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Background: Central to the 'medical home' concept is the premise that the delivery of effective primary care requires a fundamental shift in relationships among practice members and between practice members and patients. Primary care practices can potentially increase their capacity to deliver effective care through knowledge management (KM), a process of sharing and making existing knowledge available or by developing new knowledge among practice members and patients. KM affects performance by influencing work relationships to enhance learning, decision making, and task execution. Purpose: We extend our previous work to further characterize, describe, and contrast how primary care practices exhibit KM and explain why KM deserves attention in medical home redesign initiatives. Methodology: Case studies were conducted, drawn from two higher and lower performing practices, which were purposely selected based on disease management, prevention, and productivity measures from an improvement trial. Observations of operations, clinical encounters, meetings, and interviews with office members and patients were transcribed and coded independently using a KM template developed from a previous secondary analysis. Face-to-face discussions resolved coding differences among research team members. Confirmation of findings was sought from practice participants. Findings: Practices manifested varying degrees of KM effectiveness through six interdependent processes and multiple overlapping tools. Social tools, such as face-to-face-communication for sharing and developing knowledge, were often more effective than were expensive technical tools such as an electronic medical record. Tool use was tailored for specific outcomes, interacted with each other, and leveraged by other organizational capacities. Practices with effective KM were more open to adopting and sustaining new ways of functioning, ways reflecting attributes of a medical home. Practice Implications: Knowledge management differences occur within and between practices and can explain differences in performance. By relying more on social tools rather than costly, high-tech investment, KM leverages primary care's relationship-centered strength, facilitating practice redesign as a medical home. [ABSTRACT FROM AUTHOR]

BACKGROUND: Knowledge management (KM) is the process by which people in organizations find, share, and develop knowledge for action. KM affects performance by influencing work relationships to enhance learning and decision making. PURPOSE: To identify how family medicine practices exhibit KM. METHODOLOGY: A model and a template of KM concepts were derived from a comprehensive organizational literature review. Two higher and two lower performing family medicine practices were purposefully selected from existing comparative case studies based on prevention delivery rates and innovation. Interviews, fieldnotes of operations, and clinical encounters were coded independently using the template. Face-to-face discussions resolved coding differences. FINDINGS: All practices had processes and tools for finding, sharing, and developing knowledge; however, KM overall was limited despite implementation of expensive technologies like an electronic medical record. Where present, KM processes and tools were used by individuals but not integrated throughout the organization. Loss of information was prominent, and finding knowledge was underdeveloped. The use of technical tools and developing knowledge by reconfiguration and measurement were particularly limited. Socially related tools, such as face-to-face-communication for sharing and developing knowledge, were more developed. As in other organizations, tool use was tailored for specific outcomes and leveraged by other organizational capacities. PRACTICE IMPLICATIONS: Differences in KM occur within family practices and between family practices and other organizations and may have implications for improving practice performance. Understanding interaction patterns of work relationships and KM may explain why costly technical or externally imposed 'one size fits all' practice organizational interventions have had mixed results and limited sustainability. [ABSTRACT FROM AUTHOR]

BACKGROUND: Efforts to redesign primary care practices are beginning to address how decisions are made in the practice setting. This study contributes to these efforts by examining associations between staff participation in decision-making, productivity, and turnover in primary care practices. The study is informed by organizational theories of participation that emphasize cognitive and affective influences on employee output and behavior. METHODS: This research used data collected from primary care practices involved in a national initiative sponsored by the Robert Wood Johnson Foundation. Cross-sectional survey data on organizational structures and attributes among 49 practices were analyzed. Regression analysis was used to examine associations among practice productivity, staff participation in decision-making, and formal structures such as staff meetings. Associations between staff turnover and participative decision-making were also examined. RESULTS: Staff participation in decisions regarding quality improvement, practice change, and clinical operations was positively associated with practice productivity, whereas formal structures such as staff meetings were not. In addition, higher levels of participation in decision-making were associated with reduced turnover among nonclinicians and administrative staff. CONCLUSION: Examination of organizational features is increasingly recognized as a key to improving primary care performance. Study findings suggest that one important strategy may be implementation of a participative model emphasizing greater staff involvement in practice decisions. This may enhance information-sharing, work satisfaction, and commitment to organizational decisions, all of which can lead to beneficial outcomes such as increased productivity and stability in primary care practices. [ABSTRACT FROM AUTHOR]

Joint and soft tissue injection of the ankle and foot region is a useful diagnostic and therapeutic tool for the family physician. This article reviews the injection procedure for the plantar fascia, ankle joint, tarsal tunnel, interdigital space, and first metatarsophalangeal joint. Indications for plantar fascia injection include degeneration secondary to repetitive use and traumatic injuries that are unresponsive to conservative treatment. Diagnostic aspiration or therapeutic injection of the ankle or first metatarsophalangeal joints can be performed for management of advanced osteoarthritis, rheumatoid arthritis, and other inflammatory arthritides such as gout, or synovitis or an arthrosis such as 'turf toe.' Persistent pain and disability resulting from tarsal tunnel syndrome, an analog of carpal tunnel syndrome of the wrist respond to local injection therapy. A painful interdigital space, such as that occurring in patients with Morton's neuroma, is commonly relieved with corticosteroid injection. The proper technique, choice and quantity of pharmaceuticals, and appropriate follow-up are essential for effective outcomes. [ABSTRACT FROM AUTHOR]

Joint injection of the hip and knee regions is a useful diagnostic and therapeutic tool for the family physician. In this article, the injection procedure for the greater trochanteric bursa, the knee joint, the pes anserine bursa, the iliotibial band, and the prepatellar bursa is reviewed. Indications for greater trochanteric bursa injection include acute and chronic inflammation associated with osteoarthritis, rheumatoid arthritis, repetitive use, and other traumatic injuries to the area. For the knee joint, aspiration may be performed to aid in the diagnosis of an unexplained effusion and relieve discomfort caused by an effusion. Injection of the knee can be performed for viscosupplementation or corticosteroid therapy. Indications for corticosteroid injection include advanced osteoarthritis and other inflammatory arthritides, such as gout or calcium pyrophosphate deposition disease. Swelling and tenderness of pes anserine or prepatellar bursae can be relieved with aspiration and corticosteroid injection. Persistent pain and disability from iliotibial band syndrome respond to local injection therapy. The proper technique, choice and quantity of pharmaceuticals, and appropriate follow-up are essential for effective outcomes. [ABSTRACT FROM AUTHOR]

The shoulder is the site of multiple injuries and inflammatory conditions that lend themselves to diagnostic and therapeutic injection. Joint injection should be considered after other therapeutic interventions such as nonsteroidal anti-inflammatory drugs, physical therapy, and activity-modification have been tried. Indications for glenohumeral joint injection include osteoarthritis, adhesive capsulitis, and rheumatoid arthritis. For the acromioclavicular joint, injection may be used for diagnosis and treatment of osteoarthritis and distal clavicular osteolysis. Subacromial injections are useful for a range of conditions including adhesive capsulitis, subdeltoid bursitis, impingement syndrome, and rotator cuff tendinosis. Scapulothoracic injections are reserved for inflammation of the involved bursa. Persistent pain related to inflammatory conditions of the long head of the biceps responds well to injection in the region. The proper technique, choice and quantity of pharmaceuticals, and appropriate follow-up are essential for effective outcomes. [ABSTRACT FROM AUTHOR]

Joint injection of the wrist and hand region is a useful diagnostic and therapeutic tool for the family physician. In this article, the injection procedures for carpal tunnel syndrome, de Quervain's tenosynovitis, osteoarthritis of the first carpometacarpal joint, wrist ganglion cysts, and digital flexor tenosynovitis (trigger finger) are reviewed. Indications for carpal tunnel syndrome injection include median nerve compression resulting from osteoarthritis, rheumatoid arthritis, diabetes mellitus, hypothyroidism, repetitive use injury, and other traumatic injuries to the area. For the first carpometacarpal joint, injection may be used to treat pain secondary to osteoarthritis and rheumatoid arthritis. Pain associated with de Quervain's tenosynovitis is treated effectively by therapeutic injection. If complicated by pain or paresthesias, wrist ganglion cysts respond to aspiration and injection. Painful limitation of motion occurring in trigger fingers of patients with diabetes or rheumatoid arthritis also improves with injection. The proper technique, choice and quantity of pharmaceuticals, and appropriate follow-up are essential for effective outcomes. [ABSTRACT FROM AUTHOR]

Joint injection of the elbow is a useful diagnostic and therapeutic tool for the family physician. In this article, the injection procedures for the elbow joint, medial and lateral epicondylitis, and olecranon bursitis are reviewed. Persistent pain related to inflammatory conditions responds well to injection in the region. Indications for elbow joint injection include osteoarthritis and rheumatoid arthritis. Corticosteroid injection is an accepted treatment option for medial and lateral epicondylitis. Olecranon bursa aspiration and injection are useful when that bursa is inflamed. The proper techniques, choice and quantity of pharmaceuticals, and appropriate follow-up essential for effective outcomes are discussed. [ABSTRACT FROM AUTHOR]

Injection techniques are helpful for diagnosis and therapy in a wide variety of musculoskeletal conditions. Diagnostic indications include the aspiration of fluid for analysis and the assessment of pain relief and increased range of motion as a diagnostic tool. Therapeutic indications include the delivery of local anesthetics for pain relief and the delivery of corticosteroids for suppression of inflammation. Side effects are few, but may include tendon rupture, infection, steroid flare, hypopigmentation, and soft tissue atrophy. Injection technique requires knowledge of anatomy of the targeted area and a thorough understanding of the agents used. In this overview, the indications, contraindications, potential side effects, timing, proper technique, necessary materials, pharmaceuticals used and their actions, and post-procedure care of patients are presented. [ABSTRACT FROM AUTHOR]

Your practice's success may depend on getting those who work for you to share what they know. Here's how to do it. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to identify areas for developing management skills-focused continuing education for managers working in home health, hospice, and community-based settings., Background: Healthcare managers play a vital role in organizations, yet they have a range of management training., Methods: Researchers conducted a cross-sectional survey of managers at a large Visiting Nurse Association. Descriptive and bivariate analyses were performed to examine confidence in management skills by respondent characteristic. Factor and cluster analyses were used to examine differences by role., Results: For all 33 management tasks, managers with 6+ years of experience reported greater confidence than managers with 0 to 5 years of experience. Tasks with the lowest confidence were budgeting, interpreting annual reports, strategic planning, measuring organizational performance, and project planning. Managers were clustered into 5 "profiles.", Conclusion: Management training is not 1-size-fits-all. Healthcare organizations should consider investing in training specific to the identified low-confidence areas and manager roles to better support and develop a robust management workforce., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

At-home COVID-19 testing offers convenience and safety advantages. We evaluated at-home testing in Black and Latino communities through an intervention comparing community-based organization (CBO) and health care organization (HCO) outreach. From May through December 2021, 1100 participants were recruited, 94% through CBOs. The odds of COVID-19 test requests and completions were significantly higher in the HCO arm. The results showed disparities in test requests and completions related to age, race, language, insurance, comorbidities, and pandemic-related challenges. Despite the popularity of at-home testing, barriers exist in underresourced communities. ( Am J Public Health . 2022;112(S9):S918-S922. https://doi.org/10.2105/AJPH.2022.306989).

Objective: Effective physician-patient communication is important, but physicians who are seeking to improve have few opportunities for practice or receive actionable feedback. The Video-based Communication Assessment (VCA) provides both. Using the VCA, physicians respond to communication dilemmas depicted in brief video vignettes; crowdsourced analog patients rate responses and offer comments. We characterized analog patients' comments and generated actionable recommendations for improving communication., Methods: Physicians and residents completed the VCA; analog patients rated responses and answered:"What would you want the provider to say in this situation?" We used qualitative analysis to identify themes., Results: Forty-three participants completed the VCA; 556 analog patients provided 1035 comments. We identified overarching themes (e.g., caring, empathy, respect) and generated actionable recommendations, incorporating analog patient quotes., Conclusion: While analog patients' comments could be provided directly to users, conducting a thematic analysis and developing recommendations for physician-patient communication reduced the burden on users, and allowed for focused feedback. Research is needed into physicians' reactions to the recommendations and the impact on communication., Practice Implications: Physicians seeking to improve communication skills may benefit from practice and feedback. The VCA was designed to provide both, incorporating the patient voice on how best to communicate in clinical situations., (Copyright © 2021. Published by Elsevier B.V.)

Emergency department (ED) use for non-urgent needs is widely viewed as a contributor to various health care system flaws and inefficiencies. There are few qualitative studies designed to explore the complexity of patients' decision-making process to use the ED vs. primary care alternatives. In this study, semi-structured interviews were conducted with 30 patients who were discharged from the low acuity area of a university hospital ED. A grounded theory approach including cycles of immersion/crystallization was used to identify themes and reportable interpretations. Patients reported multiple decision-making considerations that hinged on whether or not they knew about primary care options. A model is developed depicting the complexity and variation in patients' decision-making to use the ED. Optimizing health system navigation and use requires improving objective factors such as access and costs as well as subjective perceptions of patients' health care, which are also a prominent part of their decision-making process.

Health care reform presents academic health centers with an opportunity to test new systems of care, such as accountable care organizations (ACOs), that are intended to improve patients' health and well-being, mitigate the anticipated shortage in primary care providers, and bend the cost curve. In its ongoing efforts to develop an ACO, the Robert Wood Johnson Medical School, an academic health center, has found helpful a rapidly evolving competitive environment and insurers willing to experiment with new models of care. But the center has also encountered six types of barriers: conceptual, financial, cultural, regulatory, organizational, and historical. How this academic health center has faced these barriers offers valuable lessons to other health systems engaged in creating ACOs.

Academic health centers (AHCs) have opportunities to advance the agenda of U.S. health care reform by tying the needs of populations to the AHCs' missions and areas of expertise. Serving as accountable care organizations and advancing the agenda of the patient-centered medical home are two important potential actions AHCs can take. By fostering discovery, learning, and care through rational organizational structures that meet the needs of populations and bend the curve of growing health care expenditures, AHCs can lead health care reform in the 21st century.

The practice of medicine is a shared social contract between the medical profession and the public. Assessments for licensure should reflect competencies that patients expect of their physicians and should be patient-centered and mirror the progressive nature of medical education. The National Board of Medical Examiners recently accepted the recommendations of the Committee to Review the United States Medical Licensing Examination Program to align the examination sequence with two patient-centered decision points: when a student enters into supervised graduate training, and when a physician receives initial licensure for unsupervised practice. The revised examination program would aim to evaluate for the presence of at least minimum proficiency in all competencies that are measurable in a valid, reliable manner at each decision point, including the scientific foundation of medical practice, the application of medical knowledge to patient care, and the clinical skills relevant to practice level, whether measured by standardized patient-based assessments or other formats. Students, educators, educational leaders, and program directors have raised legitimate concerns about the anticipated changes. The anticipated costs, the changes' effect on basic science education, their impact on dual-degree candidates and international medical graduates, and the utility of score reporting are each of concern. Anticipated benefits include a closer alignment of assessments with the expectations of patients and licensing authorities, closer integration of the sciences fundamental to medical practice throughout the examination sequence, and an increased breadth of competency assessment. The authors believe that the benefits to patients and the profession will outweigh the acknowledged challenges the changes will pose to medical education.

Background: Understanding the role of relationships health care organizations (HCOs) offers opportunities for shaping health care delivery. When quality is treated as a property arising from the relationships within HCOs, then different contributors of quality can be investigated and more effective strategies for improvement can be developed., Methods: Data were drawn from four large National Institutes of Health (NIH)-funded studies, and an iterative analytic strategy and a grounded theory approach were used to understand the characteristics of relationships within primary care practices. This multimethod approach amassed rich and comparable data sets in all four studies, which were all aimed at primary care practice improvement. The broad range of data included direct observation of practices during work activities and of patient-clinician interactions, in-depth interviews with physicians and other key staff members, surveys, structured checklists of office environments, and chart reviews. Analyses focused on characteristics of relationships in practices that exhibited a range of success in achieving practice improvement. Complex adaptive systems theory informed these analyses., Findings: Trust, mindfulness, heedfulness, respectful interaction, diversity, social/task relatedness, and rich/lean communication were identified as important in practice improvement. A model of practice relationships was developed to describe how these characteristics work together and interact with reflection, sensemaking, and learning to influence practice-level quality outcomes., Discussion: Although this model of practice relationships was developed from data collected in primary care practices, which differ from other HCOs in some important ways, the ideas that quality is emergent and that relationships influence quality of care are universally important for all HCOs and all medical specialties.

Purpose: The aim of this study was to assess whether the quality of diabetes care differs among practices employing nurse-practitioners (NPs), physician's assistants (PAs), or neither, and which practice attributes contribute to any differences in care., Methods: This cross-sectional study of 46 family medicine practices from New Jersey and Pennsylvania measured adherence to American Diabetes Association diabetes guidelines via chart audits of 846 patients with diabetes. Practice characteristics were identified by staff surveys. Hierarchical models determined differences between practices with and without NPs or PAs., Results: Compared with practices employing PAs, practices employing NPs were more likely to measure hemoglobin A(1c) levels (66% vs 33%), lipid levels (80% vs 58%), and urinary microalbumin levels (32% vs 6%); to have treated for high lipid levels (77% vs 56%); and to have patients attain lipid targets (54% vs 37%) (P

Background: Diabetes care requires management of complex clinical information. We examine the relationship between diabetic outcomes and practices' use of information., Methods: We performed a cross-sectional, secondary analysis of baseline data from 50 community primary care practices participating in a practice improvement project. Medical record review assessed clinical targets for diabetes (HbA(1c) < or =8, LDL < or =100, BP < or =130/85). Practices' use of information was derived from clinician responses to a survey on their use of clinical information systems for patient identification and tracking. Hierarchical linear modeling examined relationships between patient outcomes and practice use of information, controlling for patient level covariates (age, gender, hypertension, and cardiovascular comorbidities) and practice level covariates (solo/group, and electronic health record [EHR] presence)., Results: Practices' use of identification and tracking systems significantly (P < .007 and 0.002) increased odds of achieving diabetes care targets (odds ratio [OR] 1.23 95%, confidence interval [CI] 1.06 to 1.44, and OR 1.32 95% CI 1.11 to 1.59). For diabetic patients with hypertension, odds of hypertension control were higher with higher use of tracking systems (OR = 1.52, P = .0017) and reflected similar trend with higher use of identification systems (OR = 1.28, P = .1349). EHR presence was not associated with attainment of clinical targets., Conclusions: Use of relatively simple systems to identify and track patient information can improve diabetic care outcomes. Practices making investments in an EHR must recognize that this technology alone is not sufficient for achieving desirable clinical outcomes. Researchers must explore the interrelationships of organizational factors necessary for successful information use.

Background: While visits to the doctor's office are appropriate times to advise patients on health behaviors, these opportunities are often missed. Lapses in care quality are no longer attributed solely to individuals, but are also increasingly understood to be the result of organizational factors. This research examines the influence that both practice and provider attributes have on the delivery of preventive services for health behaviors., Methods: This study used data collected from the Prescription for Health initiative sponsored by the Robert Wood Johnson Foundation. Quantitative data on 52 primary care practices and 318 healthcare providers were gathered from September 2003 to September 2004, and were analyzed upon completion of data collection. Hierarchical linear modeling was used to examine associations between both practice and provider attributes and preventive service delivery., Results: Practice staff participation in decisions regarding quality improvement, practice change, and clinical operations positively influenced the effect of work relationships and negatively influenced the effect of practice size on service delivery. Nurse practitioners and allied health professionals reported more frequent delivery of services compared to physicians. Last, use of reminder systems and patient registries were positively associated with preventive service delivery., Conclusions: This study offers preliminary support for staff participation in practice decisions as a positive aspect of teamwork and collaboration. Findings also suggest leveraging nonphysician clinical staff and organized clinical systems to improve the delivery of preventive services for health behaviors.

Are organizational attributes associated with better health outcomes in large health care organizations applicable to primary care practices? In comparative case studies of two community family practices, it was found that attributes of organizational performance identified in larger health care organizations must be tailored to their unique context of primary care. Further work is required to adapt or establish the significance of the attributes of management infrastructure and information mastery.

Background: This study aimed to elucidate how clinical preventive services are delivered in family practices and how this information might inform improvement efforts., Methods: We used a comparative case study design to observe clinical preventive service delivery in 18 purposefully selected Midwestern family medicine offices from 1997 to 1999. Medical records, observation of outpatient encounters, and patient exit cards were used to calculate practice-level rates of delivery of clinical preventive services. Field notes from direct observation of clinical encounters and prolonged observation of the practice and transcripts from in-depth interviews of practice staff and physicians were systematically examined to identify approaches to delivering clinical preventive services recommended by the US Preventive Services Task Force., Results: Practices developed individualized approaches for delivering clinical preventive services, with no one approach being successful across practices. Clinicians acknowledged a 3-fold mission of providing acute care, managing chronic problems, and prevention, but only some made prevention a priority. The clinical encounter was a central focus for preventive service delivery in all practices. Preventive services delivery rates often appeared to be influenced by competing demands within the clinical encounter (including between different preventive services), having a physician champion who prioritized prevention, and economic concerns., Conclusions: Practice quality improvement efforts that assume there is an optimal approach for delivering clinical preventive services fail to account for practices' propensity to optimize care processes to meet local contexts. Interventions to enhance clinical preventive service delivery should be tailored to meet the local needs of practices and their patient populations.

Purpose: Our objective was to identify themes that emerged from the evaluation of 17 interventions funded by the Robert Wood Johnson Foundation's Prescription for Health that aimed to enhance adherence to healthy behaviors in the primary care setting., Methods: We performed a content analysis of diary data from this 16-month initiative. Other data sources used to complement this analysis include funded grant applications and field notes from interviews with investigative teams and a limited number of site visits. Participants were 17 practice-based research networks (PBRNs) that had projects funded during Round 1 of Prescription for Health., Results: Five themes emerged regarding implementation of health behavior change: (1) health behavior change resources are enthusiastically received by practices and patients, and when given a choice, patients prefer methods of assistance that involve personal contact; (2) practice extenders require extensive training, as well as careful case management and support, in order to function fully and avoid burnout; (3) integrating behavior change tools into the primary care setting requires time, effort, and often specialized expertise; (4) even simple interventions require practice change, and use of a practice change model to guide implementation efforts is crucial; and (5) research philosophy and project management approaches vary across PBRNs and have implications for the potential sustainability of an intervention., Conclusions: A more versatile, multifaceted solution involving new tools, technologies, and multidisciplinary care teams is needed in order to integrate health behavior change into everyday primary care routines. Even the best interventions require a model to articulate how to integrate an innovation into practices.

During the past decade, many hospitals experienced difficulty integrating primary care practices into their health systems. We hypothesized that this difficulty may be, in part, a result of limited understanding of practice organizational designs. The structure and function of practices have not been well studied. In this article, we answer the following questions: Are practices all the same, or do variations in their organizational design exist? Do hospital designs predict the designs of affiliated practices? If variation exists, what are the management implications? Eighteen family practices, including nine affiliated with five separate hospital systems, were studied using an in-depth comparative case study design. A content analysis of the rich descriptive data from these cases indicates that a great variety exists in the organizational design of primary care practices, and this variety appears to be influenced by the initial conditions under which the practice was organized. Hospital system design in and of itself did not predict the design of affiliated practices. In fact, both affiliated and independent practices exhibited a range of design characteristics, some of which did not fit traditional models. Hospital systems that allowed greater flexibility of practice organizational designs were more effective at integrating and managing practices. Practices response to environmental change was greater when practice autonomy was highest. These findings suggest that a science of practice organizational design separate from that of hospitals is needed to help explain the success and failure of practices within health systems and to provide information for planning practice change.

Background: Although dietary supplements are in widespread use, and some have been endorsed by the medical community and complementary and alternative practitioners, not much is known about their potential side effects or drug interactions., Methods: A case of asthma exacerbated by the use of a glucosamine-chondroitin supplement for osteoarthritis pain is described. The literature was searched from 1980 to 2002 using the terms "glucosamine," "chondroitin sulfate," "alternative medicine," and "dietary supplements," combined with "asthma.", Results and Conclusions: The biological link between both chondroitin and glucosamine and secretions from the respiratory tree of persons with asthma lends biologic plausibility to the hypothesis that the patient's asthmatic episode was related to the dietary substance. Physicians would be wise to question their patients about use of dietary supplements as self-medication and consider the possibility of such supplements causing exacerbations of underlying conditions.

Objectives: Our study describes patient care staff patterns and roles in community-based family practices., Study Design: We used a multimethod comparative case study design that included detailed descriptive field notes of the office environment of 18 family practices and of 1637 clinical encounters, as well as in-depth interviews of practice staff and physicians. Systematic analysis of these data provided detailed descriptions of patient care staff patterns and functions., Population: We included physicians and staff in 18 community-based Nebraska family practices., Results: Practices are staffed with a range of clinical personnel, including registered nurses, licensed practical nurses, certified medical assistants, radiology technicians, and trained and untrained medical assistants. Each of these has specific educational preparation that potentially qualifies them for different patient care roles; however, staff roles were determined primarily by local needs and physician expectations rather than by education, training, or licensure. Staffing patterns varied greatly; the majority of practices employed at least one registered nurse (10 of 18), one licensed practical nurse (5), or both (4). Still, the overall majority of practices used non-nursing personnel as the predominate patient care staff. Patient care staff-to-clinician ratios ranged from a low of 0.5 to a high of 3.3., Conclusions: Many recent recommendations about collaborative models of clinical care seem problematic when put into a context of the findings of current staffing patterns and use of personnel in family practices. Staff members often fulfill roles independent of training. Staff leadership is also potentially important for designing effective collaborative care models; however, we found leadership only occurred with the approval of clinic authorities. These practical issues are rarely addressed in normative recommendations about system change and intervention. Our findings indicate that there are considerable opportunities for better use of the nursing and other patient care staff in the delivery of clinical services. Developing a collaborative practice model should include formalizing expectations of staff to reflect training and experience, and explicitly configuring staff to meet the needs, values, and goals of a practice.

Background: Community-based curricular experiences have been proposed to fulfill the graduate training needs of future family physicians. Are such experiences feasible? How can such experiences be started? What outcomes can be expected?, Methods: We describe 15 years' experience with community-based training in family practice graduate medical education at UMDNJ-Robert Wood Johnson Medical School. We also describe the process of creating academic-community linkages using stakeholder management and the resultant programs that evolved to fulfill specific training requirements., Results: Five of the curricular programs designed are described, four of which were successful. Community-based training enhanced recruitment of students of minority background into the residency, and a high proportion of residency graduates have established practices in communities with underserved populations., Conclusions: Community-based training of family physicians is a feasible and effective means of addressing unmet health needs of communities served by graduate medical education programs and their related health care institutions.

Background: More generalists are needed for the American health care system. Will training these practitioners add to hospital costs? Although graduate medical education has been shown to add to hospital patient care costs, the authors questioned whether this were true for the hospital training of family physicians., Method: Based on data supplied by 12 participating New Jersey hospitals with family practice residencies, inpatients in 1991 were separated into three categories by the teaching status of their attending physicians: family practice, other teaching, non-teaching. The hospitals were stratified into two types for analysis: seven community and five multiresidency hospitals. Average cost (per case-mix--neutral case) was found for each category of patients within medical, surgical, pediatric, and obstetrical classes., Results: Among community teaching hospitals, the mean case-mix--adjusted cost per case for inpatients associated with family practice training was 6.3% less than that for inpatients with an equivalent case mix not associated with family practice training. Among multiresidency teaching hospitals, there was no difference between mean costs for inpatients associated with family practice training and non-teaching patients. The mean cost for inpatients associated with graduate medical training other than family practice was 8% higher than that for non-teaching inpatients., Conclusion: These findings suggest that family practice residencies do not add to the direct inpatient costs of teaching hospitals, and in certain instances may even reduce hospital patient care costs. In times of increasing cost consciousness in health care and medical education, this provides a further rationale for institutions to sponsor graduate training in family practice.

Health care planning requires characterization of the population to be served. Examination of available demographic and epidemiologic data is one early step in this process. However, aggregate data for the entire geographic area of concern often fail to reveal important differences among geographically defined sub-populations--differences that influence the form an effective delivery system should take. We present a methodology based on exploratory data analysis (EDA) techniques that we have found useful in examining health-related data for our ambulatory care catchment area. Our examples use three population characteristics that have major implications for health care planning for the elderly: 1970-1980 change in population aged 65+; the percent of the population aged 65+ below poverty level; and the percent of single-person households among households with one or more persons aged 65+. With these data for the 25 municipalities of Middlesex County, New Jersey, we illustrate a two-step process: (1) the construction of stem-and-leaf displays that permit examination of a data distribution for asymmetry, concentrations around specific values, gaps in values, and outliers; and (2) the use of the median, the fourth-spread, and other information from the stem-and-leaf display in the systematic selection of data value classes to be given distinct shadings on a map of the selected geographic area. Discussion emphasizes the usefulness of graphic display of data in detecting similarities and unusual data values. Comparison of maps based on the EDA techniques and maps based on several traditional methods of value classing for the same data illustrates the influence of classing choices on the interpretation of cartographic displays of health-related data.