This document provides supplementary material regarding the grounded theory methodology used in Optimal Care for Rheumatoid Arthritis(RA): A Focus Group Study, Bernatsky et al.

The themes identified in our study were derived from the focus group discussions. The focus group questions were presented as follows: The first three questions for individuals with RA, related to: 1: What their experience has been seeking care to control arthritis 2: Experience related to contact with specialists 3: Factors that impede/ facilitate their journey toward health The first three questions for health care professionals related to: 1: How non-specialists respond to an individual with RA (or suspected RA) 2: Priority health care that the individual should receive 3: What facilitates/impedes them from providing optimal care The first three questions for health care decision makers related to 1. What facilitates optimal care in chronic diseases like RA 2. Where/ how optimal care for chronic diseases like RA may be impeded 3. Knowledge of what individuals experience in seeking care The last two questions were similar for all participants: 4: In the 1st phase of our research, we noted differences in care trajectories according to demographics & proximity to care. What might explain this? 5: What changes would improve RA care? As explained by Kennedy & Lingard (Medical Education, 2006; 40; 101-108) and Corbin & Strauss (Qualitative Sociology, 13; 3-21), grounded theory can be used when the research question targets experiences, and where the aim is to not to test or verify existing theories, but rather explain a process and/or put forth a new understanding. In our study, we did not have any a priori hypotheses, but rather we aimed to uncover explanations about the experience of seeking care in RA from a number of different perspectives. In addition, we used an iterative approach where preliminary analyses, performed early in the study process, informed what focus groups questions required clarification. This also indicated which aspects of emerging ideas required further exploration in later groups. For instance, in a first group of family physicians, the notion of relationships with rheumatologists was further explored in the next and third groups of family physicians by asking specifically about these relationships and why they were important to facilitate the patient's journey. We later learned about the importance of ‘economizing’ on referrals, wherein doctors felt that they had to employ judgment when making a call to a rheumatologist, for the sake of future requests. As another example of how initial results informed our approach, focus groups with all professional groups showed a pattern pointing to the importance of nurses. Hence, we recruited nurse to form a final focus group, and we asked them principally to describe their role in addition to addressing the targeted the focus group questions. The data analysis proceeded group by group, with constant comparisons of issues, actions, events, experiences, and examples, in terms of similarities and differences as expressed by participants. These were grouped together into categories and subcategories. The constant comparison of these categories and subcategories allowed further reorganization; in some cases categories and subcategories were renamed and reclassified as we continued to refine our understanding of the thematic ideas emerging. Our analysis did not stress correlation between raters and ‘frequency’ counts of ideas, given that the spirit of grounded theory focuses on inquiry and constant comparisons. This is what gave shape to the unfolding story about the journey of persons with RA toward optimal care.

Supplementary material regarding methodology for Optimal Care for Rheumatoid Arthritis(RA): A 1 Focus Group Study, Bernatsky et al.