A conceptual framework to develop a patient-reported experience questionnaire on the cystic fibrosis journey in France: the ExPaParM collaborative study.

BACKGROUND: The objective of the study was to elaborate a conceptual framework related to the domains of patient experience along the cystic fibrosis (CF) journey from the patients and parents of children with CF to inform the design of a patient-reported experience questionnaire. METHOD: A collaborative research group including patients and parents with clinicians and academic researchers was set up. They identified the situations along the CF care pathway from diagnosis to paediatric care, transition to adult care and adult follow-up, transfer to transplant centres and follow-up after transplantation. Participants were recruited by CF centres in metropolitan France and overseas departments. Semi-structured interviews were conducted, transcribed verbatim and subjected to an inductive analysis conducted in duos of researchers/co-researchers using NVivo®. The conceptual framework was discussed with the research group and presented to the CF centres during two video conferences. The protocol obtained a favourable opinion from the Ethics Evaluation Committee of INSERM (IRB00003888-no. 20-700). RESULTS: The analysis led to a conceptual framework composed of domains of the CF journey, each divided into several items. 1. CF care: Management of care by the CF centre team; in-hospital care; quality of care in the community; therapeutic education and self-management support; at-home care; new therapies and research; procreation; 2. Transplant care: management of transplant and CF care; coordination with other specialties; education and self-management support; at-home care; procreation; new therapies and research; 3. Turning points along the journey: diagnosis of CF, transition to adult care, transfer to transplantation; 4. Social life with CF: housing, employment and education, social relations, social welfare and family finances. The number of patients included and the diversity of situations made it possible to achieve a sufficient richness and saturation of codes by domain to develop patient experience questionnaires. CONCLUSION: This conceptual framework, resulting from the participants' experience, will inform the design of a patient-reported experience tool, whose construct will be tested during the next phase of the ExPaParM project to assess its fidelity, intelligibility, and ability to report patient experience of the CF journey.

Collaborative research protocol to define patient-reported experience measures of the cystic fibrosis care pathway in France: the ExPaParM study.

INTRODUCTION: In France, the cystic fibrosis (CF) care pathway is coordinated by multidisciplinary teams from specialised CF centres or transplant centres. It includes the care provided at home or out of hospital, risk prevention in daily life and adjustments to social life, which together contribute to the person's quality of life. Patient experience is used to describe and evaluate the care and life of patients living with the disease. OBJECTIVES: Our collaborative research aims to identify the most significant areas and criteria that characterise the CF pathway. It will lead to the development of a questionnaire to collect patients' experience, which can be administered to all patients or parents of children registered and followed in the centres. The article describes the protocol developed in partnership with patients and parents of children living with the disease. METHOD: A multidisciplinary research group brings together researchers, patients, parents of children with CF and health care professionals. The patient partnership is involved in the 4 phases of the protocol: (1) setting up the study, recruiting patient and parent co-researchers, training them in qualitative research methods, defining the situations and profiles of patients in the study population, elaborating the protocol; (2) selecting the study sites, recruiting participants, carrying out semi-structured interviews, analysing verbatims using the grounded theory approach; (3) co-elaborating Patient-Reported Experience Measures (PREM) questionnaires adapted to the 4 types of participants: parents, adolescents, non-transplanted adults and transplanted adults; (4) validating the construct with participants and professionals from the study centres. RESULTS: The protocol obtained a favourable opinion from the Ethics Evaluation Committee of INSERM (IRB00003888-no. 20-700). Training was provided to the 5 patients and 2 parent co-researchers to enable them to participate effectively in the research. Eleven centres participated in the recruitment of participants in mainland France and Reunion Island. Eighty hours of interviews were conducted. DISCUSSION: The PREM questionnaires to be elaborated will have to undergo psychometric validation before being used by the actors of the CF network to assess the impact on the care pathways of quality approaches or new therapies available in cystic fibrosis. Trial Registration Registry: IRB00003888 - no. 20-700. Issue date: 06/09/2020.

[Social inequalities in oral health and early childhood caries: How can they be effectively prevented? A scoping review of disease predictors]. / Inégalités sociales de santé orale et caries précoces de l'enfant : comment prévenir efficacement ? Une revue de portée des prédicteurs de la maladie.

BACKGROUND: Early childhood caries represent a major public health problem. In addition to their individual impact, the massive social inequalities in oral health that are at the roots and result from the disease have largely underestimated consequences for the child, his family and the community. In response to the question of "how and where to act?", this scoping review identifies the individual characteristics associated with the disease on which it would be possible to act, using appropriate prevention strategies. METHODS: This scoping review is aimed at describing and analyzing available data in the literature on the different factors associated with early childhood caries. RESULTS: The predictors of early childhood caries are represented by mediating (knowledge, attitudes and parents' oral health practices) and moderating (psychosocial parameters, parental health literacy and alcohol consumption) factors. Twenty-eight articles fulfilled the selection criteria, twenty of which studied mediators related to early childhood caries, and fourteen of which dealt with moderators. The lower the parents' level of knowledge and literacy in oral health, the higher a child's dmft index. Additional studies are needed to assess the role of psychosocial parameters. CONCLUSION: Parents' knowledge and oral health literacy are the key predictors to be preferentially targeted in view of reducing social inequalities in health through actions undertaken on a local scale. The prevention of early childhood caries necessitates a combination of generic and targeted interventions.

What do we mean by multimorbidity? An analysis of the literature on multimorbidity measures, associated factors, and impact on health services organization.

BACKGROUND: Multimorbidity is a consequence of both epidemiological and demographic transition. Unlike comorbidity, it currently has no consensus definition, making it difficult to assess its epidemiological and socioeconomic burden, to organize healthcare services rationally, and to determine the skills needed for patient self-reliance. The aim of this study is to define the spectrum of multimorbidity and to discuss current implications for the organization of care. METHODS: Two independent readers analyzed the literature indexed in PubMed, Embase, CINAHL, and Scopus. RESULTS: The bibliographic search conducted on July 16, 2013, retrieved 2287 articles (670 in PubMed, 666 in Embase, 582 in Scopus, and 369 in CINAHL). Of these, 108 articles were retained. Multimorbidity is designated by a variety of terms, none of them being MeSH terms. There is no single measure of multimorbidity, as this entity is usually studied for its functional or economic impact, rather than its causes. The prevalence varies considerably, depending on the measure used and the population studied. Factors associated with multimorbidity are age, gender, and socioeconomic characteristics of the populations studied. Studies evaluating the organization-of-care are inconclusive or insufficient. CONCLUSIONS: Multimorbidity serves as an avatar for the fundamental, recurrent problems of modern medicine and the organization-of-care. It may be defined by its causes or its consequences and reflects our concept of both individual health and its collective management. Tools that would allow a more appropriate measurement of this entity are available; we should use them to match medical reality to the needs of patients.

[Avoidable hospitalizations: the sole responsibility of primary care?]. / Hospitalisations potentiellement évitables: une responsabilité des seuls soins de premier recours?

BACKGROUND: Avoidable hospitalizations are used as a performance indicator of primary care in many countries. We investigate here the validity and usefulness of this measure both at a global scale and for the French healthcare system. METHODS: A scoping study was performed to take a critical look at this concept. The different uses of avoidable hospitalizations as an indicator have already been reported in two recent systematic literature reviews. RESULTS: Rates of avoidable hospitalizations seem to be far more correlated with the socioeconomic attributes of patients than with primary care supply. The few studies conducted in France confirm this international trend. Several weaknesses have been spotted in the building of this indicator: the choice of conditions that can be considered as sources of avoidable hospitalizations, their identification among hospitalization disease codes, the quality of hospital coding procedures, the ecological bias in the data collection of illustrative variables. CONCLUSION: Guidelines for improvement of this indicator are provided. In particular, we discuss the possibility of its use at the scale of the whole healthcare system.

Stress perception among employees in a French University Hospital.

BACKGROUND: Nantes University Hospital comprises 20 activity sectors. AIMS: To investigate the role of the work environment at the individual level, as well as the workplace level, in explaining the variability in employees' perception of stress. METHODS: A self-administered enhanced Karasek Job Content Questionnaire was sent to employees. The main variables were the psychological job demand (PJD) score and the job decision latitude (JDL) score. Univariate and multivariate logistic regression analyses were conducted to estimate crude odds ratio (OR) and adjusted OR. RESULTS: One thousand eight hundred and sixty-eight workers were included. Nursing managers (25.9 ± 3.4), non-specialized nurses (25.6 ± 3.5) and physicians (25.3 ± 3.4) had the highest PJD. Cleaning staff (61.4 ± 11.4) and nurse aides (63.6 ± 8.8) had the lowest JDL. Items correlated with high PJD are: unacceptable work schedule, adjusted OR 2.16 (95% CI = 1.3-3.5); unsatisfactory workstation accessibility, OR 1.92 (95% CI = 1.1-3.2); getting from A to B, OR 1.67 (95% CI = 1.2-2.4); and heavy manual handling, OR 1.62 (95% CI = 1.1-2.3). Sleeping tablet use was linked to high PJD (P < 0.01), extra workload (P < 0.05) and tiredness (P < 0.05). Use of painkillers was correlated with musculoskeletal disorders (P < 0.05). CONCLUSIONS: Our study highlighted women >40 years old, nurse managers, physicians, permanent and/or full-time workers having a high PJD. Nursing aides, medical secretary and nurses presented with high strain. Better control measures should be implemented for those socioprofessional categories to improve prevention measures. This study should be repeated in the future with a multi-centre approach to determine the generalizability of the findings.

Topical corticosteroid phobia in atopic dermatitis: a study of its nature, origins and frequency.

BACKGROUND: Topical corticosteroids remain the mainstay of atopic dermatitis therapy. Many atopic dermatitis therapeutic failures appear to be attributable to poor adherence to treatment due to topical corticosteroid phobia. OBJECTIVES: To assess the facets, origins and frequency of fear of topical corticosteroid use among patients with atopic dermatitis. METHODS: A questionnaire comprising 69 items, generated from information gathered during interviews with 21 patients and 15 health professionals, was given to consecutive patients consulting at the outpatient dermatology departments of five regional university hospitals or with 53 dermatologists in private practice. RESULTS: A total of 208 questionnaires were analysed (including 144 from parents and 87 from adult patients, 27 of whom were also parents); 80·7% of the respondents reported having fears about topical corticosteroids and 36% admitted nonadherence to treatment. A correlation was found between topical corticosteroid phobia and the need for reassurance, the belief that topical corticosteroids pass through the skin into the bloodstream, a prior adverse event, inconsistent information about the quantity of cream to apply, a desire to self-treat for the shortest time possible or poor treatment adherence. Topical corticosteroid phobia was not correlated with atopic dermatitis severity. CONCLUSION: Topical corticosteroid phobia is a genuine and complex phenomenon, common among French patients with atopic dermatitis, that has an important impact on treatment compliance.

Multiple sclerosis and access to healthcare in the Pays de la Loire region: preliminary study based on 130 self-applied double questionnaires.

OBJECTIVE: To check whether the use of an autoquestionnaire is adapted to obtain information about perceptions of multiple sclerosis (MS) patients concerning access to healthcare in the Pays de la Loire region of France. PATIENTS AND METHODS: Patients with MS were asked to complete a questionnaire concerning access to 31 healthcare professionals or social services. The questionnaires were anonymous and consisted of one page for the patient and one page for a member of his or her entourage. The questionnaires were returned in a prepaid stamped addressed envelope. The first 130 exploitable questionnaires were analysed. RESULTS: Over 50% of patients with MS found access to general practitioners, neurologists, nurses and pharmacists useful, as well as access to less MS-specific specialists, for example, dentists, ophthalmologists or gynaecologists. Physical medicine and rehabilitation practitioners were not required until later in the course of the disease. Patients and their entourage rated the importance of access to care differently for bladder and sexual problems, and for support for cognitive and psychological problems. CONCLUSION: This study validates the use of a questionnaire to obtain information about patient perceptions of access to healthcare. The study also suggests a hierarchy of care needs, insufficient patient information, and disparities in access to care related to where the patients live.

[Epidemiological study on addictive behaviours during pregnancy in a universitary department]. / Étude de prévalence des conduites addictives chez les femmes enceintes dans une maternité universitaire.

OBJECT: Epidemiological study on addictive disorders during pregnancy. METHODS: An epidemiological study about addictive disorders has been led in the maternity of the University Hospital of Nantes in 2008 on a sample of 300 women, just after childbirth. The prevalence of consumption of drugs was assessed on declared consumption of legal and illegal substances and on the Fagerström questionnaire, the AUDIT questionnaire and the CAST questionnaire. Diagnostic of eating disorders was based on DSM IV criteria of mental anorexia and bulimia nervosa. RESULTS: At the beginning of pregnancy, 34% of women used tobacco, 63% alcohol and 8% cannabis. Among the women of the study 0.7% had criteria for mental anorexia, 2.3% for bulimia nervosa and 9% for sub clinic forms. After the first trimester, 22% of women declared using tobacco, 20% alcohol and 3% cannabis. The use of various drugs during pregnancy concerned 6.3% of women, and 38% used at least one drug after the first trimester. CONCLUSION: The high prevalence of addictive disorders during pregnancy should incite professional of prenatal care to improve their screening methodology and not only when tobacco or alcohol is suspected.

Who are the carriers of MRSA in the community? A prospective study in the Pays de la Loire region of France.

The aim of this study was to determine the demographic characteristics of methicillin-resistant Staphylococcus aureus (MRSA) carriers in the community, to assess their risk factors and possible past hospitalization history and to describe the different resistance phenotypes of community isolates of S. aureus. Data were collected over the course of 16 months (from June 2005 to September 2006) in the Pays de la Loire region of France by MedQual, a network of private biological analysis laboratories. This work was based solely on the analysis of strains isolated in the community as opposed to isolates from private facilities such as nursing homes or hospitals. The antimicrobial susceptibility results for a total of 313 MRSA isolates were included in this study. The isolates were most frequently recovered from skin and soft tissue infections (41.2%), urine (38.3%) and genital samples (8.3%). We distinguished 36 patients without classical risk factors (WRF), such as demographic individual medical, healthcare exposure, carried MRSA, from the other 277 patients with at least one risk factor (RF). WRF MRSA patients were younger than RF patients and an infection was more often found among WRF patients. MRSA strains isolated from RF patients were resistant to ofloxacin in 81.1% of cases, whereas only 50% of the MRSA strains isolated from WRF patients were resistant (p <0.001). Nine resistance phenotypes were observed among the 313 MRSA strains. MRSA resistance profiles in the community have evolved in recent years. Therefore, it is necessary to study the resistance phenotypes of the circulating strains in order to adapt therapeutic care in the community.

Susceptibility to the main antibiotics of Escherichia coli and Staphylococcus aureus strains identified in community acquired infections in France (MedQual, 2004-2007).

BACKGROUND: The aim of this study was to determine the susceptibility of bacterial strains identified in community-acquired infections. Surveillance was made by a network of 32 medical analysis laboratories in the five departments of the French Region "Pays de la Loire". METHODS: All Escherichia coli (E. coli) and Staphylococcus aureus (S. aureus) strains isolated in these laboratories over a 4-year period, from January 2004 to December 2007, were included in the investigation. RESULTS: Eighty-four thousand and twenty-nine strains were collected: 90.6% of E. coli and 9.4% of S. aureus. E. coli isolates were mainly isolated from urine (97.2%). S. aureus isolates were more frequently isolated from pus (42.30%), from urinary samples (19.53%), or genital tract samples (14.36%). This study confirms the worrying E. coli evolution of resistance to quinolones. Indeed, during the study period, ofloxacin or norfloxacin susceptibility decreased gradually and the susceptibility rate to ciprofloxacin decreased slightly during and after 2006 (94.01% in 2005; 92.81% in 2006, and 91.62% in 2007). One thousand four hundred and thirty-five methicillin-resistant S. aureus (MRSA) strains were isolated. We observed a decrease of resistance to oxacillin: 20.73% in 2004 and 16.65% in 2006 (p<0.01). In 2007, this resistance to oxacillin seemed to increase (18.26%). CONCLUSIONS: Our data confirms the serious need to monitor transmission of these strains between community and hospitals. A better knowledge of the epidemiological behavior of these BMR will contribute to better-adapted antibiotics strategies.

[Use of antibiotics in emergency units: qualitative and quantitative assessment]. / L'antibiothérapie aux urgences, évaluation par une approche qualitative et quantitative.

INTRODUCTION: Most antibiotic therapies are initiated in the emergency unit (EU). To better understand the antibiotic consumption survey in this unit, we compared our results to two neighbor hospitals. This quantitative data was then compared to a quality assessment of antibiotic prescription (audit). METHODS: The quantitative measure of antibiotic consumption (three markers: ceftriaxone, amoxicillin-clavulanate, and fluoroquinolones) based on the ratio DDD:1000 patient admitted in the EU was compared between one teaching hospital and the two neighbor hospitals. Qualitative measure: a retrospective clinical targeted audit of antibiotic prescriptions was performed. The compliance to guidelines for infection diagnosis and antibiotic treatment were assessed. RESULTS: Antibiotic consumption: the survey showed a higher consumption of the three antibiotics in the teaching hospital, especially for amoxicillin-clavulanate (3.7-5.5 higher). Audit: 93 files of EU patients were reviewed; their mean age was 71 years (18-96). Diagnosis was conform to the expert opinion in 70% of cases. No antibiotic was really necessary in 20% of cases, and delay between hospitalization and antibiotic prescription was relevant only for 56% of patients. The most frequently prescribed antibiotics were betalactams (penicillins 43%, third generation cephalosporin 21%, and fluoroquinolones 22%). The choice was conform to local and national guidelines in 78% of justified prescribed antibiotherapy. CONCLUSION: The qualitative assessment cannot explain the higher antibiotic consumption trend. The number of unjustified antibiotic prescriptions does not explain the variable antibiotic consumption.

[Incidence and prognostic factors of breast cancer diagnosed within and outside of the organised screening program in the department of Loire-Atlantique (1991-2002)]. / Incidence et facteurs pronostiques des cancers du sein découverts au cours et en dehors du programme de dépistage organisé en Loire-Atlantique (1991-2002).

BACKGROUND: This study aimed to evaluate the impact of breast cancer mass screening, which began in 1996 in Loire-Atlantique (France), on the evolution of incidence and characteristics of breast cancer between 1991 and 2002. METHODS: The cancer Registry of Loire-Atlantique recorded characteristics of 9263 incident breast cancers diagnosed between 1991 and 2002. The level of participation to the organised screening program was 48%, thus the screening management structure allowed characterizing 736 cancers discovered by organised screening between 1997 and 2002. RESULTS: The 1991-2002 period was marked by a strong increase of in situ cancer proportion (from 5% at the beginning to 10% at the end of the period) and of standardised incidence rates (from 77 to 103/10(5) and from 4 to 13/10(5) for invasive and in situ cancers, respectively). Incidence was already rising before the beginning of the organised screening program in 1996. During the 1997-2002 period, in spite of steady rates for cancers detected by organised screening, incidence of cancers detected outside organised screening went on increasing. Cancers detected by organised screening were more often of smaller size (33% versus 22% smaller than 10mm) and without lymph node invasion (70% versus 62%). CONCLUSION: A strong increase of breast cancer incidence was observed in Loire-Atlantique, particularly in the organised screening age groups. The persistent increase of in situ cancers for women younger than 50 years old unconcerned by the organised screening program, and also for women of 50-74 years old detected outside the organised screening program suggested a parallel contribution of individual screening. These preliminary results confirm better prognostic factors for cancer detected by organised screening than for others.

[Assessing the application of Rwanda's national protocol for uncomplicated malaria treatment in healthcare institutions in Kigali City, Rwanda]. / Evaluation de l'application du protocole national de traitement du paludisme simple dans les formations sanitaires de la ville de Kigali, Rwanda.

UNLABELLED: In November 2001, the National Health Ministry of Rwanda advocated a new therapeutic protocol replacing chloroquine by an amodiaquine+sulfadoxine-pyrimethamine combination for the treatment of uncomplicated malaria. OBJECTIVES: This study had for aim to assess the application of this new protocol in Kigali healthcare institutions. POPULATION AND METHODS: A knowledge, attitudes and practices study (KAP) was carried out between June and August 2003. A questionnaire was answered by 120 care providers working in 15 healthcare institutions selected randomly in health facilities treating uncomplicated malaria. Antimalarial treatments prescribed to 150 patients were also reviewed from consultation files and analyzed. RESULTS: After analysis, 63.3% prescriptions were in line with the national protocol. Factors associated to the nonobservance of the national protocol were: the carer's ignorance of any recommended treatment, his doubt of efficacy of recommended drugs, and his fear of adverse effects. CONCLUSIONS: The authors recommend informing the care providers about the national protocol. Findings also demonstrate the need to include care providers in any modifications of the national policy in terms of drug efficacy and potential adverse effects of the new strategy.

An objective method for bed capacity planning in a hospital department - a comparison with target ratio methods.

OBJECTIVES: To propose an objective approach in order to determine the number of beds required for a hospital department by considering how recruitment fluctuates over time. To compare this approach with classical bed capacity planning techniques. METHODS: A simulated data-based evaluation of the impact that the variability in hospital department activity produces upon the performance of methods used for determining the number of beds required. The evaluation criteria included productive efficiency measured by the bed occupancy rate, accessibility measured by the transfer rate of patients due to lack of available beds and a proxy of clinical effectiveness, by the proportion of days during which there is no possibility for unscheduled admission. RESULTS: When the variability of the number of daily patients increases, the Target Occupancy Rate favors productive efficiency at the expense of accessibility and proxy clinical effectiveness. On the contrary, when the variability of the department activity is marginal, the Target Activity Rate penalizes the proxy of clinical effectiveness, and the Target Occupancy Rate underoptimizes productive efficiency. The method we propose led to a superior performance in terms of accessibility and proxy of clinical effectiveness at the expense of productive efficiency. Such a situation is suitable for intensive care units. In the case of other departments, a weighting procedure should be used to improve productive efficiency. CONCLUSIONS: This approach could be considered as the first step of a family of methods for quantitative healthcare planning.

[Health care and secondary access to care inequalities]. / Inégalités de santé et d'accès secondaire aux soins.

The role of health care inequalities in social inequalities in health should be reconsidered since the quality of health care varies according to the social status. Some of the health care inequalities are constructed by not taking account of health inequalities in the development of programs or recommendations of medical practice and thus ending up with management procedures that do not reduce inequalities to a minimum but even contribute to increasing them. Other health care inequalities are due to omission, linked to the operating inertia of a health care system that does not recognize these inequalities and has no plan to catch them up. To reverse this situation it seems necessary to act at the three levels of the health care system: to change the clinical paradigm at the micro level, tackle the organizations issues at the meso level, and pursue the reform of the entire health care system at the macro level.

[An evaluation of a patient education programme for children with asthma at a French teaching hospital ("l'espace du souffle", Nantes) (2002-2003)]. / Programme d'éducation thérapeutique collective pour l'enfant asthmatique à Nantes.

A program of patient education was set up at the CHU of Nantes, for groups of children with asthma in 1997. The aim of this study is to realize a formative evaluation to corelate with some effects. This study was proposed to 99 families with asthmatic children. A written questionnaire, was administered to the parents and children, exploring their satisfaction with the programme, their general knowledge and know-how, biomedical parameters. The observation focused on skills and day-to-day life with the illness. The study was completed by 21 families. The majority of the children, aged 7 to 11 years old, had asthma that needed treatment. All of the parents and children were satisfied with their visit to "l'espace du souffle". They all declared having increased their general knowledge and know-how and biomedical parameters did better. They did, however, feel that they did not know enough about how to recognise precursory symptoms of an attack, about how to practise a sport or how to use "corticoids". They also could not control their personal fear during an attack. During the oral questionnaire a general feeling of stress and worry was clearly noticeable in the parents feeling, that did not appear in the written questionnaire. This patient education program appears to be beneficial. Furthermore, this evaluation highlights some subjects that pass unseen during current individual consultations.

[Main issues and contributions of the evaluation of health care networks]. / Les problématiques et les apports de l'evaluation d'un réseau de santé.

Health care networks correspond to a form of horizontal and flexible organisation, which consists in dealing with complex problems of health and long-term care. Networks rest entirely on the mechanisms of coordination between the various actors of care, whose keystone is the medical information flow. The challenge of the health networks evaluation is to prove the added value of a network organization, instead of a conventional disease-centred health care. The evaluation of health care networks is legally required but not sustained by specialists. Evaluation must ensure the existence of a real management; measure the interest of health care professionals and the impact of the network on professional practices. Moreover, evaluation accompanies the development of the network and offers the advisability to the decision maker of obtaining a tool for control of management, i.e. an information tool and a decision-making help, with the aim of a continuous improvement of the quality of care. However the absence of formation of the medical coordinators to management, makes networks management problematic. Thus, health care networks cannot make the saving in a good administrative and management base. In the same way health care networks must obtain an information system adapted to their type of coordination, allowing the evaluation required by the financier.