Flocke Susan A, Litaker David
Department of Family Medicine, Case Western Reserve University, Cleveland, OH, USA.
J Gen Intern Med. 2007 Feb;22(2):191-6. doi: 10.1007/s11606-006-0042-y.
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.
We identified naturally occurring configurations of physician practice characteristics (PPCs) and assessed their association with PSD, including variation within configurations.
Cross-sectional study.
One hundred thirty-eight family physicians in 84 community practices and 4,046 outpatient visits.
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.
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.
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.
改善预防服务提供（PSD）的策略效果有限。一种多维方法，即考察医生属性、执业流程和背景因素的独特组合，可能有助于理解这种重要医疗形式的提供情况。
我们确定了医生执业特征（PPC）的自然形成的组合，并评估了它们与PSD的关联，包括组合内的差异。
横断面研究。
84个社区诊所的138名家庭医生以及4046次门诊就诊。
通过人种学和调查方法评估医生的知识、态度、工具和工作人员的使用情况以及执业模式。通过直接观察就诊情况和查阅病历评估PSD。聚类分析确定了PPC的独特组合。使用多层次随机效应模型检验了关于在PSD方面可能表现最佳的组合的先验假设。
确定了六种不同的PPC组合。尽管不同组合的PSD存在显著差异，但PSD最低和最高的组合之间的平均差异较小（即，在100分制中，健康行为咨询、筛查和免疫接种分别为3.4分、7.7分和10.8分）。假设未得到证实。观察到组合内PSD率存在相当大的差异。
通过不同的医生执业组合可以实现相似的PSD率。组合内的显著差异可能反映了PPC之间以及这些特征与医生执业环境之间的动态相互作用。对于改善PSD而言，追求单一的理想组合可能不如理解和利用初级保健实践中的现有特征有价值。
