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Table 2 Facilitators and barriers of intermediate care with example quotes

From: Evaluation of intermediate care for knee and hip osteoarthritis: a mixed-methods study

Main themes

Subthemes

Example quotes

Facilitators

 Facilitators for healthcare providers

Relationship between healthcare providers:

1) better multidisciplinary communication

2) more mutual respect

Quote 1: “And the specialist is more aware of the problems the GP actually has. In other words, you end up respecting one another more. That’s also an objective I actually find quite important: that you have respect for one another and the patient can see that. If the specialist says, ‘Go back to your GP; what he says is right’, or if I say, ‘This specialist is really good with this particular problem’. And you say that about one another, which gives the patient more confidence too.” (interview 10, GP)

Learning effect of healthcare providers:

1) more competent in specific skills

2) more confident about their clinical diagnosis

3) more knowledge about patients’ referral

Quote 2: “You educate one another a bit. I learn from the GP and [the GP] learns from us.”(Interview 5, orthopaedist)

Quote 3: “But when you have someone sitting next to you who does an awful lot, you start doing it more often too. You see that happening with the knees. Giving an injection in the knee isn’t so difficult, but if you aren’t doing that and you don’t have someone sitting next to you who does it at some point, then you don’t start doing it yourself.” (interview 6, GP)

 Facilitators for patients

Better access to healthcare

Quote 4: “Right, I reckon that patients – certainly older patients – can get there on their own. They don’t need to find someone who can take them to the hospital. Certainly for older patients: they don’t need to find someone who can take them to the hospital.” (Interview 2, orthopaedist)

Healthcare in familiar environment on a small scale

Quote 5: “It’s a more pleasant environment because it’s familiar.” (Interview 9, patient)

More specialized care

Quote 6: “That sense of involvement with the orthopaedist. Of course you’re more in his field of expertise. The GP is a bit more of a generalist, after all.” (Interview 4, patient)

Longer consultations

Quote 7: “That’s precisely what I like about it: the fact that you have more time. And that’s exactly what all the patients say. The fact that there’s plenty of time for the explanation is something that everyone really likes. […] Right, well, you have… I think your contact with the patient is rather more intensive. Of course, that’s because you have more time.” (Interview 2, orthopaedist)

 Facilitators for society as a whole

Lower healthcare costs due to less healthcare consumption

Quote 8: “I also think […] that the extra time […] that I have for a patient in the GP practice means that I don’t see the same people coming back so soon. Because I can really explain things properly to them in one go.” (Interview 2, orthopaedist)

Quote 9: “We educate one another in that regard too, so if there are pointless examinations, we say ‘Don’t do that’. […] It’s also very much a learning process, and we’re going to end up with fewer diagnostic tests.” (Interview 5, orthopaedist)

Lower healthcare costs due to better selection of patients for secondary care

Quote 10: “Yes, we’ve been able to keep more than 80 per cent [of the patients] in primary care. Assuming you start with 100 per cent, then an expensive hospital treatment product would have been initialized for all of them and we’ve now managed to prevent that for four fifths.” (Interview 11, healthcare manager)

Barriers

 Less access to additional diagnostic facilities for orthopaedists

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Quote 11: “A minus point for orthopaedics in an intermediate care project is that you often don’t have access to additional examinations. So you don’t have any X-rays and if someone comes in and you’re thinking it could be osteoarthritis, you’ll still need… to see that, you’ll still need to have an X-ray

Interviewer: “And what impact does that have for you in your work – the fact that you can’t easily get the additional diagnostics?”

“Well, it means you still, um, you still end up with people coming back one more time. And so you hesitate just that little bit, as it were, before making the definite diagnosis.” (Interview 2, orthopaedist)

 Workload for orthopaedists

Workload in secondary care

Quote 12:That [not being the case] has to do with the big wave [of osteoarthritis patients] we are now facing. You can simply see it coming now. So we’re getting just as many people now, but we’re seeing more severe cases. The more minor cases are fortunately staying with the GPs for longer.”(Interview 5, orthopaedist)

Quote 13: “They are seeing an increase in complex care needs. The contamination [hospital overuse] that you basically get rid of, because that’s the intermediate care, you are taking that away. And the better care ends up in the right place, so it’s really a reciprocal process.” (Interview 10, healthcare manager)

Quote 14: “I think that as doctors and specialists, we need to look at whether we shouldn’t perhaps be allocating more time for that patient visiting the outpatient clinic. Because if that’s a more severe case, they’ll need more explanation.”(Interview 3, orthopaedist)

Additional workload in general due to intermediate care

Quote 15: “It [working in intermediate care in addition to working in a hospital] is busy so that means you have to organize it well. I always do that on my free afternoon. […] There is more pressure on you, quite apart from organizing the whole intermediate care consultations and it takes an awful lot of time. (Interview 5, orthopaedist)