BACKGROUND: Our objective was to understand family practices from the ground up through intensive direct observation of the practice environment and patient care.
METHODS: Eighteen practices were purposefully drawn from a random sample of Nebraska family practices that had earlier participated in a study of preventive service delivery. Each practice was studied intensely over a 4- to 12-week period using a comparative case study design that included extended direct observation of the practice environment and clinical encounters, formal and informal interviews of clinicians and staff, and medical record review.
DESIGN: This multimethod assessment process (map) provided insights into a wide range of practice activities ranging from descriptions of the organization and patient care activities to quantitative documentation of physician- and practice-level delivery of a variety of evidence-based preventive services. Initial insights guided subsequent data collection and analysis and led to the integration of complexity science concepts into the design. In response to the needs and wishes of the participants, practice meetings were initiated to provide feedback, resulting in a more collaborative model of practice-based research.
CONCLUSIONS: Our map provided rich data for describing multiple aspects of primary care practice, testing a priori hypotheses, discovering new insights grounded in the actual experience of practice participants, and fostering collaborative practice change.
Clinicians, researchers, and policymakers now recognize that multiple competing demands1 and opportunities2 are simultaneously affecting the physicians, staff, and patients within primary care practices. Our current understanding of outpatient practice is largely based on administrative databases, national surveys, and medical record reviews, with additional insights from surveys of patients or clinicians. These data generally are not designed to capture the richness of the content and context that is needed to better understand the realities and complexities of practice.3-6 The underlying premise of The Prevention and Competing Demands in Primary Care (P&CD) Study is that efforts to change practice should be preceded by efforts to understand it.2,7 The explicit goal of this study is to understand practice structure and process, including details of patients, physicians, staff, and clinical encounters; the practice as an organization; and its relationship to the larger community and health system.
In this paper we describe a dynamic observational multimethod assessment process (MAP) that can be used to understand the complex reality of primary care practice. MAP is based on a multimethod comparative case study design8,9 that integrates elements of epidemiology with methods derived from the qualitative traditions of anthropology and sociology and relies most heavily on qualitative observation and interviewing methods. Studies of this type require an iterative data collection and analysis approach that evolves over time so that new methods can be introduced as the investigators gain a better understanding of important issues. A major strength of our study design was that it allowed hypotheses and insights gained from participants and from ongoing analyses to be integrated into the ongoing investigation.
The study’s primary research questions related to how practice characteristics affect preventive service delivery. Thus, the research design included: (1) an examination of the organizational contexts that support preventive services, (2) an examination of the competing demands imposed by carrying out clinical prevention and illness care in clinical encounters and in the practice, (3) a comparison of the approaches used by practices with high versus low intensity of preventive services delivered to eligible patients, and (4) an examination of approaches used to deliver different types of preventive services. Although the particular focus was on preventive services, the rich MAP allowed pursuit of other research topics that are presented in this issue of JFP.
This article describes the evolutionary methods of the P&CD study, focusing on how data were collected to ensure that sufficient details were available to understand a practice’s values, structures, and processes.*
Emergent research design
The P&CD study was conceived in 1994 to be an in-depth follow-up of insights from the Direct Observation of Primary Care (DOPC) Study that was just getting under way in northeastern Ohio.5 The DOPC Study provided a largely quantitative assessment of patients, physicians, encounters, and practices using patient questionnaires, physician surveys, medical record audits, and direct observation of clinical encounters using the Davis Observation Code.10 That study’s initial findings were presented in the May 1998 theme issue of JFP, and the study processes have recently been described.11 Details of the DOPC methods have been published elsewhere.4,5,12
Although the initial design allowed the DOPC research nurses to collect brief observational notes, the intensity of the quantitative data collection limited the scope of the study’s qualitative data for understanding details of the practice’s organization and the competing demands within clinical encounters. As a consequence, the P&CD study was designed to provide more in-depth description and understanding of the competing demands of family practice, and in particular, to evaluate factors affecting preventive services delivery using a comparative case study design and a MAP.