Delivery of clinical preventive services in family medicine offices

Association Between Primary Care Use Prior to Cancer Diagnosis and Subsequent Cancer Mortality in the Veterans Affairs Health System

IMPORTANCE

Primary care physicians (PCPs) are significant contributors of early cancer detection, yet few studies have investigated whether consistent primary care translates to improved downstream outcomes.

OBJECTIVE

To evaluate the association of prediagnostic primary care use with metastatic disease at diagnosis and cancer-specific mortality (CSM).

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used databases with primary care and referral linkage from multiple Veterans' Affairs centers from 2004 to 2017 and had a 68-month median follow-up. Analysis was completed between July 2021 and September 2022. Participants included veterans older than 39 years who had been diagnosed with 1 of 12 cancers. Inclusion criteria included known clinical staging, survival follow-up, cause of death, and receiving care at the Veterans Affairs health system (VA).

EXPOSURES

Prediagnostic PCP use, measured in the 5 years prior to diagnosis. PCP visits were binned into none (0 visits), some (1-4 visits), and annual (5 visits).

MAIN OUTCOMES AND MEASURES

Metastatic disease at diagnosis, cancer-specific mortality (CSM) for entire cohort and stratified by tumor subtype.

RESULTS

Among 245 425 patients representing 12 tumor subtypes, mean age was 65.8 (9.3) years, and the cohort skewed male (97.6%), and White (76.1%), with higher levels of comorbidity (58.6% with Charlson Comorbidity Index scores ≥2). Compared with no prior visit, some PCP use was associated with 26% decreased odds of metastatic disease at diagnosis (odds ratio [OR], 0.74; 95% CI, 0.71-0.76; P < .001) and 12% reduced risk of CSM (subdistribution hazard ratio [SHR], 0.88; 95% CI, 0.86-0.89; P < .001). Annual PCP use was associated with 39% decreased odds of metastatic disease (OR, 0.61; 95% CI, 0.59-0.63; P < .001) and 21% reduced risk of CSM (SHR, 0.79; 95% CI, 0.77-0.81; P < .001). Among tumor subtypes, prostate cancer had the largest effect size for prior PCP use on metastatic disease at diagnosis (OR for annual use, 0.32; 95% CI, 0.30-0.35; P < .001) and CSM (SHRfor annual use, 0.51; 95% CI, 0.48-0.55; P < .001).

CONCLUSIONS AND RELEVANCE

In this cohort study, increased primary care use before cancer diagnosis was associated with significant decreases in metastatic disease at diagnosis and cancer-related death, with potentially the greatest difference from annual use. PCPs play a vital role in cancer prevention, and additional resources should be allocated to assist these physicians.

The role of organization of care in GPs' prevention practice

BACKGROUND

General practitioners (GPs) do not systematically include preventive recommendations in their practice, and some characteristics of health care organization are associated with more systematic prevention. But the characteristics of health care organization may act in a nonuniform manner depending on the type of preventive care. Thus, one characteristic can be positively associated with one type of preventive care and negatively associated with another. Our aim was to investigate the association between health care organization in general practice and different areas of preventive care (immunization and addiction prevention), in search of nonuniform associations.

METHODS

We used a representative survey of 1,813 French GPs conducted in 2009. Four preventive care practices were studied: immunization through flu and HPV vaccination, and prevention of addictive behaviors concerning tobacco and alcohol use.Characteristics of GPs' health care organization and the social context of their practice were collected (spatial accessibility to GPs and socioeconomic level of the area of practice). We constructed mixed models to study associations and interactions between the organization variables and preventive care.

RESULTS

Four out of five characteristics of GPs' organization have uneven impacts on different types of preventive care (p-interaction < 10-4). For example, number of daily consultations is associated with better immunization prevention but with poorer prevention counseling in addictive behaviors. In contrast, working with digital medical files is uniformly associated with both types of preventive care (OR = 1.29 [1.15-1.45]; P < 10-4).

CONCLUSION

An approach centered on specific types of preventive care should help deepen our understanding of prevention and possibly help to identify a new typology for preventive care.

Sustaining Successful Clinical-community Partnerships in Medically Underserved Urban Areas: A Qualitative Case Study

Clinical-community partnerships can improve access and receipt of preventive health services in community settings. Understanding how to sustain their potential benefits is warranted. Qualitative case-study of the Faith Community Health Partnership (FCHP), a collaboration between faith-community nurses and community organizations sustained over 25 years. We used content analysis principles to report on partnership sustainability themes identified through semi-structured interviews with FCHP partners (n = 18). Factors supporting partnership sustainability: Maintaining partners' commitment over time; strategic resource-sharing; facilitating engagement; and preserving partnership flexibility. Sustaining clinical-community partnerships is a dynamic and continuous process requiring significant time, effort, and resources on behalf of partners.

Advancing clinical leadership to improve the implementation of evidence-based practice in surgery: a longitudinal mixed-method study protocol

BACKGROUND

Clinical leadership is fundamental in facilitating service improvements in healthcare. Few studies have attempted to understand or model the different approaches to leadership which are used when promoting the uptake and implementation of evidence-based interventions. This research aims to uncover and explain how distributed clinical leadership can be developed and improved to enhance the use of evidence in practice. In doing so, this study examines implementation leadership in orthopaedic surgery to explain leadership as a collective endeavour which cannot be separated from the organisational context.

METHODS

A mixed-method study consisting of longitudinal and cross-sectional interviews and an embedded social network analysis will be performed in six NHS hospitals. A social network analysis will be undertaken in each hospital to uncover the organisational networks, the focal leadership actors and information flows in each organisation. This will be followed by a series of repeated semi-structured interviews, conducted over 4 years, with orthopaedic surgeons and their professional networks. These longitudinal interviews will be supplemented by cross-sectional interviews with the national established surgical leaders. All qualitative data will be analysed using a constructivist grounded theory approach and integrated with the quantitative data. The participant narratives will enrich the social network to uncover the leadership configurations which exist, and how different configurations of leadership are functioning in practice to influence implementation processes and outcomes.

DISCUSSION

The study findings will facilitate understanding about how and why different configurations of leadership develop and under what organisational conditions and circumstances they are able to flourish. The study will guide the development of leadership interventions that are grounded in the data and aimed at advancing leadership for service improvement in orthopaedics. The strength of the study lies in the combination of multi-component, multi-site, multi-agent methods to examine leadership processes in surgery. The findings may be limited by the practical challenges of longitudinal qualitative data collection, such as ensuring participant retention, which need to be balanced against the theoretical and empirical insights generated through this comprehensive exploration of leadership across and within a range of healthcare organisations.

The association between GP organisational factors and the effectiveness of a prevention programme for cardiometabolic diseases: a prospective intervention study

Background

Owing to the rising disease burden of cardiometabolic diseases (CMD), prevention programmes for CMD are increasingly implemented in primary care. Organisational practice characteristics and availability of preventive services may be associated with a more effective programme.

Aim

To identify possible organisational success factors from general practices related to an effective primary prevention programme for CMD.

Design & setting

A prospective intervention study involving 37 Dutch general practices was undertaken.

Method

Patients aged 45–70 years without known CMD, hypertension, or hypercholesterolemia were invited for the prevention programme. The outcome measures were an improvement (yes/no) in four different CMD risk factors between baseline and 1-year follow-up on an individual level (body mass index [BMI], smoking, systolic blood pressure, and cholesterol ratio). Multivariate logistic regression analysis was used for assessing associations between practice organisational characteristics and outcomes.

Results

Just over half of the participants showed an improvement on one or more risk factors. Marginal differences were found in the four different outcomes between the practices with different organisational characteristics. None of the practice characteristics that were tested showed a significant association with an improvement in one of the outcome measures.

Conclusion

In this study, general practice organisational and preventive service characteristics showed no impact on the effectiveness of a CMD prevention programme. Possible explanations could be the effectiveness of protocolised pharmaceutical treatment and only limited contribution of lifestyle programmes on the improvement of CMD risk factors.

Increasing Cancer Screening Rates in Primary Care

Screening for cancer has contributed to substantial reductions in death from several cancers and is one of the most cost-effective preventive interventions in all of health care. In the United States, primary care clinicians, their clinical teams, and the systems in which they work are primarily responsible for ensuring that screening occurs. In order to achieve the highest possible population-wide screening rates, primary care clinicians must embrace the responsibility to screen their entire enrolled patient population, institute several overarching general approaches to screening, and implement a combination of evidence-based interventions.

Champions in context: which attributes matter for change efforts in healthcare?

Background

Research to date has focused on strategies and resources used by effective champions of healthcare change efforts, rather than personal characteristics that contribute to their success. We sought to identify and describe champion attributes influencing outcomes of healthcare change efforts. To examine attributes of champions, we used postpartum contraceptive care as a case study, because recommended services are largely unavailable, and implementation requires significant effort.

Methods

We conducted a comparative case study of the implementation of inpatient postpartum contraceptive care at 11 U.S. maternity hospitals in 2017–18. We conducted site visits that included semi-structured key informant interviews informed by the Consolidated Framework for Implementation Research (CFIR). Phase one analysis (qualitative content analysis using a priori CFIR codes and cross-case synthesis) showed that implementation leaders (“champions”) strongly influenced outcomes across sites. To understand champion effects, phase two inductive analysis included (1) identifying and elaborating key attributes of champions; (2) rating the presence or absence of each attribute in champions; and 3) cross-case synthesis to identify patterns among attributes, context, and implementation outcomes.

Results

We completed semi-structured interviews with 78 clinicians, nurses, residents, pharmacy and revenue cycle staff, and hospital administrators. All identified champions were obstetrician-gynecologists. Six key attributes of champions emerged: influence, ownership, physical presence at the point of change, persuasiveness, grit, and participative leadership style. These attributes promoted success by enabling champions to overcome institutional siloing, build and leverage professional networks, create tension for change, cultivate a positive learning climate, optimize compatibility with existing workflow, and engage key stakeholders. Not all champion attributes were required for success, and having all attributes did not guarantee success.

Conclusions

Effective champions appear to leverage six key attributes to facilitate healthcare change efforts. Prospective evaluations of the interactions among champion attributes, context, and outcomes may further elucidate how champions exert their effects.

Leading Innovative Practice: Leadership Attributes in LEAP Practices

Policy Points An onslaught of policies from the federal government, states, the insurance industry, and professional organizations continually requires primary care practices to make substantial changes; however, ineffective leadership at the practice level can impede the dissemination and scale-up of these policies. The inability of primary care practice leadership to respond to ongoing policy demands has resulted in moral distress and clinician burnout. Investments are needed to develop interventions and educational opportunities that target a broad array of leadership attributes.

CONTEXT

Over the past several decades, health care in the United States has undergone substantial and rapid change. At the heart of this change is an assumption that a more robust primary care infrastructure helps achieve the quadruple aim of improved care, better patient experience, reduced cost, and improved work life of health care providers. Practice-level leadership is essential to succeed in this rapidly changing environment. Complex adaptive systems theory offers a lens for understanding important leadership attributes.

METHODS

A review of the literature on leadership from a complex adaptive system perspective identified nine leadership attributes hypothesized to support practice change: motivating others to engage in change, managing abuse of power and social influence, assuring psychological safety, enhancing communication and information sharing, generating a learning organization, instilling a collective mind, cultivating teamwork, fostering emergent leaders, and encouraging boundary spanning. Through a secondary qualitative analysis, we applied these attributes to nine practices ranking high on both a practice learning and leadership scale from the Learning from Effective Ambulatory Practice (LEAP) project to see if and how these attributes manifest in high-performing innovative practices.

FINDINGS

We found all nine attributes identified from the literature were evident and seemed important during a time of change and innovation. We identified two additional attributes-anticipating the future and developing formal processes-that we found to be important. Complexity science suggests a hypothesized developmental model in which some attributes are foundational and necessary for the emergence of others.

CONCLUSIONS

Successful primary care practices exhibit a diversity of strong local leadership attributes. To meet the realities of a rapidly changing health care environment, training of current and future primary care leaders needs to be more comprehensive and move beyond motivating others and developing effective teams.

Usability testing of a smartphone-based retinal camera among first-time users in the primary care setting

Smartphone-based retinal photography is a promising method for increasing accessibility of retinal screening in the primary care and community settings. Recent work has focused on validating its use in detection of diabetic retinopathy. However, retinal imaging can be technically challenging and additional work is needed to improve ease of retinal imaging in the primary care setting. We therefore performed usability testing of a smartphone-based retinal camera, RetinaScope, among medical assistants in primary care who had never performed retinal imaging. A total of 24 medical assistants performed first-time imaging in a total of five rounds of testing, and iterative improvements to the device were made between test rounds based on the results. The time to acquire a single ~50 degree image of the posterior pole of a model eye decreased from 283 ± 60 seconds to 34 ± 17 seconds (p < 0.01) for first-time users. The time to acquire 5 overlapping images of the retina decreased from 325 ± 60 seconds to 118 ± 26 seconds (p = 0.02) for first-time users. Testing in the human eye demonstrated that a single wide-view retinal image could be captured in 65 ± 7 seconds and 5 overlapping images in 229 ± 114 seconds. Users reported high Systems Usability Scores of 86 ± 13 throughout the rounds, reflecting a high level of comfort in first-time operation of the device. Our study demonstrates that smartphone-based retinal photography has the potential to be quickly adopted among medical assistants in the primary care setting.

Patients' and General Practitioners' Views About Preventive Care in Family Medicine in Switzerland: A Cross-sectional Study

Objectives

The aim of this study was to describe general practitioners (GPs)’ opinions and practices of preventive care and patients’ opinions, attitudes, and behaviors towards prevention.

Methods

The data stemmed from a cross-sectional national survey on prevention conducted in Switzerland from 2015 to 2016. In total, 170 randomly drawn GPs and 1154 of their patients participated. The GPs answered an online questionnaire and the patients answered a questionnaire administrated by fieldworkers present at their practices.

Results

Both patients and GPs agreed that delivering preventive care is the dedicated role of a GP. It appeared that beyond classical topics of prevention such as cardiovascular risk factors, other prevention areas (e.g., cannabis consumption, immunization, occupational risks) were scarcely covered by GPs and reported as little-known by patients. In addition, GPs seemed to use a selective approach to prevention, responding to the clinical context, rather than a systematic approach to health promotion. The results also highlight possibilities to improve prevention in family medicine through options such as more supportive tools and public advertising, more time and more delegated tasks and, finally, a more recognized role.

Conclusions

Despite an unfavorable context of prevention within the healthcare system, preventive care in family medicine is reasonably good in Switzerland. However, some limitations appear regarding the topics and the circumstances of preventive care delivery. A global effort is needed to implement necessary changes, and the responsibility should be broadened to other stakeholders.

Family Medicine Program in Iran: SWOT Analysis and TOWS Matrix Model

BACKGROUND

We aimed to determine strength, weakness, opportunities and threats analysis and intended to present strengths, weaknesses, opportunities and threats matrix model for appropriate implementation of Family medicine program in Iran.

METHODS

This was a descriptive-analytical and cross-sectional study. All attending physicians in 30 health care centers of Tehran University of Medical Sciences, Tehran, Iran were asked to present and prioritized their views about strengths, weaknesses, opportunities, and threats factors of family medicine program in Iran in 2015. Then, the prioritization of these factors was showed by weighted score of each factor. Finally, the respondents determined four groups of TOWS model including SO, ST, WO, and WT strategy for development of family medicine in Iran.

RESULTS

Totally, the respondents expressed 44 factors as strengths, weaknesses, opportunities, and threats of family medicine program and prioritized these factors and suggested 30 TOWS matrix strategy for efficient implementation of this program.

CONCLUSION

There were many internal and external factors that impress the implementation of family medicine program. There is a gap between the ideal and the current situation of this program. We suggest the health care system policy makers notice the TOWS matrix strategies determined for improvement of family medicine program in Iran.

A structural equation model of the family physicians attitude towards their role in prevention: a cross-sectional study in Switzerland

BACKGROUND

In contrast to many studies exploring barriers to preventive care in family medicine, there is less quantitative research regarding the self-perceived role of family physicians (FPs) in prevention and its predictive factors. Moreover, the existing studies considered this attitude as a homogeneous entity. The objective of this study is firstly, to characterize FPs' attitudes towards prevention taking into account nine different prevention themes, and secondly, to explore the factors that could be predictive of this attitude.

METHODS

The data stem from a cross-sectional national survey on prevention we conducted in Switzerland from 2015 to 2016 (170 physicians randomly drawn, online questionnaire). We first performed a confirmatory factor analysis to define a homogeneous latent variable regarding physicians' attitude towards prevention, then, a structural equation modeling to identify potential predictors.

RESULTS

The FP' attitude towards their role in preventive care was homogeneously positive whatever the topic (smoking, drinking dietary habits, physical activities, and more generally, cardiovascular risk factors) except for occupational risks and cannabis consumption. A feeling of good effectiveness was a positive predictor of this positive attitude while seniority, the lack of reimbursement and being a physician from the German-speaking area were negative predictors.

CONCLUSION

The FP' attitude about their role in prevention is homogeneous concerning the 'classical' topics of prevention, whereas they still under-recognize certain topics as important fields for prevention. To change this situation, we probably need a global effort to introduce other ways of thinking about prevention, including not only FP but also all stakeholders.

Shifting Implementation Science Theory to Empower Primary Care Practices

Observers of the past 10 to 15 years have witnessed the simultaneous growth of dramatic changes in the practice of primary care and the emergence of a new field of dissemination and implementation science (D&I). Most current implementation science research in primary care assumes practices are not meeting externally derived standards and need external support to meet these demands. After a decade of initiatives, many stakeholders now question the return on their investments. Overall improvements in quality metrics, utilization cost savings, and patient experience have been less than anticipated. While recently conducting a research project in primary care practices, we unexpectedly discovered 3 practices that profoundly shifted our thinking about the sources and directionality of practice change and the underlying assumptions of D&I. Inspired by these practices-along with systems thinking, complexity theory, action research, and the collaborative approaches of community-based participatory research-we propose a reimagining of D&I theory to empower practices. We shift the emphasis regarding the source and direction of change from outside-in to inside-out Such a shift has the potential to open a new frontier in the science of dissemination and implementation and inform better health policy.

Delivering clinical preventive services in the Islamic Republic of Iran: A model for screening and behavior consultation practices

Background: Screening and behavior consultation are considered to be limited, dispersed and expensive services across the country. To deliver efficient and equitable services current disordered practices need to be consolidated.

Methods: An analysis of current situation, learned lessons and future scopes of country’s preventive care delivery, along with a review of international experience and generous participation of various stakeholders, led to proposing a model for screening and behavior consultation practices in IR. Iran.

Results: Upon the results of the previous steps, the desired model was based on the network system and family physician. Comprehensive health centers and other centers affiliated to the network are the most appropriate service positions. However, private and academic preventive centers are playing their rules.

Conclusion: The proposed model matches the overall pattern of service delivery in the health system (network system with the private sector and the educational sector).

A qualitative study of clinical champions in context: Clinical champions across three levels of acute care

Objectives:

To compare activities and field descriptions of clinical champions across three levels of stroke centers.

Methods:

A cross-sectional qualitative study using quota sampling was conducted. The setting for this study was 38 acute stroke centers based in US Veterans Affairs Medical Centers with 8 designated as Primary, 24 as Limited Hours, and 6 as Stroke Support Centers. Key informants involved in stroke care were interviewed using a semi-structured approach. A cross-case synthesis approach was used to conduct a qualitative analysis of clinical champions’ behaviors and characteristics. Clinical champion behaviors were described and categorized across three dimensions: enthusiasm, persistence, and involving the right people.

Results:

Clinical champions at Primary Stroke Centers represented diverse medical disciplines and departments (education, quality management); directed implementation of acute stroke care processes; coordinated processes across service lines; and benefited from supportive contexts for implementation. Clinical champions at Limited Hours Stroke Centers varied in steering implementation efforts, building collaboration across disciplines, and engaging in other clinical champion activities. Clinical champions at Stroke Support Centers were implementing limited changes to stroke care and exhibited few behaviors fitting the three clinical champion dimensions. Other clinical champion behaviors included educating colleagues, problem-solving, implementing new care pathways, monitoring progress, and standardizing processes.

Conclusion:

These data demonstrate clinical champion behaviors for implementing changes to complex care processes such as acute stroke care. Changes to complex care processes involved coordination among clinicians from multiple services lines, persistence facing obstacles to change, and enthusiasm for targeted practice changes.

Uncovering the wisdom hidden between the lines: the Collaborative Reflexive Deliberative Approach

BACKGROUND

Meta-analysis and meta-synthesis have been developed to synthesize results across published studies; however, they are still largely grounded in what is already published, missing the tacit 'between the lines' knowledge generated during many research projects that are not intrinsic to the main objectives of studies.

OBJECTIVE

To develop a novel approach to expand and deepen meta-syntheses using researchers' experience, tacit knowledge and relevant unpublished materials.

METHODS

We established new collaborations among primary health care researchers from different contexts based on common interests in reforming primary care service delivery and a diversity of perspectives. Over 2 years, the team met face-to-face and via tele- and video-conferences to employ the Collaborative Reflexive Deliberative Approach (CRDA) to discuss and reflect on published and unpublished results from participants' studies to identify new patterns and insights.

RESULTS

CRDA focuses on uncovering critical insights, interpretations hidden within multiple research contexts. For the process to work, careful attention must be paid to ensure sufficient diversity among participants while also having people who are able to collaborate effectively. Ensuring there are enough studies for contextual variation also matters. It is necessary to balance rigorous facilitation techniques with the creation of safe space for diverse contributions.

CONCLUSIONS

The CRDA requires large commitments of investigator time, the expense of convening facilitated retreats, considerable coordination, and strong leadership. The process creates an environment where interactions among diverse participants can illuminate hidden information within the contexts of studies, effectively enhancing theory development and generating new research questions and strategies.

Primary care colorectal cancer screening correlates with breast cancer screening: implications for colorectal cancer screening improvement interventions

Objective

National colorectal cancer (CRC) screening rates have plateaued. To optimize interventions targeting those unscreened, a better understanding is needed of how this preventive service fits in with multiple preventive and chronic care needs managed by primary care providers (PCPs). This study examines whether PCP practices of other preventive and chronic care needs correlate with CRC screening.

Methods

We performed a retrospective cohort study of 90 PCPs and 33,137 CRC screening-eligible patients. Five PCP quality metrics (breast cancer screening, cervical cancer screening, HgbA1c and LDL testing, and blood pressure control) were measured. A baseline correlation test was performed between these metrics and PCP CRC screening rates. Multivariable logistic regression with clustering at the clinic-level estimated odds ratios and 95% confidence intervals for these PCP quality metrics, patient and PCP characteristics, and their relationship to CRC screening.

Results

PCP CRC screening rates have a strong correlation with breast cancer screening rates (r = 0.7414, p < 0.001) and a weak correlation with the other quality metrics. In the final adjusted model, the only PCP quality metric that significantly predicted CRC screening was breast cancer screening (OR 1.25; 95% CI 1.11–1.42; p < 0.001).

Conclusions

PCP CRC screening rates are highly concordant with breast cancer screening. CRC screening is weakly concordant with cervical cancer screening and chronic disease management metrics. Efforts targeting PCPs to increase CRC screening rates could be bundled with breast cancer screening improvement interventions to increase their impact and success.

Information needs of physicians, care coordinators, and families to support care coordination of children and youth with special health care needs (CYSHCN)

Objectives

Identify and describe information needs and associated goals of physicians, care coordinators, and families related to coordinating care for medically complex children and youth with special health care needs (CYSHCN).

Materials and Methods

We conducted 19 in-depth interviews with physicians, care coordinators, and parents of CYSHCN following the Critical Decision Method technique. We analyzed the interviews for information needs posed as questions using a systematic content analysis approach and categorized the questions into information need goal types and subtypes.

Results

The Critical Decision Method interviews resulted in an average of 80 information needs per interview. We categorized them into 6 information need goal types: (1) situation understanding, (2) care networking, (3) planning, (4) tracking/monitoring, (5) navigating the health care system, and (6) learning, and 32 subtypes.

Discussion and Conclusion

Caring for CYSHCN generates a large amount of information needs that require significant effort from physicians, care coordinators, parents, and various other individuals. CYSHCN are often chronically ill and face developmental challenges that translate into intense demands on time, effort, and resources. Care coordination for CYCHSN involves multiple information systems, specialized resources, and complex decision-making. Solutions currently offered by health information technology fall short in providing support to meet the information needs to perform the complex care coordination tasks. Our findings present significant opportunities to improve coordination of care through multifaceted and fully integrated informatics solutions.

Conceptual models to guide integration during analysis in convergent mixed methods studies

Methodologists have offered general strategies for integration in mixed-methods studies through merging of quantitative and qualitative data. While these strategies provide researchers in the field general guidance on how to integrate data during mixed-methods analysis, a methodological typology detailing specific analytic frameworks has been lacking. The purpose of this article is to introduce a typology of analytical approaches for mixed-methods data integration in mixed-methods convergent studies. We distinguish three dimensions of data merging analytics: (1) the relational dimension, (2) the methodological dimension, and (3) the directional dimension. Five different frameworks for data merging relative to the methodological and directional dimension in convergent mixed-methods studies are described: (1) the explanatory unidirectional approach, (2) the exploratory unidirectional approach, (3) the simultaneous bidirectional approach, (4) the explanatory bidirectional approach, and (5) the exploratory bidirectional approach. Examples from empirical studies are used to illustrate each type. Researchers can use this typology to inform and articulate their analytical approach during the design, implementation, and reporting phases to convey clearly how an integrated approach to data merging occurred.

Individualising Chronic Care Management by Analysing Patients' Needs - A Mixed Method Approach

Background

Modern health systems are increasingly faced with the challenge to provide effective, affordable and accessible health care for people with chronic conditions. As evidence on the specific unmet needs and their impact on health outcomes is limited, practical research is needed to tailor chronic care to individual needs of patients with diabetes. Qualitative approaches to describe professional and informal caregiving will support understanding the complexity of chronic care. Results are intended to provide practical recommendations to be used for systematic implementation of sustainable chronic care models.

Method

A mixed method study was conducted. A standardised survey (n = 92) of experts in chronic care using mail responses to open-ended questions was conducted to analyse existing chronic care programs focusing on effective, problematic and missing components. An expert workshop (n = 22) of professionals and scientists of a European funded research project MANAGE CARE was used to define a limited number of unmet needs and priorities of elderly patients with type 2 diabetes mellitus and comorbidities. This list was validated and ranked using a multilingual online survey (n = 650). Participants of the online survey included patients, health care professionals and other stakeholders from 56 countries.

Results

The survey indicated that current care models need to be improved in terms of financial support, case management and the consideration of social care. The expert workshop identified 150 patient needs which were summarised in 13 needs dimensions. The online survey of these pre-defined dimensions revealed that financial issues, education of both patients and professionals, availability of services as well as health promotion are the most important unmet needs for both patients and professionals.

Conclusion

The study uncovered competing demands which are not limited to medical conditions. The findings emphasise that future care models need to focus stronger on individual patient needs and promote their active involvement in co-design and implementation. Future research is needed to develop new chronic care models providing evidence-based and practical implications for the regional care setting.

Why aren't they happy? An analysis of end-user satisfaction with Electronic health records

Introduction. Implementations of electronic health records (EHR) have been met with mixed outcome reviews. Complaints about these systems have led to many attempts to have useful measures of end-user satisfaction. However, most user satisfaction assessments do not focus on high-level reasoning, despite the complaints of many physicians. Our study attempts to identify some of these determinants. Method. We developed a user satisfaction survey instrument, based on pre-identified and important clinical and non-clinical clinician tasks. We surveyed a sample of in-patient physicians and focused on using exploratory factor analyses to identify underlying high-level cognitive tasks. We used the results to create unique, orthogonal variables representative of latent structure predictive of user satisfaction. Results. Our findings identified 3 latent high-level tasks that were associated with end-user satisfaction: a) High- level clinical reasoning b) Communicate/coordinate care and c) Follow the rules/compliance. Conclusion: We were able to successfully identify latent variables associated with satisfaction. Identification of communicability and high-level clinical reasoning as important factors determining user satisfaction can lead to development and design of more usable electronic health records with higher user satisfaction.

Time and feasibility of prevention in primary care

BACKGROUND

Prevention is an essential task in primary care. According to primary care physicians (PCPs),lack of time is one of the principal obstacles to its performance.

OBJECTIVE

To assess the feasibility of prevention in terms of time by estimating the time necessary to perform all of the preventive care recommended, separately from the PCPs and patient's perspectives, and to compare them to the amount of time available.

METHODS

A review of the literature identified the prevention procedures recommended in France, the duration of each procedure and its recommended frequency, as well as PCPs' consultation time. A hypothetical patient panel size of 1000 patients, representative of the French population, served as the basis for our calculations of the annual time necessary for prevention for a PCP. The prevention time from the patient's perspective was estimated from data collected from a previous study of a panel of 3556 patients.

RESULTS

For PCPs, the annual time necessary for all of the required preventive care was 250 hours, or 20% of their total patient time. For a patient, the annual time required for prevention during encounters with a PCP ranged from 9.7 to 26.4 minutes per year. The mean total encounter time was 75.9 minutes per year. Nearly 73% of patients had a prevention-to-care time ratio exceeding 15%.

CONCLUSION

Feasibility thus differs substantially between patients. These differences correspond especially to disparities in the annual care time used by each patient. Specific solutions should be developed according to the patients' utilization of care.

Interprofessional teamwork innovations for primary health care practices and practitioners: evidence from a comparison of reform in three countries

Context

A key aim of reforms to primary health care (PHC) in many countries has been to enhance interprofessional teamwork. However, the impact of these changes on practitioners has not been well understood.

Objective

To assess the impact of reform policies and interventions that have aimed to create or enhance teamwork on professional communication relationships, roles, and work satisfaction in PHC practices.

Design

Collaborative synthesis of 12 mixed methods studies.

Setting

Primary care practices undergoing transformational change in three countries: Australia, Canada, and the USA, including three Canadian provinces (Alberta, Ontario, and Quebec).

Methods

We conducted a synthesis and secondary analysis of 12 qualitative and quantitative studies conducted by the authors in order to understand the impacts and how they were influenced by local context.

Results

There was a diverse range of complex reforms seeking to foster interprofessional teamwork in the care of patients with chronic disease. The impact on communication and relationships between different professional groups, the roles of nursing and allied health services, and the expressed satisfaction of PHC providers with their work varied more within than between jurisdictions. These variations were associated with local contextual factors such as the size, power dynamics, leadership, and physical environment of the practice. Unintended consequences included deterioration of the work satisfaction of some team members and conflict between medical and nonmedical professional groups.

Conclusion

The variation in impacts can be understood to have arisen from the complexity of interprofessional dynamics at the practice level. The same characteristic could have both positive and negative influence on different aspects (eg, larger practice may have less capacity for adoption but more capacity to support interprofessional practice). Thus, the impacts are not entirely predictable and need to be monitored, and so that interventions can be adapted at the local level.

Maintenance of Increased Childhood Influenza Vaccination Rates 1 Year After an Intervention in Primary Care Practices

OBJECTIVE

Influenza vaccination rates among some groups of children remain below the Healthy People 2020 goal of 70%. Multistrategy interventions to increase childhood influenza vaccination have not been evaluated recently.

METHODS

Twenty pediatric and family medicine practices were randomly assigned to receive the intervention in either year 1 or year 2. This study focuses on influenza vaccine uptake in the 10 year 1 intervention sites during intervention and the following maintenance year. The intervention included the 4 Pillars Immunization Toolkit-a practice improvement toolkit, early delivery of donated vaccine for disadvantaged children, staff education, and feedback on progress. During the maintenance year, practices were not assisted or contacted, except to complete follow-up surveys. Student's t tests assessed vaccine uptake of children aged 6 months to 18 years, and multilevel regression modeling in repeated measures determined variables related to the likelihood of vaccination.

RESULTS

Influenza vaccine uptake increased 12.4 percentage points (PP; P < .01) during active intervention and uptake was sustained (+0.4 PP; P > .05) during maintenance, for an average change of 12.7 PP over all sites, increasing from 42.2% at baseline to 54.9% (P < .001) during maintenance. In regression modeling that controlled for age, race, and insurance, likelihood of vaccination was greater during intervention than baseline (odds ratio 1.47; 95% confidence interval 1.44-1.50; P < .001) and greater during maintenance than baseline (odds ratio 1.50; 95% confidence interval 1.47-1.54; P < .001).

CONCLUSIONS

In primary care practices, a multistrategy intervention that included the 4 Pillars Immunization Toolkit, early delivery of vaccine, and feedback was associated with significant improvements in childhood influenza vaccination rates that were maintained 1 year after active intervention.

What are the similarities and differences in structure and function among the three main models of community health centers in China: a systematic review

Background

There are three major models of primary care providers (Community Health Centers, CHCs) in China, i.e., government managed, hospital managed and privately owned CHCs. We performed a systematic review of structures and health care delivery patterns of the three models of CHCs.

Methods

Studies from relevant English and Chinese databases for the period of 1997–2011 were searched. Two independent researchers extracted data from the eligible studies using a standardized abstraction form. Methodological quality of included articles was assessed with the Mixed Methods Appraisal Tool (MMAT).

Results

A total of 13 studies was included in the final analysis. Compared with the other two models, private CHCs had a smaller health workforce and lower share of government funding in their total revenues. Private CHCs also had fewer training opportunities, were less recognized by health insurance schemes and tended to provide primary care services of poor quality. Hospital managed CHCs attracted patients through their higher quality of clinical care, while private CHCs attracted users through convenience and medical equipment.

Conclusions

Our study suggested that government and hospital managed CHCs were more competent and provided better primary care than privately owned CHCs. Further studies are warranted to comprehensively compare performances among different models of CHCs.

Eligibility for interventions, co-occurrence and risk factors for unhealthy behaviours in patients consulting for routine primary care: results from the Pre-Empt study

Background

Smoking, excessive drinking, lack of exercise and a poor diet remain key causes of premature morbidity and mortality globally, yet it is not clear what proportion of patients attending for routine primary care are eligible for interventions about these behaviours, the extent to which they co-occur within individuals, and which individuals are at greatest risk for multiple unhealthy behaviours. The aim of the trial was to examine ‘intervention eligibility’ and co-occurrence of the ‘big four’ risky health behaviours – lack of exercise, smoking, an unhealthy diet and excessive drinking – in a primary care population.

Methods

Data were collected from adult patients consulting routinely in general practice across South Wales as part of the Pre-Empt study; a cluster randomised controlled trial.

After giving consent, participants completed screening instruments, which included the following to assess eligibility for an intervention based on set thresholds: AUDIT-C (for alcohol), HSI (for smoking), IPAQ (for exercise) and a subset of DINE (for diet). The intervention following screening was based on which combination of risky behaviours the patient had. Descriptive statistics, χ2 tests for association and ordinal regressions were undertaken.

Results

Two thousand sixty seven patients were screened: mean age of 48.6 years, 61.9 % female and 42.8 % in a managerial or professional occupation. In terms of numbers of risky behaviours screened eligible for, two was the most common (43.6 %), with diet and exercise (27.2 %) being the most common combination. Insufficient exercise was the most common single risky behaviour (12.0 %). 21.8 % of patients would have been eligible for an intervention for three behaviours and 5.9 % for all four behaviours. Just 4.5 % of patients did not identify any risky behaviours. Women, older age groups and those in managerial or professional occupations were more likely to exhibit all four risky behaviours.

Conclusion

Very few patients consulting for routine primary care screen ineligible for interventions about common unhealthy behaviours, and most engage in more than one of the major common unhealthy behaviours. Clinicians should be particularly alert to opportunities to engaging younger, non professional men and those with multi-morbidity about risky health behaviour.

Trial registration

ISRCTN22495456

The myth of standardized workflow in primary care

OBJECTIVE

Primary care efficiency and quality are essential for the nation's health. The demands on primary care physicians (PCPs) are increasing as healthcare becomes more complex. A more complete understanding of PCP workflow variation is needed to guide future healthcare redesigns.

METHODS

This analysis evaluates workflow variation in terms of the sequence of tasks performed during patient visits. Two patient visits from 10 PCPs from 10 different United States Midwestern primary care clinics were analyzed to determine physician workflow. Tasks and the progressive sequence of those tasks were observed, documented, and coded by task category using a PCP task list. Variations in the sequence and prevalence of tasks at each stage of the primary care visit were assessed considering the physician, the patient, the visit's progression, and the presence of an electronic health record (EHR) at the clinic.

RESULTS

PCP workflow during patient visits varies significantly, even for an individual physician, with no single or even common workflow pattern being present. The prevalence of specific tasks shifts significantly as primary care visits progress to their conclusion but, notably, PCPs collect patient information throughout the visit.

DISCUSSION

PCP workflows were unpredictable during face-to-face patient visits. Workflow emerges as the result of a "dance" between physician and patient as their separate agendas are addressed, a side effect of patient-centered practice.

CONCLUSIONS

Future healthcare redesigns should support a wide variety of task sequences to deliver high-quality primary care. The development of tools such as electronic health records must be based on the realities of primary care visits if they are to successfully support a PCP's mental and physical work, resulting in effective, safe, and efficient primary care.

The challenges of trying to increase preventive healthcare for children in general practice: results of a feasibility study

BACKGROUND

In Australia, general practice, the linchpin for delivery of preventive health care to large segments of the population, provides child-immunisation and preventive health alongside government services. Despite this, less than half of eligible children complete a Healthy Kids Check (HKC), a preschool preventative health assessment available since 2008. Using a rigorous theoretical process, the barriers that affected delivery and reduced general practitioner and practice nurse motivation to provide HKCs, were addressed. The resulting multifaceted intervention, aimed at increasing the proportion of children receiving evidence informed HKCs from general practice, was piloted to inform a future randomised controlled trial.

METHODS

The intervention was piloted in a before and after study at three sites located southeast of Melbourne, between February and October 2014. The HKC-intervention involved: 1) Delivery of training modules that motivated reception and clinical staff by delivering key messages about local prevalence rates and the "Core Story of Child Development" 2) Practical advice to prepare clinics for specific HKC-examinations 3) Workflow advice regarding systems that included all staff in the HKC process, and 4) Provision of a "Community Resources Folder" that enabled decision making and referrals. A major component of the intervention incorporated the promotion of structured developmental screening by the practice team using Parents' Evaluation of Developmental Status.

RESULTS

Twenty of 22 practitioners and practice managers agreed to join the study. Post-training questionnaires showed participants had developed their skills working with young children as a result of the training and all respondents believed they had successfully implemented standardised HKC services. Post intervention proportions of children completing HKCs significantly increased in two of the practices and quality improvements in HKC-processes were recorded across all three sites.

CONCLUSION

This pilot study confirmed the feasibility of delivering a multi-faceted intervention to increase HKCs from general practice and demonstrated that significant quality improvements could be made. Future studies need to extend the intervention to other states and research the health outcomes of HKCs.

Front-office staff can improve clinical tobacco intervention: health coordinator pilot project

OBJECTIVE

To learn whether front-line personnel in primary care practices can increase delivery of clinical tobacco interventions and also help smokers address physical inactivity, at-risk alcohol use, and depression.

DESIGN

Uncontrolled before-and-after design.

SETTING

Vancouver, BC, area (4 practices); northern British Columbia (2 practices).

PARTICIPANTS

Six practices, with 1 staff person per practice serving as a "health coordinator" who tracked and, after the baseline period, delivered preventive interventions to all patients who smoked. To assess delivery of preventive interventions, each practice was to sample 300 consecutive patient records, both at baseline and at follow-up 15 months later.

INTERVENTIONS

Front-office staff were recruited, trained, paid, and given ongoing support to provide preventive care. Clinicians supplemented this care with advice and guided the use of medication.

MAIN OUTCOME MEASURES

Effectiveness of the intervention was based on comparison, at baseline and at follow-up, of the proportion of patients with any of the following 6 proven intervention components documented in their medical records: chart reminder, advice received, self-management plan, target quit date, referral, and follow-up date (as they applied to tobacco, physical inactivity, at-risk alcohol use, and depression). A Tobacco Intervention Flow Sheet cued preventive care, and its data were entered into a spreadsheet (which served as a smokers' registry). Qualitative appraisal data were noted.

RESULTS

For tobacco, substantial increases occurred after the intervention period in the proportion of patients with each of the intervention components noted in their charts: chart reminder (20% vs 94%); provision of advice (34% vs 79%); self-management plan (14% vs 57%); target quit date (5% vs 11%); referral (6% vs 11%); and follow-up date (7% vs 42%). Interventions for physical inactivity and depression showed some gains, but there were no gains for at-risk alcohol use. Front-line staff, patients, and clinicians were enthusiastic about the services offered.

CONCLUSION

Selected front-office personnel can substantially increase the delivery of evidence-based clinical tobacco intervention and increase patient and staff satisfaction in doing so. How far these findings can be generalized and their population effects require further study.

Achieving integration in mixed methods designs-principles and practices

Mixed methods research offers powerful tools for investigating complex processes and systems in health and health care. This article describes integration principles and practices at three levels in mixed methods research and provides illustrative examples. Integration at the study design level occurs through three basic mixed method designs-exploratory sequential, explanatory sequential, and convergent-and through four advanced frameworks-multistage, intervention, case study, and participatory. Integration at the methods level occurs through four approaches. In connecting, one database links to the other through sampling. With building, one database informs the data collection approach of the other. When merging, the two databases are brought together for analysis. With embedding, data collection and analysis link at multiple points. Integration at the interpretation and reporting level occurs through narrative, data transformation, and joint display. The fit of integration describes the extent the qualitative and quantitative findings cohere. Understanding these principles and practices of integration can help health services researchers leverage the strengths of mixed methods.

Left behind: widening disparities for males and females in US county life expectancy, 1985-2010

BACKGROUND

The United States spends more than any other country on health care. The poor relative performance of the US compared to other high-income countries has attracted attention and raised questions about the performance of the US health system. An important dimension to poor national performance is the large disparities in life expectancy.

METHODS

We applied a mixed effects Poisson statistical model and Gaussian Process Regression to estimate age-specific mortality rates for US counties from 1985 to 2010. We generated uncertainty distributions for life expectancy at each age using standard simulation methods.

RESULTS

Female life expectancy in the United States increased from 78.0 years in 1985 to 80.9 years in 2010, while male life expectancy increased from 71.0 years in 1985 to 76.3 years in 2010. The gap between female and male life expectancy in the United States was 7.0 years in 1985, narrowing to 4.6 years in 2010. For males at the county level, the highest life expectancy steadily increased from 75.5 in 1985 to 81.7 in 2010, while the lowest life expectancy remained under 65. For females at the county level, the highest life expectancy increased from 81.1 to 85.0, and the lowest life expectancy remained around 73. For male life expectancy at the county level, there have been three phases in the evolution of inequality: a period of rising inequality from 1985 to 1993, a period of stable inequality from 1993 to 2002, and rising inequality from 2002 to 2010. For females, in contrast, inequality has steadily increased during the 25-year period. Compared to only 154 counties where male life expectancy remained stagnant or declined, 1,405 out of 3,143 counties (45%) have seen no significant change or a significant decline in female life expectancy from 1985 to 2010. In all time periods, the lowest county-level life expectancies are seen in the South, the Mississippi basin, West Virginia, Kentucky, and selected counties with large Native American populations.

CONCLUSIONS

The reduction in the number of counties where female life expectancy at birth is declining in the most recent period is welcome news. However, the widening disparities between counties and the slow rate of increase compared to other countries should be viewed as a call for action. An increased focus on factors affecting health outcomes, morbidity, and mortality such as socioeconomic factors, difficulty of access to and poor quality of health care, and behavioral, environmental, and metabolic risk factors is urgently required.

Rural, suburban, and urban differences in factors that impact physician adherence to clinical preventive service guidelines

PURPOSE

Rural-urban disparities in provision of preventive services exist, but there is sparse research on how rural, suburban, or urban differences impact physician adherence to clinical preventive service guidelines. We aimed to identify factors that may cause differences in adherence to preventive service guidelines among rural, suburban, and urban primary care physicians.

METHODS

This qualitative study involved in-depth semistructured interviews with 29 purposively sampled primary care physicians (10 rural, 10 suburban, 9 urban) in Missouri. Physicians were asked to describe barriers and facilitators to clinical preventive service guideline adherence. Using techniques from grounded theory analysis, 2 coders first independently conducted content analysis then reconciled differences in coding to ensure agreement on intended meaning of transcripts.

FINDINGS

Patient epidemiologic differences, distance to health care services, and care coordination were reported as prominent factors that produced differences in preventive service guideline adherence among rural, suburban, and urban physicians. Epidemiologic differences impacted all physicians, but rural physicians highlighted the importance of occupational risk factors in their patients. Greater distance to health care services reduced visit frequency and was a prominent barrier for rural physicians. Care coordination among health care providers was problematic for suburban and urban physicians. Patient resistance to medical care and inadequate access to resources and specialists were identified as barriers by some rural physicians.

CONCLUSIONS

The rural, suburban, or urban context impacts whether a physician will adhere to clinical preventive service guidelines. Efforts to increase guideline adherence should consider the barriers and facilitators unique to rural, suburban, or urban areas.

Race, ethnicity and income as factors for HPV vaccine acceptance and use

If distributed equitably, Human Papillomavirus (HPV) vaccines have the potential to reduce racial disparities in HPV-related diseases and cervical cancers. However, current trends in the US indicate low uptake among all adolescents, with persistent disparities among minority and low-income adolescents despite largely positive views of vaccination among their parents. As Black, Hispanic, and Asian populations continue to grow in the US over the next 40 y, it is imperative that we not only improve HPV vaccination rates overall, but focus on high-risk populations to prevent an increase in cervical cancer disparities. This review discusses initiation and completion rates of the three-dose HPV vaccine series among adolescents in high-risk groups and describes cultural similarities and differences in motivation and barriers to vaccination. The goal of this review is to highlight factors leading to vaccination in different adolescent racial groups and to help guide the development of strategies to increase rates of vaccine initiation and completion among groups at the highest risk for developing cervical cancer.

Which practice characteristics are associated with the quality of cardiovascular disease prevention in European primary care?

BACKGROUND

Prevention of cardiovascular diseases (CVD) is a major health issue worldwide. Primary care plays an important role in cardiovascular risk management (CVRM). Guidelines and quality of care measures to assess CVRM in primary care practices are available. In this study, we assessed the relationship between structural and organisational practice characteristics and the quality of care provided in individuals at high risk for developing CVD in European primary care.

METHODS

An observational study was conducted in 267 general practices from 9 European countries. Previously developed quality indicators were abstracted from medical records of randomly sampled patients to create a composite quality measure. Practice characteristics were collected by a practice questionnaire and face to face interviews. Data were aggregated using factor analysis to four practice scores representing structural and organisational practice features. A hierarchical multilevel analysis was performed to examine the impact of practice characteristics on quality of CVRM.

RESULTS

The final sample included 4223 individuals at high risk for developing CVD (28% female) with a mean age of 66.5 years (SD 9.1). Mean indicator achievement was 59.9% with a greater variation between practices than between countries. Predictors at the patient level (age, gender) had no influence on the outcome. At the practice level, the score 'Preventive Services' (13 items) was positively associated with clinical performance (r = 1.92; p = 0.0058). Sensitivity analyses resulted in a 5-item score (PrevServ_5) that was also positively associated with the outcome (r = 4.28; p < 0.0001).

CONCLUSIONS

There was a positive association between the quality of CVRM in individuals at high risk for developing CVD and the availability of preventive services related to risk assessment and lifestyle management supported by information technology.

Influence of health insurance coverage on breast, cervical, and colorectal cancer screening in rural primary care settings

BACKGROUND

The current study was performed to determine, in rural settings, the relation between the type and status of insurance coverage and being up-to-date for breast, cervical, and colorectal cancer screening.

METHODS

Four primary care practices in 2 rural Oregon communities participated. Medical chart reviews that were conducted between October 2008 and August 2009 assessed insurance coverage and up-to-date status for breast, cervical, and colorectal cancer screening. Inclusion criteria involved having at least 1 health care visit within the past 5 years and being aged ≥ 55 years.

RESULTS

The majority of patients were women aged 55 years to 70 years, employed or retired, and who had private health insurance and an average of 2.5 comorbid conditions. The overall percentage of eligible women who were up-to-date for cervical cancer screening was 30%; approximately 27% of women were up-to-date for clinical breast examination, 37% were up-to-date for mammography, and 19% were up-to-date for both mammography and clinical breast examination. Approximately 38% of men and 35% of women were up-to-date for colorectal cancer screening using any test at appropriate screening intervals. In general, having any insurance versus being uninsured was associated with undergoing cancer screening. For each type of screening, patients who had at least 1 health maintenance visit were significantly more likely to be up-to-date compared with those with no health maintenance visits. A significant interaction was found between having health maintenance visits, having any health insurance, and being up-to-date for cancer screening tests.

CONCLUSIONS

Overall, the percentage of patients who were up-to-date for any cancer screening, especially cervical cancer screening, was found to be very low in rural Oregon. Patients with some form of health insurance were more likely to have had a health maintenance visit within the previous 2 years and to be up-to-date for breast, cervical, and/or colorectal cancer screening.

Primary care physicians' prevention counseling with patients with multiple morbidity

The prevalence of multiple health conditions, or multiple morbidity (MM), is increasing. Providing medical care for adults with MM presents challenges, including balancing disease management with prevention. We conducted in-depth semistructured interviews with 12 primary care physicians to explore their perspectives on prevention counseling among patients with MM. Participants described the complex relationship between disease management and prevention, highlighted the importance of patient motivation, and discussed various strategies to promote receptivity to prevention recommendations. The perceived potential benefits of prevention recommendations encouraged physicians to persist with such counseling, despite challenges presented by visit time constraints, reimbursement procedures, and concerns over futility. Physicians recommended the development of alternate care delivery and reimbursement models to overcome challenges of the existing health care system and to meet the prevention needs of patients with MM. We explore the implications of these findings for maximizing the health and quality of life of adults with MM.

Caries treatment in a dental practice-based research network: movement toward stated evidence-based treatment

OBJECTIVES

Practice-based research networks (PBRNs) provide a venue to foster evidence-based care. We tested the hypothesis that a higher level of participation in a dental PBRN is associated with greater stated change toward evidence-based practice.

METHODS

A total of 565 dental PBRN practitioner-investigators completed a baseline questionnaire entitled 'Assessment of Caries Diagnosis and Treatment'; 405 of these also completed a follow-up questionnaire about treatment of caries and existing restorations. Certain questions (six treatment scenarios) were repeated at follow-up a mean (SD) of 36.0 (3.8) months later. A total of 224 were 'full participants' (enrolled in clinical studies and attended at least one network meeting); 181 were 'partial participants' (did not meet 'full' criteria).

RESULTS

From 10% to 62% of practitioners were 'surgically invasive' at baseline, depending on the clinical scenario. Stated treatment approach was significantly less invasive at follow-up for four of six items. Change was greater among full participants and those with a more-invasive approach at baseline, with an overall pattern of movement away from the extremes.

CONCLUSIONS

These results are consistent with a preliminary conclusion that network participation fostered movement of scientific evidence into routine practice. PBRNs may foster movement of evidence into everyday practice as practitioners become engaged in the scientific process.

Primary care practice transformation is hard work: insights from a 15-year developmental program of research

BACKGROUND

Serious shortcomings remain in clinical care in the United States despite widespread use of improvement strategies for enhancing clinical performance based on knowledge transfer approaches. Recent calls to transform primary care practice to a patient-centered medical home present even greater challenges and require more effective approaches.

METHODS

Our research team conducted a series of National Institutes of Health funded descriptive and intervention projects to understand organizational change in primary care practice settings, emphasizing a complexity science perspective. The result was a developmental research effort that enabled the identification of critical lessons relevant to enabling practice change.

RESULTS

A summary of findings from a 15-year program of research highlights the limitations of viewing primary care practices in the mechanistic terms that underlie current or traditional approaches to quality improvement. A theoretical perspective that views primary care practices as dynamic complex adaptive systems with "agents" who have the capacity to learn, and the freedom to act in unpredictable ways provides a better framework for grounding quality improvement strategies. This framework strongly emphasizes that quality improvement interventions should not only use a complexity systems perspective, but also there is a need for continual reflection, careful tailoring of interventions, and ongoing attention to the quality of interactions among agents in the practice.

CONCLUSIONS

It is unlikely that current strategies for quality improvement will be successful in transforming current primary care practice to a patient-centered medical home without a stronger guiding theoretical foundation. Our work suggests that a theoretical framework guided by complexity science can help in the development of quality improvement strategies that will more effectively facilitate practice change.

Impact of remuneration and organizational factors on completing preventive manoeuvres in primary care practices

BACKGROUND

Several jurisdictions attempting to reform primary care have focused on changes in physician remuneration. The goals of this study were to compare the delivery of preventive services by practices in four primary care funding models and to identify organizational factors associated with superior preventive care.

METHODS

In a cross-sectional study, we included 137 primary care practices in the province of Ontario (35 fee-for-service practices, 35 with salaried physicians [community health centres], 35 practices in the new capitation model [family health networks] and 32 practices in the established capitation model [health services organizations]). We surveyed 288 family physicians. We reviewed 4108 randomly selected patient charts and assigned prevention scores based on the proportion of eligible preventive manoeuvres delivered for each patient.

RESULTS

A total of 3284 patients were eligible for at least one of six preventive manoeuvres. After adjusting for patient profile and contextual factors, we found that, compared with prevention scores in practices in the new capitation model, scores were significantly lower in fee-for-service practices (β estimate for effect on prevention score = -6.3, 95% confidence interval [CI] -11.9 to -0.6) and practices in the established capitation model (β = -9.1, 95% CI -14.9 to -3.3) but not for those with salaried remuneration (β = -0.8, 95% CI -6.5 to 4.8). After accounting for physician characteristics and organizational structure, the type of funding model was no longer a statistically significant factor. Compared with reference practices, those with at least one female family physician (β = 8.0, 95% CI 4.2 to 11.8), a panel size of fewer than 1600 patients per full-time equivalent family physician (β = 6.8, 95% CI 3.1 to 10.6) and an electronic reminder system (β = 4.6, 95% CI 0.4 to 8.7) had superior prevention scores. The effect of these three factors was largely but not always consistent across the funding models; it was largely consistent across the preventive manoeuvres.

INTERPRETATION

No funding model was clearly associated with superior preventive care. Factors related to physician characteristics and practice structure were stronger predictors of performance. Practices with one or more female physicians, a smaller patient load and an electronic reminder system had superior prevention scores. Our findings raise questions about reform initiatives aimed at increasing patient numbers, but they support the adoption of information technology.

Internet-based developmental screening: a digital divide between English- and Spanish-speaking parents

BACKGROUND

Internet-based developmental screening is being implemented in pediatric practices across the United States. Little is known about the application of this technology in poor urban populations.

OBJECTIVE

We describe here the results of focus groups, surveys, and in-depth interviews during home visits with families served by an urban safety-net organization to address the question of whether it is possible to use Internet or e-mail communication for medical previsit engagement in a population that is majority Hispanic, of low socioeconomic status, and has many non-English-speaking families.

METHODS

This study included families in 4 clinics within a safety-net health care system. The study design included the use of (1) parental surveys (n = 200) of a convenience sample of parents whose children received primary care in the clinics, (2) focus groups (n = 7 groups) with parents, and (3) in-depth interviews during home visits with 4 families. We used χ(2) and multivariate analyses to compare Internet access in English- and Spanish-speaking families. Standard qualitative methods were used to code focus-group texts and identify convergent themes.

RESULTS

In multivariate analysis, independent factors associated with computer use were English versus Spanish language (odds ratio: 3.2 [95% confidence interval: 1.4-6.9]) and education through at least high school (odds ratio: 4.7 [95% confidence interval: 2.3-9.7]). In focus groups, the concept of parental previsit work, such as developmental screening tests, was viewed favorably by all groups. However, many parents expressed reservations about doing this work by using the Internet or e-mail and stated a preference for either paper or telephone options. Many Spanish-speaking families discussed lack of access to computers and printers.

CONCLUSIONS

In this economically disadvantaged population, language and maternal education were associated with access to the Internet. Given the potential power of previsit work to tailor well-child visits to the needs of individual families, alternative strategies to using the Internet should be explored for populations without reliable Internet access.

Appreciative Inquiry for quality improvement in primary care practices

PURPOSE

To test the effect of an Appreciative Inquiry (AI) quality improvement strategy on clinical quality management and practice development outcomes. Appreciative inquiry enables the discovery of shared motivations, envisioning a transformed future, and learning around the implementation of a change process.

METHODS

Thirty diverse primary care practices were randomly assigned to receive an AI-based intervention focused on a practice-chosen topic and on improving preventive service delivery (PSD) rates. Medical-record review assessed change in PSD rates. Ethnographic field notes and observational checklist analysis used editing and immersion/crystallization methods to identify factors affecting intervention implementation and practice development outcomes.

RESULTS

The PSD rates did not change. Field note analysis suggested that the intervention elicited core motivations, facilitated development of a shared vision, defined change objectives, and fostered respectful interactions. Practices most likely to implement the intervention or develop new practice capacities exhibited 1 or more of the following: support from key leader(s), a sense of urgency for change, a mission focused on serving patients, health care system and practice flexibility, and a history of constructive practice change.

CONCLUSIONS

An AI approach and enabling practice conditions can lead to intervention implementation and practice development by connecting individual and practice strengths and motivations to the change objective.

Understanding change in medical practice: the role of shared meaning in preventive treatment

Health care organizations are experiencing a rising demand for change in the organization of preventive health services. Many initiatives designed to cater for change fail to achieve their aim. To understand how organizational dynamics in health care organizations influence the adoption of new initiatives, I explored the implementation of motivational interviewing, a health behavior concept that was introduced into ten general practice clinics in Denmark. Within an institutional framework I explored how modern ideas of prevention related to this concept were translated into medical practices. Using a qualitative multiple-case study design, I examined the institutionalization process in different clinical settings. I found that clinics constructed various types of preventive routines and thereby imposed new meaning on the health behavior concept. In adopting the concept, clinics developed a new routine against the background of existing practice, (re)producing an alternative, self-contained routine that diverged from their usual medical practice.

Basic public health services delivered in an urban community: a qualitative study

OBJECTIVES

To understand the advancements in and barriers to the implementation of measures to improve basic public health services in an urban Chinese community.

STUDY DESIGN

A qualitative study based on semi-structured interviews. Interviews were audio-taped, transcribed and analysed using thematic content analysis.

METHODS

In-depth interviews were undertaken with the directors of the management centres for community health services in 15 of the 18 districts in Beijing from December 2008 to February 2009. Content analysis of the data was completed in May 2009.

RESULTS

Fifteen types of free basic public health services had been delivered in Beijing. Some were supplied at a low level. An average of £2.38 per person per year was provided for inhabitants since 2008, but demand for funding far exceeded monies available. Teams consisting of general practitioners, community nurses and public health specialists delivered these services. The number of practitioners and their low levels of skill were insufficient to provide adequate services for community residents. Respondents gave recommendations of how to resolve the above problems.

CONCLUSIONS

In order to improve the delivery of basic public health services, it is necessary for Beijing Municipal Government to supply clear and detailed protocols, increase funding and increase the number of skilled practitioners in the community health services.

Midwives' Knowledge, Perceptions, Beliefs, and Practice Supports Regarding Tobacco Dependence Treatment

Clinical practice guidelines and evidence-based reviews confirm the efficacy of tobacco dependence treatment for pregnant women. The purpose of this study was to examine tobacco dependence treatment practices among certified nurse-midwives who treat pregnant women who smoke. Midwives were surveyed to determine knowledge, perceptions, and beliefs about tobacco cessation treatment and to identify practice environmental factors that support treatment practices. Half of all midwives had not heard of the US Public Health Service Guidelines (5 A's) to assist smokers in cessation treatment. We found varying levels of adherence to the clinical practice guidelines. Nearly all midwives routinely ask, advise, and assess; while fewer encourage patients to set a quit date or discuss medication options (assist) and perform follow-up activities (arrange). Barriers significantly associated with clinical tobacco treatment practice are lack of training and competing priorities in the visit. One-office support, a system in place to provide smoking cessation information and resources, was associated with increased practice. In summary, midwives believe they should be providing tobacco dependence treatment, yet they identify a need for training. The findings of this study also indicate that sustained practice change, which includes the entire practice environment, should be targeted to enhance tobacco dependence treatment.

Measuring organizational attributes in primary care: a validation study in Germany

OBJECTIVE

Models for the structured delivery of care rely on organizational attributes of practice teams. The Survey of Organizational Attributes for Primary Care (SOAPC) is known to be a valid instrument to measure this aspect in the primary care setting. The aim of this study was to determine the validity of a translated and culturally adapted German version of the SOAPC.

METHODS

The SOAPC was translated and culturally adapted according to established standards. The external validity of the German SOAPC was assessed using the German version of the Warr-Cook-Wall scale. A total of 200 practices randomly selected from a conference database were asked to participate in the validation study. Practice, clinicians and staff characteristics were determined via short-form questionnaires. We used standardized statistical procedures to reveal the psychometric properties of the SOAPC.

RESULTS

A total of 54 practice teams participated by returning 297 completed questionnaires (297/425, response rate 69.8%). All four domains of the SOAPC (communication, decision making, stress/chaos, history of change) could be approved by factor analysis. Internal consistency is underlined by a Cronbach's alpha of 0.70 or higher in all categories. We show strong correlation with the Warr-Cook-Wall scale in all corresponding categories indexing high external validity.

CONCLUSIONS

The German SOAPC is a reliable and valid instrument for the assessment of organizational attributes of practice teams as the providers of quality of care. Moreover, the tool makes it possible to map the state of implementation of quality management and practice organization. The availability of the German SOAPC encourages further research on this topic in German-speaking countries.

Clinical Decision Support Technology to Increase Advance Care Planning in the Primary Care Setting

Physicians are often unable to guide patients through the advance care planning (ACP) process due to cost and time constraints. We conducted a retrospective analysis in the primary care setting targeting older adults without an advance medical directive (AMD). An ACP educational packet was sent to intervention patients before their health maintenance examination (HME). Additionally, their physicians had access to a computerized clinical decision support system on AMD completion at the time of the HME. Control participants’ physicians had access to the computerized decision support system and traditional resources only. All participants who received the packet were sent a follow-up survey. In all, 21.6% of intervention participants completed an AMD, compared with 4.1% of control participants. Combining clinical decision support systems and standardized processes enhances the ACP process.

Does Receiving Clinical Preventive Services Vary across Different Types of Primary Healthcare Organizations? Evidence from a Population-Based Survey

OBJECTIVE

To measure the association between primary healthcare (PHC) organizational types and patient coverage for clinical preventive services (CPS).

METHOD

Study conducted in Quebec (2005), including a population-based survey of patients' experience of care (N=4,417) and a survey of PHC clinics.

OUTCOME MEASURES

Patient-reported CPS delivery rates and CPS coverage scores. Multiple logistic regressions used to assess factors associated with higher probability of receiving CPS.

RESULTS

CPS delivery rates were higher among patients with a regular source of PHC. Higher CPS score was associated with having a public (OR 1.79; 95% CI 1.35-2.37) or mixed (OR 1.22; 95% CI 1.01-1.48) type of organization as source of PHC compared to a private one, and having had a high number of visits to the regular source of PHC in the past two years (≤6: OR 1.83; 95% CI 1.41-2.38) compared to a single visit.

CONCLUSION

Public and mixed PHC organizations seem to perform better. CPS delivery is strongly associated with having a regular source of care.

Change in stated clinical practice associated with participation in the Dental Practice-Based Research Network

Clinical researchers have attempted many methods to translate scientific evidence into routine clinical practice, with varying success. Practice-based research networks (PBRNs) provide an important, practitioner-friendly venue to test these methods. Dentist practitioner-investigators from the Dental Practice-Based Research Network (DPBRN) completed a detailed questionnaire about how they diagnose and treat dental caries. Next, they received a customized report that compared their answers to those from all other practitioner-investigators. Then, 126 of them attended the DPBRN's first network-wide meeting of practitioner-investigators from all five of its regions. During that meeting, certain questions were repeated and new ones were asked about the dentist's intention to change the way that he or she diagnosed or treated dental caries. Less than one-third of practitioner-investigators intended to change how they diagnosed or treated caries as a result of receiving the customized report. However, as a result of the meeting, the majority of these same practitioner-investigators stated an intention to change toward a more conservative, less surgically invasive approach. These findings are consistent with the idea that a highly interactive meeting with fellow practitioner-investigators may be an effective means to translate scientific findings into clinical practice. Practitioner-investigators are open to changing how they treat patients as a result of engaging fellow practitioner-investigators in the scientific process.