature on TS and health psychology, which we completed by a psychosocial and discursive point of view. Our results show that médical and scientific uncertainties surrounding TS do not stop people suffering from it to give it a sense and even contribute to construct their représentations. These représentations vary in a same individual and they aim at a double récognition: that of the person and that of the illness. People suffering from TS look for this double récognition because of the stigmatizing eyes of others, which urge people to develop stratégies to control their syndrome. At a collective level, people join associations of ill persons. If the association seems to give an effective help, our results show that it also contributes to the construction of a social as well as individual identity, by allowing the comparison with a similar other

Dealing with clients' diversity in test situations: Client categorisations in psychologists' accounts of their practices

Reducing a test administration to standardised procedures reflects the test designers' standpoint. However, from the practitioners' standpoint, each client is unique. How do psychologists deal with both standardised test administration and clients' diversity? To answer this question, we interviewed 17 psychologists working in three public services for children and adolescents about their assessment practices. We analysed the numerous "client categorisations" they produced in their accounts. We found that they had shared perceptions about their clients' diversity, and reported various non-standard practices that complemented standardised test administration, but also differed from them or were even forbidden. They seem to experience a dilemma between: (a) prescribed and situated practices; (b) scientific and situated reliability; (c) commutative and distributive justice. For practitioners, dealing with clients' diversity this is a practical problem, halfway between a problem-solving task and a moral dilemma

Acceptance of inflammatory bowel disease treatment recommendations based on appropriateness ratings : do practicing gastroenterologists agree with experts?

BACKGROUND: Appropriateness criteria for the treatment of Crohn's disease (CD) and ulcerative colitis (UC) have been developed by experts' panels. Little is known about the acceptance of such recommendations by care providers. The aim was to explore how treatment decisions of practicing gastroenterologists differ from experts using a vignette case study and a focus group. METHODS: Seventeen clinical vignettes were drawn from clinical indications evaluated by the expert panel. A vignette case questionnaire asking for treatment options in 9-10 clinical situations was submitted to 26 practicing gastroenterologists. For each vignette case, practitioners' answers on treatments deemed appropriate were compared to panel decisions. Qualitative analysis was made based on focus group discussion to explore acceptance and divergence reasons. RESULTS: 239 clinical vignettes were completed, 98 for CD and 141 for UC. Divergence between proposed treatments and results from panels was more frequent for CD (34%) than for UC (27%). Among UC clinical vignettes, the main divergences with the panel were linked to 5-ASA failure assessment and to situations where stopping treatment was the main decision. For CD, the care provider propositions diverged with the panel in mild-to-moderate active disease, where practitioners were more prone to an accelerated step up than the panel's recommendations. CONCLUSIONS: In about one third of vignettes cases, IBD treatment propositions made by practicing gastroenterologists diverged as compared to expert recommendations. Practicing gastroenterologists may experience difficulties in applying recommendations in daily practice

Chronic disease management: a qualitative study investigating the barriers, facilitators and incentives perceived by Swiss healthcare stakeholders.

BACKGROUND: Chronic disease management has been implemented for some time in several countries to tackle the increasing burden of chronic diseases. While Switzerland faces the same challenge, such initiatives have only emerged recently in this country. The aim of this study is to assess their feasibility, in terms of barriers, facilitators and incentives to participation. METHODS: To meet our aim, we used qualitative methods involving the collection of opinions of various healthcare stakeholders, by means of 5 focus groups and 33 individual interviews. All the data were recorded and transcribed verbatim. Thematic analysis was then performed and five levels were determined to categorize the data: political, financial, organisational/ structural, professionals and patients. RESULTS: Our results show that, at each level, stakeholders share common opinions towards the feasibility of chronic disease management in Switzerland. They mainly mention barriers linked to the federalist political organization as well as to financing such programs. They also envision difficulties to motivate both patients and healthcare professionals to participate. Nevertheless, their favourable attitudes towards chronic disease management as well as the fact that they are convinced that Switzerland possesses all the resources (financial, structural and human) to develop such programs constitute important facilitators. The implementation of quality and financial incentives could also foster the participation of the actors. CONCLUSIONS: Even if healthcare stakeholders do not have the same role and interest regarding chronic diseases, they express similar opinions on the development of chronic disease management in Switzerland. Their overall positive attitude shows that it could be further implemented if political, financial and organisational barriers are overcome and if incentives are found to face the scepticism and non-motivation of some stakeholders