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OCR for page 47
Chapter 5
\
ANALYSIS OF CURRENT PRACTICES
SCARY OF PRACTICES ENGAGED IN COPE
~ typical instance of pr imary health care delivery in Me United
States begins with a person identifying a personal health problem and
either self-treating the problem themselves or seeking help from a pri-
mary care provider or a specialist. Primary care tends to be patient-
initiated and episodic. This mode of practice is very different from
the fully developed model of community-oriented primary care described
in Chapter 4. The focus of attention is different in primary care it
tends to be on individuals, whereas in COPE it is on a defined commu-
nity or population, many of whom do not present themselves for care.
Moreover, the services thenmel~res and the trays they are organized and
provided are often very different when the target of those cervices is
an entire community rather than an aggregate of patients.
Despite the apparent discrepancy between the ideal COPC described
in the conceptual model and what i. known to be the prevailing mode of
primary care practice, there are examples of primary care practices
that approach the ideal, i.e., practices or programs that have assumed
responsibility for ache health of a population defined more broadly than
ache patients who present themselves for treatment and, having assumed
that responsibility, are regularly performing some COPC functions. One
objective of this study was to locate such practices and programs and
determine the extent of knowledge about the operations, costs, and
benef its of COPC in the United States.
The study set out to find some of the best examples of COPC being
practiced in this country today . As descr ibed in the methods chapter,
identifying these examples was an open-ended process. Inquiries were
made of individuals considered to be familiar with the concept of COPC,
who had knowledge of health service program, both public and private,
that might include COPC type programs, andiron who had knowledge of the
published and unpublished literatire relevant to COPC or its major
definitional components. About 185 letters were sent out and inquiries
were made in person at several meetings and Conferences.
As a result, there were 147 sites suggested as places engaged in
COPC-type ac~ci~rities. The suggestions ranged from solo practices in
rural West Virginia to community health centers in San Franci~co to
47
OCR for page 48
48
large multispecialty group practices in the Midwest. Further infor-
mation was obtained on 84 of the suggested sites, both from written
materials sent to us and from personal contacts. This group reflected
the broad range of sites elicited by the initial inquiries. Out of
these, 58 met the three criteria for COPC: the provision of primary
care services, a defined community, and systematic efforts to identify
and address the major health problems of the community.
It was not the objective of the study to determine the prevalence
of COPC in the united States, rather the intent was to find and study
the best examples of COPC. Therefore, the sites identified above were
not the result of an exhaustive search to uncover all the practices and
programs engaged in COPC-type activities and they should not be inter-
preted as the sum total of such practices. However, it is interesting
to review the pool of potential COPC sites. It helps to put in
perspective the seven sites that were selected for case studies.
The 58 sites found to be engaged in son COPC activities included
both public and private arrangement';. For 34 sites, ache major source
of operating revenue was from public grants or contracts, whereas 24
sites were not dependent on public grants for operation. Ten of the 24
practices, however, were part of the Rural Practice Network; originally
funded by the Robert Wood Johnson Foundation in their initial phase of
development. Several of these practices also have received indirect
subsidies in the form of National Bealth Services Corps physicians.
There were several different types of practices and program Mung
the 58 suggested sites. There were 17 community health center program
(5 rural and 12 urban}, 15 median Health Service units, 3 health main-
tenance organizations, 12 nonprofit private practices, 7 for-profit
private practices, 2 hospital-based programs, ~ consortium of neighbor-
hood heals cen~cers, and a union health program. Of Me S8 sites, 18
were located in urban areas, 37 were in rural areas, and only the 3 EMOs
were located in areas "at included both urban and suburban co'unities.
AS indicated above, all S8 sites claimed that they were responsible
for the health of a population defined more broadly than ache patients
who use their practice. They usually defined their community in goon
graphic or geopolitical terms or, in the case of Boos, in membership
terms. The COPC-type activities =at were reported by these sites
tended to cluster at ache early stages of identification and character-
ization of their community, the identification of Me community's
health needs, and Edification of the heals care program. Specific
and cam- parable details of these activities across the 58 sites were
difficult to obtain without a Ire elaborate survey or site visits.
From the 58 sites identified as barring some of the characteristics
of COPC, seven were chosen an canes for study. The final seven were
selected to represent COPC practices that evolved in very different
environments--single specialty as well as multi~pecialty, rural as well
as urban, public as well as private, and fee for service as well as
capitation. The seven were selected after contact either by telephone
or in person with the principals in the practice. It appeared from
these inquiries that these seven sites were performing several of the
COPC functions at a mare advanced stage than the other practices
OCR for page 49
49
contacted. None of ache Biter was performing all the COPC functions
cons intently at Me h ighest stage of development .
C8ARACTE:RISTICS OF COPC STUDY SITES
The seven COPC study sites were selected not only on the basis of
how well they were performing COPC functions, but also on some external
characteristics. Efforts were made to find practices and programs
engaged in COPC activities that were situated in different parts of the
country and organized in different ways. These efforts proved succe~-
ful, and suitable COPC sites were found in a variety of situations and
c ircu~tances {Table 5 .1) .
An effort was made to select sites so that there would be fair
geographic distribution. Three of the seven sites are on ache east
coast, two in urban areas, and one in rural North Carolina; the other
four are west of the Mississippi, including sites in ache mountains
outside of Denver, the rural southwest, and the area around Portland,
Oregon. With the exception of Raiser/Oregon, whose community includes
urban and suburban residents, the COPC communities studied either were
inner city (e . g ., East Boston and Monte f tore ~ or more than 50 miles
away from a large metropolitan area (e.g., Checkerboard, Crow Mill,
Sells, and Tarboro}. The extreme differences in the size of the
communities served (ranging from 7,000 to 255,0001, reflects the full
spectrum from urban to rural.
Ownership of the practice or program and predominant sources of
revenue were two other factors of concern to the committee. An effort
was made to find COPC study sites that met the basic structural and
functional criteria for COPC but that also practiced in different
fiscal environments. Only one of the study sites, Sells, is a totally
publicly owned program. Crow Hill is a private family practice, owned
by two physicians and operating for profit. Four sites are privately
owned but have not-for-profit status, and Tarboro represents a mix of
all of the above, i.e., a publicly owned county health department, a
private, for-profit multispeczalty group practice association, and a
pr ivately-owned not-for-prof it community foundation. Private owner-
ship, however, does not necessarily mean independence from public
support. With the exception of Raiser/Oregon, which generates revenues
from member dues, the four sites (Checkerboard, East Boston, Montefiore,
and Tarboro} that exist all or in part as not-for-profit operations
have public grants and contracts as one cuff the ma jor sources of revenue .
In was noted, however, that for several of these sites, third-E,arty
payment is becoming an increasingly more significant source of revenue.
Finally, there is var iation across COPC practice sites on the size
of the practice. The range is from a two-physician family practice at
Crow Hill to a 250-physician, multispecialty practice at Raiser/Oregon.
There does seem to be a clustering, however, around the small groups,
e.g., Crow Bill with two, Checkerboard with four, Mantefiore with six,
and Sells with seven.
OCR for page 50
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sl
It is interesting to keep in mind the variations in the practices
when reading the cross-case analysis that follows. Thin is not a ho~-
geneous group engaged in COPC; rather it is an assortment of practices
and programs that, in different ways and in different environments,
have approximated some elements of the fully~operational model of COPC.
THE: SEVEN STORY S ITES
This section provides a brief sketch of each of the seven Rites,
describing their organization, where they are located, and how they
have approximated the COPC model. In each site, there is ~ tabular
display summarizing selected examples of COEC activities. The full
case study report for each site is presented in volume II.
Checkerboard Area Bealth System*
The Checkerboard Area Besith System is a primary care program
composed of ~ health center and four satellite clinics serving
culturally diverse population in northwestern New Mexico. The
approximately 14,000 residents are widely dispersed over 4,000 square
miles in small villages or family camps.
___ ~ . _, Navajo Indians represent
about 63 percent of the population served by the system sod the
remaining 37 percent is made up of Spanish Americans and Anglos.
The Checkerboard area, so need because of the pattern of land
ownerships by federal and state government, railroad, Navajo, and
private organizations and individuals, shares posse of the character-
istics of an underdeveloped rural area.
The only signif icant local
sources of income, other than cattle ranching and sheepherding, are
natural resource extraction, small service businesses and trading
posts, and go~rernmente1 service system= such as school, health, and
highway departments. In some communities, over one half of the work
force is unemployed.
The maioritv of ares residents depend for
survival on subsistence agriculture and stock raising, along with
Approximately 85 percent of the
governmental f inancial assistance.
area families live on incomes below the federal poverty level.
Geographic isolation and minimal communication facilities charac-
terize the area. Communicable disease and poor nutrition expressed in
the high prevalence of diseases such as shigella, enteritis, trachea,
impetigo, pneumonia, and otitis media reflect ache relatively hostile
physical en~riron~nt.
Recognizing these factors Checkerboard has developed ~ health care
program tailored to the needs of the population living in the area,
including diagnostic and treatment procedures for acute and chronic
conditions, screening and health assessments, dental programs, health
*Hereafter referred to BS Checkerboard
OCR for page 52
S2
education, transportation ser~rices, and ~ variety of outreach programs.
{See Table 5.2 for some examples of COPC activities at Checkerboard.)
Consolidating and integrating pre~renti~re and curative services in
the Checkerboard ares has been made possible in part through coordina-
tion of ~ series of grants and contracts negotiated over the last
decade. Checkerboard contracts with the Indian Bealth Service to
provide inpatient, outpatient and dental services to the Navajo
residents in the catchment population. Checkerboard receives grants
from federal agencies {U.S. Public Health Service and U.S. Department
of Agriculture) to provide comprehensive services to the non-~avejo
population. PUbliC health services, previously provided by a branch
health office of the state health agency, are currently provided by
Checkerboard under contract with the state health agency. Likewise,
health promotion and disease prevention responsibilities for all school
children in the Checkerboard population have been assumed by Checker-
board under contractus1 arrangements with 10C81 school districts.
These servicer and program. are provided through a system of four
satellite clinics supported by a central health center. Limited
hospital (Medicare certified} and emergency medical services are
available 24-hours per day, seven days per week at the centrs1 health
center. Both preventive and curative services are provided in
continuous and Coordinated way.
Crow Bl11 Family Medicine Center.
The Crow Bill Family Medicine Center, a priorate family practice
begun in 1977, is located on a major highway in Bailey, Colorado, 60
miles west of Denver. The ares served by Crow Bill stretches from the
far western suburbs of Denver to Fairplay, ~ town on the far west side
of ~ major mountain pass. Crow Bill is the only medical practice in
the area. Until July 1982, the practice was ache responsibility of one
family practitioner committed to ache ides of meeting ache health needs
of this community. Currently, Crow }fill is shared by two family
practitioners with the assistance of four nurses, a receptionist,
typist, and a bookkeeper.
The population served by Crow Bill tends to be white, middle class
and employed or retired. One subset of the population is made up of
young families who cosmwee to Denver for work and in some cases medical
care. There also are many retirees in He community, many of whom cone
tinge to travel to Denver for shopping and medical services. (According
to the 1980 census 60 percent of senior citizens of Park County live in
Bailey/Crow Bill area). A third subset of Me population served by Crow
Bill are E - 3ple who have Tiered in the ares for many year';, who identify
strongly winch the local community and tend to support volunteer efforts
*hereafter referred to as Crow Hill.
OCR for page 53
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OCR for page 55
55
with in the community. This latter group is descr ibed as self-reliant;
they scud not to be heavy utilizers of pr imary care services. En',mer-
ating ache individuals or families that make up this community and
identifying the health needs of ~ community this diverse hen presented
a challenge to the staff at Crow Hill. Through their Family Medicine
Information System (FISTS}, the practice has been able to precisely
define a practice community that extends beyond the users of services.
They can, and do for Various screening purposes, enumerate all members
of registered families, i.e., families from which any single meter has
visited the practice within the previous two years. Severs1 community
health needs have been identified, e.g., emergency care, extended
office hours, vulnerability to strep throat, etc. and services have
been modified in response to those needs. (See Table 5.3 for ~ sunmury
of some of the examples of COPC activities at Crow }lill.) No attempt
has been made ~ document or monitor the effects of these Edifications.
East Boston Neighborhood Health Center*
East Boston Neighborhood Bealth Center is a large community owned
and operated health center that provides comprehensive primary care
services to the residents of East Boston, - ~sachusette. The health
center has been operating since the late 1960 s under the direction of a
community board that decides on major policy questions, owns the
building , is responsible for hiring and firing staff, and is the
grantee and/or contracting agent in awards of this kind. The board is
assisted in program planning and in the day-t~day operations by a five
person executive committee.
East Boston is a part of Boston that is physically cut off from the
rest of the city try Boston Barbor. It shares t" geography with Logan
International Airport. The population of "at Boston, which n''mhers
approximately 32,000 people, is predominantly working class Italian
Americans with ~ strong community identification. With the exception
of a few aging solo practitioners, the East Boston Neighborhood Health
Center is the only source of medical care located in East Boston.
There are, of course, a multiplicity of medical resources on the other
side of the harbor. The health center staff estates that about half
of the residents of East Boston here actually registered with the
health center.
Since its early days the East Boston Neighbor he Health Center has
been committed to pra',iding priory care services to all the residents
of East Boston. East 80~10n was assisted in enumerating its population
and identifying its health needs when the center became a practice site
an a national study of hypertension detection and follow up. This
survey and subsequent surveys have revealed a good deal of information
.
*hereafter referred to as East Boston.
OCR for page 56
56
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OCR for page 57
~7
about the health needs of the East Boston community. When fees ible, as
in the case of identifying a need for congregate housing for ache depen-
dent elderly, the community board has taken action and modified the
program in response to community needs. (For other examples of COPC
activities at =st Boston, see Table 5.4.} However, there has been no
systematic documentation or monitoring of the effects of these changes.
Kaiser-Permanente Medical Care Program of Oregon.
The Raiser-Per~nente Medical Care Program in Portland, Oregon is
one of the nine regional programs of the nationwide Raiser-Permanente
Medical Care Program, the largest health maintenance organization in
the United States. Raiser/Oregon, like the other eight regions is a
joint endeavor involving representatives of the professions of medicine
and management, "baring responsibilities for organizing, financing and
delivering health care service on ~ prepaid basis. Approximately 2S0
salaried physicians are organized as ~ separate and independent medical
group known as Northwest Permanente, and management functions through
the Raiser Foundation Health Plan and the Raiser Foundation Bospitals.
The Oregon region of the program has been in operation since the early
1940s and currently serves a community of enrollees numbering
approximately 25G,000.
In addition to ache organizing, financing, and delivery of health
services Xaiser/Oregon has had, since 1964, an active health services
. . . . . .
research division and ~ very rich cats base specifically designed to
study ache effects of changes in the organizaton of health services and
to improve understanding and appreciation of the theoretical issues of
medical care utilization. Although it functions semisutonomously in
the Oregon region, the research center has had a profound Impact on the
direction and operations of the health program.
Many of the innovative ways the Raiser/Oregon membership has been
expanded (e.g., Medicare and Medicaid groups brought into the plan),
needs identified (e.g., preventive services for the indigent population
and home health services), services modified {e.g., outreach programs,
home health agency) and effectiveness measured trace their origins to
the Health Services Research Center. (See Table S.5 for examples of
COPC activities at Raiser/Oregon.}
The community for which Raiser/Oregon is responsible is made up of
the approximately 2S0,000 plan oaember-, those individuals with whom the
plan has a contractual relationship to provide health care. By virtue
of this contractual relationship, Raiser/Oregon' ~ population i. clearly
and specifically defined and the individual members can, at any time,
be enumerated. Raiser/Oregon has as its community approximately 20
percent of the population of greater Portland. The demographic char-
acteristics of the membership are almost identical to the Portland
*Hereafter referred to as Raiser/Oregon.
OCR for page 86
86
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OCR for page 87
87
cost implications. Virtually all of the study sites made use of
information available from local health and planning agencies, and a
few relied almost entirely on this type of secondary data. Both East
Boston and Tarboro side a substantial special effort to characterize
their community, going considerably beyond the data available from
local agencies. while neither site is able exactly to determine the
cost of their efforts, they would probably have been unable to accom-
plish them without the special funding support each had received for
specif it: research activities.
Whether primary or secondary data is used, additional analysis was
necessary in order to tranform the data into useful information. With
the exception of the sites that routinely engaged in research (East
Boston, Sells, Raiser/Oregon, Tarboro} most of the time-consum~ng
analysis and interpretation of. the raw data fell to the physician.
Several of the principals pointed out that they were not following a
definite protocol, and thus it was easier to deal with the data
themselves than to teach someone else to ass ist.
The task of identifying and character iz ing the community is
considerably simpler (and relatively less costly ~ in the sites with ~
population-based data system. Both Checkerboard and Sells are able to
maintain a reasonably up-to-date demographic description of their comm~-
n ity from their data system. Raiser/Oregon expends considerable effort
and expense to closely monitor the characteristics of their community,
and their performance far exceeds all other study sites in precision
and timeliness which would not be feasible without ~ data system.
Among the study sites, monitoring the impact of the program
modifications was relatively ache weakest of the COPC activities.
Virtually all sites acknowledged the importance of this function but
cited the cost and lack of personnel skilled in evaluation techniques
as the major impediment. Thus, on the surface, it would appear that
the perceived cost of the monitoring function exceeded the resources in
most sites. The exceptions of course were generally among the sites
with strong research affiliations, in which case the cost of the moni-
toring function was covered within the research activity.
The costs associated with the function of community participation
varied widely song the study sites. Conceptually, the cost of commu-
nity participation includes those direct and indirect costs born by the
primary care program and not the cost to the community as a whole. For
example, if a particular community board meets regularly with the
professional staff, the cost must account for the time of the
professional staff, but not for the board members unless they are paid
by the program. Similarly, the cost of community participation also
must include the time-value of the professional staf f who participate
in the activities of community health programs and serve on ache board
of community agencies, even if they do do on their own time.
Of all the COPC functions, the cost for the modification of the
health care program is most difficult to estimate . This set of costs
generally falls into two categories--the cost of planning and imple-
menting the Edification and the differential cost to the 'system of
operating over time with the Edification. The costs of planning and
implementing a Edification in the program are particularly difficult
OCR for page 88
88
to estimate. For the most part, these are time-costs for the health
professionals to consider the range of alternative changes that can be
made, selecting one particular approach, planning its implementation,
and working with other personnel to affect the change in program
modification. This set of nativities is closely associated with the
activities that are an integral part of managing a primary care program
and it is difficult to identify the .margin. that in attributable to
the COPC process. For example, at East Boston much of the cost of the
weekly meeting with the Board would be attributable to the operation of
the primary care program. Given this cost, the marginal cost of
planning and implementing the COPC program modification probably would
be small. Generally Tong the study sites, these costs are probably
less than those associated with the quantitative processes of COEC, and
certainly would involve fewer rout of pocket. expenses than conducting
a household survey to characterize the community.
On the other hand, the costs associated with the modification
itself can be substantial. Tong the study sites most of these costs
were positive, that is;, the modification involved ~ new program with
additional costs rather than a realignment of an existing program
within ~ fixed budget. Notable exceptions included Checkerboard, which
adjusted its screening procedures for children based on ache prevalence
of selected health problems in the community and discontinued several
screening procedures while adding emphasis to several priority health
problems of children. Sells instituted a fundamental change in its
approach to infant gastroenter itis involving both ache pr zmary care and
several community health program with no appreciable change in budget,
However, it is dangerous to conclude that such programs had no asso-
cisted increase in cost, since it is difficult to attribute the trade-
off involved in making a program Edification. One wonders to what
extent the costs of such an effort are in fact borne by other emphasis
areas within ache total health care program.
Of the program modifications identified in the study sites, most
clearly involved an incremental cost, and often were identifiable as
separate budget categories. The study 'sites usually implemented the
program Edification win an increase in Heir revenue base, often
sought through external grunts and contracts.
Although the case studies offer little new information on the costs
associated winch the practice of COPC, some general points can be offered
regarding the relative magnitude of He costs and who bears ached under
different financing arrangements. The COPC functions ~chemselves are
not inherently expensive, and if embedded in a large heals care organi-
zation pose marginal costs not large relative to the cost of the total
program. Clearly, there is an economy of scale because the costs asso-
ciated with the COPC probably are not linearly related to the size of
the community. It it; unlikely to cost twice as much to identify and
address the major health issues of a community of 20,000 as a community
of 10,000. Thus, within limits, the cost per capita of the COPC func-
tions would probably decrease as the size of the community increases.
The total costs of a COPC practice may not necessarily be higher
than that of orthodox primary care and in fact may be less Costly
overall to society. If successful, a COP C practice may achieve savings
OCR for page 89
89
that more than offset the incremental costs of special COPC-related
activities. For example, savings may result from targeting interven-
tion at high risk groups, from discontinuing services with no benefit,
or from reductions in the need for hospitalization. Also, COPC can
lead to more efficient operations and should lead to concentration of
efforts on services that have higher priority and productivity in terms
of the community's health.
Decreased costs because of reductions in the future need for health
services do not represent savings in all health care programs. If the
program has a mandate to provide all necessary care to a community
(e.g., as in the Indian Health Service or an EMO), then certain cost
trade-offs can be made. However, a practice that generates revenue
only when services are delivered cannot reduce their costs by activi-
ties that reduce the future need for service, and in fact such
activities may actually serve to reduce the future revenue base.
The Impact of COPC
The impact of COPC can best be expressed as the marginal effect of
those activities that are unique to COPC and not considered to be
activities of orthodox primary care. By its nature the COPC process
directs the attention of the health care system to particular health
problems and issues in the health of the community. At one level COPC
activities would be expected to improve the status of the particular
health issue being addressed. This micro effect is normally observed
in the monitoring of impact activities, which constitute the fourth
function of COPC. Bowever, the dynamic relationships among the
activities of the health program and the expression of disease in a
community are complex, and efforts to improve one aspect of health
could draw resources from another effort. The activities of COPC
themselves have a finite cost, which in a non-COPC practice would be
directed toward providing more services. Thus, the macro effect of
COPC would consider the net change in the health care or health status
of the community and would consider both positive and negative effects.
There is very little definitive information on the marginal impact
of COPC. The literature contains no systematic studies of the orthodox
primary care. The case studies generated very little new information
on the marginal impact of that set of activities that belong uniquely
to the domain of COPC rather than to orthodox primary care. Many of
the sites demonstrated changes in the processes or outcomes of their
programs, although it was rare that causality could be established
(Colombo et al., 1979; Freeborn et al., 1978). None of the sites had
data, however, which allowed an assessment of the marginal impact of
the COPC activities. However, there is evidence in the literature on
the impact of innovations in primary care which share some of the
characteristics of COPC. For example, there have been a number of
studies which attempt to examine the impact of comprehensive care using
community health centers and health maintenance organizations. Still,
determining whether primary care in a comprehensive framework has an
impact remains an illusive and unanswered question {Lewis, 1971~.
OCR for page 90
so
Although studies of comprehensive health centers have found posi-
tive effects on specific disease entities. including rheumy tic fever
{Gordis, 1973) and hypertension (NACHO, 1980}, general indicators of
maternal and child care are the most frequently reported. Evaluations
of the community health centers have frequently reported important
effects on infant mortality (Davis and Schoen, 1978). Studies of
health centers in rural areas of Alabama (Anderson and Morgan, 1973
and Mississippi (Seaeat, 1977), as well as urban neighborhoods in
Denver (Chabot, 1971) and New York City (Gold and Rosenberg, 1974) have
reported reductions in infant mortality ranging from 25 percent to 60
percent. A nation-wide analysis on a county basis confirmed the posi-
tive impact of health centers on infant mortality, especially among
black children; the estimated effect between 1970 and 1978 was one
death per 1000 live births, about 12 percent of the total decline
during those years.
Quantitative Techniques for COPC
The quantitative techniques required for the functions of COPC are
drawn largely from several traditional disciplines. Identification and
characterization of the community relies on the tools of demography,
identification of community health problems draws from the traditional
techniques of epidemiology, and the methods for monitoring ache impact
of promos Edifications are provided by health services and evaluation
research. Among ache principals of the study sites scheme was an mpres-
sive capability to engage in quantitative activities, and several were
ma jor figures in their respective research fields. However, the study
s ites probably represent exceptions in this; regard and to ask that full
facililty with the techniques of these fields become available to the
primary care practitioner is not reasonable. either do the current
problems and trends in the f inancing of health care encourage the
addition of a COPC specialist into each primary care setting. Instead
there is a need to develop a tool kit of quantitative techniques for
use in the pr imary care setting that emphasizes an appropr late balance
between scientif ic r igor and feasibility.
For many of the quantitative activities inherent in the COPC
functions, significant developmental work has been undertaken, often in
diverse fields. Although a great deal of developmental work has to be
done, some important efforts have been directed at defining and charac-
terizing the community. Research in primary care family practice has
dealt with the problem of determining an appropriate denominator for
identifying the community. ~ The work was pioneered by Rilpatrick of
Medical College of Virginia. The estimation of ache size and age sex
composition of the population potentially served by a specific pr imary
care practice became known as the Denominator problem. ~ In 1975,
Kilpatrick proposed a negative binomial distribution of Episodes of
illness" drawn from the Second National Morbidity Survey in the United
Kingdom (Kilpatrick 1975a,b, 1977). This encouraged others to pursue
the topic and the work still continues (Bass, 1976; Cherkin et al.,
1982; Cronies 1977; Falk, 1977; Galazka and P=dr iguez, 1982;
OCR for page 91
91
Carson, 1976; Kretchmar and Shaklett, 1977~. Recently, Rilpatrick has
said, .as yet the denominator problem has not been solved. Progress
with research will be made by comparing methods at different sites over
several years. It is not clear whether this commitment and the re-
sources for these necessary studies exist. (Rilpatr ick and Boyle,
19841. Until then the concept that primary care practices equates with
applied epidemiology is not tenable. If it is solved the evolution
from primary
care practice to COPC will be conceptually and logistically much more
direct, and as the research unfolds perhaps the most comprehensive
approach to defining and characterizing the primary care community is
emerging from the work of Mettee (1981} at Case-Western Reserve Univer-
sity.
Techniques are needed that apply the rich heritage of epidemiology
to the busy primary care setting in order to produce economical, yet
scientifically sound, assessments of the important health indices of
the community. In addition to identifying the patterns of illness in
the community, this COPC function requires an understanding of the
extent to which the current operations of the health care program is
influencing those patterns. Thus, COPC must offer the clinician tech-
niques for the simple examination of the extent to which his mix of
primary care services is adequately serving the needs of his entire
community. Methods must accommodate the community, made up of active
patients, persons who are nonusers of health service=, and Chose who
obtain services from other sources. Although a number of techniques
for assessing the quality of care were developed in ache late 1960s and
1970s, many focused on single visits or on single sources; of care and
only a few techniques were truly population based. Although techniques
which examine ache quality of care for active user'; of health services
are useful to the clinician, the practice of COPC requires techniques
which examine the care received by the entire community and the distri-
bution of critical health services therein (Nutting et al., 1981; Shorr
and Nutting, 19771.
Although modifying the health care program is not a function
heavily dependent on quantitative techniques, it is often critical to
target health services on the high r isk individuals within the com~u-
nity. Classical epidemiology has contributed tremendously to the know-
ledge of the correlates and determinants of disease, and has provided a
basis for identifying those risk factors that characterize subsets of
the population at increased risk to morbidity and mortality. In an
operational 'letting, however, one needs to know Me specific individuals
at risk and not simply their characteristics. There have been only a
few applications of risk models to defined communities in an attempt to
identify those specif ic individuals at increased r isk to a particular
health outcome. Perhaps the best example comes from the Indian Bealth
Service where a simple paper-and-pencil model enabled Practitioners to
identify infants at increased risk for severe gastroenter it's (Nutting
and Strotz, 1975} . Pinpointing individuals at r isk, rather than the
characteristics of such individuals, allowed the health care system to
target constrained resources on specific infants who would benefit from
preventive services. Subsequent analysis showed the model to be highly
sensitive and spoof in . Evaluation of the total program revealed that
OCR for page 92
92
a simple educational task targeted at the parents of Ache higher isk
infant resulted in a drastic reduction in morbidity among the infants
at r isk for severe gastroenter itis .
Finally, the practice of COPC requires techniques that the practi-
tioner may employ to determine if modifications in the health care
program are achieving the desired result, and along the study sites,
this appeared to be the weakest function. Evaluation techniques must
avoid a narrow focus on the active tossers of service, but must examine
the impact of program modifications on the magnitude of the problem
among all members of the community, distinguishing among individuals of
differential risk. Again, an example from the Indian Health Service
illustrates such an application. A population-based examination of the
adequacy of prenatal care demonstrated that a large number of high risk
women were receiving either late or inadequate prenatal care. A
seemingly appropriate modification was made in the primary care program
aimed at improving prenatal services. In monitoring the impact of the
edification, two parallel evaluation efforts were conducted. The
traditional approach suggested a substantial and statistically signi-
ficant Improvement in the quality of prenatal care provided. However,
the population-based evaluation suggested no improvement in the pattern
of care received by the community as a whole. More Important, when the
data were disaggregated by risk groups, the results suggested that the
care received by the average risk subset of the community had Improved
slightly, but a deterioration was observed in the care received by the
high risk group. Thus, the prenatal care program had a paradoxical
effect: it resulted in a substantial improvement in care provided to
program users, but led to a maldistribution of services away from the
high risk prenatal group. Of note is that the adverse effect was not
detected by a standard evaluation approach which was not population
based (Nutting et al., 1979~.
Data Systems for COPC
The presence of a data base containing clinical data for all indi-
viduals within the community would 'seem to greatly enhance the ability
to conduct the activities of COPC. The value of such a data base in
identifying the major health problems of a community would be sizable.
The data base could be used either to conduct limited epidemiologic
studies, limited only by the variety of clinical data available, and
would be useful in identifying samples of the community for further
epidemiologic investigation. The data base could be used similarly to
monitor the impact of modifications made in We health care program by
tracking the extent of application of the program Edification and
observing outcomes, again limited only by the scope and specificity of
the clinical data. Also, a population data base would be of immeasur-
able value in the implementation of the intervention program itself.
Population-based systems can be used to identify the high risk or target
group for the program intervention and can be used to efficiently moni-
tor the extent to which the new or modified health services are applied
to the individuals who most need them. Where outreach is a component
OCR for page 93
93
of the program modification, a data base permits outreach workers to
selectively target individuals in the community who will most benefit
from their services, and thus a data system can greatly increase the
efficiency of outreach efforts.
Bigher-order COPC
COPC is usually discussed as though the concept is limited to a
single practice, and often the single practice is located in a commu-
nity in which there are a number of other practices. Thus, there is a
fatalistic sense that one cannot really deal with the community, since
it also ~belongs. to a number of other practices, and must therefore
focus on one's Active patients. *''to = ~ = ~~~~
. ma__ ~ _, ~ ~ ~ .. . .
= ~ ~ ~ ~ ~ · . · _ -
^~l~uyr~ no, Juan `;U~c; practices were
-__~-c", allege `~ nolulng inherent in the concept that precludes a COPC
,_~-~y ~-vm ~ Baron or pracezces, which cooperate in the COPC func-
tions while maintaining independence in their direct service primary
care activities. In this regard, the Montefiore Family Bealth Center
was a member of a coalition of all of the community health centers in
the Bronx, which gained an economy of scale in the quantitative func-
tions of COPC through collaboration. This essentially also was accom-
plished at Tarboro and Checkerboard. Although both incorporated other
components of the health care system, neither attempted to incorporate
other well-established and active physician practices. At another
level of organization, a local health department could act as the focal
point for COPC activities, by carrying out the quantitative functions
and coordinating the primary care provider organizations and the commu-
nity health organizations in programs which are indicated. Some of the
15 local health departments studied by Miller and Moos (Miller and Mods,
1981) are approaching the basic requirements of the COPC definition.
OCR for page 94
94
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Representative terms from entire chapter:
east boston
