Exploring the macro-level, meso-level and micro-level barriers and facilitators to the provision of good quality early inflammatory arthritis (EIA) care in England and Wales

Abstract

BackgroundEvidence from a national clinical audit of early inflammatory arthritis (EIA) shows considerable variability between hospitals in performance, unexplained by controlling for case-mix.ObjectiveTo explore the macro-level, meso-level and micro-level barriers and facilitators to the provision of good quality EIA care.MethodsA qualitative study within 16 purposively sampled rheumatology units across England and Wales. Quality was assessed in relation to 11 quality indicators based on clinical opinion, evidence and variability observed in the data. Data from semi-structured interviews with staff (1–5 from each unit, 56 in total) and an online questionnaire (n=14/16 units) were integrated and analysed using the framework method for thematic analysis using a combined inductive and deductive approach (underpinned by an evidence-based framework of healthcare team effectiveness), and constant comparison of data within and between units and its relationship with the quality criteria.FindingsQuality of care was influenced by an interplay between macro, meso and micro domains. The macro (eg, shared care arrangements and relationships with general practitioners) and meso (eg, managerial support and physical infrastructure) factors were found to act as crucial enablers of and barriers to higher quality service provision at the micro (team) level. These organisational factors directly influenced team structure and function, and thereby EIA care quality.ConclusionsVariability in quality of EIA care is associated with an interplay between macro, meso and micro service features. Tackling macro and meso barriers is likely to have a significant impact on quality of EIA service, and ultimately patient experience and outcomes.

Changes of working conditions and job-related challenges due to the SARS-CoV-2 pandemic for medical assistants in general practices in Germany: a qualitative study

“…This grouping corresponds to a framework of macro (superordinate level), meso (practice level) and micro (individual level) level factors affecting MA's working conditions and challenges during the pandemic. Such a framework has been largely applied in other qualitative studies [27][28][29][30] and can be seen as an adaption of the determinants of health model by Dahlgren and Whitehead [31,32].…”

Disseminating and assessing implementation of the EULAR recommendations for patient education in inflammatory arthritis: a mixed-methods study with patients’ perspectives

“…Thus far, this study has given us a greater understanding of acceptability and applicability of recommendations to relevant patient stakeholders at an individual (micro) level. However, in order to enable effective implementation, contextual factors also need to be considered at the service or organisational (meso) level 6. For example, the organisational context of PE is different across countries, and this will be important to understand in order to establish and sustain PE services and enable routine evaluation as per Recommendation 6.…”

“…Third, our findings represent barriers and facilitators at the individual patient (micro) level. While this is important, studying the contexts at the organisational (meso) and policy (macro) levels is necessary to enable successful implementation of the recommendations in different countries 6. This could also focus on those countries that were less represented in this study.…”

“…Dissemination is the initial stage in knowledge transfer. However, bringing about changes in practice requires an understanding of acceptability and applicability of recommendations to relevant stakeholders such as patients and healthcare professionals (micro-level), then analysis of the contextual factors including organisational context (meso and macro levels), as these are key to enabling implementation 1 5 6…”

The Meso-Level in Quality Improvement: Perspectives From a Maternal-Neonatal Health Partnership in South Africa

“… 15 However, this intervention research mostly approaches the meso-level as a support to the micro-level, rather than being its central focus, or alternatively, as the proximal organisational and system context explaining variations in micro-level performance. 16 - 18 …”