Roberto Jaén - Academia.edu (original) (raw)

Papers by Roberto Jaén

other disciplines the potential benefi ts of the proposed studies and be able to articulate “this... more other disciplines the potential benefi ts of the proposed studies and be able to articulate “this is the best we have in the fi eld ” (if indeed this is the case) and defend overly critical exercises in tearing projects down. How do we prepare the next group of FM researchers to be study section members for NIH? Preparing faculty for participation in study sections is a critical faculty development need and opportunity. ADFM needs to partner with NAPCRG and STFM, as well as the CTSA programs, in preparing faculty for these tasks. The limited orientation sessions pre-pared by the Scientifi c Review Administrators are not enough. We feel that those family medicine research-ers who have study section experience should share experiences with other family medicine researchers so that the learning curve can be accelerated for the benefi t of the applications being considered. ADFM is supporting a lecture-discussion during the upcoming STFM meeting in Baltimore entitled “How To Be an Effec...

Nearly 50 % of deaths in the United States are related to preventable causes.1 The Healthy People... more Nearly 50 % of deaths in the United States are related to preventable causes.1 The Healthy People 2010 report2 challenges primary care clinicians to improve the de-livery of preventive services to their patients. Recom-mended services include a range of primary, secondary, and tertiary prevention, such as immunizations and healthy lifestyle counseling, periodic health screenings and early disease identification, and the prevention of complications from chronic diseases. These have all been shown to decrease morbidity and mortality when provided to eligible patients in clinical settings.3-5 Most practicing physicians embrace the concept of prevention,6,7 with family physicians having an ex-tended history of incorporating prevention as a core component of clinical practice.8-14 The concept of a dedicated health care maintenance (HCM) visit to ensure the delivery of preventive services emerged in 1975 from a critique by family physician Paul Frame regarding the shortcomings of the annu...

Context: Cervical cancer is preventable and curable, yet Hispanic populations in certain areas of... more Context: Cervical cancer is preventable and curable, yet Hispanic populations in certain areas of the country have higher mortality rates from invasive cervical cancer than non-Hispanic white women. Objective: Our study aims to identify contextual and environmental features at the county level that are acting as barriers or facilitators of cervical cancer long-term survival in Hispanic women. Study Design: This is a mixed methods exploratory study utilizing fRAP (focused Rapid Assessment Process) methodology to uncover modifiable differences in cervical cancer survivorship contributing to mortality differences. We investigate multi-level community, medical and policy contextual elements within a county through both quantitative GIS mapping of ZCTA level data linked to fieldwork and key informant interviews. This poster highlights the qualitative Phase II of our methods, including participant observation in three Texas counties. Setting or Dataset: Phase II of fRAP includes qualitative data collected by the lead author during fieldwork from three Texas counties. Counties chosen for inclusion in the study due to differences in mortality rates between Hispanic and non-Hispanic white women were identified during Phase I GIS mapping of the study. They include Bexar, Dallas and Tarrant, all of which hold a unique disparity profile based on mortality rates. Population studied: Participants for key informant interviews identified during fieldwork visits to each county and stratified by level of interest: community, medical systems, policy, e.g. a community resource executive director, a practicing gynecologic oncologist and a county-level payment plan manager. Outcome Measures: Qualitative transcripts analyzed for themes across levels within a county, and across counties based on level. Results: Research to date has uncovered modifiable environmental and contextual differences within each of the three Texas counties contributing to how Hispanic cervical cancer survivors experience care. Outcomes to be Reported: Cross comparison of themes within a county across multiple levels and across counties within levels will allow us to identify environmental and contextual features unique to each of the three counties that contribute to their particular cervical cancer disparity profile seen on mapping. Next stages of fRAP include evaluation of modifiable features found for possible policy change targets to address disparities in care

Family practice management, 2019

Helping patients safely bridge the gap from acute care to ambulatory care is good for patients an... more Helping patients safely bridge the gap from acute care to ambulatory care is good for patients and practices too.

Journal of Family Practice, 2001

Health services research, Aug 27, 2015

To test a conceptual model of relationships, reflection, sensemaking, and learning in primary car... more To test a conceptual model of relationships, reflection, sensemaking, and learning in primary care practices transitioning to patient-centered medical homes (PCMH). Primary data were collected as part of the American Academy of Family Physicians' National Demonstration Project of the PCMH. We conducted a cross-sectional survey of clinicians and staff from 36 family medicine practices across the United States. Surveys measured seven characteristics of practice relationships (trust, diversity, mindfulness, heedful interrelation, respectful interaction, social/task relatedness, and rich and lean communication) and three organizational attributes (reflection, sensemaking, and learning) of practices. We surveyed 396 clinicians and practice staff. We performed a multigroup path analysis of the data. Parameter estimates were calculated using a Bayesian estimation method. Trust and reflection were important in explaining the characteristics of practice relationships and their associatio...

The Journal of family practice

ABSTRACT

Geriatrics Models of Care, 2015

The Patient-Centered Medical Home (PCMH) is proposed as a vehicle to deliver primary health care ... more The Patient-Centered Medical Home (PCMH) is proposed as a vehicle to deliver primary health care to older adults. The PCMH has the ability to improve the quality of care and reduce unnecessary expenditures while fostering functional independence and improving quality of life. Steps to develop a PCMH for older adults include clarity of purpose, team building, process improvement, setting time for reflection and course adjustment, defining accountability, providing a supportive and safe work environment, fully utilizing capabilities of the electronic health record and building relationships with external community partners. Building and maintaining a PCMH requires payment changes in the form of blended or direct primary care payments. Some organizational structures beyond the PCMH can hinder development of the PCMH by excessive standardization and micromanaging or they can facilitate development by providing appropriate support with facilitative leadership. The PCMH is a journey, not a destination and requires ongoing evolution of medical models and attention to patient preferences.

Healthcare, 2015

Complexity of care has implications for quality of care, health costs, medical errors, and patien... more Complexity of care has implications for quality of care, health costs, medical errors, and patient and physician satisfaction. The objective was to compare complexity of ambulatory care across 14 medical specialties. This secondary analysis uses the 2010 National Ambulatory Medical Care Survey, which used a multistage probability design of primary sampling units throughout U.S. ambulatory practices across 14 specialties. Sampling weights enable results from 29,179 ambulatory visits to represent 878,653,561 visits. Data included symptoms, diagnoses, diagnostic procedures, and treatments provided. Measures of input, output and total encounter complexity and hourly complexity densities were computed. Internal Medicine leads in total input and total encounter complexity with Family Medicine second in total encounter complexity. When duration-of-visit is considered, Family Medicine is the most complex discipline while Internal Medicine is the second most complex. Pediatrics lacks the complexity of Family Medicine and General Internal Medicine, and OB/GYN bears little similarity to Family Medicine or General Internal Medicine. Family Medicine and Internal Medicine encounters are the most complex overall, especially when duration-of-visit is considered. Revaluing payments based on complexity could bring better balance to cognitive and procedural services, and better meet the needs of people receiving insurance under the ACA.

Family medicine, 2006

The health care maintenance (HCM) visit is a primary vehicle for delivering preventive services i... more 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. 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. 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 visit...

The Journal of family practice, 1999

Concerns exist about the quality of care provided to heart failure patients by primary care physi... more Concerns exist about the quality of care provided to heart failure patients by primary care physicians. Using an evidence-based clinical guideline, we evaluated the care given to patients with systolic heart failure. We retrospectively reviewed the medical records of 420 patients from 25 primary care practices in upstate New York who had received a diagnosis of heart failure. Chart documentation confirmed the diagnosis (n = 395). We excluded patients with noncardiogenic volume overload or correctable valvular disease (n = 338). Performance profiles measured use of diagnostic tests, left ventricular ejection fraction (LVEF) measurement, patient education, and prescription of angiotensin-converting enzyme (ACE) inhibitors. For treatment recommendations, patients were classified according to LVEF status. Only 82% of the patients studied had an LVEF test result documented in their charts. Of these, 49% had an LVEF < or = 40%. ACE inhibitor use was greater among patients with low LVEF...

American family physician, 2001

The Journal of family practice, 1998

Primary care physicians are expected to identify mental health problems. Currently, it is unclear... more Primary care physicians are expected to identify mental health problems. Currently, it is unclear how a recent experience of emotional distress affects the physician-patient encounter and the diagnostic process. Using the Davis Observation Code, we studied 1269 encounters between family physicians and adult patients who completed brief questionnaires after the visit. Patients were separated into three groups using self-report and billing data: those denying recent emotional distress, those reporting recent emotional distress but not receiving a mental health diagnosis, and those reporting recent emotional distress and receiving a diagnosis of anxiety or depression. Nineteen percent of patients reported significant emotional distress during the previous 4 weeks; 18% of these patients received a billing diagnosis of depression or anxiety. Patients not reporting emotional distress had the shortest visits (10.0 minutes); recent emotional distress was associated with significantly longer...

The Journal of family practice, 1998

The content and context of family practice outpatient visits have never been fully described, lea... more The content and context of family practice outpatient visits have never been fully described, leaving many aspects of family practice in a "black box," unseen by policymakers and understood only in isolation. This article describes community family practices, physicians, patients, and outpatient visits. Practicing family physicians in northeast Ohio were invited to participate in a multimethod study of the content of primary care practice. Research nurses directly observed consecutive patient visits, and collected additional data using medical record reviews, patient and physician questionnaires, billing data, practice environment checklists, and ethnographic fieldnotes. Visits by 4454 patients seeing 138 physicians in 84 practices were observed. Outpatient visits to family physicians encompassed a wide variety of patients, problems, and levels of complexity. The average patient paid 4.3 visits to the practice within the past year. The mean visit duration was 10 minutes. F...

The Journal of family practice, 1998

The objective of this study was to examine the incidence, targeting, and time demands of tobacco ... more The objective of this study was to examine the incidence, targeting, and time demands of tobacco cessation advice by community family physicians. Research nurses directly observed 2 days of outpatient visits to 138 family physicians in northeast Ohio. Smoking status was identified by patient questionnaire. Visit characteristics were determined from direct observation and billing data. Visits by smokers with and without smoking cessation advice were compared. The incidence of tobacco cessation advice was highest during wellness visits (55% vs 22% for illness visits; P < .001). Smokers seen for a tobacco-related chronic illness were more likely to receive advice than those seen for a chronic problem not related to tobacco (32% vs 17%; P = .05). The average duration of advice was less than 1 1/2 minutes. There were no significant differences in the duration of advice across different types of visits. Physicians are providing brief, targeted interventions for smoking cessation in fam...

The Journal of family practice, 1994

Despite a high level of support for the importance of clinical prevention, physician delivery of ... more Despite a high level of support for the importance of clinical prevention, physician delivery of preventive services falls well below recommended levels. Competing demands faced by physicians during the medical encounter present a major barrier to the provision of specific preventive services to patients. These demands include acute care, patient requests, chronic illnesses, psychosocial problems, screening for asymptomatic disease, counseling for behavior change, other preventive services, and administration and management of care. This paper outlines how competing demands affect physician delivery of clinical preventive services and provides a model designed to help practicing physicians improve the delivery of preventive services. This model can be helpful in the planning of preventive interventions in primary care settings and can facilitate a better understanding of physician behavior.

The Journal of family practice, 1992

No large-scale work has yet assessed the reactions of physicians to the report of the US Preventi... more No large-scale work has yet assessed the reactions of physicians to the report of the US Preventive Services Task Force (USPSTF), despite its potential for fostering a consensus among practitioners. This study undertook a survey of family physicians to assess their agreement with the recommendations of the Task Force. A survey containing the verbatim summary recommendations of the USPSTF was mailed to all 1784 active members of the Ohio Academy of Family Physicians. No evidence of selection bias was found among the 898 responding physicians. The average physician agreed with 88% of the recommendations. For a number of recommendations, however, particularly those in which the Task Force differed with the American Cancer Society, there was a high level of disagreement. Physician disagreement with the recommendations was associated with older age, not having completed a residency, male sex, less prior exposure to the USPSTF guidelines, and greater perception of the impracticality of ap...

Family medicine, 1995

The aim of the study was to identify predictors of first-contact care in a population of poor urb... more The aim of the study was to identify predictors of first-contact care in a population of poor urban residents. Information from a community health needs survey was used for the study. The sample included adult residents in five urban census tracts with a large proportion of Puerto Rican Hispanics. Potential predictors included social characteristics, source of health insurance, perceived health status, number of chronic diseases, use of alternatives to medical care, smoking status, and problems with alcohol use. A total of 826 household interviews were completed for a participation rate of 78% among eligible households. Individuals with no health insurance were six times more likely to lack a source of first-contact care, compared with those who have traditional indemnity insurance. Those who only had Medicaid were four times more likely to lack a source of first-contact care. Respondents involved in Medicaid-managed care programs had similar access to first-contact care as those wi...

The Journal of family practice, 2009

Building strong relationships among physicians and staff improves the practice's ability to d... more Building strong relationships among physicians and staff improves the practice's ability to deal with the uncertainties of a rapidly changing environment. Interacting proactively with the economic, social, political, and cultural environment-the practice landscape-provides opportunities for adaptation and ongoing learning.

other disciplines the potential benefi ts of the proposed studies and be able to articulate “this... more other disciplines the potential benefi ts of the proposed studies and be able to articulate “this is the best we have in the fi eld ” (if indeed this is the case) and defend overly critical exercises in tearing projects down. How do we prepare the next group of FM researchers to be study section members for NIH? Preparing faculty for participation in study sections is a critical faculty development need and opportunity. ADFM needs to partner with NAPCRG and STFM, as well as the CTSA programs, in preparing faculty for these tasks. The limited orientation sessions pre-pared by the Scientifi c Review Administrators are not enough. We feel that those family medicine research-ers who have study section experience should share experiences with other family medicine researchers so that the learning curve can be accelerated for the benefi t of the applications being considered. ADFM is supporting a lecture-discussion during the upcoming STFM meeting in Baltimore entitled “How To Be an Effec...

Nearly 50 % of deaths in the United States are related to preventable causes.1 The Healthy People... more Nearly 50 % of deaths in the United States are related to preventable causes.1 The Healthy People 2010 report2 challenges primary care clinicians to improve the de-livery of preventive services to their patients. Recom-mended services include a range of primary, secondary, and tertiary prevention, such as immunizations and healthy lifestyle counseling, periodic health screenings and early disease identification, and the prevention of complications from chronic diseases. These have all been shown to decrease morbidity and mortality when provided to eligible patients in clinical settings.3-5 Most practicing physicians embrace the concept of prevention,6,7 with family physicians having an ex-tended history of incorporating prevention as a core component of clinical practice.8-14 The concept of a dedicated health care maintenance (HCM) visit to ensure the delivery of preventive services emerged in 1975 from a critique by family physician Paul Frame regarding the shortcomings of the annu...

Context: Cervical cancer is preventable and curable, yet Hispanic populations in certain areas of... more Context: Cervical cancer is preventable and curable, yet Hispanic populations in certain areas of the country have higher mortality rates from invasive cervical cancer than non-Hispanic white women. Objective: Our study aims to identify contextual and environmental features at the county level that are acting as barriers or facilitators of cervical cancer long-term survival in Hispanic women. Study Design: This is a mixed methods exploratory study utilizing fRAP (focused Rapid Assessment Process) methodology to uncover modifiable differences in cervical cancer survivorship contributing to mortality differences. We investigate multi-level community, medical and policy contextual elements within a county through both quantitative GIS mapping of ZCTA level data linked to fieldwork and key informant interviews. This poster highlights the qualitative Phase II of our methods, including participant observation in three Texas counties. Setting or Dataset: Phase II of fRAP includes qualitative data collected by the lead author during fieldwork from three Texas counties. Counties chosen for inclusion in the study due to differences in mortality rates between Hispanic and non-Hispanic white women were identified during Phase I GIS mapping of the study. They include Bexar, Dallas and Tarrant, all of which hold a unique disparity profile based on mortality rates. Population studied: Participants for key informant interviews identified during fieldwork visits to each county and stratified by level of interest: community, medical systems, policy, e.g. a community resource executive director, a practicing gynecologic oncologist and a county-level payment plan manager. Outcome Measures: Qualitative transcripts analyzed for themes across levels within a county, and across counties based on level. Results: Research to date has uncovered modifiable environmental and contextual differences within each of the three Texas counties contributing to how Hispanic cervical cancer survivors experience care. Outcomes to be Reported: Cross comparison of themes within a county across multiple levels and across counties within levels will allow us to identify environmental and contextual features unique to each of the three counties that contribute to their particular cervical cancer disparity profile seen on mapping. Next stages of fRAP include evaluation of modifiable features found for possible policy change targets to address disparities in care

Family practice management, 2019

Helping patients safely bridge the gap from acute care to ambulatory care is good for patients an... more Helping patients safely bridge the gap from acute care to ambulatory care is good for patients and practices too.

Journal of Family Practice, 2001

Health services research, Aug 27, 2015

To test a conceptual model of relationships, reflection, sensemaking, and learning in primary car... more To test a conceptual model of relationships, reflection, sensemaking, and learning in primary care practices transitioning to patient-centered medical homes (PCMH). Primary data were collected as part of the American Academy of Family Physicians' National Demonstration Project of the PCMH. We conducted a cross-sectional survey of clinicians and staff from 36 family medicine practices across the United States. Surveys measured seven characteristics of practice relationships (trust, diversity, mindfulness, heedful interrelation, respectful interaction, social/task relatedness, and rich and lean communication) and three organizational attributes (reflection, sensemaking, and learning) of practices. We surveyed 396 clinicians and practice staff. We performed a multigroup path analysis of the data. Parameter estimates were calculated using a Bayesian estimation method. Trust and reflection were important in explaining the characteristics of practice relationships and their associatio...

The Journal of family practice

ABSTRACT

Geriatrics Models of Care, 2015

The Patient-Centered Medical Home (PCMH) is proposed as a vehicle to deliver primary health care ... more The Patient-Centered Medical Home (PCMH) is proposed as a vehicle to deliver primary health care to older adults. The PCMH has the ability to improve the quality of care and reduce unnecessary expenditures while fostering functional independence and improving quality of life. Steps to develop a PCMH for older adults include clarity of purpose, team building, process improvement, setting time for reflection and course adjustment, defining accountability, providing a supportive and safe work environment, fully utilizing capabilities of the electronic health record and building relationships with external community partners. Building and maintaining a PCMH requires payment changes in the form of blended or direct primary care payments. Some organizational structures beyond the PCMH can hinder development of the PCMH by excessive standardization and micromanaging or they can facilitate development by providing appropriate support with facilitative leadership. The PCMH is a journey, not a destination and requires ongoing evolution of medical models and attention to patient preferences.

Healthcare, 2015

Complexity of care has implications for quality of care, health costs, medical errors, and patien... more Complexity of care has implications for quality of care, health costs, medical errors, and patient and physician satisfaction. The objective was to compare complexity of ambulatory care across 14 medical specialties. This secondary analysis uses the 2010 National Ambulatory Medical Care Survey, which used a multistage probability design of primary sampling units throughout U.S. ambulatory practices across 14 specialties. Sampling weights enable results from 29,179 ambulatory visits to represent 878,653,561 visits. Data included symptoms, diagnoses, diagnostic procedures, and treatments provided. Measures of input, output and total encounter complexity and hourly complexity densities were computed. Internal Medicine leads in total input and total encounter complexity with Family Medicine second in total encounter complexity. When duration-of-visit is considered, Family Medicine is the most complex discipline while Internal Medicine is the second most complex. Pediatrics lacks the complexity of Family Medicine and General Internal Medicine, and OB/GYN bears little similarity to Family Medicine or General Internal Medicine. Family Medicine and Internal Medicine encounters are the most complex overall, especially when duration-of-visit is considered. Revaluing payments based on complexity could bring better balance to cognitive and procedural services, and better meet the needs of people receiving insurance under the ACA.

Family medicine, 2006

The health care maintenance (HCM) visit is a primary vehicle for delivering preventive services i... more 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. 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. 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 visit...

The Journal of family practice, 1999

Concerns exist about the quality of care provided to heart failure patients by primary care physi... more Concerns exist about the quality of care provided to heart failure patients by primary care physicians. Using an evidence-based clinical guideline, we evaluated the care given to patients with systolic heart failure. We retrospectively reviewed the medical records of 420 patients from 25 primary care practices in upstate New York who had received a diagnosis of heart failure. Chart documentation confirmed the diagnosis (n = 395). We excluded patients with noncardiogenic volume overload or correctable valvular disease (n = 338). Performance profiles measured use of diagnostic tests, left ventricular ejection fraction (LVEF) measurement, patient education, and prescription of angiotensin-converting enzyme (ACE) inhibitors. For treatment recommendations, patients were classified according to LVEF status. Only 82% of the patients studied had an LVEF test result documented in their charts. Of these, 49% had an LVEF < or = 40%. ACE inhibitor use was greater among patients with low LVEF...

American family physician, 2001

The Journal of family practice, 1998

Primary care physicians are expected to identify mental health problems. Currently, it is unclear... more Primary care physicians are expected to identify mental health problems. Currently, it is unclear how a recent experience of emotional distress affects the physician-patient encounter and the diagnostic process. Using the Davis Observation Code, we studied 1269 encounters between family physicians and adult patients who completed brief questionnaires after the visit. Patients were separated into three groups using self-report and billing data: those denying recent emotional distress, those reporting recent emotional distress but not receiving a mental health diagnosis, and those reporting recent emotional distress and receiving a diagnosis of anxiety or depression. Nineteen percent of patients reported significant emotional distress during the previous 4 weeks; 18% of these patients received a billing diagnosis of depression or anxiety. Patients not reporting emotional distress had the shortest visits (10.0 minutes); recent emotional distress was associated with significantly longer...

The Journal of family practice, 1998

The content and context of family practice outpatient visits have never been fully described, lea... more The content and context of family practice outpatient visits have never been fully described, leaving many aspects of family practice in a "black box," unseen by policymakers and understood only in isolation. This article describes community family practices, physicians, patients, and outpatient visits. Practicing family physicians in northeast Ohio were invited to participate in a multimethod study of the content of primary care practice. Research nurses directly observed consecutive patient visits, and collected additional data using medical record reviews, patient and physician questionnaires, billing data, practice environment checklists, and ethnographic fieldnotes. Visits by 4454 patients seeing 138 physicians in 84 practices were observed. Outpatient visits to family physicians encompassed a wide variety of patients, problems, and levels of complexity. The average patient paid 4.3 visits to the practice within the past year. The mean visit duration was 10 minutes. F...

The Journal of family practice, 1998

The objective of this study was to examine the incidence, targeting, and time demands of tobacco ... more The objective of this study was to examine the incidence, targeting, and time demands of tobacco cessation advice by community family physicians. Research nurses directly observed 2 days of outpatient visits to 138 family physicians in northeast Ohio. Smoking status was identified by patient questionnaire. Visit characteristics were determined from direct observation and billing data. Visits by smokers with and without smoking cessation advice were compared. The incidence of tobacco cessation advice was highest during wellness visits (55% vs 22% for illness visits; P < .001). Smokers seen for a tobacco-related chronic illness were more likely to receive advice than those seen for a chronic problem not related to tobacco (32% vs 17%; P = .05). The average duration of advice was less than 1 1/2 minutes. There were no significant differences in the duration of advice across different types of visits. Physicians are providing brief, targeted interventions for smoking cessation in fam...

The Journal of family practice, 1994

Despite a high level of support for the importance of clinical prevention, physician delivery of ... more Despite a high level of support for the importance of clinical prevention, physician delivery of preventive services falls well below recommended levels. Competing demands faced by physicians during the medical encounter present a major barrier to the provision of specific preventive services to patients. These demands include acute care, patient requests, chronic illnesses, psychosocial problems, screening for asymptomatic disease, counseling for behavior change, other preventive services, and administration and management of care. This paper outlines how competing demands affect physician delivery of clinical preventive services and provides a model designed to help practicing physicians improve the delivery of preventive services. This model can be helpful in the planning of preventive interventions in primary care settings and can facilitate a better understanding of physician behavior.

The Journal of family practice, 1992

No large-scale work has yet assessed the reactions of physicians to the report of the US Preventi... more No large-scale work has yet assessed the reactions of physicians to the report of the US Preventive Services Task Force (USPSTF), despite its potential for fostering a consensus among practitioners. This study undertook a survey of family physicians to assess their agreement with the recommendations of the Task Force. A survey containing the verbatim summary recommendations of the USPSTF was mailed to all 1784 active members of the Ohio Academy of Family Physicians. No evidence of selection bias was found among the 898 responding physicians. The average physician agreed with 88% of the recommendations. For a number of recommendations, however, particularly those in which the Task Force differed with the American Cancer Society, there was a high level of disagreement. Physician disagreement with the recommendations was associated with older age, not having completed a residency, male sex, less prior exposure to the USPSTF guidelines, and greater perception of the impracticality of ap...

Family medicine, 1995

The aim of the study was to identify predictors of first-contact care in a population of poor urb... more The aim of the study was to identify predictors of first-contact care in a population of poor urban residents. Information from a community health needs survey was used for the study. The sample included adult residents in five urban census tracts with a large proportion of Puerto Rican Hispanics. Potential predictors included social characteristics, source of health insurance, perceived health status, number of chronic diseases, use of alternatives to medical care, smoking status, and problems with alcohol use. A total of 826 household interviews were completed for a participation rate of 78% among eligible households. Individuals with no health insurance were six times more likely to lack a source of first-contact care, compared with those who have traditional indemnity insurance. Those who only had Medicaid were four times more likely to lack a source of first-contact care. Respondents involved in Medicaid-managed care programs had similar access to first-contact care as those wi...

The Journal of family practice, 2009

Building strong relationships among physicians and staff improves the practice's ability to d... more Building strong relationships among physicians and staff improves the practice's ability to deal with the uncertainties of a rapidly changing environment. Interacting proactively with the economic, social, political, and cultural environment-the practice landscape-provides opportunities for adaptation and ongoing learning.