Physician practice patterns and variation in the delivery of preventive services

Abstract

Background: Strategies to improve preventive services delivery (PSD) have yielded modest effects. A multidimensional approach that examines distinctive configurations of physician attributes, practice processes, and contextual factors may be informative in understanding delivery of this important form of care.

Objective: We identified naturally occurring configurations of physician practice characteristics (PPCs) and assessed their association with PSD, including variation within configurations.

Design: Cross-sectional study.

Participants: One hundred thirty-eight family physicians in 84 community practices and 4,046 outpatient visits.

Measurements: Physician knowledge, attitudes, use of tools and staff, and practice patterns were assessed by ethnographic and survey methods. PSD was assessed using direct observation of the visit and medical record review. Cluster analysis identified unique configurations of PPCs. A priori hypotheses of the configurations likely to perform the best on PSD were tested using a multilevel random effects model.

Results: Six distinct PPC configurations were identified. Although PSD significantly differed across configurations, mean differences between configurations with the lowest and highest PSD were small (i.e., 3.4, 7.7, and 10.8 points for health behavior counseling, screening, and immunizations, respectively, on a 100-point scale). Hypotheses were not confirmed. Considerable variation of PSD rates within configurations was observed.

Conclusions: Similar rates of PSD can be attained through diverse physician practice configurations. Significant within-configuration variation may reflect dynamic interactions between PPCs as well as between these characteristics and the contexts in which physicians function. Striving for a single ideal configuration may be less valuable for improving PSD than understanding and leveraging existing characteristics within primary care practices.

Figure 1

Rates of A) health behavior counseling, B) screening, and C) immunization by physician practice configuration type. The vertical bar represents the distribution of rates for each service among physician practices; each box is delimited by one standard deviation above and below the group mean, indicated by the thick horizontal line. The multilevel random effects model to assess between configuration comparisons used the illness-focused group as the referent. The figures indicate the referent group with vertical stripes and those groups that are significantly different from the referent with horizontal stripes. All associations are evaluated at P < .05 level. For health behavior counseling, the prevention team, average, well-care-focused, and chaotic groups significantly differed from the illness-focused group. For screening, the prevention team, average, and well-care-focused groups significantly differed from the illness-focused group. For immunizations, the prevention team and the average group significantly differed from the illness-focused group.