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.
Crabtree
Benjamin F
BF
Department of Family Medicine, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ 08873, USA. crabtrbf@umdnj.edu
Miller
William L
WL
Tallia
Alfred F
AF
Cohen
Deborah J
DJ
DiCicco-Bloom
Barbara
B
McIlvain
Helen E
HE
Aita
Virginia A
VA
Scott
John G
JG
Gregory
Patrice B
PB
Stange
Kurt C
KC
McDaniel
Reuben R
RR
D005194:Family Practice / Q000706:statistics & numerical data*; D006801:Humans; D015146:Midwestern United States; D010818:Practice Patterns, Physicians'; D011314:Preventive Health Services / Q000706:statistics & numerical data*