Alfred F. Tallia

Rethinking Prevention in Primary Care: Applying the Chronic Care Model to Address Health Risk Behaviors

This study examines the Chronic Care Model (CCM) as a framework for preventing health risk behaviors such as tobacco use, risky drinking, unhealthy dietary patterns, and physical inactivity. Data were obtained from primary care practices participating in a national health promotion initiative sponsored by the Robert Wood Johnson Foundation. Practices owned by a hospital health system and exhibiting a culture of quality improvement were more likely to offer recommended services such as health risk assessment, behavioral counseling, and referral to community-based programs. Practices that had a multispecialty physician staff and staff dieticians, decision support in the form of point-of-care reminders and clinical staff meetings, and clinical information systems such as electronic medical records were also more likely to offer recommended services. Adaptation of the CCM for preventive purposes may offer a useful framework for addressing important health risk behaviors.

How Improving Practice Relationships Among Clinicians and Nonclinicians Can Improve Quality in Primary Care

BACKGROUND Understanding the role of relationships health care organizations (HCOs) offers opportunities for shaping health care delivery. When quality is treated as a property arising from the relationships within HCOs, then different contributors of quality can be investigated and more effective strategies for improvement can be developed. METHODS Data were drawn from four large National Institutes of Health (NIH)-funded studies, and an iterative analytic strategy and a grounded theory approach were used to understand the characteristics of relationships within primary care practices. This multimethod approach amassed rich and comparable data sets in all four studies, which were all aimed at primary care practice improvement. The broad range of data included direct observation of practices during work activities and of patient-clinician interactions, in-depth interviews with physicians and other key staff members, surveys, structured checklists of office environments, and chart reviews. Analyses focused on characteristics of relationships in practices that exhibited a range of success in achieving practice improvement. Complex adaptive systems theory informed these analyses. FINDINGS Trust, mindfulness, heedfulness, respectful interaction, diversity, social/task relatedness, and rich/lean communication were identified as important in practice improvement. A model of practice relationships was developed to describe how these characteristics work together and interact with reflection, sensemaking, and learning to influence practice-level quality outcomes. DISCUSSION Although this model of practice relationships was developed from data collected in primary care practices, which differ from other HCOs in some important ways, the ideas that quality is emergent and that relationships influence quality of care are universally important for all HCOs and all medical specialties.

Social Network Analysis as an Analytic Tool for Interaction Patterns in Primary Care Practices

PURPOSE Social network analysis (SNA) provides a way of quantitatively analyzing relationships among people or other information-processing agents. Using 2 practices as illustrations, we describe how SNA can be used to characterize and compare communication patterns in primary care practices. METHODS Based on data from ethnographic field notes, we constructed matrices identifying how practice members interact when practice-level decisions are made. SNA software (UCINet and KrackPlot) calculates quantitative measures of network structure including density, centralization, hierarchy and clustering coefficient. The software also generates a visual representation of networks through network diagrams. RESULTS The 2 examples show clear distinctions between practices for all the SNA measures. Potential uses of these measures for analysis of primary care practices are described. CONCLUSIONS SNA can be useful for quantitative analysis of interaction patterns that can distinguish differences among primary care practices.

Delivery of Clinical Preventive Services in Family Medicine Offices

BACKGROUND This study aimed to elucidate how clinical preventive services are delivered in family practices and how this information might inform improvement efforts. METHODS We used a comparative case study design to observe clinical preventive service delivery in 18 purposefully selected Midwestern family medicine offices 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. RESULTS Practices 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 influenced 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.

Quality of Diabetes Care in Family Medicine Practices: Influence of Nurse-Practitioners and Physician’s Assistants

PURPOSE The aim of this study was to assess whether the quality of diabetes care differs among practices employing nurse-practitioners (NPs), physician’s assistants (PAs), or neither, and which practice attributes contribute to any differences in care. METHODS This cross-sectional study of 46 family medicine practices from New Jersey and Pennsylvania measured adherence to American Diabetes Association diabetes guidelines via chart audits of 846 patients with diabetes. Practice characteristics were identified by staff surveys. Hierarchical models determined differences between practices with and without NPs or PAs. RESULTS Compared with practices employing PAs, practices employing NPs were more likely to measure hemoglobin A1c levels (66% vs 33%), lipid levels (80% vs 58%), and urinary microalbumin levels (32% vs 6%); to have treated for high lipid levels (77% vs 56%); and to have patients attain lipid targets (54% vs 37%) (P ≤ .005 for each). Practices with NPs were more likely than physician-only practices to assess hemoglobin A1c levels (66% vs 49%) and lipid levels (80% vs 68%) (P≤.007 for each). These effects could not be attributed to use of diabetes registries, health risk assessments, nurses for counseling, or patient reminder systems. Practices with either PAs or NPs were perceived as busier (P=.03) and had larger total staff (P <.001) than physician-only practices. CONCLUSIONS Family practices employing NPs performed better than those with physicians only and those employing PAs, especially with regard to diabetes process measures. The reasons for these differences are not clear.

Implementing Health Behavior Change in Primary Care: Lessons From Prescription for Health

PURPOSE Our objective was to identify themes that emerged from the evaluation of 17 interventions funded by the Robert Wood Johnson Foundation’s Prescription for Health that aimed to enhance adherence to healthy behaviors in the primary care setting. METHODS We performed a content analysis of diary data from this 16-month initiative. Other data sources used to complement this analysis include funded grant applications and field notes from interviews with investigative teams and a limited number of site visits. Participants were 17 practice-based research networks (PBRNs) that had projects funded during Round 1 of Prescription for Health. RESULTS Five themes emerged regarding implementation of health behavior change: (1) health behavior change resources are enthusiastically received by practices and patients, and when given a choice, patients prefer methods of assistance that involve personal contact; (2) practice extenders require extensive training, as well as careful case management and support, in order to function fully and avoid burnout; (3) integrating behavior change tools into the primary care setting requires time, effort, and often specialized expertise; (4) even simple interventions require practice change, and use of a practice change model to guide implementation efforts is crucial; and (5) research philosophy and project management approaches vary across PBRNs and have implications for the potential sustainability of an intervention. CONCLUSIONS A more versatile, multifaceted solution involving new tools, technologies, and multidisciplinary care teams is needed in order to integrate health behavior change into everyday primary care routines. Even the best interventions require a model to articulate how to integrate an innovation into practices.

Online Diaries for Qualitative Evaluation: Gaining Real-Time Insights

Interactive online diaries are a novel approach for evaluating project implementation and provide real-time communication between evaluation staff members and those implementing a program. Evaluation teams can guide the lines of inquiry and ensure that data are captured as implementation develops. When used together with conventional evaluation strategies, interactive online diaries allow for an in-depth understanding of project implementation, as well as the challenges program staff members confront and the solutions they develop. Interactive online diaries also can help evaluators address challenges such as self-reporting bias, documenting project evolution, and capturing implementers’ ongoing insights as they develop. These insights might otherwise be lost to the evaluation process. The authors describe the development and use of this online approach in the evaluation of a foundation-sponsored program to improve the provision of preventive care in physicians’ offices. The program included 17 practice-based research networks and their participating primary care practices.

Understanding Organizational Designs of Primary Care Practices.

EXECUTIVE SUMMARY During the past decade, many hospitals experienced difficulty integrating primary care practices into their health systems. We hypothesized that this difficulty may be, in part, a result of limited understanding of practice organizational designs. The structure and function of practices have not been well studied. In this article, we answer the following questions: Are practices all the same, or do variations in their organizational design exist? Do hospital designs predict the designs of affiliated practices? If variation exists, what are the management implications? Eighteen family practices, including nine affiliated with five separate hospital systems, were studied using an in‐depth comparative case study design. A content analysis of the rich descriptive data from these cases indicates that a great variety exists in the organizational design of primary care practices, and this variety appears to be influenced by the initial conditions under which the practice was organized. Hospital system design in and of itself did not predict the design of affiliated practices. In fact, both affiliated and independent practices exhibited a range of design characteristics, some of which did not fit traditional models. Hospital systems that allowed greater flexibility of practice organizational designs were more effective at integrating and managing practices. Practice response to environmental change was greater when practice autonomy was highest. These findings suggest that a science of practice organizational design separate from that of hospitals is needed to help explain the success and failure of practices within health systems and to provide information for planning practice change.

Improving Outcomes for High-Risk Diabetics Using Information Systems

Background: Diabetes care requires management of complex clinical information. We examine the relationship between diabetic outcomes and practices’ use of information. Methods: We performed a cross-sectional, secondary analysis of baseline data from 50 community primary care practices participating in a practice improvement project. Medical record review assessed clinical targets for diabetes (HbA1c ≤8, LDL ≤100, BP ≤130/85). Practices’ use of information was derived from clinician responses to a survey on their use of clinical information systems for patient identification and tracking. Hierarchical linear modeling examined relationships between patient outcomes and practice use of information, controlling for patient level covariates (age, gender, hypertension, and cardiovascular comorbidities) and practice level covariates (solo/group, and electronic health record [EHR] presence). Results: Practices’ use of identification and tracking systems significantly (P < .007 and 0.002) increased odds of achieving diabetes care targets (odds ratio [OR] 1.23 95%, confidence interval [CI] 1.06 to 1.44, and OR 1.32 95% CI 1.11 to 1.59). For diabetic patients with hypertension, odds of hypertension control were higher with higher use of tracking systems (OR = 1.52, P = .0017) and reflected similar trend with higher use of identification systems (OR = 1.28, P = .1349). EHR presence was not associated with attainment of clinical targets. Conclusions: Use of relatively simple systems to identify and track patient information can improve diabetic care outcomes. Practices making investments in an EHR must recognize that this technology alone is not sufficient for achieving desirable clinical outcomes. Researchers must explore the interrelationships of organizational factors necessary for successful information use.

Decision-Making Processes of Patients Who Use the Emergency Department for Primary Care Needs

Emergency department (ED) use for non-urgent needs is widely viewed as a contributor to various health care system flaws and inefficiencies. There are few qualitative studies designed to explore the complexity of patients’ decision-making process to use the ED vs. primary care alternatives. In this study, semi-structured interviews were conducted with 30 patients who were discharged from the low acuity area of a university hospital ED. A grounded theory approach including cycles of immersion/crystallization was used to identify themes and reportable interpretations. Patients reported multiple decision-making considerations that hinged on whether or not they knew about primary care options. A model is developed depicting the complexity and variation in patients’ decision-making to use the ED. Optimizing health system navigation and use requires improving objective factors such as access and costs as well as subjective perceptions of patients’ health care, which are also a prominent part of their decision-making process.