Commonalities and differences in the implementation of models of care for arthritis: key informant interviews from Canada

Organisation of care for people receiving drug-resistant tuberculosis treatment in South Africa: a mixed methods study

OBJECTIVES

Treatment for multidrug-resistant/rifampicin-resistant tuberculosis (MDR/RR-TB) is increasingly transitioning from hospital-centred to community-based care. A national policy for decentralised programmatic MDR/RR-TB care was adopted in South Africa in 2011. We explored variations in the implementation of care models in response to this change in policy, and the implications of these variations for people affected by MDR/RR-TB.

DESIGN

A mixed methods study was done of patient movements between healthcare facilities, reconstructed from laboratory records. Facility visits and staff interviews were used to determine reasons for movements.

PARTICIPANTS AND SETTING

People identified with MDR/RR-TB from 13 high-burden districts within South Africa.

OUTCOME MEASURES

Geospatial movement patterns were used to identify organisational models. Reasons for patient movement and implications of different organisational models for people affected by MDR/RR-TB and the health system were determined.

RESULTS

Among 191 participants, six dominant geospatial movement patterns were identified, which varied in average hospital stay (0-281 days), average patient distance travelled (12-198 km) and number of health facilities involved in care (1-5 facilities). More centralised models were associated with longer delays to treatment initiation and lengthy hospitalisation. Decentralised models facilitated family-centred care and were associated with reduced time to treatment and hospitalisation duration. Responsiveness to the needs of people affected by MDR/RR-TB and health system constraints was achieved through implementation of flexible models, or the implementation of multiple models in a district.

CONCLUSIONS

Understanding how models for organising care have evolved may assist policy implementers to tailor implementation to promote particular patterns of care organisation or encourage flexibility, based on patient needs and local health system resources. Our approach can contribute towards the development of a health systems typology for understanding how policy-driven models of service delivery are implemented in the context of variable resources.

A Parsimonious Taxonomy of The Newly Retired: Spousal and Disability Combinations Shape Part or Complete Retirement

The inadequate classification of retiree sub-groups ultimately results in misaligned policy. To generate sets of sub-groups that may be appropriately targeted for policy and interventions, variables are used that reflect the social structure of retirees, particularly the options of partial and complete retirement, marital status, gender, as well as the retirement status of the spouse, where relevant, and disability. Three sets of longitudinal Australian data were combined, each reflecting a four-year period (2003-2007, 2007-2011, 2011-2015) during which the individuals aged 45 to 69 retired (n = 1179). A multiway frequency analysis was performed to develop an inductive, combinatorial model of retirement from work. The resulting parsimonious taxonomy of sub-groups of the newly retired reflected main effects and interactions of key social-structural variables. Notably, a key driver of the pattern of results was that couples tend to coordinate their retirement behavior in both the decision to retire and form of retirement. Non-partnered retirees were more likely to be women. Disability was also a driver of retirement for non-partnered retirees, regardless of gender. Identifying sub-groups based on combinations of retiree characteristics can better inform policy design, appropriate health promotion interventions and potential specific triggers for enacting those policies. Overall, marital status, spousal retirement behavior and disability may each present a more useful basis for a taxonomy of retirement than more individually oriented age- and wealth-based systems.

Appropriating and asserting power on inflammatory arthritis teams: A social network perspective

Background

Therapeutic interventions for people with inflammatory arthritis (IA) increasingly involve multidisciplinary teams and strive to foster patient‐centred care and shared decision making. Participation in health‐care decisions requires patients to assert themselves and negotiate power in encounters with clinicians; however, clinical contexts often afford less authority for patients than clinicians. This disadvantage may inhibit patients' involvement in their own health care.

Objective

To identify communication attributes, IA patients use to influence and negotiate their treatment with members of their health‐care network.

Method

A qualitative social network approach was used to analyse data from a larger study that investigated IA patients' overall experiences of multidisciplinary care. Fourteen patients with IA attended individual semi‐structured interviews. Researchers used thematic analysis to identify patterns of assertiveness and influence in the data.

Results

Participants experienced loss of identity, control and agency in addition to the physical symptoms of IA. However, they had a sense of personal responsibility for managing their health care. Perceptions of health‐care team support enhanced patients' influence in treatment negotiations. Notably, there appeared to be an underlying tension between being empowered or disempowered.

Discussion and conclusions

The findings have significant implications for treatment decision communication approaches to IA care. A social network perspective may provide a pathway for clinicians to better understand the complexities of communication with their patients. This approach may reduce unequal power dynamics that occur within clinician/patient interactions and afford people with IA agency, control and affirmation of identity within their health‐care network.

Total joint arthroplasty: practice variation of physiotherapy across the continuum of care in Alberta

Background

Comprehensive and timely rehabilitation for total joint arthroplasty (TJA) is needed to maximize recovery from this elective surgical procedure for hip and knee arthritis. Administrative data do not capture the variation of treatment for rehabilitation across the continuum of care for TJA, so we conducted a survey for physiotherapists to report practice for TJA across the continuum of care. The primary objective was to describe the reported practice of physiotherapy for TJA across the continuum of care within the context of a provincial TJA clinical pathway and highlight possible gaps in care.

Method

A cross-sectional on-line survey was accessible to licensed physiotherapists in Alberta, Canada for 11 weeks. Physiotherapists who treated at least five patients with TJA annually were asked to complete the survey. The survey consisted of 58 questions grouped into pre-operative, acute care and post-acute rehabilitation. Variation of practice was described in terms of number, duration and type of visits along with goals of care and program delivery methods.

Results

Of the 80 respondents, 26 (33 %) stated they worked in small centres or rural settings in Alberta with the remaining respondents working in two large urban sites. The primary treatment goal differed for each phase across the continuum of care in that pre-operative phase was directed at improving muscle strength, functional activities were commonly reported for acute care, and post-acute phase was directed at improving joint range-of-motion. Proportionally, more physiotherapists from rural areas treated patients in out-patient hospital departments (59 %), whereas a higher proportion in urban physiotherapists saw patients in private clinics (48 %). Across the continuum of care, treatment was primarily delivered on an individual basis rather than in a group format.

Conclusions

Variation of practice reported with pre-and post-operative care in the community will stimulate dialogue within the profession as to what is the minimal standard of care to provide patients undergoing TJA.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1873-9) contains supplementary material, which is available to authorized users.