Delivery of Clinical Preventive Services in Family Medicine Offices

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

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

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

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