Suchergebnisse

The aim of this in-depth, longitudinal, qualitative case study was to understand and explain the dynamics of implementing a pilot project to deliver integrated healthcare for type 2 diabetic patients. Data gathering included in-depth, face-to-face interviews with family physicians, nurses and other healthcare providers, managers and policy makers (n = 25) at various points during the research period, and focus groups (n = 3) with patients. These data were complemented by onsite observations of numerous committee meetings, and analysis of project documentation. Benson's (1975) political economy perspective provided a valuable conceptual framework for tracking the complex dynamics of implementing service integration. Manipulative strategies (continuing medical education, new information technology) did not engage physicians. Of the cooperative strategies attempted (disease management, patient education, community mobilization), only patient education appears to have succeeded: patients acknowledged that project educational activities enabled them to improve self-management of their disease. However, the project's emphasis on patient education effectively increased nurses' bargaining power within the healthcare team, to the detriment of the focus on integrated care. Integrating care is a laborious process that takes time to reach fruition. This one-year pilot project was insufficient for mobilizing health professionals away from fragmented practices toward integrated ones. New resources mostly allowed them to maintain or increase their power positions within the network of care providers. Nevertheless, this initiative raised physicians' awareness and appreciation of the care that other health professionals provided to their patients.

This paper reports on a research collective on primary healthcare (PHC) conducted in Quebec in 2004. Thirty ongoing or recently completed studies were synthesized through a process involving a high degree of exchange among researchers who conducted the original studies, investigators and decision-makers. The viewpoints expressed by decision-makers who participated in the process were analyzed in terms of convergence with and divergence from the researchers' viewpoints. In four cases, there was convergence between the decision-makers' and the researchers' viewpoints, thus increasing the validity of the collective's findings. The main divergence between the two groups' viewpoints concerns the strategy adopted in Quebec to create local health and social services networks. Such divergence reflects the distinction made by Klein between scientific evidence and organizational and political evidence.

This article presents and discusses five challenges encountered in conducting a knowledge synthesis on primary healthcare, commissioned by the Canadian Health Services Research Foundation. These challenges are (1) conceptualizing, defining and operationalizing complex interventions; (2) integrating quantitative and qualitative studies and assessing strength of evidence; (3) incorporating expert opinions and decision-makers' viewpoints; (4) producing timely results; and (5) presenting the results in a concise yet understandable form. We also propose methods and operational tools to deal with these issues, particularly regarding integration of qualitative and quantitative evidence and incorporation of expert opinions into syntheses. The major challenge of the synthesis was to provide pertinent and useful information for decision- and policy-makers, while maintaining an acceptable level of scientific rigour. This approach seems promising for knowledge syntheses, which sustain a deliberative process that leads to more enlightened decision and policy-making.