Process Evaluation of a Tailored Multifaceted Approach to Changing Family Physician Practice Patterns and Improving Preventive Care
Patient Education. All sites were provided with patient education materials from credible sources on request, and all received a binder of patient education materials constructed specifically to contain materials on the appropriate preventive maneuvers under study. The binders were regularly updated.
Patient Mediated. Posters designed to prompt patients to ask about folic acid, flu vaccine, and mammography were offered to all sites. Thirteen sites implemented a patient consent form for prostate-specific antigen (PSA) testing. Eight sites received preventive care diaries for patients. Five sites had a prevention newsletter for patients. Four sites agreed to pilot a health risk appraisal software program.
Physician Feedback
At the end of the intervention the facilitator asked physicians about their experience, including what was most and least useful to them. Table 5 provides a summary of the content analysis of physician responses.
Audit and feedback, both initially and subsequently, comprised the component most frequently considered to be important in creating change. Almost as often, the preventive care flow sheet was identified as useful. The facilitator sessions designed to seek consensus on preventive care guidelines and strategies for implementation were also appreciated.
Several physicians did not agree with the evidence on PSA testing. Others did not feel that counseling for folic acid was a priority. Some found the patient education binder cumbersome, and others found the sticker system for tobacco counseling unwieldy. Thus, both were underused. Two physicians noted that the preventive care wall chart was not helpful.
Physician Self-Reported Practice Changes
Eighty-six percent (93/108) of the intervention and control physicians responded to a questionnaire at the end of the study. Due to sample size, statistical power was limited to detecting an absolute difference of approximately 0.30 between groups, assuming an alpha of 0.05 and 80% power.33 Table 6 shows that 71% of intervention physicians compared with 28% of control physicians reported an audit of their practice for preventive services (P<.001). By the end of the study, 65% of the intervention physicians versus 48% of the control physicians indicated that they had a prevention policy or screening protocol in place, and 70% of intervention physicians compared with 58% of control physicians had created reminder systems for disease prevention.
Satisfaction with PF Intervention
At the telephone interview 6 months into the intervention, the mean satisfaction rating of intervention physicians was 4.08 on a scale of 1 (very dissatisfied) to 5 (very satisfied) with 80% satisfied with the intervention. At 17 months the mean satisfaction rating had risen to 4.5 with a 95% satisfaction rate.
At 6 months, 85% of the practices were satisfied with the frequency of visits of their assigned facilitator. At 17 months there was a 64% satisfaction rate, with the remaining 36% wanting more visits from the facilitator. The physicians commented on how the intervention had focused them on prevention in their practice. When the physicians were asked if they would agree to have a facilitator visit their practice in the future if given the opportunity, 90% agreed.
Concerns included not being able to continue the recall of patients at the end of the intervention and questioning the inappropriate maneuvers as too controversial. A physician from a large practice with 6 physicians commented that the facilitator could not easily work in the complex practice environment.
Discussion
Our study demonstrates that PFs can significantly improve the delivery of preventive services and in the process make quality contributions to a practice environment with high satisfaction rates from participating physicians.
Our intervention had a higher frequency and intensity of visits than other studies of this genre. The PFs had an average of almost 2 visits per month lasting approximately 105 minutes per visit. Dietrich and colleagues21 reported only 4 visits over a 3-month period lasting an average of 120 minutes, and Hulscher and coworkers22 reported approximately 25 visits with an average duration of 73 minutes. Others have been even less frequent,20 and in other studies it is not reported.34-36
The critical intervention components as evidenced by physician feedback, changes between control and intervention practices, and the amount of facilitator time spent on each component were: (1) audit and feedback, (2) sharing and discussing information to build consensus on an action plan, and (3) a reminder system. Similarly, the Cancer Prevention in Community Practice Project achieved 100% success in implementing change using customized preventive care flowsheets.37 Of the 7 intervention components, patient education materials and patient-mediated interventions such as posters in the waiting room were considered to be the least useful.
Overall, physicians and nurses working within the practices were very satisfied with the intervention, and 90% were willing to have the nurse facilitator continue working with their practice.
