Referral

About: Referral is a research topic. Over the lifetime, 27614 publications have been published within this topic receiving 479918 citations.

Measuring Organizational Attributes of Primary Care Practices: Development of a New Instrument

Abstract: The impact of the work environment on clinical performance and outcomes is receiving renewed interest by health systems researchers, health care administrators, and policy makers (IOM Committee on Quality of Health Care in America 2001; Shortell 2002; Shortell and Selberg 2002). A growing body of literature derived from research in large health care settings, such as hospitals and large multispecialty group practices, suggests that better health outcomes are associated with particular organizational attributes (Shortell and LoGerfo 1981; Shortell 1985, 1990, 2002; Davies and Ware 1988; Shortell, O'Brien et al. 1994; Shortell, Zimmerman et al. 1994; Shortell et al. 1998; Mitchell and Shortell 1997; Davies and Nutley 2000; Donaldson et al. 2000; Ferlie and Shortell 2001). Similar studies within primary care have the potential to impact a broader spectrum of the American population. In a given year most Americans visit a primary care physician (Benson and Marano 1994), with more than a quarter of these visits to family medicine practices (Woodwell 1999). Primary care practices, including family medicine, general internal medicine, and pediatric practices, are unique among health providers in that they must serve as the front line for large variety of health care needs, from prevention to identification of disease and illness to the treatment of ailments or referral to specialists. To understand the impact of organizational attributes of primary care practices on delivery of patient care, one first needs to understand the attributes of these typically small medical providers and develop a method for measuring these attributes. A key element of a practice's ability to maintain and improve quality of care for their patients is their ability to adapt to the evolving understanding of medicine, to demands for enhanced clinical performance, and to changes in the larger health care management system. While general models of change have been proposed (Senge 1990, 1994; Rogers 1995), these models have typically not incorporated the features unique to primary care practices. One exception is the primary care change model recently described by Cohen et al. (2004) that includes four interdependent elements that determine a practice's capacity for sustainable change. This model emerged from three federally funded studies, two descriptive studies, the Direct Observation of Primary Care (DOPC) study (Crabtree et al. 1998; Miller et al. 1998) and Prevention & Competing Demands in Primary Care (PC Miller et al. 1998; Tallia et al. 2003), and one intervention study, the Study to Enhance Prevention by Understanding Practice (STEP-UP) (Goodwin et al. 2001; Cohen et al. 2004). The model identifies clinician and staff characteristics, particularly their interrelationships, as important in distinguishing the between practices' abilities to improve their rates of delivery of prevention services. Of the four elements described by Cohen et al. (motivation of key stakeholders, resources for change, outside motivators, and opportunities for change), resources for change best describes organizational characteristics that a practice must have to modify not only its technical aspects, but also its values and beliefs regarding itself as an organization. The resources for change element includes internal resources such as relationships among practice members, leadership and decision-making approaches, communication and perception of competing demands. Information management and management infrastructure, are also facets of the internal resources for change element. Measurement tools exist for assessing important organizational attributes of larger health systems, such as hospitals (Shortell 1985; Shortell et al.1991, 2000; Jennings and Westfall 1994; Nabitz et al. 2000; Weeks et al. 2000; Meyer and Collier 2001; Nordhaus-Bike 2001; Goldstein and Schweikhart 2002). These attributes include: (1) leadership that engages a diversity of perspectives and shares critical information in order to enhance problem solving processes; (2) a culture that fosters openness, connectedness, and learning; (3) relationships that foster communication and collaboration; (4) management functions that describe presence of diverse structural components and processes such as fiscal, material, clinical, recognition, and feedback, and strategic planning; and (5) information mastery that includes the access and use of information that supports learning and problem solving activities (Shortell et al. 1998; Davies and Nutley 2000; Donaldson et al. 2000; Ferlie and Shortell 2001). The first three of these attributes, in particular, were also identified by Cohen et al. (2004) as internal resources that are needed to create and sustain change (Cohen et al. 2004) in the primary care practice. However, a systematic tool to measure these attributes in primary care practices has not been developed. Because these practices are much smaller and have much more limited resources than hospitals and other larger health systems, instruments for measuring attributes of larger health systems are not expected to describe and differentiate between primary care practices well. As such, an instrument must be created specifically for use in the primary care practice. This study aims to develop an instrument to measure organizational attributes of primary care practices and to evaluate the measurement properties of this newly developed instrument. The instrument, intended to be a survey of clinicians, nurses and staff within the practice, seeks to measure some facets of resources for change, including relationships among practice members, leadership and decision-making approaches, communication, and perception of competing demands. The other facets, specifically information management and management infrastructure, are thought to be better addressed at the practice level by one or two key members of the practice, for example the office manager or medical director. This instrument is developed based on the experience of investigators in family medicine, internal medicine, and pediatric practices; however, its use will be evaluated within family medicine practices. It was hypothesized that this instrument's items would measure internal resources for change and be able to sort practices according to the strength of their available internal resources.

Diagnosis, treatment, comorbidity, and resource utilization of depressed patients in a general medical practice.

Abstract: Objective. The objective of the study was to determine the effect of depression on the utilization of health care resources, after adjusting for age and comorbidity from data obtained on routine clinical practice. Method: The study is an observational cohort of 15,186 patients followed over a one-year period beginning December 1993. Comprehensive demographic, clinical, and utilization data were available from the computerized medical information system generated database of a general internal medicine practice in an urban academic medical center. Results: Four point seven percent of patients carried a provider-coded diagnosis of depression. With regards to utilization of health care resources, even after controlling for age and comorbidity, depressed patients had more primary care visits (5.3 vs. 2.9 visits, p <.001), higher rates of referral to specialists (1.1 vs. 0.5, p <.002), and radiologic tests (0.9 vs. 0.4 tests, p <.001). They had higher total outpatient charges ($1,324 vs. $701, p<.001) and total charges ($2,808 vs. $1,891, p<.001). Depressed patients also had longer length of stay when hospitalized (14.1 vs. 9.5 days, p <.002). Conclusions: Patients diagnosed as depressed had significantly higher resource utilization of all types, even after controlling for the higher burden of comorbid medical illness associated with depression.

Prognostic conflict in life-and-death decisions: the organization as an ecology of knowledge.

Abstract: This paper examines prognostic conflict in life-and-death decisions in intensive care units for newborn infants. The data were collected during 16 months of field research in two intensive care nurseries which differed with respect to their size, relative prestige, referral patterns, and the demographic composition of their clientele. This analysis approaches life-and-death decisions from the standpoint of the sociology of knowledge, which relates decisions to the social context in which they take place. Prognostic conflict is used as a paradigmatic case to illustrate how the organization as an ecology of knowledge allocates different information to those who reach life-and-death decisions. A major finding is that physicians and nurses, because of their experiences in the intensive care nursery, differ systematically in their views of infants' prognoses. Residents, whose contact with infants is limited and technologically focused, assess prognosis largely on the basis of diagnostic technology. Nurses, who sustain continuous contact with infants, also assess prognosis on the basis of cues gleaned from interactions with infants, but may assume a more pessimistic attitude toward infants who pose management difficulties. These contrasting and "partial" views of reality are rooted in the culture and social structure of technology-intensive medical settings. Following medical historians, we suggest that medical practice has been characterized by a diminishing attention to patients' subjective symptoms, a waning confidence in clinical observation, and an increasing reliance on diagnostic technology. These organizational features of neonatal intensive care units complicate life-and-death decisions. By implication, a change in some of these features might result in more informed and equitable decision-making.