Primary Care Practice: Surprise & Uncertainty

Benjamin F. CrabtreeUMDNJ-RWJMSDept Family Medicine

Overview

Translating evidence into practice

Results from two studies of family practices

Practices as complex systems

Implications of complexity science for

managing uncertainty

1000 persons

800 report symptoms

327 consider seeking medical care

217 visit a physician’s office (113 visit a primary care physician’s office)

65 visit a complementary or alternative medical care provider

21 visit a hospital outpatient clinic

14 receive home health care

13 visit an emergency dept

8 are hospitalized

<1 is hospitalized in an academic medical center

Fig. Results of a reanalysis of the monthly prevalence of illness in the community and the roles of various sources of health care. (Green LA et al., N Engl J Med 2001, 344:2021-2024)

Background

Recent advances in diagnostic and treatment technologies have produced great opportunities to decrease morbidity and mortality from many common diseases.

Clinical trials and evidence-based reviews have established widely accepted clinical guidelines for the management and prevention of diseases.

The Uncertainty & SurpriseDissemination of these advances into clinical

practice has been disappointing, resulting in disparity between scientific evidence and actual practice.

There is an ongoing onslaught of new information and technology resulting in the need for continual learning in practice.

Current models of organizational change limit change in clinical practices and do not anticipate uncertainty.

Dissemination StrategiesContinuing medical educationEvidence-based guidelinesOpinion leadersAudit and feedbackIncentives & disincentivesAcademic detailingPatient and/or consumer activationOffice system innovationsContinuous quality improvement

Difficulty with current approaches

Each has demonstrated some success under certain circumstances, but none is effective in a generalizable manner.

Combination of approaches are more effective than individual approaches.

Each assumes that physician and practice change is a linear process and fails to account for the complexity of practice systems.

Two Studies of Practices

Direct Observation of Primary Care (DOPC)

Funded by grant from NCI (1 R01 CA60862)

Prevention & Competing Demands in Primary Care (P&CD)

Funded by grant from AHRQ (R01 HS08776)

Direct Observation of Primary Care

Cross-sectional observation of 84 family practices & 4454 patient visits to 138 physicians in Ohio

Direct ObservationDavis Observation CodeChecklists

Medical Record ReviewsPatient Exit questionnaireBilling DataPractice Environment ChecklistEthnographic Fieldnotes

Prevention & Competing DemandsIn-depth multimethod comparative case study of

18 family practices & 1,600 visits to 56 clinicians in Nebraska

Prolonged direct observation of practice environment recorded in checklists and field notes

Direct observation of 30 encounters/clinician recorded in checklists and field notes

Chart audits of patients who were observed

Interviews of all clinicians and most staff

Variation in Practice

Physicians provide integrated, prioritized care within an ongoing personal relationship. Stange KC, Jaen CR, Flocke SA, Miller WL, Crabtree BF. The value

of a family physician. J Fam Pract 1998; 46:363-368.

Services are tailored to meet risk factors, patient preferences, and teachable moments. Jaen CR, Crabtree BF, Zyzanski SJ, Stange KC. Making time for

tobacco counseling. J Fam Pract 1998; 46:425-428.

Variation in PracticeAntibiotics are prescribed inappropriately for

acute URI despite evidence. Scott J, Cohen D, DiCicco-Bloom B, Orzano J, Jaen C, Crabtree B.

Antibiotics use in acute respiratory infections and the ways patients pressure physicians for a prescription. J Fam Pract, 2001; 50(10): 853-8.

Smoking cessation counseling rates of physicians vary considerably. Jaen C, McIlvain H, Pol L, Phillips R, Flocke S, Crabtree BF.

Tailoring tobacco counseling to the competing demands in the clinical encounter. J Fam Pract, 2001; 50(10): 859-63.

Management of emotional distress varies considerably among physicians. Robinson D, Prest L, Susman J, Rouse J, Crabtree B. Technician,

friend, detective, and healer: family physicians’ responses to emotional distress. J Fam Pract, 2001; 50(10): 864-70.

Variation in Practice

Patient care staff roles in practices often do not match professional training. Aita V, Dodendorf D, Lebsack J, Tallia A, Crabtree B. Patient care

staffing patterns and roles in community-based family practices. J Fam Pract, 2001; 50(10): 889.

Geographic location of practice influences the delivery of services. Pol L, Rouse J, Zyzanski S, Rasmussen D, Crabtree B. Rural, urban,

and suburban comparisons of preventive services in family practice clinics. J Rural Health, 2001; 17(2): 114-121.

Practices are complexForced discontinuity of care results in 24% of

patients with managed care insurance changing physicians over a 2 year period, impacting quality of care. Flocke S, et al. The impact of insurance type and forced discontinuity

on the delivery of primary care. J Fam Pract, 1997; 45: 129-135.

Visits are complex with a large variety of problems & multiple problems/visit that are covered in visits of 10 minute average duration. Stange KC, et al. Illuminating the “black box:” A description of 4454

patient visits to 138 family physicians. J Fam Pract, 1998; 46: 377-389.

Practice are complexMultiple family members are treated in 18% of

visits making visits longer, but with no difference in billing. Flocke S, et al. The effect of a secondary patient on the family practice

visit. J Fam Pract, 1998; 46: 429-434.

Many patients have emotional distress (19% of patients seeing a family physician) with dramatic differences in time use (10 min no distress vs. 11.5 min distress & no dx vs. 12.8 min distress & dx) Callahan EJ, et al. The impact of a recent emotional distress and

diagnosis of depression or anxiety on the physician-patient encounter. J Fam Pract, 1998; 46410-418.

How can you make sense of all this variation and complexity?

5Local Community

3Clinical

Encounter

2Clinician

1Patient

4Practice

6Health System

Practices as Complex Adaptive SystemsPractices co-evolve locally with communities to

meet the particular needs of patients. Miller WL, Crabtree BF, McDaniel R, Stange KC. Understanding

change in primary care practice using complexity theory. J Fam Pract 1998; 46:369-376.

Important features of practices that make them unique:• History and initial condition• Particular agents and patterns of nonlinear interaction• Local fitness landscape• Regional and global influences Miller WL, McDaniel RR, Crabtree BF, Stange KC. Practice jazz:

understanding variation in family practices using complexity science. J Fam Pract, 2001; 50(10): 872-8.

Three Properties of Complex SystemsSelf-organization

Spontaneous development of structures and forms of behavior according to non-linear interactions among agents seeking a better position in the local fitness landscape.

Co-evolutionEach system evolves over time in relationship to

other systems in the local fitness landscape.Emergence

The system that evolves is greater than the sum of its parts and cannot be understood just by understanding the individual parts.

Franchise Family Practice

Suburban practice created by a hospital system to serve an insured middle-class population.

Focus is on providing efficient medical services and maximizing financial success.

Internal processes related to patient care, office operations, income generation, and physician style all work towards this focus and related goals.

Dusty Garden Family Practice

Four physician inner-city practice serving a local indigent population.

Vision is to empower its underserved community and to improve the community’s health.

Founding physician has strong beliefs about caring for the underserved.

Internal processes related to patient care, office operations, preventive service delivery, and physician style all work towards this vision.

Observation Intervention

DOPC

STEP-UPDirectObservation of PrimaryCare Study To

Enhance Prevention by Understanding

Practice

P&CDPrevention & Competing Demands in Primary Care

Study To Enhance Prevention by Understanding Practice

STEP-UPRandomized clinical trial of 80 family practices

in Ohio

Multimethod assessment (MAP) of values, structures, and processes Crabtree B, Miller W, Stange K. Understanding practice from the

ground up. J Fam Pract, 2001; 50(10): 881-887.

Tailored change strategies Goodwin M, Zyzanski S, Zronek S, et al. A clinical trial of tailored office

systems for preventive service delivery. The Study to Enhance Prevention by Understanding Practice (STEP-UP). Am J Prev Med, 2001; 21: 20-8.

Practice Assessment Methods

Direct observation of practice and clinical encounters (2-5 days)• Participant observation fieldnotes• Structured and unstructured checklists• Chart reviews and billing data• Informal and formal interviews

Physician, staff, and patient surveysPractice Genogram

Practice GenogramMcIlvain HE, Crabtree BF, Medder J, et al. Using “practice genograms” to understand and describe practice configurations. Fam Med, 1998; 30:490-6.

EMD

1992Age: 30's

CMD

1987Age: 50's

DMD

1990Age: 40's

HBusinessManager

promoted 1992

GHead Nurse

F(C's wife)

CollectionsPart time

BMD

1987-92

IAide

Part time

KAide

Part time

JOld timer

MFront Desk

4 years

LFront Desk

1987

NInsurance

5 years

OTranscriptionist

4 years

AMD

1987-89

HFront Desk

1987-92

GHead Nurse3 days/week

Feedback & FacilitationPractice report & genogram generated

and shared with practice stakeholdersValues, structures, processes, and

outcomes shared along with reflection points

Negotiated intervention• Instrumental approaches• Motivational approaches

Follow-up & facilitation

Global Preventive Service Delivery Rates

Per

cen

t of

Eli

gib

le S

ervi

ces

Up

to

Dat

e

0.43

0.41

0.39

0.37

0.35

0.33

0.31

0.29

0.27

0.25Baseline 6 months 12 months 18 months 24 months

Intervention Control

Goodwin MA, Zyzanski SJ, Zronek S, Ruhe M, Weyer SM, Konrad N,Esola D, Stange KC. A clinical trial of tailored office systems for preventive service delivery: The Study to Enhance Prevention by Understanding Practice (STEP-UP). Am J Prev Med, 2001; 21:20-8.

Implications of STEP-UP

Assessments for tailoring interventions to fit local fitness landscapes

Facilitate interventions to identify and maximize practice capacity to change

Practice and clinician self-reflection for ongoing learning

Observation Intervention

DOPC

STEP-UP

IMPACT

DirectObservation of PrimaryCare Study To

Enhance Prevention by Understanding

Practice

Insights from Multimethod Practice Assessment of Change over Time

P&CDPrevention & Competing Demands in Primary Care

ULTRAUsing Learning Teams for Reflective Adaptation

Multi-method Assessment Process (MAP)/ Reflective Adaptive Process (RAP):

an iterative assessment and reflective change approach that uses complexity science as a conceptual framework to guide the processes.

Emergent Quality

ULTRANHLBI funded group randomized clinical

trial of 60 practices in NJ and PAIntervention focused on interrelationships of

key stakeholders (agents)Two week practice assessment (MAP),

followed by a practice summary report and 3-6 months of facilitated reflective practice teams (RAP)

Outcome measures: smoking screening; management of hyperlipidemia, hypertension, diabetes, and asthma; and practice culture and capacity for change

Intervention OverviewMAP

Collected by facilitator first two weeks in practicePractice information form (Completed by Practice Mgr)General observation & key informant interviews &

DocumentsPractice genogram

RAPBased on MAP, facilitator helps identify team leader

and members with the goal of diversity among agentsTeam meets for 1 hour weekly, with initial focus on team

skills and collaboration Using MAP assessment as starting point, team identifies

problems with system level implications and begins improvement cycle

A Last Word From Yogi

“In theory, there is no difference between theory and practice. In practice there is.”