Abstract
Previous observational research confirms abundant variation in primary care practice. While variation is sometimes viewed as problematic, its presence may also be highly informative in uncovering ways to enhance health care delivery when it represents unique adaptations to the values and needs of people within the practice and interactions with the local community and health care system. We describe a theoretical perspective for use in developing interventions to improve care that acknowledges the uniqueness of primary care practices and encourages flexibility in the form of intervention implementation, while maintaining fidelity to its essential functions.
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Perlin J, Kolodner R, Roswell R. The Veterans Health Administration: quality, value, accountability, and information as transforming strategies for patient-centered care. Am J Manag Care. 2004;10:828–36.
Krein S, Hofer T, Kerr E, Hayward R. Whom should we profile? Examining diabetes care practice variation among primary care providers, provider groups, and health care facilities. Health Serv Res. 2002;37:1125–7.
Solberg L, Brekke M, Kottke T, Steel R. Continuous quality improvement in primary care: what’s happening? Med Care. 1998;36:625–35.
Solberg LI, Kottke TE, Brekke ML, et al. Failure of a continuous quality improvement intervention to increase the delivery of preventive services. A randomized trial. Eff Clin Pract. 2000;3:105–15.
Kritchevsk SB, Simmins BP. Continuous quality improvement. Concepts and applications for physician care. JAMA. 1992;267:55–6.
Palmer RH, Louis TA, Hsu LN, et al. A randomized controlled trial of quality assurance in sixteen ambulatory care practices. Med Care. 1985;23:751–70.
Macklis R. Successful patient safety initiatives: driven from within. Group Pract J. 2001;50:1–5.
Marsh D, Schroeder D, Dearden K, Sternin J, Sternin M. The power of positive deviance. Br Med J. 2004;329:1177–9.
Miller W, McDaniel R, Crabtree B, Stange K. Practice jazz: understanding variation in family practices using complexity science. J Fam Pract. 2001;50:872–80.
Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q. 2004;82:581–629.
Patrick DL, Chiang YP. Measurement of health outcomes in treatment effectiveness evaluations: conceptual and methodological challenges. Med Care. 2000;38(suppl):14–25.
Dooley K, Johnson TL, Bush D. TQM, chaos, and complexity. Human Syst Manag. 1995;14:287–302.
Miller W, Crabtree B, McDaniel R, Stange K. Understanding change in primary care practice using complexity theory. J Fam Pract. 1998;46:369–76.
Plsek P. Complexity and the adoption of innovation in health care. In: Accelerating Quality Improvement in Health Care-Strategies to Speed the Diffusion of Evidence-Based Innovations. Washington, DC, USA, 2003 Available at: www.nihcm.org/plsek.pdf. Accessed September 19, 2005.
Rogers E. A prospective and retrospective look at the diffusion model. J Health Commun. 2004;9:13–9.
Manson S. Simplifying complexity: a review of complexity theory. Geoform. 2001;32:405–14.
Phelan S. What is complexity science really? Emergence. 2003;3:120–36.
Kernick D. Complexity and Healthcare Organization: A View from the Street. Oxford, UK: Radcliffe Publishing; 2004.
Mandelbort B. The Fractal Geometry of Nature. San Francisco: W.H. Freeman and Co.; 1982.
Liebovitch L. Fractals and Chaos Simplified for the Life Sciences. New York: Oxford University Press; 1998.
Aron DC. Chaos, complexity and cardiology. In: Holt T, ed. Complexity for Clinicians. Oxford, UK: Radcliffe Press; 2004.
Karagiannis T, Faloutsos M. SELFIS: a tool for self-similarity and long-range dependence analysis. First workshop on fractals and self-similarity in data mining: issues and approaches; 2002.
Plsek P. Redesigning health care with insights from the science of complex adaptive systems. Crossing the quality chasm: a new health system for the 21st century. The National Academy of Sciences, 2000:309–17.
Stange KC. The paradox of the parts and the whole in understanding and improving general practice. Int J Qual Health Care. 2002;14:267–8.
Kauffman S. The Origins of Order. Oxford, UK: Oxford University Press; 1993.
Stacey R. Mapping the Science of Complexity onto Organizations. Complexity and Creativity in Organizations. San Francisco, CA: Berrett-Koehler; 1996:107–17.
Tallia A, Stange K, McDaniel R, Aita V, Miller W. Understanding organizational designs of primary care practices. J Healthc Manag. 2003;48:45–9.
Stroebel CK, McDaniel R, Crabtree B, Miller W, Nutting P, Stange KC. How complexity science can inform a reflective process for improvement in primary care practices. Jt Comm J Qual Patient Saf. 2005;31:438–46.
Stange K, Jaen C, Flocke S, Miller W, Crabtree B, Zyzanski S. The value of a family physician. J Fam Pract. 1998;46:363–8.
Brewick DM. Disseminating innovations in health care. JAMA. 2003;289:1969–75.
Greco PJ, Eisenberg JM. Changing physicians’ practices. N Engl J Med. 1993;329:1271–4.
Eisenberg JM. Physician utilization: the state of research about physicians’ practice patterns. Med Care. 1985;23:461–83.
Davis D, O’Brien M, Freemantle N, et al. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA. 1999;282:867–74.
Davis D, Thomson MA, Oxman A, Haynes R. Evidence for the effectiveness of CME. A review of 50 randomized controlled trials. JAMA. 1992;268:1111–7.
Davis DA, Thomson MA, Oxman AD, Haynes B. Changing physician performance. A systematic review of the effect of continuing medical education strategies. JAMA. 1995;274:700–5.
Haynes RB, McKibbon KA, Kanani R. Systematic review of randomised trials of interventions to assist patients to follow prescriptions for medications. Lancet. 1996;348:383–6.
Shortell S, Bennett C, Byck G. Assessing the impact of continuous quality improvement on clinical practice: what it will take to accelerate progress. Milbank Q. 1998;76:593–624.
Goodwin MA, Zyzanski SJ, Zronek S, et al. A clinical trial of tailored office systems for preventive service delivery: the study to enhance prevention by understanding practice (STEP-UP). Am J Prev Med. 2001;21:20–8.
Hawe P, Shiell A, Riley T. Complex interventions: how “out of control” can a randomized controlled trial be? Br Med J. 2004;328:1561–3.
Stange KC, Goodwin MA, Zyzanski SJ, Dietrich AJ. Sustainability of a practice-individualized preventive service delivery intervention. Am J Prev Med. 2003;25:296–300.
Ruhe MC, Gotler RS, Goodwin MS, Stange KC. Physician and staff turnover in community primary care practice. J Ambulatory Care Manag. 2004;27:242–8.
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The authors have no conflict of interest to declare for this article.
Source of Funding: This project was partly funded from Veterans Administration Health Service (HSR&D) grants to Dr. Litaker (Career Development Award) and Dr. Aron (REA 01-100).
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Litaker, D., Tomolo, A., Liberatore, V. et al. Using complexity theory to build interventions that improve health care delivery in primary care. J Gen Intern Med 21 (Suppl 2), S30–S34 (2006). https://doi.org/10.1007/s11606-006-0272-z
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DOI: https://doi.org/10.1007/s11606-006-0272-z