This new three-year study is submitted by the University of Nebraska Medical Center. The focus of the proposed research is on discovering practice features that enhance or inhibit the delivery of preventive services among family physicians in private practice. Specifically, the study proposes to employ multimethod ethnographic analysis to examine how preventive services are managed in primary care practices in view of the multiple competing demands of office practice. The proposed research focuses on: 1) examining the organizational contexts that support preventive services; 2) examining the competing demands imposed in carrying out both prevention and illness care; 3) comparing approaches used by practices with high versus low intensity in preventive services; 4) identifying approaches used to deliver different types of preventive services; and 5) describing new methods for evaluating guidelines being implemented by AHCPR and other government and professional organizations. The study employs a comparative case study design with replicative follow-up. Two separate pools of practices drawn from over 100 practices participating in a pervious study will constitute the sampling frame for the investigation. The first phase of the analysis will be based on ten practices that will be purposefully drawn based on the extent of preventive services provided in the primary care practice (high and low). These ten practices will be examined through intensive, qualitative ethnographic methods in which a research nurse spends as much as eight weeks in the practice collecting data. Hypotheses will be generated regarding the intensity of delivery of preventive services among these primary care practices. An additional sample of at least 8 primary care practice sites will be used to confirm or disconfirm the hypotheses generated during the initial phase of the case study investigation or to develop new, alternative hypotheses. Primary data will be based on participant observation by research nurses participating in practice activities, in-depth interviews of physicians and staff, and focus groups of patients. The final product of the study will be a set of 18 in-depth case studies describing strategies to develop preventive services that work within the competing demands of primary care practice. The first two years of the project will be spent in intensive data collection activity, and the third year is largely devoted to writing up the 18 case studies. The project will be directed by Dr. Benjamin Crabtree, a medical anthropologist based at the University of Nebraska Medical Center, Department of Family Medicine. The project will include nationally know consultants and an external advisory committee which is designed to ensure representation of different perspectives from the academic and "real world" of primary care practice. Finally, independent auditors will review individual and comparative case studies to ensure data accountability, assess quality of methods, review analysis, and guard against overinterpretation and interpretive discrepancies.