Using complexity theory to build interventions that improve health care delivery in primary care

  • David Litaker
  • Anne Tomolo
  • Vincenzo Liberatore
  • Kurt C. Stange
  • David Aron


Previous observational research confirms abundant variation in primary care practice. While variation is sometimes viewed as problematic, its presence may also be highly informative in uncovering ways to enhance health care delivery when it represents unique adaptations to the values and needs of people within the practice and interactions with the local community and health care system. We describe a theoretical perspective for use in developing interventions to improve care that acknowledges the uniqueness of primary care practices and encourages flexibility in the form of intervention implementation, while maintaining fidelity to its essential functions.

Key words

health care delivery nonlinear dynamics quality of health care 


  1. 1.
    Perlin J, Kolodner R, Roswell R. The Veterans Health Administration: quality, value, accountability, and information as transforming strategies for patient-centered care. Am J Manag Care. 2004;10:828–36.PubMedGoogle Scholar
  2. 2.
    Krein S, Hofer T, Kerr E, Hayward R. Whom should we profile? Examining diabetes care practice variation among primary care providers, provider groups, and health care facilities. Health Serv Res. 2002;37:1125–7.CrossRefGoogle Scholar
  3. 3.
    Solberg L, Brekke M, Kottke T, Steel R. Continuous quality improvement in primary care: what’s happening? Med Care. 1998;36:625–35.CrossRefPubMedGoogle Scholar
  4. 4.
    Solberg LI, Kottke TE, Brekke ML, et al. Failure of a continuous quality improvement intervention to increase the delivery of preventive services. A randomized trial. Eff Clin Pract. 2000;3:105–15.PubMedGoogle Scholar
  5. 5.
    Kritchevsk SB, Simmins BP. Continuous quality improvement. Concepts and applications for physician care. JAMA. 1992;267:55–6.CrossRefGoogle Scholar
  6. 6.
    Palmer RH, Louis TA, Hsu LN, et al. A randomized controlled trial of quality assurance in sixteen ambulatory care practices. Med Care. 1985;23:751–70.CrossRefPubMedGoogle Scholar
  7. 7.
    Macklis R. Successful patient safety initiatives: driven from within. Group Pract J. 2001;50:1–5.Google Scholar
  8. 8.
    Marsh D, Schroeder D, Dearden K, Sternin J, Sternin M. The power of positive deviance. Br Med J. 2004;329:1177–9.CrossRefGoogle Scholar
  9. 9.
    Miller W, McDaniel R, Crabtree B, Stange K. Practice jazz: understanding variation in family practices using complexity science. J Fam Pract. 2001;50:872–80.PubMedGoogle Scholar
  10. 10.
    Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q. 2004;82:581–629.CrossRefPubMedGoogle Scholar
  11. 11.
    Patrick DL, Chiang YP. Measurement of health outcomes in treatment effectiveness evaluations: conceptual and methodological challenges. Med Care. 2000;38(suppl):14–25.Google Scholar
  12. 12.
    Dooley K, Johnson TL, Bush D. TQM, chaos, and complexity. Human Syst Manag. 1995;14:287–302.Google Scholar
  13. 13.
    Miller W, Crabtree B, McDaniel R, Stange K. Understanding change in primary care practice using complexity theory. J Fam Pract. 1998;46:369–76.PubMedGoogle Scholar
  14. 14.
    Plsek P. Complexity and the adoption of innovation in health care. In: Accelerating Quality Improvement in Health Care-Strategies to Speed the Diffusion of Evidence-Based Innovations. Washington, DC, USA, 2003 Available at: Accessed September 19, 2005.Google Scholar
  15. 15.
    Rogers E. A prospective and retrospective look at the diffusion model. J Health Commun. 2004;9:13–9.CrossRefPubMedGoogle Scholar
  16. 16.
    Manson S. Simplifying complexity: a review of complexity theory. Geoform. 2001;32:405–14.CrossRefGoogle Scholar
  17. 17.
    Phelan S. What is complexity science really? Emergence. 2003;3:120–36.CrossRefGoogle Scholar
  18. 18.
    Kernick D. Complexity and Healthcare Organization: A View from the Street. Oxford, UK: Radcliffe Publishing; 2004.Google Scholar
  19. 19.
    Mandelbort B. The Fractal Geometry of Nature. San Francisco: W.H. Freeman and Co.; 1982.Google Scholar
  20. 20.
    Liebovitch L. Fractals and Chaos Simplified for the Life Sciences. New York: Oxford University Press; 1998.Google Scholar
  21. 21.
    Aron DC. Chaos, complexity and cardiology. In: Holt T, ed. Complexity for Clinicians. Oxford, UK: Radcliffe Press; 2004.Google Scholar
  22. 22.
    Karagiannis T, Faloutsos M. SELFIS: a tool for self-similarity and long-range dependence analysis. First workshop on fractals and self-similarity in data mining: issues and approaches; 2002.Google Scholar
  23. 23.
    Plsek P. Redesigning health care with insights from the science of complex adaptive systems. Crossing the quality chasm: a new health system for the 21st century. The National Academy of Sciences, 2000:309–17.Google Scholar
  24. 24.
    Stange KC. The paradox of the parts and the whole in understanding and improving general practice. Int J Qual Health Care. 2002;14:267–8.CrossRefPubMedGoogle Scholar
  25. 25.
    Kauffman S. The Origins of Order. Oxford, UK: Oxford University Press; 1993.Google Scholar
  26. 26.
    Stacey R. Mapping the Science of Complexity onto Organizations. Complexity and Creativity in Organizations. San Francisco, CA: Berrett-Koehler; 1996:107–17.Google Scholar
  27. 27.
    Tallia A, Stange K, McDaniel R, Aita V, Miller W. Understanding organizational designs of primary care practices. J Healthc Manag. 2003;48:45–9.PubMedGoogle Scholar
  28. 28.
    Stroebel CK, McDaniel R, Crabtree B, Miller W, Nutting P, Stange KC. How complexity science can inform a reflective process for improvement in primary care practices. Jt Comm J Qual Patient Saf. 2005;31:438–46.PubMedGoogle Scholar
  29. 29.
    Stange K, Jaen C, Flocke S, Miller W, Crabtree B, Zyzanski S. The value of a family physician. J Fam Pract. 1998;46:363–8.PubMedGoogle Scholar
  30. 30.
    Brewick DM. Disseminating innovations in health care. JAMA. 2003;289:1969–75.CrossRefGoogle Scholar
  31. 31.
    Greco PJ, Eisenberg JM. Changing physicians’ practices. N Engl J Med. 1993;329:1271–4.CrossRefPubMedGoogle Scholar
  32. 32.
    Eisenberg JM. Physician utilization: the state of research about physicians’ practice patterns. Med Care. 1985;23:461–83.CrossRefPubMedGoogle Scholar
  33. 33.
    Davis D, O’Brien M, Freemantle N, et al. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA. 1999;282:867–74.CrossRefPubMedGoogle Scholar
  34. 34.
    Davis D, Thomson MA, Oxman A, Haynes R. Evidence for the effectiveness of CME. A review of 50 randomized controlled trials. JAMA. 1992;268:1111–7.CrossRefPubMedGoogle Scholar
  35. 35.
    Davis DA, Thomson MA, Oxman AD, Haynes B. Changing physician performance. A systematic review of the effect of continuing medical education strategies. JAMA. 1995;274:700–5.CrossRefPubMedGoogle Scholar
  36. 36.
    Haynes RB, McKibbon KA, Kanani R. Systematic review of randomised trials of interventions to assist patients to follow prescriptions for medications. Lancet. 1996;348:383–6.CrossRefPubMedGoogle Scholar
  37. 37.
    Shortell S, Bennett C, Byck G. Assessing the impact of continuous quality improvement on clinical practice: what it will take to accelerate progress. Milbank Q. 1998;76:593–624.CrossRefPubMedGoogle Scholar
  38. 38.
    Goodwin MA, Zyzanski SJ, Zronek S, et al. A clinical trial of tailored office systems for preventive service delivery: the study to enhance prevention by understanding practice (STEP-UP). Am J Prev Med. 2001;21:20–8.CrossRefPubMedGoogle Scholar
  39. 39.
    Hawe P, Shiell A, Riley T. Complex interventions: how “out of control” can a randomized controlled trial be? Br Med J. 2004;328:1561–3.CrossRefGoogle Scholar
  40. 40.
    Stange KC, Goodwin MA, Zyzanski SJ, Dietrich AJ. Sustainability of a practice-individualized preventive service delivery intervention. Am J Prev Med. 2003;25:296–300.CrossRefPubMedGoogle Scholar
  41. 41.
    Ruhe MC, Gotler RS, Goodwin MS, Stange KC. Physician and staff turnover in community primary care practice. J Ambulatory Care Manag. 2004;27:242–8.Google Scholar

Copyright information

© Society of General Internal Medicine 2006

Authors and Affiliations

  • David Litaker
    • 1
    • 2
  • Anne Tomolo
    • 1
  • Vincenzo Liberatore
    • 3
  • Kurt C. Stange
    • 2
    • 4
  • David Aron
    • 1
    • 2
  1. 1.VA HSR&D Center for Quality Improvement Research, Louis Stokes Cleveland Department of Veterans Affairs Medical Center and Department of MedicineCase Western Reserve UniversityUSA
  2. 2.Departments of Epidemiology and Biostatistics, School of MedicineCase Western Reserve UniversityUSA
  3. 3.Division of Computer Sciences, School of EngineeringCase Western Reserve UniversityUSA
  4. 4.Departments of Family Medicine and Sociology, School of Medicine, Case Comprehensive Cancer CenterCase Wester Reserve UniversityUSA

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