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Biomedical subjects

Benjamin F Crabtree

Publications and source records attributed to Benjamin F Crabtree.

At least 19 recordsLinked to original sources
PubMed2007

Modelling effectiveness of internally heterogeneous organizations in the presence of survey non-response: an application to the ULTRA study.

Levels of turbulence and uncertainty in family medicine practices participating in the ULTRA study are measured via a survey from heterogeneous viewpoints within each practice, including clinicians, nursing staff and office staff. In order to examine the effect of the average practice 'chaos' score on screening provided to patients, the analysis needed to account for large amounts of missing survey responses. Patterns of missing data included portions of missing responses within a job group (e.g. one out of three clinicians) to missing responses from whole subgroups within a practice (e.g. all three clinicians) to a whole practice of missing survey responses (e.g. all clinicians, nursing staff and office staff). The expectation-maximization (EM) algorithm, using a hierarchical model for covariate information, is used to handle the missing data. It was found that the varied patterns of missingness of survey responses among the heterogeneous subgroups within the practices had large effects on estimated effects of practice chaos on patient care.

Cholesterol↗
PubMed2006

Colorectal cancer screening among obese versus non-obese patients in primary care practices.

BACKGROUND: Obesity is associated with increased colorectal cancer incidence and mortality. Previous studies using telephone survey data showed that obese women were less likely to receive colorectal cancer screening. It is unknown if this is true among patients in primary care practices. METHODS: Retrospective chart reviews were conducted in 2003-2004 of men and women in 22 suburban New Jersey and Pennsylvania primary care practices. Data from patients age 50 years and over (n=1297) were analyzed using hierarchical logistic regression. The outcome measure was receipt of colorectal cancer screening (fecal occult blood test within 1 year, sigmoidoscopy within 5 years, colonoscopy within 10 years, or barium enema within 5 years) among obese and non-obese patients. RESULTS: Overall, 39% of patients were obese and 29% received colorectal cancer screening. After controlling for age, gender, total number of co-morbidities, number of visits in the past 2 years, and number of years in the practice, obese patients had 25% decreased odds of being screened for colorectal cancer compared to non-obese patients (OR 0.75, 95% CI, 0.62-0.91). The relationship of obesity and colorectal cancer screening did not differ according to gender. Number of visits (OR 1.04, 95% CI, 1.01-1.06) and male gender (OR 1.53, 95% CI, 1.19-1.97) was associated with increased odds of receiving colorectal cancer screening. CONCLUSION: Identification of physician and patient barriers to colorectal cancer screening is needed, particularly in obese patients, so that effective interventions may be developed to increase screening in this high-risk group.

Aged↗
PubMed2006

Influence of primary care practice and provider attributes on preventive service delivery.

BACKGROUND: While visits to the doctor's office are appropriate times to advise patients on health behaviors, these opportunities are often missed. Lapses in care quality are no longer attributed solely to individuals, but are also increasingly understood to be the result of organizational factors. This research examines the influence that both practice and provider attributes have on the delivery of preventive services for health behaviors. METHODS: This study used data collected from the Prescription for Health initiative sponsored by the Robert Wood Johnson Foundation. Quantitative data on 52 primary care practices and 318 healthcare providers were gathered from September 2003 to September 2004, and were analyzed upon completion of data collection. Hierarchical linear modeling was used to examine associations between both practice and provider attributes and preventive service delivery. RESULTS: Practice staff participation in decisions regarding quality improvement, practice change, and clinical operations positively influenced the effect of work relationships and negatively influenced the effect of practice size on service delivery. Nurse practitioners and allied health professionals reported more frequent delivery of services compared to physicians. Last, use of reminder systems and patient registries were positively associated with preventive service delivery. CONCLUSIONS: This study offers preliminary support for staff participation in practice decisions as a positive aspect of teamwork and collaboration. Findings also suggest leveraging nonphysician clinical staff and organized clinical systems to improve the delivery of preventive services for health behaviors.

Adult↗
PubMed2006

Hyperlipidemia guideline adherence and association with patient gender.

BACKGROUND: Gender disparities in cardiovascular disease (CVD) management have become increasingly apparent in recent years. Previous research has focused on inpatient disparities, but little is known about how patient gender affects assessment, treatment, and management of patients for hyperlipidemia and cardiovascular risk in primary care settings. Patients with coronary artery disease (CAD) and hyperlipidemia are at high risk for cardiovascular and cerebrovascular morbidity. We sought to examine the effect of patient gender on assessment, treatment, and target maintenance of hyperlipidemia among patients with CAD in a primary care setting. METHODS: Chart abstraction was done for 715 patients with CAD in 55 family practices in New Jersey and eastern Pennsylvania as part of the Using Learning Teams for Reflective Adaptation (ULTRA) project. Hyperlipidemia assessment, treatment, and target adherence scores were determined for those at-risk patients based on National Heart, Lung, and Blood Institute (NHLBI) recommended National Cholesterol Education Program (NCEP) ATP III guidelines. Generalized linear models were used to determine the association of hyperlipidemia guideline adherence with patient gender, using comorbidities and age as confounders. RESULTS: After controlling for comorbidities and age, women were less likely to be assessed for lipids (p = 0.0462). There was no difference in treatment (p = 0.1074) or target laboratory values (p = 0.3949). CONCLUSIONS: Women with CAD are less often assessed for lipids than men in primary care practices. More intensive efforts may be necessary to educate physicians and patients about cardiovascular risk for women.

Adult↗
PubMed2006

Recruiting minority primary care practices into practice-based research.

BACKGROUND: A potentially fruitful strategy for increasing enrollment of minority patients in research is to engage minority clinicians. However, little attention has been paid to unique challenges and effective strategies for engaging practices with minority physicians. OBJECTIVE: The objective of this study was to provide a model for recruiting community-based primary care practices with minority physicians into research studies. RESEARCH DESIGN: Practices were recruited using a 3-step process that included telephone contact, on-site meetings, and follow-up discussions. Strategies used to recruit 18 New Jersey community-based primary care practices with minority physicians for a quality improvement intervention study were assessed. RESULTS: Twelve of 18 practices (67%) were successfully recruited into the study. Effective recruitment strategies included building rapport using a multiethnic/multidisciplinary team led by a minority physician recruiter and stressing study benefits for the practice. We attempted to match recruiters and key practice members by race, underrepresented minority status of the lead recruiter, gender, career stage, experience in urban practice, and experience in clinical instruction. Practices that were successfully recruited had more characteristics in common between recruiters and key practice members than unsuccessfully recruited practices (mean number of characteristic matches = 3.75 vs. 1.83, P = 0.020). Study benefits cited by participants as motivators for participation included a general desire to provide good patient care by understanding their practices' strengths and challenges (92%) and improving their practice (85%). CONCLUSIONS: Our experience suggests that a staged, tailored, and iterative recruitment process emphasizing communication and relationship building can be successful in recruiting community-based primary care minority physicians into practice-based research.

Clinical Trials as Topic↗
PubMed2006

Productivity and turnover in PCPs: the role of staff participation in decision-making.

BACKGROUND: Efforts to redesign primary care practices are beginning to address how decisions are made in the practice setting. This study contributes to these efforts by examining associations between staff participation in decision-making, productivity, and turnover in primary care practices. The study is informed by organizational theories of participation that emphasize cognitive and affective influences on employee output and behavior. METHODS: This research used data collected from primary care practices involved in a national initiative sponsored by the Robert Wood Johnson Foundation. Cross-sectional survey data on organizational structures and attributes among 49 practices were analyzed. Regression analysis was used to examine associations among practice productivity, staff participation in decision-making, and formal structures such as staff meetings. Associations between staff turnover and participative decision-making were also examined. RESULTS: Staff participation in decisions regarding quality improvement, practice change, and clinical operations was positively associated with practice productivity, whereas formal structures such as staff meetings were not. In addition, higher levels of participation in decision-making were associated with reduced turnover among nonclinicians and administrative staff. CONCLUSION: Examination of organizational features is increasingly recognized as a key to improving primary care performance. Study findings suggest that one important strategy may be implementation of a participative model emphasizing greater staff involvement in practice decisions. This may enhance information-sharing, work satisfaction, and commitment to organizational decisions, all of which can lead to beneficial outcomes such as increased productivity and stability in primary care practices.

Cross-Sectional Studies↗
PubMed2006

The qualitative research interview.

BACKGROUND: Interviews are among the most familiar strategies for collecting qualitative data. The different qualitative interviewing strategies in common use emerged from diverse disciplinary perspectives resulting in a wide variation among interviewing approaches. Unlike the highly structured survey interviews and questionnaires used in epidemiology and most health services research, we examine less structured interview strategies in which the person interviewed is more a participant in meaning making than a conduit from which information is retrieved. PURPOSE: In this article we briefly review the more common qualitative interview methods and then focus on the widely used individual face-to-face in-depth interview, which seeks to foster learning about individual experiences and perspectives on a given set of issues. We discuss methods for conducting in-depth interviews and consider relevant ethical issues with particular regard to the rights and protection of the participants.

Data Collection↗
PubMed2006

A closer look at adult female health care maintenance visits.

BACKGROUND/OBJECTIVES: The health care maintenance (HCM) visit is a primary vehicle for delivering preventive services in primary care, but how these visits are actually utilized is poorly understood. This paper describes the content and process of HCM visits for adult women in family medicine. METHODS: Data were collected as part of a multi-method comparative case study of 57 clinicians from 18 purposefully selected Midwestern urban, suburban, and rural practices. Descriptive observational field notes, medical records reviews, and depth interviews were used to identify the overall content,process, and style of these visits and to examine the management of additional concerns. RESULTS: The preventive services addressed most frequently included clinical breast exams, pelvic exams,and mammography. Cholesterol screening, flexible sigmoidoscopy, alcohol use, and vaccinations were infrequently addressed. Health habit counseling regarding obesity was inconsistent. While some encounters followed a checklist, the majority of visits were structured but open to patients'questions/concerns. An "open-ended" format was seldom utilized. Additional patient concerns were raised and addressed during the majority of HCM visits. CONCLUSIONS: HCM visits provide unique opportunities to deliver preventive care. Physicians may need to expand the range of services offered,involve other members of the primary care team, and address competing demands to ensure more-comprehensive preventive care delivery.

Adult↗
PubMed2005

How complexity science can inform a reflective process for improvement in primary care practices.

BACKGROUND: Quality improvement processes have sometimes met with limited success in small, independent primary care settings. The theoretical framework for these processes uses an implied understanding of organizations as predictable with potentially controllable components. However, most organizations are not accurately described using this framework. Complexity science provides a better fit for understanding small primary care practices. METHODS: The Multimethod Assessment Process (MAP)/Reflective Adaptive Process (RAP) is informed by complexity science. This process was developed in a series of studies designed to understand and improve primary care practice. A case example illustrates the application and impact of the MAP/RAP process. RESULTS: Guiding principles for a reflective change process include the following: an understanding of practices' vision and mission is useful in guiding change, learning and reflection helps organizations adapt to and plan change, tension and discomfort are essential and normal during change, and diverse perspectives foster adaptability and new insights for positive change. DISCUSSION: A reflective change process that treats organizations as complex adaptive systems may help practices make sustainable improvements.

Organizational Case Studies↗
PubMed2005

Healing landscapes: patients, relationships, and creating optimal healing places.

Healing can be both an intensely personal and a social and community event that often surprises us when it emerges from the landscape of everyday life. This observation raises at least three questions that serve as the focus for this paper's reflections about creating optimal healing places. Who are patients? What relationships and features of those relationships help patients toward healing? How do we understand and facilitate the emergence of healing over time and place? Using existing literature and our own past and current studies of patients, clinical encounters, and primary care practices, we explore each of these questions. We identify four different aspects or faces of patients: patients as human animals, patients as persons, patients as techno-consumers, and patients as patients. We highlight 10 lessons or observations about patients and their healing experiences. Key features of relational process are described, and nine interdependent relationship characteristics that appear to promote healing are discussed. The idea of healing landscapes as an emergent life space is introduced as a way of conceptualizing and further investigating these observations. A reflective action process for facilitating the emergence of healing landscapes and creating an ecology of hope is presented, and recommendations for future research are briefly shared.

Environment Design↗
PubMed2005

Case study research: the view from complexity science.

Many wonder why there has been so little change in care quality despite substantial quality improvement efforts. Questioning why current approaches are not making true changes draws attention to the organization as a source of answers. The authors bring together the case study method and complexity science to suggest new ways to study health care organizations. The case study provides a method for studying systems. Complexity theory suggests that keys to understanding the system are contained in patterns of relationships and interactions among the system's agents. They propose some of the "objects" of study that are implicated by complexity theory and discuss how studying these using case methods might provide useful maps of the system. They offer complexity theory, partnered with case study method, as a place to begin the daunting task of studying a system as an integrated whole.

Delivery of Health Care, Integrated↗
PubMed2004

Key issues in transforming health care organizations for quality: the case of advanced access.

BACKGROUND: The 2001 Institute of Medicine (IOM) report highlighted the need for transformation of the U.S. health care system. This rigorous qualitative evaluation of transformational change for patient access in one large multispecialty group practice identifies the major issues facing organizations addressing the IOM challenge. METHODS: Semistructured depth interviews were conducted with the medical and administrative leaders at all levels, physicians, and nurses from 17 primary care clinics in one integrated medical group two years after they began to transform their approach to primary care patient appointment access. RESULTS: The mean time to third-next-available appointment was reduced by 76% during one year, from 17.8 days to 4.2 days. Nine important issues related to the change process were identified from clinic interviews. When combined with issues identified by central leaders, 13 themes stood out as lessons in transformational change. A major issue is the tension between physician autonomy and both effective organizational function and putting patients first. Physician autonomy is also diminished by the need to standardize and systematize care. CONCLUSIONS: Transformational change in care delivery is possible in large and complex group practices. Changes that directly affect care delivery and physician autonomy present particular challenges to physicians that need to be attended to if the changes are to be successful.

Ambulatory Care Information Systems↗
PubMed2003

Keeping up appearances: using qualitative research to enhance knowledge of dental practice.

Current issues in dentistry including a focus on patients' wishes for outcomes and dentists' role in that process raise important questions that cannot be addressed by quantitative, statistical study alone. The intriguing complexities and ambiguities that are emerging with ever-improving techniques and materials in dentistry, as well as competing demands for attention in dental health, require a range of research methodologies to address important existing and future research questions. Qualitative research, much like what a dentist does in an office visit, can seem intuitive and almost common sense in nature. Yet behind that research, when it is done well, lie years of training and practice, rules of evidence, guidelines for rigor, and various subspecializations in its pursuit. Qualitative research begins with a clearly defined problem; identifies the appropriate strategy to gather data from people, existing documents, and other sources of information that will help address the problem; uses a multifaceted tool kit of analytic methods to work with those data; and proceeds to investigate the data for their insight into the research problem and interpretation of the findings. This article provides an overview of common approaches to qualitative methods and resources to explore their potential for dental research.

Anthropology, Cultural↗
PubMed2002

Primary care for elderly people: why do doctors find it so hard?

PURPOSE: Many primary care physicians find caring for elderly patients difficult. The goal of this study was to develop a detailed understanding of why physicians find primary care with elderly patients difficult. DESIGN AND METHODS: We conducted in-depth interviews with 20 primary care physicians. Using an iterative approach based on grounded theory techniques, a multidisciplinary team analyzed the content of the interviews and developed a conceptual model of the difficulty. RESULTS: Three major domains of difficulty emerged: (i) medical complexity and chronicity, (ii) personal and interpersonal challenges, and (iii) administrative burden. The greatest challenge occurred when difficulty in more than one area was present. Contextual conditions, such as the practice environment and the physician's training and personal values, shaped the experience of providing care and how difficult it seemed. IMPLICATIONS: Much of the difficulty participants experienced could be facilitated by changes in the health care delivery system and in medical education. The voices of these physicians and the model resulting from our analysis can inform such change.

Adult↗
PubMed2002

Assessing diversity and quality in primary care through the multimethod assessment process (MAP).

The U.S. health care system serves a diverse population, often resulting in significant disparities in delivery and quality of care. Nevertheless, most quality improvement efforts fail to systematically assess diversity and associated disparities. This article describes application of the multimethod assessment process (MAP) for understanding disparities in relation to diversity, cultural competence, and quality improvement in clinical practice. MAP is an innovative quality improvement methodology that integrates quantitative and qualitative techniques and produces a system level understanding of organizations to guide quality improvement interventions. A demonstration project in a primary care practice illustrates the utility of MAP for assessing diversity.

Cultural Diversity↗
PubMed2002

Physician attitudes and the use of office-based activities for tobacco control.

OBJECTIVES: This study explored family physicians' attitudes about smoking cessation counseling-its importance, their confidence in their ability to counsel, outcome expectations of counseling, perception of their influence on patient behavior types of counseling skills used, and the extent to which office-based activities are used to support their counseling. METHODS: A cross-sectional design using qualitative and quantitative analyses was used. Data, including information from participant observation of the environment, medical chart reviews, and in-depth interviews, were collected from 89 physicians, drawn randomly from a list of family physicians in Nebraska. RESULTS: All physicians felt that counseling was important, and most were confident with their ability to provide cessation counseling. Only one third of physicians had positive expectations regarding the outcome of this counseling or of their influence on patient behavior in general. The counseling skills most likely to be used were giving advice to quit, prescriptions for pharmaceutical aids, and discussing barriers and resources. Office-based strategies to support physician counseling were seldom used. CONCLUSIONS: Physician attitudes and tobacco-control activities present a complex picture of low expectations, little office support, and limited counseling skills combined with a strong belief in the professional responsibility to counsel. Motivation to increase skills or implement supportive systems could be expected to be low.

Attitude of Health Personnel↗