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1 Department of Family Medicine, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ
2 Cancer Institute of New Jersey, New Brunswick, NJ
3 Department of Family Medicine, Lehigh Valley Hospital & Health Network, Allen-town, Pa
4 Department of Family Medicine, University of Nebraska Medical Center, Omaha, Neb
5 Department of Preventive and Societal Medicine, University of Nebraska Medical Center, Omaha, Neb
6 Departments of Family Medicine, Epidemiology & Biostatistics, and Sociology, Case Western Reserve University, and the Case Comprehensive Cancer Center, Cleveland, Ohio
7 McCombs School of Business, University of Texas at Austin, Austin, Tex
CORRESPONDING AUTHOR: Benjamin F. Crabtree, PhD, Department of Family Medicine, UMDNJ-Robert Wood Johnson, Medical School, New Brunswick, NJ 08873, crabtrbf{at}umdnj.edu
BACKGROUND This study aimed to elucidate how clinical preventive services are delivered in family practices and how this information might inform improvement efforts.
METHODS We used a comparative case study design to observe clinical preventive service delivery in 18 purposefully selected Midwestern family medicine offices from 1997 to 1999. Medical records, observation of outpatient encounters, and patient exit cards were used to calculate practice-level rates of delivery of clinical preventive services. Field notes from direct observation of clinical encounters and prolonged observation of the practice and transcripts from in-depth interviews of practice staff and physicians were systematically examined to identify approaches to delivering clinical preventive services recommended by the US Preventive Services Task Force.
RESULTS Practices developed individualized approaches for delivering clinical preventive services, with no one approach being successful across practices. Clinicians acknowledged a 3-fold mission of providing acute care, managing chronic problems, and prevention, but only some made prevention a priority. The clinical encounter was a central focus for preventive service delivery in all practices. Preventive services delivery rates often appeared to be influenced by competing demands within the clinical encounter (including between different preventive services), having a physician champion who prioritized prevention, and economic concerns.
CONCLUSIONS Practice quality improvement efforts that assume there is an optimal approach for delivering clinical preventive services fail to account for practices’ propensity to optimize care processes to meet local contexts. Interventions to enhance clinical preventive service delivery should be tailored to meet the local needs of practices and their patient populations.
Key Words: Prevention • mass screening • office visits • family medicine offices • professional practice • health care quality, access, and evaluation • quality assurance, health care • quality improvement • qualitative research • Papanicolaou smear • cholesterol testing • smoking/prevention and control • mammography • immunizations
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