Delivery of Clinical Preventive Services in Family Medicine Offices

Abstract

BACKGROUND This study aimed to elucidate how clinical preventive services are delivered in family practices and how this information might inform improvement efforts. METHODSWe used a comparative case study design to observe clinical preventive service delivery in 18 purposefully selected Midwestern family medicine offi ces from 1997 to 1999. Medical records, observation of outpatient encounters, and patient exit cards were used to calculate practice-level rates of delivery of clinical preventive services. Field notes from direct observation of clinical encounters and prolonged observation of the practice and transcripts from in-depth interviews of practice staff and physicians were systematically examined to identify approaches to delivering clinical preventive services recommended by the US Preventive Services Task Force. RESULTSPractices developed individualized approaches for delivering clinical preventive services, with no one approach being successful across practices. Clinicians acknowledged a 3-fold mission of providing acute care, managing chronic problems, and prevention, but only some made prevention a priority. The clinical encounter was a central focus for preventive service delivery in all practices. Preventive services delivery rates often appeared to be infl uenced by competing demands within the clinical encounter (including between different preventive services), having a physician champion who prioritized prevention, and economic concerns.CONCLUSIONS Practice quality improvement efforts that assume there is an optimal approach for delivering clinical preventive services fail to account for practices' propensity to optimize care processes to meet local contexts. Interventions to enhance clinical preventive service delivery should be tailored to meet the local needs of practices and their patient populations. INTRODUCTIONT he Healthy People 2010 report calls for a major effort to improve rates of preventive service delivery by primary care clinicians.1 Despite prevention being a core component of primary care practice, 2 studies show that clinical preventive service delivery rates are low.3,4 A range of interventions to enhance the delivery of clinical preventive services have been tried with varying degrees of success, including the use of continuing medical education, audit and feedback, computerized reminder systems, the involvement of nursing staff, the use of chart-based algorithms, and the implementation of continuous quality improvement programs. [5][6][7][8][9][10] Efforts to improve clinical preventive services delivery are limited by our understanding of how clinicians and practices actually incorporate and deliver preventive services within the competing demands of care. [11][12][13] Although recent research provides insight into the emergent nature of practices as human organizations, 14,15 much remains to be understood about how the specifi cs of patients, their families, communities, clinicians, and health systems affect the approaches used in practices to provide clinical...

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