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Research ArticleOriginal Research

Delivery of Clinical Preventive Services in Family Medicine Offices

Benjamin F. Crabtree, William L. Miller, Alfred F. Tallia, Deborah J. Cohen, Barbara DiCicco-Bloom, Helen E. McIlvain, Virginia A. Aita, John G. Scott, Patrice B. Gregory, Kurt C. Stange and Reuben R. McDaniel
The Annals of Family Medicine September 2005, 3 (5) 430-435; DOI: https://doi.org/10.1370/afm.345
Benjamin F. Crabtree
PhD
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William L. Miller
MD, MA
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Alfred F. Tallia
MD, MPH
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Deborah J. Cohen
PhD
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Barbara DiCicco-Bloom
RN, PhD
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Helen E. McIlvain
PhD
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Virginia A. Aita
RN, PhD
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John G. Scott
MD, PhD
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Patrice B. Gregory
PhD, MPH
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Kurt C. Stange
MD, PhD
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Reuben R. McDaniel Jr
EdD
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  • Addendum to Babies and Bathwater
    Allen J. Dietrich, MD
    Published on: 19 October 2005
  • Don't throw out the baby with the bathwater.
    Allen J. Dietrich, MD
    Published on: 18 October 2005
  • What more have we learned?
    Stephen H Taplin
    Published on: 06 October 2005
  • Questions about care categories: acute, chronic, preventive
    Mary C. Hroscikoski
    Published on: 06 October 2005
  • Systems needed to facilitate preventive care
    Paul S. Frame
    Published on: 06 October 2005
  • Preventive Services and Family Medicine Offices: The Dynamics of Patient Care
    Michael L Parchman
    Published on: 29 September 2005
  • Published on: (19 October 2005)
    Page navigation anchor for Addendum to Babies and Bathwater
    Addendum to Babies and Bathwater
    • Allen J. Dietrich, MD, Hanover, NH, USA

    It should also be noted that literature on office systems and cancer screening is growing. Not surprisingly, different systems in different settings have yielded different results.(1-6)

    1. McPhee SJ, Bird JA, Jenkins CN, Fordham D. Promoting cancer screening. A randomized, controlled trial of three interventions. Arch Intern Med. Aug 1989;149(8):1866-1872.

    2. McPhee SJ, Bird JA, Fordham D, Rodnick JE,...

    Show More

    It should also be noted that literature on office systems and cancer screening is growing. Not surprisingly, different systems in different settings have yielded different results.(1-6)

    1. McPhee SJ, Bird JA, Jenkins CN, Fordham D. Promoting cancer screening. A randomized, controlled trial of three interventions. Arch Intern Med. Aug 1989;149(8):1866-1872.

    2. McPhee SJ, Bird JA, Fordham D, Rodnick JE, Osborn EH. Promoting cancer prevention activities by primary care physicians. Results of a randomized, controlled trial. Jama. Jul 24-31 1991;266(4):538-544.

    3. McPhee SJ, Detmer WM. Office-based interventions to improve delivery of cancer prevention services by primary care physicians. Cancer. Aug 1 1993;72(3 Suppl):1100-1112.

    4. Roetzheim RG, Christman LK, Jacobsen PB, et al. A randomized controlled trial to increase cancer screening among attendees of community health centers. Ann Fam Med. Jul-Aug 2004;2(4):294-300.

    5. Gemson DH, Ashford AR, Dickey LL, et al. Putting prevention into practice. Impact of a multifaceted physician education program on preventive services in the inner city. Arch Intern Med. Nov 13 1995;155(20):2210-2216.

    6. Gemson DH, Dickey LL, Ganz ML, Ashford AR, Francis CK. Acceptance and use of Put Prevention into practice materials at an inner-city hospital. Am J Prev Med. Jul-Aug 1996;12(4):233-237.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (18 October 2005)
    Page navigation anchor for Don't throw out the baby with the bathwater.
    Don't throw out the baby with the bathwater.
    • Allen J. Dietrich, MD, Hanover, NH, USA

    In an observational report of 18 purposely selected practices, Crabtree, et al, find that practice prevention priorities vary and that both competing demands within the clinical encounter and the presence of a prevention champion can impact preventive services delivered. In addition, they note in their discussion that efforts to encourage diverse practices to adopt a systematic approach to prevention are likely to fail....

    Show More

    In an observational report of 18 purposely selected practices, Crabtree, et al, find that practice prevention priorities vary and that both competing demands within the clinical encounter and the presence of a prevention champion can impact preventive services delivered. In addition, they note in their discussion that efforts to encourage diverse practices to adopt a systematic approach to prevention are likely to fail.

    In my view, their assessment is overly pessimistic. In a randomized controlled trial of 98 small New England practices, we found that use of a preventive services flow sheet, better cooperation between practice clinicians and their staff, and modest assistance from an external facilitator increased needed services in the short and long term.(1,2,3) Some of these practices to this day ask me to restock updated preventive services flow sheets. I do so gladly. A subsequent trial in larger more complex urban centers found a more limited impact from a similar intervention. Improved screening depended on stable leadership in these centers.(4)

    What does this tell us? Some practices can engage their staff and use flow sheets to make systematic approaches that lead to measurably enhanced preventive care. Other practices may need different approaches or should wait for the right time to implement a system. I agree that better intervention studies are needed and that systems need to be customized to the practice situation, but practices ready now to improve their preventive care through better systems should not be discouraged. Systems work given a stable office environment and their appropriate adaptation to it.

    1. Dietrich AJ, O'Connor GT, Keller A, Carney PA, Levy D, Whaley FS. Cancer: improving early detection and prevention. A community practice randomised trial. BMJ. Mar 14 1992;304(6828):687-691.

    2. Dietrich AJ, Sox CH, Tosteson TD, Woodruff CB. Durability of improved physician early detection of cancer after conclusion of intervention support. Cancer Epidemiol Biomarkers Prev. Jun 1994;3(4):335-340.

    3. Rebelsky MS, Sox CH, Dietrich AJ, Schwab BR, Labaree CE, Brown-McKinney N. Physician preventive care philosophy and the five year durability of a preventive services office system. Soc Sci Med. Oct 1996;43(7):1073-1081.

    4. Dietrich AJ, Tobin JN, Sox CH, et al. Cancer early-detection services in community health centers for the underserved. A randomized controlled trial. Arch Fam Med. Jul-Aug 1998;7(4):320-327; discussion 328.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (6 October 2005)
    Page navigation anchor for What more have we learned?
    What more have we learned?
    • Stephen H Taplin, Bethesda USA

    RE: Delivery of Clinical Preventive Services:

    Crabtree et al

    I read with some interest Dr. Crabtree’s recent article and appreciated its rich description of clinical practice. Anyone who has spent time in practice could recognize the challenges of competing priorities facing patients and physicians, the presence of committed champions as influential, and the complexities of care highlighted in this wo...

    Show More

    RE: Delivery of Clinical Preventive Services:

    Crabtree et al

    I read with some interest Dr. Crabtree’s recent article and appreciated its rich description of clinical practice. Anyone who has spent time in practice could recognize the challenges of competing priorities facing patients and physicians, the presence of committed champions as influential, and the complexities of care highlighted in this work. While this rich description is familiar, I could not reconcile it with the conclusions that were drawn.

    The authors state, “The structure of practices may need redesign as described in the recent IOM report and Future of Family Medicine recommendations” yet they also conclude that “efforts at getting diverse clinical offices to adopt a standardized set of processes for implementing preventive services are likely to fail regardless of the quality of the process”. There qualification seems to deny their conclusion, that redesign is needed.

    It seems to me that the interpretation of a “standardized set of processes” misses the whole point of that standardization. We examine practice to precisely make adjustments in processes, but the goal of describing and pursuing standardized evidence-based processes is to improve care that is sorely lacking. This report demonstrates the deficiency in preventive care implementation quite clearly when implementation is 65% at best. But then the authors seem to through up their hands and say its way to complicated to fix.

    However, we’ve known for many years that it can be done, and that it takes tenacity for the very reasons described (1). Crabtree et al describe practice well but I don’t find the conclusions helpful. Before this paper was written, we knew practice was complicated. What more have we learned?

    Reference List

    (1) Carney-Gersten P, Keller A, Landgraf J, Dietrich AJ. Tools, teamwork, and tenacity: an office system for cancer prevention. Journal of Family Practice 1992; 35(4):388-394.

    These comments are mine alone and not reflective of the the opinion of the federal government or the National Cancer Institute.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (6 October 2005)
    Page navigation anchor for Questions about care categories: acute, chronic, preventive
    Questions about care categories: acute, chronic, preventive
    • Mary C. Hroscikoski, Minneapolis, MN

    Besides the need for longitudinal designs to better understand practice variability and design improvement interventions, this study also suggests the need for examining the care categories we use: acute vs. chronic vs. preventive. Crabtree et al find that care systems are organized around the predominant visit type, acute illness visits, with relatively little attention given to preventive services (p. 432). It is not c...

    Show More

    Besides the need for longitudinal designs to better understand practice variability and design improvement interventions, this study also suggests the need for examining the care categories we use: acute vs. chronic vs. preventive. Crabtree et al find that care systems are organized around the predominant visit type, acute illness visits, with relatively little attention given to preventive services (p. 432). It is not clear, though, how the categorization is working here and just whose it is. Either way, what does it mean to classify a visit type as being for acute illness rather than for preventive services?

    Certainly it’s in part about our orientation to time. The clinical approach I learned was that something we designate “acute illness” has little past or future in the life of the person living with it. It demands immediate attention and then can be forgotten about. Chronic illness is about a future that never goes away; it is something that needs ongoing attention. Preventive services, on the other hand, are about a future that may or may not ever come. What meanings do others – clinicians, patients, care system innovators, etc. – make with these categories?

    Does this visit categorization, in combination with a condition- centered care focus, lead us to lose sight of broader health needs? The variability the authors find in preventive service rates and delivery approaches both within and across practices indicates the categorization is descriptive, not operational. Would it help practices to think more systematically if instead we had visit categories that were more operational and more centered on the patient live-course, which always has a past and a future?

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (6 October 2005)
    Page navigation anchor for Systems needed to facilitate preventive care
    Systems needed to facilitate preventive care
    • Paul S. Frame, Dansville, NY USA

    The main conclusion to be drawn from the article by Crabtree et. al. is that practices need to have a system in place to ensure delivery of preventive services, and that few practices have such a system.

    Many practitioners claim that having all patients get an annual physical is their system but this is not feasible in the real world. A primary care physician with 2000 patients working 200 days a year would ne...

    Show More

    The main conclusion to be drawn from the article by Crabtree et. al. is that practices need to have a system in place to ensure delivery of preventive services, and that few practices have such a system.

    Many practitioners claim that having all patients get an annual physical is their system but this is not feasible in the real world. A primary care physician with 2000 patients working 200 days a year would need to do 10 physicials a day just for this purpose.

    Systems can and have been developed but they cost money and take ongoing effort. Electronic health records facilitate creating a system but by themselves will not do the job.

    Given the current financial and time pressures faced by primary care practitioners incentives and help from external sources will be needed before there is widespread adoption of systems for implementing preventive services. This role is most logically the responsibility of payors for health services, although specialty organizations can help. Do they have the desire to put their money where their mouth is?

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (29 September 2005)
    Page navigation anchor for Preventive Services and Family Medicine Offices: The Dynamics of Patient Care
    Preventive Services and Family Medicine Offices: The Dynamics of Patient Care
    • Michael L Parchman, San Antonio, Texas

    Crabtree and colleagues have reminded us again that primary care practices are complex systems.(1) One of the concepts captured in their work is that of competing demands and the dynamics of patient care in a primary care practice. In prior work they describe primary care practices as dynamic systems comprised of multiple agents, each interacting, adapting and reacting to their landscape and the behavior of other agents...

    Show More

    Crabtree and colleagues have reminded us again that primary care practices are complex systems.(1) One of the concepts captured in their work is that of competing demands and the dynamics of patient care in a primary care practice. In prior work they describe primary care practices as dynamic systems comprised of multiple agents, each interacting, adapting and reacting to their landscape and the behavior of other agents in the system.(2-4) Patients are agents too, and they rush through our offices like water through a garden hose: check-in at the front desk, nurse triage, clinician encounter with a series of questions, answers, examinations, more discussion, more questions, refilling of prescriptions, referrals, health advice, check out at the front desk, schedule next visit and arrange for referrals and or tests, and repeat the process with the next patient. Some days go smoother than others. Turbulence in the flow of our “garden hose practice” might be created by the overwhelming viscosity of the patient who requires hospitalization in the middle of the afternoon session. Perhaps the variety or “case-mix” of the of patients who come through a family practice on a given day or week might be considered as molecules of different sizes, shapes and properties such as viscosity as they flow through the “garden hose” of the practice. The cramped inner- city urban practice described by Crabtree and colleagues certainly suggests patients with higher viscosity. The capacity of the garden hose to carry fluids of differing viscosity or other properties may very from practice to practice. This capacity may be determined by the unique properties of the garden hose, such as the lining inside the hose, or the number of bends in the hose. These may be the different inherent properties of the practice such as the organizational features described by Crabtree in this study. Crabtree and colleagues continue to push us to think about primary care practice settings. Perhaps it is time to move on from cross-sectional observation and case studies to longitudinal studies with frequent measurements (hourly?) of the dynamics of the interaction between agents in the primary care practice if we are ever to make any progress in improving something that appears so simple on the surface: the delivery of a clinical preventive service. 1. Crabtree BF, Miller WL, Talia AF, Cohen DJ, DiCiccio-Bloom B, et al. Delivery of clinical preventive services in family medicine offices. Ann Fam Med 2005;3:430-435. 2. Miller WL, McDaniel RRJ, Crabtree BF, Stange KC. Practice jazz: understanding variation in family practices using complexity science. J Fam Pract 2001 Oct;50(10):872-8. 3. Crabtree BF. Individual attitudes are no match for complex systems. [letter; comment]. J Fam Pract 1997 May;44(5):447-8. 4. Miller WL, Crabtree BF, McDaniel R, Stange KC. Understanding change in primary care practice using complexity theory. J Fam Pract 1998 May;46(5):369-76.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
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Delivery of Clinical Preventive Services in Family Medicine Offices
Benjamin F. Crabtree, William L. Miller, Alfred F. Tallia, Deborah J. Cohen, Barbara DiCicco-Bloom, Helen E. McIlvain, Virginia A. Aita, John G. Scott, Patrice B. Gregory, Kurt C. Stange, Reuben R. McDaniel
The Annals of Family Medicine Sep 2005, 3 (5) 430-435; DOI: 10.1370/afm.345

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Delivery of Clinical Preventive Services in Family Medicine Offices
Benjamin F. Crabtree, William L. Miller, Alfred F. Tallia, Deborah J. Cohen, Barbara DiCicco-Bloom, Helen E. McIlvain, Virginia A. Aita, John G. Scott, Patrice B. Gregory, Kurt C. Stange, Reuben R. McDaniel
The Annals of Family Medicine Sep 2005, 3 (5) 430-435; DOI: 10.1370/afm.345
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