Community organization to promote breast cancer screening ordering by primary care physicians

Community organization has been viewed as a promising approach to changing preventive behaviors. We evaluated the impact of community organization strategies to promote breast cancer screening ordering by primary care physicians in Washington State. Physicians practicing in two intervention and two control communities were surveyed by mail pre-intervention (1989) and post-intervention (1993). Intervention activities targeting the health care sector included the formation of local physician planning groups, a series of informational mailings, medical office staff training sessions, and reminder system support. There were no significant post-intervention differences in the self-reported mammography ordering of physicians practicing in the intervention and control areas. Over the four-year study period, the proportions of physicians who ordered regular mammography increased by 36%. By 1993, over 80% of the respondents routinely used mammographie screening. Concerns about the high price of mammograms and inadequate insurance coverage were significantly reduced over time in both community pairs. Also, use of patient reminder systems increased significantly between 1989 and 1993. Secular trends resulting from diffusion of strategies to promote mammography were responsible for increases in physician ordering of the procedure. Year 2000 goals for breast cancer screening use by physicians may already have been met in some communities.Funded by grant CA34847 from the National Cancer Institute.     

A breast cancer screening educational intervention targeting medical office staff

There is persistent evidence that breast cancer screening techniques remain under-utilized. While physicians cite lack of time as a barrier to the provision of preventive services, nurses and other medical office staff are in an ideal position to educate women and motivate adherence to screening recommendations. This paper describes the design, implementation and process evaluation of a breast cancer screening educational program targeting primary care medical office staff. This intervention was conducted in two Washington State counties as part of a larger community organization study. The PRECEDE model, educational outreach principles and focus groups were used to guide the program development. Consistent with 'academic detailing' concepts, the sessions were delivered at health care facilities. The program included a review of breast cancer-related data and screening methods, an overview of the nurse's role as a 'change agent' and breast self-examination instructor, and a discussion of women's barriers to mammography. Community-level penetration was relatively high, with sessions being completed by approximately 50% of the eligible staff. Overall, participants were positive about the value of the program. Medical office-based educational sessions have the potential of reaching a large proportion of primary health care workers and increasing disease prevention in communities.     

Pilot educational outreach project on partner violence

BACKGROUND: To assess the impact of a multimodal educational outreach on physician screening and documentation of intimate partner violence (IPV) in primary care. METHODS: Pre- and post-intervention assessment of physician screening and chart documentation of IPV. Physician screening was assessed by post-visit survey of patients and documentation was assessed by medical record review. SETTING: Three medical offices in an urban community of approximately 1 million. PARTICIPANTS: Three primary care physicians (one internist, one obstetrician, and one family physician) and 100 patients from each of these practices. INTERVENTIONS: Multimodal educational outreach to physicians and their office staff regarding appropriate screening and management of IPV. A trained IPV educator made periodic office visits in 2002 to educate the physician and office staff regarding appropriate screening and management of IPV. RESULTS: Before the intervention, 36/150 (24%) of sample patients reported having been previously asked about IPV and 24/150 (16%) reported being asked in a written format. After the intervention, 100/149 (67%) and 41/108(28%) reported being asked verbally or in writing, respectively. CONCLUSIONS: This pilot study of three physicians suggests educational outreach represents a promising and feasible means of improving physician screening and documentation of IPV in primary care.     

Effects of Second Office and Hospital Consulting Practices of Physicians on Rural Communities

This research examined the prevalence of second offices and hospital consulting practices of physicians in Missouri, the characteristics of physicians participating in such practices, the change in availability of services through these practices, the characteristics of counties and hospitals involved, and the practice organization of participating physicians. The assessment of the factors was conducted within the conceptual framework of community and physician characteristics, practice form and organization, and health system resources. In 1993, 64 of the 93 nonmetropolitan counties in Missouri gained, on average, 1.3 full-time equivalent physicians through second office and hospital consulting practices. Eighteen nonmetropolitan counties lost, on average, 0.4 full-time equivalent physicians through these practices; 11 nonmetropolitan counties were not affected. The majority of physicians engaged in these two types of practices are nonprimary care specialists. Consequently, in addition to the net contribution to total physician service availability, many nonmetropolitan counties gained access locally to a wider variety of specialty services. This change in availability of physician services, not generally incorporated in decisions, needs to be considered when policy efforts are undertaken to change the spatial and specialty distribution of physicians.     

Hospitals and medical staffs: the concept of planning takes on new meaning.

Broad trends in health care are redefining medical staff planning. Hospital CEOs are recognizing the critical need to involve their physicians in hospital strategic planning at many levels. Gone are the days when it was sufficient to invite medical staff members to annual planning retreats and add individual physicians to boards; hospitals that thrive in the 1990s will be those that have created strong strategic links with their physicians. At the same time, medical staff development planning is changing in important ways. Recent federal government alerts on fraud and abuse and inurement in physician-recruiting activities are leading hospitals to document community benefit in their recruitment efforts. And hospital executives now realize that changes in the physician market will require them to plan carefully in order to ensure a strong base of primary care and other much-needed physicians. These two trends present CEOs with multilayered challenges. Following are reports on what leading-edge hospitals are doing in both areas.     

The WAMI Rural Hospital Project. Part 3: Building health care leadership in rural communities.

The WAMI Rural Hospital Project (RHP) intervention combined aspects of community development, strategic planning and organizational development to address the leadership issues in six Northwest rural hospitals. Hospitals and physicians, other community health care providers and local townspeople were involved in this intervention, which was accomplished in three phases. In the first phase, extensive information about organizational effectiveness was collected at each site. Phase two consisted of 30 hours of education for the physician, board, and hospital administrator community representatives covering management, hospital board governance, and scope of service planning. In the third phase, each community worked with a facilitator to complete a strategic plan and to resolve conflicts addressed in the management analyses. The results of the evaluation demonstrated that the greatest change noted among RHP hospitals was improvement in the effectiveness of their governing boards. All boards adopted some or all of the project's model governance plan and had successfully completed considerable portions of their strategic plans by 1989. Teamwork among the management triad (hospital, board, and medical staff) was also substantially improved. Other improvements included the development of marketing plans for the three hospitals that did not initially have them and more effective use of outside consultants. The project had less impact on improving the functioning of the medical chief of staff, although this was not a primary target of the intervention. There was also relatively less community interest in joining regional health care associations. The authors conclude that an intervention program tailored to address specific community needs and clearly identified leadership deficiencies can have a positive effect on rural health care systems.     

Improving Screening for Alcohol Use During Pregnancy: The Massachusetts ASAP Program

OBJECTIVE: To motivate prenatal care staff in public and private settings to universally screen for risk of alcohol and drug use and to conduct a brief intervention with follow-up referral when appropriate during a routine office visit. METHODS: The ASAP Project methods were engagement of site staff; staff training; self-administered questionnaires embedded with a relational and broad catch screening tool; a brief intervention protocol; unique clinical decision tree/protocols for each site; identification of treatment and referral resources; and ongoing technical assistance and consultation. Sites were located in four regions of the state and included four community health centers, a network of multi-specialty private practices and a teaching hospital. RESULTS: Across 16 sites, 118 prenatal staff were trained on use of the screening tool and 175 staff on the brief intervention. The ASAP Project resulted in 95% of pregnant women being screened for alcohol use and 77% of those screening positive for at least one risk factor receiving a brief intervention during a routine office visit. CONCLUSIONS: Screening and brief interventions for alcohol use can be delivered effectively within a routine prenatal care visit by prenatal staff by utilizing and building on existing office systems with practice staff, screening for any use not only at risk use, providing training with skills building sessions and information delivered by physicians, offering easy-to-access community treatment resources, and providing ongoing technical assistance.     

Analysis and ways of improving the organization of activities of sector physicians

Proceeding from the analysis of the organization of reception of patients in 4 city polyclinics having 104 therapeutic sectors, the study demonstrated decrease of the amount and breach of continuity of medical care rendered to the residents of the sectors where doctors were absent during the reception. It was proposed to appraise and monitor the work of sector physicians during their reception of patients through a complex indicator of intensity of consultation rates at other medical sectors. The introduced system of extra payment of physicians and paramedical staff for reception of patients from other sectors where the sector physician was absent could raise continuity of care and eliminate patients' complaints and discontent of medical workers.     

The Effects of Physician In-migration to Rural Colorado (1992 to 1995)

This paper reports the results of an analysis of the American Medical Association Masterfile. The purpose of this study was to examine changes in health care accessibility in rural Colorado from 1992 to 1995, and to describe the pattern of in-migration of physicians to nonmetropolitan statistical area counties of the state during that period. The number of direct patient care providers increased from 532 to 700 (31.6%) during the three-year period vs. a growth of 11.2 percent in the general population of nonmetropolitan statistical area counties. Of the 700 physicians serving residents of Colorado's 52 rural counties, 308 (44%) had been practicing in their community since 1992. The rate of departure from nonmetropolitan statistical area practice sites in 1992 was 26.4 percent (140 of 532). Physicians new to their rural practice locations were younger and proportionally more female, but they were similar in primary medical specialty to doctors who had remained in their 1992 sites. Population to physician and to primary care physician ratios were much more favorable for 1995 than for 1992. Accessibility to care was most improved in counties with fewer than 10,000 inhabitants.     

The production of health and the valuation of medical inputs in wage-amenity models

Using a hedonic wage-amenity model, this paper examines the valuation of medical inputs into the production of health. The data used in this study include the incomes, demographics and measures of human capital for households in eastern North Carolina with county level medical input supply. These data allow an estimate of the marginal value of medical care inputs such as the physician to population ratio and the availability of specialized services in an area of the country where the lack of available medical care has been of particular concern to policy makers. Our results indicate that while health care inputs are not a significant determinant of earnings overall, they are important in counties that have been designated as medically underserved. In underserved counties each additional physician per 10,000 individuals in the county decreases earnings by about 11.6%. This suggests that physicians act as an amenity and workers are willing to accept lower wages to locate in counties with a higher physician to population ratio.     

Addressing the unique challenges of inner-city practice: a direct observation study of inner-city, rural, and suburban family practices

Previous research on geographic variations in health care contains limited information regarding inner-city medical practice compared with suburban and rural settings. Our main objective was to compare patient characteristics and the process of providing medical care among family practices in inner-city, suburban, and rural locations. A cross-sectional multimethod study was conducted emphasizing direct observation of out patient visits by trained research nurses involving 4, 454 consecutive patients presenting for outpatient care to 138 family physicians during 2 days of observation at 84 community family practices in northeast Ohio. Time use during office visits was assessed with the Davis Observation Code; satisfaction was measured with the Medical Outcomes Study nine-item Visit Rating Scale; delivery of preventive services was as recommended by the US Preventive Services Task Force; and patient-reported domains of primary care were assessed with the Components of Primary Care Instrument. Results show that inner-city patients had more chronic medical problems, more emotional problems, more problems evaluated per visit, higher rates of health habit counseling, and longer and more frequent office visits. Rural patients were older, more likely to be established with the same physician, and had higher rates of satisfaction and patient-reported physician knowledge of the patient. Suburban patients were younger, had fewer chronic medical problems, and took fewer medications chronically. Inner-city family physicians in northeast Ohio appear to see a more challenging patient population than their rural and suburban counterparts and have more complex outpatient office visits. These findings have implications for health system organization along with the reimbursement and recruitment of physicians in medically underserved inner-city areas.     

Gradual Electronic Health Record Implementation: New Insights on Physician and Patient Adaptation

PURPOSE Although there is significant interest in implementation of electronic health records (EHRs), limited data have been published in the United States about how physicians, staff, and patients adapt to this implementation process. The purpose of this research was to examine the effects of EHR implementation, especially regarding physician-patient communication and behaviors and patients’ responses.METHODS We undertook a 22-month, triangulation design, mixed methods study of gradual EHR implementation in a residency-based family medicine outpatient center. Data collection included participant observation and time measurements of 170 clinical encounters, patient exit interviews, focus groups with nurses, nurse’s aides, and office staff, and unstructured observations and interviews with nursing staff and physicians. Analysis involved iterative immersion-crystallization discussion and searches for alternate hypotheses.RESULTS Patient trust in the physician and security in the physician-patient relationship appeared to override most patients’ concerns about information technology. Overall, staff concerns about potential deleterious consequences of EHR implementation were dispelled, positive anticipated outcomes were realized, and unexpected benefits were found. Physicians appeared to become comfortable with the “third actor” in the room, and nursing and office staff resistance to EHR implementation was ameliorated with improved work efficiencies. Unexpected advantages included just-in-time improvements and decreased physician time out of the examination room.CONCLUSIONS Strong patient trust in the physician-patient relationship was maintained and work flow improved with EHR implementation. Gradual EHR implementation may help support the development of beneficial physician and staff adaptations, while maintaining positive patient-physician relationships and fostering the sharing of medical information.     

Information technology and medical group management

Information technology permits revised patient management activities for high-quality, cost-effective care in ambulatory clinics. The electronic medical record is financially feasible for very small physician groups. Disease management for chronic and terminal care patients represents an expanding area of service in medical group management. The Internet provides access to health care information that has empowered patients and their families to approach patient-physician office visits from a new relationship. Data provided by this information technology permit benchmarking of activities by ambulatory care service, treatment modalities, specialty group, and physician.     

National Health Service Corps Staffing and the Growth of the Local Rural Non-NHSC Primary Care Physician Workforce

CONTEXT: Beyond providing temporary staffing, National Health Service Corps (NHSC) clinicians are believed by some observers to contribute to the long-term growth of the non-NHSC physician workforce of the communities where they serve; others worry that NHSC clinicians compete with and impede the supply of other local physicians. PURPOSE: To assess long-term changes in the non-NHSC primary care physician workforce of rural underserved counties that have received NHSC staffing support relative to workforce changes in underserved counties without NHSC support. METHODS: Using data from the American Medical Association and NHSC, we compared changes from 1981 to 2001 in non-NHSC primary care physician to population ratios in 2 subsets of rural whole-county health professional shortage areas: (1) 141 counties staffed by NHSC physicians, nurse practitioners, and/or physician assistants during the early 1980s and for many of the years since and (2) all 142 rural health professional shortage area counties that had no NHSC clinicians from 1979 through 2001. FINDINGS: From 1981 to 2001, counties staffed by NHSC clinicians experienced a mean increase of 1.4 non-NHSC primary care physicians per 10,000 population, compared to a smaller, 0.57 mean increase in counties without NHSC clinicians. The finding of greater non-NHSC primary care physician to population mean ratio increase in NHSC-supported counties remained significant after adjusting for baseline county demographics and health care resources (P < .001). The estimated number of "extra" non-NHSC physicians in NHSC-supported counties in 2001 attributable to the NHSC was 294 additional physicians for the 141 supported counties, or 2 extra physicians, on average, for each NHSC-supported county. Over the 20 years, more NHSC-supported counties saw their non-NHSC primary care workforces grow to more than 1 physician per 3,500 persons, but no more NHSC-supported than nonsupported counties lost their health professional shortage area designations. CONCLUSIONS: These data suggest that the NHSC contributed positively to the non-NHSC primary care physician workforce in the rural underserved counties where its clinicians worked during the 1980s and 1990s.     

Physician organization and care management in California: from cottage to Kaiser

Data from a survey of practicing physicians in California's thirteen largest urban counties were used to ascertain differences in care management processes, financial incentives for quality, and practice pressures by type of practice setting. Physicians in the Permanente medical groups have adopted and value quality-oriented, system-level care management tools to a much greater degree than physicians in independent practice association (IPA) networks or traditional "cottage-industry" practices. Our findings raise disturbing questions about how the health system will close the "quality chasm" in medical care without transforming the underlying organization of physician practices.     

Why Rural Residents Migrate for Family Physician Care

Several studies have examined why rural residents bypass local hospitals, but few have explored why they migrate for physician care. In this study, data from a random mail survey of households in rural Iowa counties were used to determine how consumers' attitudes about their local health system, health beliefs, health insurance coverage and other personal characteristics influenced their selection of local vs. nonlocal family physicians (family physician refers to the family practice, internal medicine or other medical specialist providing an individual's primary care). Migration for family physician care was positively associated with a perceived shortage of local family physicians and use of nonlocal specialty physician care. Migration was negatively associated with a highly positive rating of the overall local health care system, living in town, Lutheran religious affiliation and private health insurance coverage. By understanding why rural residents prefer to bypass local physicians, rural health system managers, physicians and policy-makers should be better prepared to design innovative health organizations and programs that meet the needs of rural consumers.     

Marketing to older patients: perceptions of service quality

Marketing has taken on increased importance in the United States' health care industry, especially with respect to Americans aged 55 and older. Given that health care costs account for 14 percent of the GNP of the U.S., and that older Americans represent nearly 25 percent of all health care expenditures, the ability of physicians to assess the perceptions of service quality, service value, and satisfaction and the effects of these variables on patient loyalty with respect to older patients is very important. A comprehensive model of patient behavior is introduced and tested. The results suggest the medical office staff and the expertise of the physician play particularly important roles in older patients' perceptions of service quality. In addition, strong relationships were found between (1) Service Quality and Satisfaction, (2) Satisfaction and Patient Behavior (repeated use of the physician), and (3) Service Quality and Patient Behavior. Conclusions and suggestions for future research are offered.     

Randomized Trial of a Program to Increase Staff Influenza Vaccination in Primary Care Clinics

PURPOSE Although vaccination of health care workers against influenza is widely recommended, vaccination uptake is low. Data on interventions to increase staff immunization in primary care are lacking. We examine the effect of a promotional and educational intervention program, not addressing vaccine availability, to raise the influenza vaccination rate among staff in primary care clinics.METHODS The study included all 344 staff members with direct patient contact (physicians, nurses, pharmacists, and administrative and ancillary staff) in 27 primary care community clinics in the Jerusalem area during the 2007–2008 influenza season. Thirteen clinics were randomly selected for an intervention that consisted of a lecture session given by a family physician, e-mail-distributed literature and reminders, and a key figure from the local staff who personally approached each staff member.RESULTS Influenza immunization rate was 52.8% (86 of 163) in the intervention group compared with 26.5% (48 of 181) in the control group (P<.001). When compared with the rate of immunization for the previous season, the absolute increase in immunization rate was 25.8% in the intervention clinics and 6.6% in the control clinics. Multivariate analysis showed a highly significant (P<.001) independent association between intervention and immunization, with an odds ratio of 3.51 (95% confidence interval, 2.03–6.09).CONCLUSION We have developed an effective intervention program to increase previously low vaccination rates among primary health care workers. This simple intervention could be reproduced easily in other clinics and organizations with an expected substantial increase in influenza immunization rates.     

Communicating with physicians: one hospital's approach

Experience with the PAL program has demonstrated that it takes approximately six months to one year for a PAL relationship to build trust and open communication. By the end of the sixth month, the relationship is usually established to the point that the physician and office staff voluntarily call on the PAL manager with concerns requiring attention. Riverside continues to explore ways to build and strengthen the PAL Program. At a recent hospital managerial conference, managers and physicians discussed the hospital-physician relationship and collaborated on ways to improve communications and alliances with the medical staff. In addition, hospital-sponsored social events that provide opportunities for physicians and PAL managers to interact outside the workplace have been introduced and well received. As the health care delivery system undergoes transformation and implementation of the computerized patient record becomes a reality, the PAL Program will serve as a foundation in the establishment of new programs and relationships between the hospital and the medical staff that will ensure Riverside's future success in the marketplace.     

A systematic primary care office-based smoking cessation program

There is a large discrepancy between apparent potential and actual practice of smoking cessation activities by physicians. This paper describes the 2-year results of an integrated system to support such physician activities with all of their tobacco-using patients. The system consists of organized identification, progress records, brief physician messages, follow-up, and assistance; it focuses on those most interested in quitting. Introduction of the system to one clinic was associated with an initial threefold to fivefold increase in quit rates of all clinic patients using tobacco. After 2 years, the overall quit rate was approximately 20%, rising to 33% for those tobacco users with more clinic contacts or at least 1 year from the first to the latest contact. Such a program has been well accepted by patients, physicians, and office staff and seems to provide the support needed for a feasible and effective long-term smoking cessation intervention in primary care practices.