Primary Care Provider Approaches and Perceptions to Preventive Health Delivery: A Qualitative Study

Thesis (Master's)--University of Washington, 2016-03University of Washington Abstract Primary Care Provider Approaches and Perceptions to Preventive Health Delivery: A Qualitative Study Hemalatha Murugan Chair of the Supervisory Committee: Professor Clarence Spigner Department of Health Services Background: How best to deliver preventive health in primary care continues to be debated. Office visits may be divided into two categories: separate, stand-alone preventive health appointments or visits for medical conditions such as diabetes or hypertension. There has been conflicting evidence regarding the efficacy of preventive health visits, and, yet, the alternative practice of “catching up” on preventive health during other visits has also not been shown to be effective. While many studies have addressed perceived barriers to preventive health, less is known regarding how primary care providers have adapted to the current medical environment to address preventive health for their patients. The objective of this qualitative study was to seek decision-making insights on the provider level to gain understanding of the values that shape how providers deliver preventive health in the primary care setting. Methods: Subjects were recruited from primary care clinics at an academic medical system. 2 interviewers conducted semi-structured, one-on-one interviews. Questions focused on several domains: use of preventive health guidelines, preventive health delivery in preventive health visits versus acute care or chronic disease visits, methods of tracking and documentation, and opinions regarding team-based care. Interviews lasted approximately 20 minutes, were recorded and then transcribed. A thematic analysis was conducted using open coding and then axial coding and, in keeping with Grounded Theory, no pre-specified hypotheses were established. Reliability and validity was assured by independent coding of transcript content. Results: 21 subjects from 4 different primary care clinics were interviewed. The following major themes have emerged: 1. Longitudinal care is perceived as integral to preventive health: Nearly all providers preferred deferring certain core preventive health services to a patient’s own primary care provider, citing the patient-provider relationship as essential in preventive health discussions. 2. Conflict and doubt accompany non-preventive visits: Providers expressed the desire to accomplish some preventive health during these visits, but often felt that they were either not able to accomplish this goal due to time constraints or focused only on brief interventions such as immunizations. 3. Time and patient risk factors provide the framework around which preventive health is delivered, regardless of type of visit: Rather than using a single checklist, providers tailored selection of preventive health services to the patient’s medical and social conditions as a whole, as well as other concerns addressed during a clinic visit. Those providers who routinely conducted separate preventive health visits deferred services that require more discussion and shared decision-making to those visits. 4. Adaptation arises: The provider’s level of confidence in the electronic medical record (EMR) tended to lead to either adaptation or discomfort. Many providers expressed discomfort with the EMR’s adequacy of tracking preventive health and consequently adopted other systems, including having their own separate tracking system in the patient’s problem list. Reasons most cited included lack of completeness and inability to express rationale for decision-making in the EMR. 5. Comfort level with team-based preventive health delivery is connected with the degree of shared decision-making required: Nearly all providers expressed that other members of the health care team should increase involvement in preventive health, but there were varying responses based on whether a preventive service was perceived as controversial, or requiring discussion. Conclusion: In this qualitative study, the themes that surfaced suggest that primary care providers are resilient in finding ways to deliver preventive health to their patients, despite a system in which they often feel uncomfortable with their efficacy. They use a number of factors in deciding what preventive health to address and when for a given clinic visit, built upon a platform that values time, the patient’s medical conditions and expectations, and a strong value that a patient’s primary care provider should be involved in complex preventive care decisions. They frequently adapt to an EMR that they lack complete confidence in or find not fully adequate. Together these findings have implications for the primary care practice of the future: flexibility, utilizing multiple methods of delivery, having provider input into EMR design, and supporting the primary care provider’s role as leader of a patient’s preventive health, even with team-based care, should be critical foundations. Limitations of this study include the inherent nature of its qualitative approach and the academic medical center setting, impacting generalizability. However, it is likely that certain dilemmas are common to the practice of primary care, and the insight into provider behavior found by these qualitative interviews, with answers unable to be gleaned from quantitative data, may provide stimulus for further research