Sampling
The comparative case study design began with an initial phase of purposefully selecting practices that included both urban and rural settings and those with different intensities of preventive services delivery, (n=10) followed by a sample to confirm or refute evolving hypotheses (n=8). The practices were selected from those that had participated in the Centers for Disease Control and Prevention/Nebraska Department of Health–funded Tobacco Use Prevention in Physicians Offices study (Helen McIlvain, principal investigator). These high-volume practices had a wide variation in practice location (urban, suburban, and rural) and organizational structure (solo vs group, independent vs system affiliated). Because we noted some interesting variations among practices from different health systems in the early analyses, the replication sample ensured at least 2 practices from each of 4 major health systems, and 2 from those practices that were seen as struggling to provide preventive services in the tobacco study.
We solicited study participation by sending an invitation letter followed by a telephone call to one of the physicians in the practice. Participation was very high, requiring contact with 23 practices to obtain the 18 deemed necessary in the study design.
Data Collection
We sent a field researcher trained in qualitative methods to each practice where she used a variety of data collection methods to produce a comprehensive picture of the practice as a functioning organization. Data were collected through direct observation of the practice,22 the use of structured checklists of the office environment,23 direct observation of patient encounters supplemented with structured checklists, the use of patient pathways,24 individual depth interviews with physicians and other key staff members,25 and chart audits. It took from 4 to 12 weeks for the field researcher to complete the data collection in each practice, depending on its size.
The field researcher observed and jotted details of the physical environment and functioning of the practice, then dictated extensive field notes at the end of each day. These field notes contained detailed descriptions of the clinic location and environment, patient characteristics, nursing station, examination rooms, the waiting area, physician offices, bulletin boards, posters, and patient education materials. Photographs were taken of each room, including the reception area, waiting area, nurses’ station, nurse intake room, and the examination rooms. Existing practice personnel, their roles and duties, and their relationships and interactions with other staff members were characterized in a practice genogram.26 Physical office systems, including charts, flow sheets, and computer systems were described, as were functional office routines and procedures. The field researcher specifically noted the storage and organization of drug samples within the clinic, comments made by staff relating to pharmaceutical representatives, and any observed interaction between staff and representatives.
The field researcher attempted to observe 30 patient encounters for each clinician; because of patient volume and scheduling this was not always possible. Thirty or more patient encounters were observed in 42 of the 53 clinicians participating in the study, and 20 or more patient encounters were observed for all but 1 provider (who had 18 encounters). After obtaining written informed consent from the patient, the field researcher shadowed the clinician and jotted notes about each encounter for later dictation. The patient encounter field notes contained rich descriptions about any verbal patient education delivered and the context of that education, including the reason for the visit, how the visit unfolded, and how the clinician and patient interacted. The patient encounter dictation captured the distribution of drug samples, discussion between the clinician and patient regarding drug samples, prescriptions written by physicians, and instructions given by physicians.
Using the depth interviewing technique, the field researcher interviewed all family physicians within the practice, the office manager, head nurse, and other significant persons within the practice.25 Questions asked by the field researcher related to overall views of medicine, general practice characteristics, the systems in place for the delivery of preventive medicine, and perceived rates of delivering preventive medicine. These interviews were tape-recorded and transcribed verbatim.
Additional data such as photographs and chart audits were collected as part of the larger study but were not included in our analysis.
Data Analysis and Interpretation
Qualitative data were transcribed, checked for accuracy by having the field worker review the manuscript, and entered into FolioViews 4.11, an infobase software package.27 We began our analysis by immersing ourselves in all the data from 2 practices to understand the function of the practices and the overall richness and variation of the data collected, and to identify any mention of drug samples or interactions with pharmaceutical representatives. Using this immersion/crystallization approach, we worked to formulate hypotheses and an initial organizational scheme.28 Group discussions led to the development of a codebook of key words.