DIRECT OBSERVATION OF PRIMARY CARE PRACTICE

美国预防服务工作组(USPSTF)和健康人 2000年报告呼吁初级保健医生采用一种新的 临床预防实践。以前的研究已经记录了一种 在许多预防性措施的实际交付中表现相对较弱 服务。先前工作的局限性包括不太详细的 了解初级保健实践的相互竞争的需求和 衡量预防性服务交付的方法可能不准确 服务，特别是咨询。 这项拟议的研究将检查120名家庭医生的执业情况 执业医师研究会(RAPP)会员。四 由两名护士兼研究人员组成的研究小组将评估提供 在每项研究的两天内连续护理患者 练习。将使用图表审计和患者退出问卷来 衡量提供的预防性服务的基线流行率，以及 按USPSTF年龄和性别列出的额外服务资格 建议。提供预防性服务的发生率将是 通过直接观察就诊情况进行评估。此外, 将使用Davis观察代码来表征花费在 医疗会诊期间的各种活动。其他潜力 将审查的预防性服务提供的决定因素包括 医生、患者、就医情况和 办公环境。 描述性分析将描述在不同的 医疗见面会的活动。USPSTF的交付水平- 将为个别服务确定推荐的预防性服务 以及咨询、筛查、免疫接种等综合类别， 和化学预防服务。此外，医学史上的和谐共鸣 病历回顾、患者退出问卷和医生问卷 关于常规做法，将与直接观测措施进行比较 针对个别和综合类别的预防性服务。最后， 就医、就医、就诊和就诊特点 与预防性服务提供相关的实践环境 将会被评估。简明民族志数据的内容分析 护士观察员的观察和修改后的焦点小组将增强 解读研究成果，启示新媒体的发展 关于如何增加预防性服务提供的假设。 拟议的研究将提供以前无法获得的有关分娩的数据 医生提供的预防服务，特别是咨询服务 在医疗需求相互竞争的情况下。关于时间如何变化的数据 在就诊期间实际花费的时间将有助于努力 实施实践指南并确定支付系统的良好程度， 例如以RBRVS为基础的新的医疗保险制度，反映了实际做法。这个 研究将提供一个独特的信息基础，以供开发 创新方法，增加初级卫生保健服务的提供 护理医生。

The U.S. Preventive Services Task Force (USPSTF) and the Healthy People 2000 reports call for primary care physicians to adopt a new paradigm of clinical preventive practice. Previous research has documented a relatively weak performance in actual delivery of many preventive services. Limitations of prior work include a poorly detailed understanding of the competing demands of primary care practice and potentially inaccurate methods for measuring the delivery of preventive services, particularly counseling. The proposed study will examine the practices of 120 family physician members of the Research Association of Practicing Physicians (RAPP). Four study teams of two nurse-researchers each will evaluate the provision of care to consecutive patients during two separate days at each of the study practices. Chart audit and patient exit questionnaires will be used to measure the baseline prevalence of preventive services delivered, and the eligibility for additional services by USPSTF age-gender specific recommendations. The incidence of delivery of preventive services will be assessed with direct observation of the medical encounter. In addition, the Davis Observation Code will be used to characterize the time spent on various activities during the medical encounter. Other potential determinants of preventive service delivery to be examined will include characteristics of physicians, patients, the medical encounter, and the office environment. Descriptive analyses will profile the time spent in the different activities of the medical encounter. The level of delivery of USPSTF- recommended preventive services will be determined for individual services and for the aggregate categories of counseling, screening, immunization, and chemoprophylaxis services. In addition, the concordance of medical record review, patient exit questionnaire, and physician questionnaire about usual practices, will be compared with direct observation measures for individual and aggregate categories of preventive services. Finally, characteristics of the medical encounter, physician, patient and the practice environment, that are associated with preventive service delivery will be assessed. Content analysis of data from brief ethnographic observations and modified focus groups of the nurse observers will enhance interpretation of study findings and enlighten the development of new hypotheses about ways to increase preventive service delivery. The proposed study will provide previously unavailable data about delivery of preventive services, particularly counseling services, by physicians within the competing demands of the medical encounter. Data on how time is actually spent during the medical encounter will be useful for efforts to implement practice guidelines and to determine how well payment systems, such as the new RBRVS-based Medicare system, reflect actual practice. The study will provide a unique base of information from which to develop innovative new methods to increase preventive service delivery by primary care physicians.