Research articleInfluence of Primary Care Practice and Provider Attributes on Preventive Service Delivery
Introduction
Changing lifestyle behaviors such as cigarette smoking, physical inactivity, unhealthy dietary practices, and excessive alcohol intake is believed to have the greatest potential for decreasing morbidity and mortality.1 Approximately 22% of adults in the United States smoke, 58% are overweight or obese, 65% do not exercise, and 21% engage in risky alcohol use.2 A recent study shows that in 2000, these four behavioral factors accounted for 39% of deaths in the United States.3
Healthcare providers can improve patient health by delivering services outlined in the U.S. Preventive Services Task Force (USPSTF) guidelines.4 These include health risk assessments, behavioral counseling, and referral to community-based health promotion activities. Primary care practices are strategic venues for initiating such preventive services.5 Yet while visits to the doctor’s office are appropriate times to advise patients on health behaviors, these opportunities are often missed.6, 7, 8, 9, 10
Lapses in care quality are no longer attributed solely to individuals, but are increasingly understood to be the result of organizational factors as well.11, 12 This study seeks to identify both practice and provider attributes associated with the delivery of preventive services for health behaviors. In particular, recent research indicates that organizational attributes such as staff participation in decision making13, 14, 15, 16, 17 can influence performance. Because primary care practices are complex organizations, theories such as the contingency perspective on decision making18, 19, 20 are informative and suggest a need for more focused attention on the interactive effects of organizational attributes. Such theories propose that associations between organizational factors and performance may not be constant but conditional and may vary depending on context. For example, the effect of a particular organizational factor on performance may be differentially influenced by existing levels of employee ownership or involvement in work decisions.
This study examines the implications of the contingency perspective on decision making by exploring whether participative processes—in this case, staff participation in decisions regarding quality improvement, practice change, and clinical operations—moderate or influence the association between various organizational attributes and preventive service delivery. Of interest is whether the effect of practice attributes such as quality of work relationships,21, 22 levels of busyness or stress,23, 24 and practice size25 on preventive service delivery is contingent on varying levels of staff participation.
Based on this framework, several hypotheses were posited for analysis. Since participative efforts were thought to provide focused and purposeful direction to work interactions, it was expected that staff participation would positively influence the effect of good work relationships and lessen the negative effect of work stress levels on preventive service delivery. However, previous conceptual work25 suggests a deterioration in the utility of participation within large working groups due to challenges of information transfer, coordination, and agreement on goals. Staff participation was therefore expected to negatively influence the association between practice size and performance.
Moreover, this study considers recommendations made by healthcare experts that medical organizations expand the use of allied health professionals and clinical information systems to improve care processes.26, 27, 28, 29, 30 In light of the emerging roles and skills of nonphysician providers as well as the limitations on physician time,26, 27 another expectation was that nonphysician providers would perform preventive services for health behaviors more frequently than physicians. Finally, based on recommendations for improving care processes,29, 30 it was expected that the use of organized support systems such as reminders and patient registries would be positively associated with preventive service delivery.
Section snippets
Data Sources
This research used data collected from the Prescription for Health initiative, a national program sponsored by the Robert Wood Johnson Foundation. The initiative funded investigative teams from 17 practice-based research networks to implement innovative programs targeting lifestyle behaviors such as diet, physical activity, and tobacco and alcohol use. Primary care practices located throughout the northeastern, southern, midwestern, and western regions of the United States participated in this
Results
Table 1 provides a description of practices in the study sample, while Table 2 describes the surveyed healthcare providers. Table 3 displays the frequencies with which providers reported delivering various preventive services for health behaviors. Table 4 provides a correlation matrix of key study variables.
The HLM results are presented in Table 5. Three interaction terms indicate whether the magnitude of the effect of each constituent variable (i.e., work relationships, work stress, practice
Discussion
This study examined the influence of both practice and provider attributes on the delivery of preventive services for health behaviors. At the organizational level, staff participation in decisions regarding quality improvement, practice change, and clinical operations significantly moderates or influences the association between certain practice attributes and performance. In particular, staff participation in practice decisions enhances the association between good work relationships and
Conclusions
Organizational issues are important to consider in improving patient care. For example, there have been many supportive commentaries on teamwork within healthcare organizations, including the Institute of Medicine’s espousal of a central role for primary care teams.12, 27, 29, 53, 54, 55, 56, 57 This study offers preliminary empirical support for staff involvement in practice decisions as a positive aspect of teamwork and collaboration. In addition, this study identifies two areas that could
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Health information systems in small practices: Improving the delivery of clinical preventive services
2011, American Journal of Preventive MedicineCitation Excerpt :Although the present study does not establish a direct cause-and-effect relationship between each of the intervention components implemented by PCIP, the increases of at least 5 percentage points provide encouraging evidence that improvement can be achieved across small practices operating in a non-integrated delivery system. Multiple factors could be contributing to the observed increases, including assisting practices to tailor improvement activities and leveraging nonphysician staff in quality improvement.23,24 Larger health systems have attributed feedback to providers and performance contracts as key factors for increasing CPS.25,26
Preventive and Anticipatory Care
2010, Brocklehurst's Textbook of Geriatric Medicine and GerontologyContinuity in provider and site of care and preventive services receipt in an adult Medicaid population with physical disabilities
2009, Disability and Health JournalImpact of remuneration and organizational factors on completing preventive manoeuvres in primary care practices
2012, CMAJ. Canadian Medical Association JournalCitation Excerpt :Further work is required to establish a benchmark for a patient number that results in better preventive care. Physicians have reported a need for reminder systems to support their preventive care,3,5 and these tools have been associated with improved care in several studies.7,8,27 We found that the presence of an electronic reminder system was positively associated with prevention scores.