Associations between supportive leadership and employees self-rated health in an occupational sample.

BACKGROUND: Protecting the health of the work force has become an important issue in public health research. PURPOSE: This study aims to explore potential associations between supportive leadership style (SLS), an aspect of leadership behavior, and self-rated health (SRH) among employees. METHOD: We drew on cross-sectional data from a cohort of industrial workers (n = 3,331), collected in 2009. We assessed employees' ratings of supportive, employee-oriented leadership behavior at their job, their SRH, and work stress as measured by the effort-reward model and scales measuring demands, control, and social support. Logistic regression estimated odds ratios (ORs) and corresponding 95 % confidence intervals (CIs) for the association between the perception of poor SLS and poor SRH controlling for work-related stress and other confounders. Sensitivity analyses stratified models by sex, age, and managerial position to test the robustness of associations. RESULTS: Perception of poor SLS was associated with poor SRH [OR 2.39 (95 % CI 1.95-2.92)]. Although attenuated following adjustment for measures of work-related stress and other confounders [OR 1.60 (95 % CI 1.26-2.04)], the magnitude, direction, and significance of this association remained robust in stratified models in most subgroups. CONCLUSION: SLS appears to be relevant to health in the workplace. Leadership behavior may represent a promising area for future research with potential for promoting better health in a large segment of the adult population.

Anti-clockwise rotating shift work and health: would you prefer 3-shift or 4-shift operation?

BACKGROUND: We explored the association between work schedules involving nightshifts and selected measures of health and whether these associations differed among those working in either 3- or 4-shift cycles. METHODS: Employees at a German industrial company who worked on a fixed daytime schedule or on one involving nightshifts were invited to participate in this cross-sectional study. Work schedules involving a nightshift were organized into either 3 or 4 shifts rotated anti-clockwise on a weekly basis. Health characteristics included a range of clinical and physiological measures and self-reported data on stress and sleep quality. We assessed the independent association of work schedules involving any nightshift and these health characteristics in separate regression analyses, adjusting for age, gender, smoking, and alcohol consumption. RESULTS: Nightshift work (N = 133) in general and 3-shift-work (N = 53) in particular was associated with decreased sleep quality (P < 0.001). Compared to those working daytime (N = 632), employees working on a 3-shift cycle had higher adjusted odds of meeting the definition of metabolic syndrome (OR = 2.56 [1.38, 4.75]). Employees working 4-shift cycles were somewhat less likely to have metabolic syndrome (OR = 1.22 [0.73, 2.05]) and had higher parasympathetic activity measured by heart rate variability (OR = 2.20 [1.04, 4.63]). CONCLUSIONS: Our data suggest important relationships between shift schedule and a selected group of objective and subjective health measures. Additional research that further clarifies potential mechanisms underlying these relationships is needed.

Influenza vaccination coverage among high-risk groups in 11 European countries.

BACKGROUND: National vaccination coverage rates for individuals at increased risk of influenza-related complications represent a useful public health indicator of preparedness. We compared European countries regarding (i) vaccination coverage among high-risk groups and (ii) the likelihood that high-risk individuals reported influenza vaccination compared with those at lower risk. METHODS: We used data from the Survey of Health, Ageing and Retirement in Europe (SHARE) collected in 2004-05. Adults aged ≥ 50 years from 11 countries provided self-reports of an influenza vaccination in the previous year (n = 16,913). We defined four high-risk groups (age ≥ 65 years, presence of vascular disease, chronic lung disease or diabetes) and calculated vaccination coverage with 95% confidence intervals for each country. Country-specific multivariable logistic regression was used to estimate odds ratios (ORs) for membership in a high-risk group and vaccination. RESULTS: The Netherlands had the highest influenza vaccination coverage in high-risk groups (≥ 75% in any group) while Greece had the lowest (<27% in any group). Older age was positively associated with report of vaccination in all countries, but the strength of this association varied from an OR of <2 (Germany) to >13 (The Netherlands). The ORs for the chronic disease groups was ≥ 4 for The Netherlands and were considerably lower (and often not statistically significant) for the other countries. CONCLUSION: Influenza vaccination coverage among high-risk groups varies considerably between European countries. Our findings highlight potential opportunities for reducing influenza-related complications through support for vaccination programs that target high-risk individuals more effectively.

Outcomes associated with matching patients' treatment preferences to physicians' recommendations: study methodology.

BACKGROUND: Patients often express strong preferences for the forms of treatment available for their disease. Incorporating these preferences into the process of treatment decision-making might improve patients' adherence to treatment, contributing to better outcomes. We describe the methodology used in a study aiming to assess treatment outcomes when patients' preferences for treatment are closely matched to recommended treatments. METHOD: Participants included patients with moderate and severe psoriasis attending outpatient dermatology clinics at the University Medical Centre Mannheim, University of Heidelberg, Germany. A self-administered online survey used conjoint analysis to measure participants' preferences for psoriasis treatment options at the initial study visit. Physicians' treatment recommendations were abstracted from each participant's medical records. The Preference Matching Index (PMI), a measure of concordance between the participant's preferences for treatment and the physician's recommended treatment, was determined for each participant at t(1) (initial study visit). A clinical outcome measure, the Psoriasis Area and Severity Index, and two participant-derived outcomes assessing treatment satisfaction and health related quality of life were employed at t(1), t(2) (twelve weeks post-t(1)) and t(3) (twelve weeks post-t(2)). Change in outcomes was assessed using repeated measures analysis of variance. The association between participants' PMI scores at t(1) and outcomes at t(2) and t(3) was evaluated using multivariate regressions analysis. DISCUSSION: We describe methods for capturing concordance between patients' treatment preferences and recommended treatment and for assessing its association with specific treatment outcomes. The methods are intended to promote the incorporation of patients' preferences in treatment decision-making, enhance treatment satisfaction, and improve treatment effectiveness through greater adherence.

How Healthy is the Behavior of Young Athletes? A Systematic Literature Review and Meta-Analyses.

Participation in sports during adolescence is considered a healthy behavior. The extent to which adolescent athletes engage in other healthful (or risky) behaviors is less clear, however. We conducted a systematic literature review following the PRISMA Statement to assess the frequency of risky behaviors among athletes in this age group. We searched the PubMed, PsycINFO and SCA Sociological Abstracts databases for observational studies published in English over the last twenty years on the frequency of selected risk behaviors (alcohol consumption, smoking behavior, use of illicit drugs, unhealthy nutrition, and doping) in adolescent athletes. Two independent reviewers selected articles following the PRISMA Statement. Behavior frequency was assessed as was comparability of study design and methods. When possible, meta- analyses were performed using data from subgroups of studies in which operational indicators were comparable. Seventy-eight articles met eligibility criteria. Although report of risky behaviors varied across studies, we observed overall, that studies tend to report higher alcohol use, less smoking, less recreational drug use, and more smokeless tobacco use in (high-involved) athletes. Considerable heterogeneity was noted in study design, definition of target groups and use of operational indicators (I(2) ranged from 93.2% to 100%). Especially the higher prevalence of using alcohol and smokeless tobacco needs more attention in interventions targeted to this group. Overall, greater consensus on methods used to assess risky behaviors in adolescent athletes. Key pointsThis is the first systematic review focusing on different health related risk behaviors of adolescent athletes aged ≤ 18 years from different countries.Health related risk behaviors such as alcohol consumption are common among recreational and elite adolescent athletes.Athletes were more likely to consume alcohol, smokeless tobacco, and steroids and less likely to smoke and to use marihuana than non-athletes.Studies show high heterogeneity in the operational indicators, statistical methods, and target groups. Therefore, greater consensus around key definitions and study methods is needed to advance knowledge.

Expanding the role of non-physician medical staff in primary care in Germany: protocol for a mixed-methods study exploring the perspectives of physicians in rural practices.

INTRODUCTION: Primary care faces substantial challenges worldwide through an increasing mismatch in supply and demand, particularly in rural areas. One option to address this mismatch might be increasing efficiency by delegation of tasks to non-physician medical staff. Possible influencing factors, motives and beliefs regarding delegation to non-physician medical staff and the potential of an expanded role, as perceived by primary care physicians, however, remain unclear. The aim of this study is to assess these factors to guide development of potential interventions for expanding the role of non-physician medical staff in delivering primary care services in rural Germany. METHODS AND ANALYSIS: This mixed-methods study based on the theoretical domains framework (TDF) consists of survey and interviews conducted sequentially. The survey, to be sent to all primary care physicians active in rural Baden-Wuerttemberg (estimated n=1250), includes 37 items: 15 assessing personal and practice characteristics, 15 matching TDF domains and 7 assessing opportunities for delegation. The interview, to be performed in a subsample (estimated n=12-20), will be informed by results of the survey. The initial interview guide consists of 11 questions covering additional TDF domains. Perspectives towards delegation will be maximised by comparing data emerging in either part of the study, seeking confirmation, disagreement or further details. ETHICS AND DISSEMINATION: The Ethics Committee of Heidelberg University approved this study (approval number: 2021-530). Written informed consent will be obtained before each interview; consent for participation in the survey will be assumed when the survey has been returned. Results will be disseminated via publications in peer-reviewed journals and talks at conferences. By combining quantitative and qualitative methods, our results will support future research for crafting potential interventions to expand the role of non-physician medical staff in rural primary care.

Service provision and utilisation in German paediatric primary care practices during public health crises: Protocol of the mixed-methods COVID-19 PedCare Study.

INTRODUCTION: Public health crises such as pandemics can cause serious disruptions to the utilisation and provision of healthcare services with negative effects on morbidity and mortality. Despite the important role of paediatric primary care in maintaining high-quality healthcare services during crises, evidence about service utilisation and provision remains limited especially in Germany. This study, therefore, explores the utilisation and provision of paediatric primary care services during the ongoing COVID-19 pandemic and their barriers and facilitators. METHODS AND ANALYSIS: The study uses a convergent mixed-methods design and comprises online surveys to parents, adolescents and primary care paediatricians (PCPs) and semistructured interviews with parents and PCPs. We recruit parents and adolescents from paediatric primary care practices and PCPs via email using mailing lists of the German Professional Association of Paediatricians and the German Society of Ambulatory Primary Care Paediatrics. The parent and adolescent surveys assess, inter alia, the utilisation of paediatric primary care services and its correlates, aspects of parental and child health as well as socioeconomic characteristics. The PCP survey investigates the provision of paediatric primary care services and its correlates, aspects of PCP health as well as sociodemographic and practice characteristics. The semistructured interviews with parents and PCPs explore several aspects of the online surveys in more detail. We use descriptive statistics and generalised linear mixed models to assess service utilisation and provision and specific correlates covered in the online surveys and apply qualitative content analysis to explore barriers and facilitators of service utilisation and provision more broadly in the semistructured interviews. We will integrate findings from the quantitative and qualitative analyses at the interpretation stage. ETHICS AND DISSEMINATION: The study was approved by the Medical Ethics Review Board of the Medical Faculty Mannheim at Heidelberg University (2020-650N). Study results will be published in journals with external peer-review.

Estimating the potential reduction in future sickness absence from optimizing group-level psychosocial work characteristics: a prospective, multicenter cohort study in German industrial settings.

BACKGROUND: Absence from work due to sickness impairs organizational productivity and performance. Even in organizations with perfect work conditions, some inevitable baseline sickness absence exists amongst working populations. The excess sickness absence observed above this baseline rate has become the focus of traditional health promotion efforts, addressing preventable physical illness, health behavior and mental health at the personal level. However, a health and safety approach following the TOP-rule would consider work-group psychosocial work characteristics as a potential risk factor amenable to organizational measures. To date, there is a scarcity of studies relating psychosocial work characteristics to possible reduction of excess sickness-absence rates. METHODS: We aimed to estimate the potentially avoidable excess fraction of absence attributable to work-group psychosocial characteristics. We considered work-group averaged perception of psychosocial work characteristics as a proxy to the methodologically elusive objective assessment of organizational characteristics. Participants were recruited from multiple sites of a German automotive manufacturer with individuals nested within work groups. We predicted 12-month follow-up work-group sickness absence rates using data from a baseline comprehensive health examination assessing work characteristics, health behavior, and biomedical risk factors. We considered the quartile of work-groups yielding favorable psychosocial work characteristics as a realistic existing benchmark. Using the population attributable fraction method we estimated the potentially amenable sickness absence from improving work-group psychosocial characteristics. RESULTS: Data from 3992 eligible participants from 29 work groups were analyzed (39% participation rate, average age 41.4 years (SD = 10.3 years), 89.9% males and 49% manual workers.). Work-group absence rates at follow up varied from 2.1 to 8.9% (mean 5.1%, 11.7 missed days). A prediction model of seven psychosocial work characteristics at the work group level explained 70% of the variance of future absence rates. The estimated reduction from improving psychosocial work characteristics to the benchmark level amounted to 32% of all sickness absence, compared to a 31% reduction from eliminating health behavioral and medical risk factors to the benchmark target. CONCLUSIONS: Psychosocial characteristics at the work-group level account for a relevant proportion of all sickness absence. Health promotion interventions should therefore address psychosocial characteristics at the work group level.

Rural-urban comparison of contextual associations with self-reported mental health status.

Ample evidence documents the association between individual-level risk factors and mental health status; relatively less is known about associations between features of the context in which individuals live and their mental health. The objective of this study is to assess differences in associations between contextual characteristics of both rural and urban settings and mental health status measured by the mental health component of the SF-12. Using state-representative data, we observed significant rural/urban differences in the association of mental health status with availability of health care resources but no significant associations in other contextual domains. Lack of overlap in contextual associations suggests that contextual influence operates differently in rural and urban settings and that interventions to improve mental health may not translate across settings.

Toward more sustainable health care quality improvement in developing countries: the "little steps" approach.

BACKGROUND: Resource constraints are often identified as a hurdle to the sustainability of large-scale (national and regional) health care quality improvement (QI) programs in developing countries. However, poor fit of a QI model with a given country's context may present the greater challenge. METHODS: To explore contextual factors influencing the sustainability of large-scale QI initiatives in developing countries, we performed a systematic literature review. RESULTS: Large-scale initiatives appear to have received significant attention only recently in these settings, as priority was traditionally given to extending service coverage. Further, these initiatives often relied on QI models originating from developed country settings, which differed significantly from the systems, resource structures, culture, and values found in the target country. The QI programs frequently focused on high-impact/immediate change rather than on program sustainability. Barriers to sustainability were identified during the planning, start-up, and continuation phases. On the basis of our review, greater attention to sustainable methods for large-scale QI in developing countries is needed. CONCLUSION: We suggest a "Little Steps" approach that begins by defining QI concepts, goals, and processes in a manner congruent with the target setting and that builds upon existing systems, structures, and values. Despite immediate short-term needs, an approach emphasizing incremental QI achievements may be more effective in yielding sustainable improvements in health care quality at the national or regional level.

A systematic approach to practice assessment and quality improvement intervention tailoring.

BACKGROUND: The ways in which tailored interventions foster sustained improvement in the quality of health care delivery across different practice settings are not well understood. Using the empirically developed Practice Change Model (PCM), we identify and describe assessment and tailoring activities with potential to enhance the fit between proposed interventions and practice settings. METHODS: We obtained quantitative and qualitative data from 2 quality improvement trials conducted in diverse primary care practices in northeast Ohio. A multidisciplinary team used a PCM-based template to identify features of practice assessment and tailoring associated with practices' willingness and ability to change. RESULTS: Our results suggest that intervention tailoring requires assessment of key stakeholders' motivations, external influences, resources and opportunities for change, and the interactions between these factors. Using this information, intervention tailoring then includes seeking and working with key stakeholders, building assets, providing options, keeping change processes flexible, offering feedback, providing exposure to scientific evidence, facilitating group processes, involving new partners, brainstorming, using stories/play acting/humor, assuming a consultant role, reframing, moving meetings off-site, and stepping back or pausing. CONCLUSIONS: A model-driven approach guiding practice assessment enables tailored responses to the unique and emerging conditions that distinguish health care practices and influence implementation of quality management interventions.

Measuring practice capacity for change: a tool for guiding quality improvement in primary care settings.

PURPOSE: Capacity for change, or the ability and willingness to undertake change, is an organizational characteristic with potential to foster quality management in health care. We report on the development and psychometric properties of a quantitative measure of capacity for change for use in primary care settings. METHODS: Following review of previous conceptual and empirical studies, we generated 117 items that assessed organizational structure, climate, and culture. Using information from direct observation and key informant interviews, a research team member rated these items for 15 primary care practices engaged in a quality improvement intervention. Distributional statistics, pairwise correlation analysis, Rasch modeling, and item content review guided item reduction and instrument finalization. Reliability and convergent validity were assessed. RESULTS: Ninety-two items were removed because of limited response distributions and redundancy or because of poor Rasch model fit. The final instrument comprising 25 items had excellent reliability (alpha = .94). A Rasch model-derived capacity for change score correlated well with an independently determined, qualitatively derived summary assessment of each practice's capacity for change (rhoS = 0.82), suggesting good convergent validity. CONCLUSION: We describe a new instrument for quantifying organizational capacity for change in primary care settings. The ability to quantify capacity for change may enable better recognition of practices likely to be successful in their change efforts and those first requiring capacity building prior to change interventions.

Association of neighborhood socioeconomic status with physical fitness in healthy young adults: the Coronary Artery Risk Development in Young Adults (CARDIA) study.

BACKGROUND: Impaired physical fitness, a contributor to obesity and cardiovascular disease, has been associated with both an individual's socioeconomic status (SES) and with residence in disadvantaged neighborhoods. The aim of the study was to examine the extent to which neighborhood socioeconomic status (SES) is associated with impaired fitness, independent of clinical characteristics and individual-level SES. METHODS: Two thousand five hundred five participants 25 to 42 years old examined in the CARDIA study from 1992 to 1993 underwent symptom-limited exercise stress testing. Physical fitness was considered impaired if metabolic equivalents were in the lowest sex-specific quintile. Neighborhood SES was determined for each census tract using 1990 census data. Generalized estimating equations assessed the association between neighborhood SES and physical fitness, before and after adjustments for individual SES, sociodemographic, and clinical characteristics, and accounted for clustering within census tracts. RESULTS: Individuals in disadvantaged neighborhoods had lower educational attainment and income, and were more likely unemployed, black, and uninsured. The odds ratio (95% CI) for impaired physical fitness in the lowest vs highest tertile of neighborhood SES was 5.8 (3.7-7.3). These became 3.9 (2.7-5.7) after adjusting for individuals' educational attainment, personal income, employment status, and ability to pay for basic needs; and 1.9 (1.2-2.9) after additional adjustment for other sociodemographic and clinical factors. CONCLUSIONS: Features of one's neighborhood of residence are relevant to cardiovascular health. A health policy perspective that looks beyond an individual's characteristics may therefore be useful in identifying more effective interventions to reduce the prevalence of low physical fitness and its consequences in young adults.

Correlates of baseline performance do not predict results of an intervention to improve preventive care.

BACKGROUND: Cross-sectional analyses of baseline performance often inform the development of interventions to improve care. An implicit assumption in these studies is that factors associated with better performance at baseline may also be useful in predicting change in performance over time. METHODS: We analyzed data collected from 1997-2002 at 77 practices in Northeast Ohio participating in an intervention to increase evidence-based preventive services delivery (PSD). Spearman's correlation coefficients and multivariable models assessed associations between practice-level characteristics (e.g., organizational structure, objectives, climate, and culture) and baseline PSD, and with final PSD controlling for baseline values. Patterns of associations for both outcomes were inspected for overlap. RESULTS: The mean PSD rate was 36.8% (+/-8.8%) at baseline. This measure increased by an average of 4.9% (+/-6.3%) by the end of the intervention. Of eight practice characteristics correlated with either baseline performance or change from baseline in PSD, only two were common to both: characteristics associated with baseline PSD did not predict final PSD in multivariable models. CONCLUSIONS: Correlates of baseline performance differ from those related to change in performance. Practice assessments that focus on factors associated with change may be more useful in developing and implementing interventions to improve care.

Pay for performance and medical education: strategies for preparing physicians of the future.

Performance-based reimbursement has become an increasingly important topic in the field of medicine and one that has met with significant legislative support. Small- and large-scale pilot programs in the United States and more comprehensive programs implemented abroad have yielded preliminary findings that raise several interesting questions regarding the form that pay-for-performance programs will take and concerns about the unintended and unforeseen consequences of this new reimbursement approach. One important area that has not been explored, however, is the potential implications of pay for performance to "clinician educators"-individuals from diverse health-related disciplines who both provide health care and are responsible for training the next generation of health care professionals. Because the effect of pay for performance is likely to vary by health care discipline, we focus here on potential implications for physician educators. Our objective is to analyze the experience to date with pay for performance, make predictions from these experiences about the potential impact of pay for performance on the education of resident physicians, and propose educational strategies that might be useful in positioning physician trainees for success as they enter the workforce.

Data quality bias: an underrecognized source of misclassification in pay-for-performance reporting?

Pay-for-performance (P4P) initiatives, in which provider reimbursement is linked to quality assessment, are receiving increasing attention as a possible approach to encouraging and accelerating quality improvement in America's health care systems. The potential of P4P programs, however, is constrained by the quality of data and information resources available for performance reporting. Accurate and reliable appraisal of health care quality is a challenging issue, as achieving recommended processes of care and desired health outcomes is influenced by a diverse range of interrelated factors occurring at multiple levels and arising from multiple sources within the patient encounter, health care system, and larger environment. The challenge of quality assessment is further complicated by the variable quality of data available for reporting by each provider. When data quality varies systematically among providers, a significant risk of inequity in assessment, and therefore reimbursement under P4P programs, may occur. The issue of data quality should be investigated and addressed before widespread implementation of P4P programs is pursued. Significant investment in data collection and reporting mechanisms may be required, especially in resource-limited settings, to achieve the intended effects and avoid increasing disparities in health care quality.

Quality of care by a hypertension expert: a cautionary tale for pay-for-performance approaches.

CONTEXT: Pay-for-performance programs may be widely implemented, but gaps remain in our understanding of the implementation of performance measurement approaches. OBJECTIVES: To compare 3 approaches to hypertension quality measurement as applied to high-quality care delivered by a hypertension expert. METHODS: Care of 23 patients treated by a single hypertension expert was assessed by 3 measurement approaches: (1) outcome, (2) a multicomponent process, and (3) "outcome-linked" process. Exemplary case studies were identified to illustrate additional challenges to applying the approaches. RESULTS: Forty-four percent of patients (n = 10) had complete concordance between the outcome and outcome-linked process approaches, 22% of patients (n = 5) had complete concordance between the outcome and multicomponent process approaches, 52% of patients (n = 12) had complete concordance between outcome-linked process and multicomponent process approaches, and 22% of patients (n = 5) had uniform agreement among all 3 approaches. Case studies revealed numerous opportunities for misinterpretation or gaming by providers. CONCLUSIONS: Currently available measurement approaches resulted in a varied assessment of provider performance under optimal hypertension care conditions suggesting that caution is required before their use for provider compensation.

Health state information derived from secondary databases is affected by multiple sources of bias.

OBJECTIVE: Secondary databases are used in descriptive studies of patient subgroups; evaluation of associations between individual characteristics and diagnosis, prognosis, and/or service utilization rates; and studies of the quality of health care delivered. This article identifies sources of bias for health state characteristics stored in secondary databases that arise from patients' encounters with health systems, highlighting sources of bias that arise from organizational and environmental factors. STUDY DESIGN AND SETTING: Potential sources of bias, from patient access of services and diagnosis, through encoding and filing of patient information in secondary databases, are discussed. A patient presenting with acute myocardial infarction is used as an illustrative example. RESULTS: The accuracy of health state characteristics derived from secondary databases is a function of both the quality and quantity of information collected before data entry and is dependent on complex interactions between patients, clinicians, and the structures and systems surrounding them. CONCLUSION: The use of health state information included in secondary databases requires that estimates of potential bias from all sources be included in the analysis and presentation of results. By making this common practice in the field, greater value can be achieved from secondary database analyses.

Physician practice patterns and variation in the delivery of preventive services.

BACKGROUND: Strategies to improve preventive services delivery (PSD) have yielded modest effects. A multidimensional approach that examines distinctive configurations of physician attributes, practice processes, and contextual factors may be informative in understanding delivery of this important form of care. OBJECTIVE: We identified naturally occurring configurations of physician practice characteristics (PPCs) and assessed their association with PSD, including variation within configurations. DESIGN: Cross-sectional study. PARTICIPANTS: One hundred thirty-eight family physicians in 84 community practices and 4,046 outpatient visits. MEASUREMENTS: Physician knowledge, attitudes, use of tools and staff, and practice patterns were assessed by ethnographic and survey methods. PSD was assessed using direct observation of the visit and medical record review. Cluster analysis identified unique configurations of PPCs. A priori hypotheses of the configurations likely to perform the best on PSD were tested using a multilevel random effects model. RESULTS: Six distinct PPC configurations were identified. Although PSD significantly differed across configurations, mean differences between configurations with the lowest and highest PSD were small (i.e., 3.4, 7.7, and 10.8 points for health behavior counseling, screening, and immunizations, respectively, on a 100-point scale). Hypotheses were not confirmed. Considerable variation of PSD rates within configurations was observed. CONCLUSIONS: Similar rates of PSD can be attained through diverse physician practice configurations. Significant within-configuration variation may reflect dynamic interactions between PPCs as well as between these characteristics and the contexts in which physicians function. Striving for a single ideal configuration may be less valuable for improving PSD than understanding and leveraging existing characteristics within primary care practices.