Relationships and Routines in Preventive Service Delivery
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Am Fam Physician. 2000 Nov 1;62(9):1984-1990.
The “Policy Center One-Pager” published in this issue1 contains take-home lessons for family physicians and challenges for policy makers. The study cited in the report found that children and adults with a usual source of care were more likely to have received preventive services, compared with patients who do not have a usual source of care. In addition, adults seeing an internist were more likely to receive these services than adults seeing a family physician. There are a number of potential reasons for these differences, but two implications of the findings are particularly worth considering.
First, the data appear to validate the importance of developing a relationship with a generalist clinician to obtain preventive services. Specific aspects of the relationship affect the delivery of different types of services.2–4 If the context of a physician-patient relationship is vital for delivery of relatively routine preventive services, it is even more important for care of chronic illnesses, recognition of mental health problems and guiding access to appropriate subspecialty care.5,6 However, the relationship context for the commodities of health care is being disrupted in the current health care environment, with detrimental consequences to the quality of patients' care.7,8 In addition, for the more than 44 million Americans who do not have access to regular medical care because of a lack of insurance, ongoing health care relationships are scarce and preventive care remains a largely unmet need.9,10
The services listed in the “One-Pager,”1 with the exception of prostate cancer screening and perhaps the general medical examination, are well-supported by scientific evidence and are generally well-accepted by patients.11 Therefore, regardless of the difficulties in maintaining ongoing patient-physician relationships, these services should be routinely available to all people. Yet, because of the competing demands and opportunities to meet a broad array of patient needs in family practice,12 physicians often have little time left for prevention after other needs are met.13
Involving nurses and office staff in systems for identifying patients eligible for these routine services and delivering services is effective.14 Outreach to patients who do not visit the office routinely is another important strategy and is a potentially valuable role for managed care organizations.15 Developing systems and team approaches can free up physicians to selectively deliver more intensive preventive services to high-risk patients or to take advantage of teachable moments that are linked to risk factors and illness presentations.3,16 The higher rates of preventive service delivery by internists are a reminder of the need to ensure routine delivery of important services that don't make it onto the agenda of the broad and more time-limited family practice visit.
All Americans deserve a relationship with a primary care physician. We need to design a health care system that fosters this relationship. We also need to design our practices so that the aspects of care that particularly benefit from a relationship are facilitated by well-established routines.
Kurt C. Stange, M.D., Ph.D., is professor of family medicine, epidemiology and biostatics, oncology and sociology at Case Western Reserve University School of Medicine in Cleveland, Ohio, and is the associate director for Prevention, Control and Population Research at the Ireland Comprehensive Cancer Center at CWRU and University Hospitals.
Address correspondence to Kurt C. Stange, M.D., Ph.D., Dept. of Family Medicine, Case Western Reserve University School of Medicine, 10900 Euclid Ave., Cleveland, OH 44106.
1. The importance of primary care physicians as the usual source of healthcare in the achievement of prevention goals. Robert Graham Center: Policy Studies in Family Practice and Primary Care. Am Fam Physician. 2000;62:1968.
2. Flocke SA, Stange KC, Zyzanski SJ. The association of attributes of primary care with the delivery of clinical preventive services. Med Care. 1998;36:AS21–30.
3. Flocke SA, Stange KC, Goodwin MA. Patient and visit characteristics associated with opportunistic preventive services delivery. J Fam Pract. 1998;47(3):202–2.
4. Medalie JH, Zyzanski SJ, Goodwin MA, Stange KC. Two physician styles of focusing on the family: their relationship to patient outcomes and process of care. J Fam Pract. 2000;49(3):209–15.
5. Franks P, Clancy CM, Nutting PA. Gatekeeping revisited—protecting patients from overtreatment. N Engl J Med. 1992;327:424–9.
6. Stange KC, Jaén CR, Flocke SA, Miller WL, Crabtree BF, Zyzanski SJ. The value of a family physician. J Fam Pract. 1998;46(5):363–8.
7. Flocke SA, Stange KC, Zyzanski SJ. The impact of insurance type and forced discontinuity on the delivery of primary care. J Fam Pract. 1997;45(2):129–135.
8. Kahana E, Stange KC, Meehan R, Raff L. Forced disruption in continuity of primary care: the patients' perspective. Sociological Focus. 1997;30:177–87.
9. Woolhandler S, Himmelstein DU. Reverse targeting of preventive care due to lack of health insurance. JAMA. 1988;259:2872–4.
10. Himmelstein DU, Woolhandler S. Care denied: U.S. residents who are unable to obtain needed medical services. Am J Public Health. 1995;85:341–4.
11. U.S. Preventive Services Task Force. Guide to clinical preventive services: report of the U.S. PreventiveServices Task Force. 2d ed. Baltimore: Williams & Wilkins, 1996.
12. Jaén CR, Stange KC, Nutting PA. Competing demands of primary care: a model for the delivery of clinical preventive services. J Fam Pract. 1994;38(2):166–71.
13. Kottke TE, Brekke ML, Solberg LI. Making “time” for preventive services. Mayo Clin Proc. 1993;68:785–91.
14. Dietrich AJ, O'Connor GT, Keller A, Carney PA, Levy D, Whaley FS. Cancer: improving early detection and prevention. A community practice randomised trial. BMJ. 1992;304:687–91.
15. Thompson RS, Taplin SH, McAfee TA, Mandelson MT, Smith AE. Primary and secondary prevention services in clinical practice. Twenty years' experience in development, implementation, and evaluation. JAMA. 1995;273:1130–5.
16. Stange KC, Flocke SA, Goodwin MA. Opportunistic preventive services delivery: Are time limitations and patient satisfaction barriers? J Fam Pract. 1998;46(5):419–24.
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