Primary Care Practice:
Surprise & Uncertainty
Benjamin F. Crabtree
UMDNJ-RWJMS
Dept 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 & Surprise
Dissemination 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 Strategies
Continuing medical education
Evidence-based guidelines
Opinion leaders
Audit and feedback
Incentives & disincentives
Academic detailing
Patient and/or consumer activation
Office system innovations
Continuous 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 Observation
Davis Observation Code
Checklists
Medical Record Reviews
Patient Exit questionnaire
Billing Data
Practice Environment Checklist
Ethnographic Fieldnotes
Prevention & Competing Demands
In-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 Practice
Antibiotics 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 complex
Forced 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: 377389.
Practice are complex
Multiple 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?
6
Health System
4
Practice
5
Local Community
1
Patient
3
Clinical
Encounter
2
Clinician
Practices as Complex Adaptive Systems
Practices 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 Systems
Self-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-evolution
Each 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
Direct
Observation
of Primary
Care
P&CD
Prevention &
Competing Demands
in Primary Care
STEP-UP
Study To
Enhance
Prevention by
Understanding
Practice
Study To Enhance Prevention by
Understanding Practice
STEP-UP
Randomized 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 surveys
Practice Genogram
Practice Genogram
McIlvain HE, Crabtree BF, Medder J, et al. Using “practice genograms” to understand
and describe practice configurations. Fam Med, 1998; 30:490-6.
A
MD
1987-89
C
MD
1987
Age: 50's
B
MD
1987-92
F
(C's wife)
Collections
Part time
G
Head Nurse
I
Aide
Part time
G
Head Nurse
3 days/week
D
MD
1990
Age: 40's
E
MD
1992
Age: 30's
H
Business
Manager
promoted 1992
J
Old timer
L
Front Desk
1987
K
Aide
Part time
M
Front Desk
4 years
H
Front Desk
1987-92
N
Insurance
5 years
O
Transcriptionist
4 years
Feedback & Facilitation
Practice report & genogram generated
and shared with practice stakeholders
Values, structures, processes, and
outcomes shared along with reflection
points
Negotiated intervention
• Instrumental approaches
• Motivational approaches
Follow-up & facilitation
Percent of Eligible Services Up to Date
Global Preventive Service Delivery Rates
0.43
0.41
0.39
0.37
0.35
0.33
0.31
0.29
0.27
0.25
Baseline
6 months
12 months
Intervention
18 months
24 months
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
Direct
Observation
of Primary
Care
P&CD
Prevention &
Competing Demands
in Primary Care
IMPACT
Insights from
Multimethod Practice
Assessment of Change
over Time
STEP-UP
Study To
Enhance
Prevention by
Understanding
Practice
ULTRA
Using Learning
Teams for Reflective
Adaptation
Emergent Quality
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.
ULTRA
NHLBI funded group randomized clinical
trial of 60 practices in NJ and PA
Intervention 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 Overview
MAP
Collected by facilitator first two weeks in practice
Practice information form (Completed by Practice
Mgr)
General observation & key informant interviews &
Documents
Practice genogram
RAP
Based on MAP, facilitator helps identify team leader
and members with the goal of diversity among agents
Team 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.”