Table 3 Joint display of quantitative and qualitative results

D8 goals

No usage of care packages

The standardised care package for lumbar spinal stenosis is less integrated into the workflow in the clinic. There are fewer patients, and there are often other care providers involved

2

My primary patient group is children and chronic pain patients, and in those two categories, I rarely find anyone who can be included in the standardised care packages

6

I see a lot of babies at the clinic, and therefore I probably have a low number of standardised care packages statistically, but it is not because I cannot or will not use the care packages

35

A clash with the organization of clinical practice

However, the many established time-fixed dates take focus away from the treatment of patients and are more time-consuming in general

52

No two patients are alike—there is a need for individual adaptations in the care pathway

19

The chiropractor’s role

Could be nice with a better definition of the chiropractor’s role concerning the spinal stenosis care package. What is expected of a treatment course, what are the treatment options, etc.?

3

The care package for spinal stenosis is still a mystery! Yes, to the exercise program, information/advice, and treatment—but it is a chronic condition that will not be cured after three months—unless one makes sense and sends them for surgical evaluation

14

D9 innovation

A clash with the organization of clinical practice

I choose to inform [the GP] when relevant e.g. if there is a need for painkillers, sick leave, referral for physiotherapy, or if I have referred the patient for MRI

10

And holidays, days off, and patients’ who don’t turn up make it practically silly with the time-fixed follow-ups. […] Overall, our standardised care packages are very impractical and have little to do with sound reality. In my opinion, a neurological examination should always take place in case of worsening—whether it is 2, 4, or 8 weeks after starting. […] Maybe time-fixed neurological examinations can result in doing examinations ‘heedlessly’?

14

No more care packages should be designed for other types of patients. It will end in a chaos of codes, deadlines, etc. It’s annoying to have to keep an eye on whether it’s time for this or that all the time

20

I find it a little difficult to remember 2, 4, and 8 weeks of follow-up—as at each and every treatment, I ask the patients about symptoms and perform tests when I feel there is a need. I also work on remembering to register the different service codes at the 2, 4, and 8 weeks of follow-up, but often forget it

28

Can be a good mechanism for not forgetting to re-evaluate continuously for some people but in terms of my way of practising it is odd, as testing, re-testing, and ongoing re-evaluation, etc. are part of my daily routine

49

D10 socio-political context

A clash with the organization of clinical practice

GPs often encourage the patient to withdraw from the standardised care package and see a physiotherapist instead

23

Letters [to GPs] have not yet resulted in a single answer or response from any GP

14

The chiropractor’s role

My challenge in using standardised care packages is to make them visible to patients. I live in [xxx] part of the country, and in this area, the GPs do not think we [chiropractors] should have the competencies and coordinate care packages concerning patients with disc herniations. Therefore, it is difficult to enrol patients unless they see me before their GP. It’s an uphill task

15

I would appreciate it if the monitor part was with the GPs and the manual part with us [chiropractors]. The reality is that when I enrol a patient in a standardised care package, I have all the responsibilities. I do not want that—to be completely honest. I want to be the biomechanical coordinator, and as previously, let the GP take care of the social challenges and medical pain treatment

46

[…] it can be difficult to explain to the patient the indication for a further charge at certain time-fixed consultations as my routine has not changed significantly

49