SKIN CONDITION CAN HELP IDENTIFY HIGH-RISK FOR DIABETES
An easily identifiable dermatologic condition, acanthosis nigricans, is associated with having multiple risk factors for type 2 diabetes, in patients aged 7 to 39 years, finds this study of 1,113 patients. As the number of type 2 diabetes risk factors increased, so did the prevalence of acanthosis nigricans in both children and adults. Patients with this dermatologic condition were nearly two times more likely to have type 2 diabetes compared with their counterparts without it. The authors suggest that in primary care practices, where competing demands exist within the brief patient encounter, a method for rapidly identifying persons at high risk for type 2 diabetes would be useful for physicians. Acanthosis Nigricans and Diabetes Risk Factors: Prevalence in Young Persons Seen in Southwestern U.S. Primary Care Practices By Alberta S. Kong, M.D., M.P.H., et al
ELECTRONIC MEDICAL RECORD USE DOES NOT GUARANTEE HIGHER QUALITY CARE
The use of an electronic medical record (EMR) in primary care practices is insufficient for insuring high-quality diabetes care finds this study of 927 diabetic patients in 50 primary care practices. Furthermore, EMR usage was associated with poor adherence to the diabetes quality of care measures. Patient care in the 37 practices not using an EMR was more likely to meet guidelines for process, treatment and intermediate outcomes than in the 13 practices using an EMR. The authors suggest this may be because physician practices often implement health information technologies without sufficient attention to workflow redesign, which can create new quality problems and adversely affect patient health. They assert that national policy makers and primary care practice owners should focus on maintaining and improving quality in primary care settings during and after EMR implementation. Electronic Medical Records and Diabetes Quality of Care: Results From a Sample of Family Medicine Practices By Jesse C. Crosson, Ph.D., et al
OTHER STUDIES IN THIS ISSUE
COMPETING DEMANDS VS. CLINICAL INERTIA
Poor glucose control is often attributed to clinical inertia: the recognition of a problem by the physician, but failing to act. This study of 211 primary care encounters between adult patients with type 2 diabetes and their physicians finds the concept of clinical inertia does not adequately characterize the complexity of the primary care encounter; it is really competing demands (patient concerns) that can cause physicians not to act. As the number of patient concerns increased, the likelihood of a change in medication decreased, independent of the length of the encounter. The authors suggest that while the comprehensiveness of care provided by primary care physicians to patients with chronic illness is a strength of primary care, it also is a balancing act that requires prioritization and goal setting by both the patient and the physician during the patient visit. Competing Demands or Clinical Inertia: The Case of Elevated Glycosylated Hemoglobin By Michael L. Parchman, M.D., M.P.H., et al
PRIMARY CARE PRACTICE-BASED RESEARCH NETWORKS REPRESENT MINORITY PATIENTS AND REAL WORLD PRACTICE
Primary care practice-based research networks (PBRNs) are known as a resource for accelerating the translation of research into practice and performing research relevant to everyday primary care. This survey of the 89 of the 111 PBRNs in the United States finds they represent 1,871 practices, 12,957 patients and 14.7 million patients. Of the PBRNs surveyed, most are affiliated with universities. Poor and minority patients are overrepresented in their practices. The networks’ common focus for research is prevention, diabetes, cardiovascular risk factors and mental health. With the majority of research in the U.S. being performed at academic medical centers, where less than one percent of Americans receive their health care, the authors suggest that PBRNs merit further attention from both private and public funding agencies and researchers interested in studying the delivery of primary care. A National Survey of Primary Care Practice-Based Research Networks By William M. Tierney, M.D., et al
THE AMOUNT OF RELIEF IMPORTANT TO PATIENTS IS LESS THAN PROVIDED BY COMMON COLD REMEDIES
People suffering from the common cold want an on-average 25 percent to 57 percent reduction in overall illness severity to justify the cost and risk of popular cold treatments finds this study. When the 253 study participants (who were suffering from the common cold) were given four treatment options – vitamin C, herbal echinacea, a zinc lozenge and a prescribed antiviral – they based their decision on a benefit-harm trade-off. Sufficiently Important Difference for Common Cold: Severity Reduction By Bruce Barrett, M.D., Ph.D., et al
HOME VISIT PROGRAM HELPS ADOLESCENT MOTHERS
A community-based home-visiting program improved adolescent mothers’ parenting attitudes and school continuation, finds this study of 84 pregnant adolescents. When compared with those who did not receive the home visits, follow-up parenting scores were 5.5 times higher for those who received the home visits, and odds of school continuation were 3.5 times greater. The home visiting program consisted of trained home visitors being paired with each adolescent and providing services through the child’s second birthday. The services included delivering a parenting curriculum, encouraging contraceptive use, connecting a teen with primary care and promoting school continuation. The program did not reduce the odds of repeated pregnancy or depression; nor did it achieve coordination with primary care. Home Visiting for Adolescent Mothers: 2-Year Follow-up Effects on Parenting, Maternal Life Course, and Primary Care Linkage By Beth Barnet, M.D., et al
DIFFERENT PATHS TO HIGH-QUALITY CARE
This case study identifies three approaches primary care practices take to achieve high-quality care. While the nine practices studied use many of the same improvement strategies, the way the improvements are organized define three distinct archetypes: the Technophiles, the Motivated Team and the Care Enterprise. The authors conclude that while there are many common strategies in achieving high-quality care, no single approach dictated superior performance. Different Paths to High-Quality Care: Three Archetypes of Top-Performing Practice Sites By Chris Feifer, Dr.P.H., et al
A GUIDE FOR CHANGE IN IMPROVEMENT OF CARE
This article presents a framework for physicians on the front lines of care who want to make transformations that will greatly improve care. Organizational leadership with an urgent vision for change is critical to successful quality improvement efforts in medical practices. The authors further cite specific leadership qualities, including the ability to manage and change process and selection of systematic changes capable of fulfilling the vision. Improving Medical Practice: A Conceptual Framework By Leif I. Solberg, M.D.
A NEW APPROACH TO CHRONIC CARE
This essay suggests an alternative way of thinking about the structure and delivery of chronic care. The author suggests that the central claim of chronic care can be summarized as what the patient, family members and health professionals do to achieve specific health outcomes within the evolving opportunities and constraints of chronic illness. Toward an Ecosystemic Approach to Chronic Care Design and Practice in Primary Care By Hassan Soubhi, M.D., Ph.D., et al
A SNAPSHOT OF DISEASE MANAGEMENT
The author of this essay reflects on commercial disease management programs, giving a current snapshot of them it by addressing their rationale and growth, their track record concerning costs and quality of care and their impact on primary care. Disease Management: Panacea, Another False Hope, or Something in Between" By John P. Geyman, M.D.
REFLECTIONS ON SENSE OF IMPORTANCE AND LEADERSHIP
In this essay, the author reflects on how a sense of importance can be detrimental in leadership, leading to failure to perform or impotence. The Impotence of Being Important – Reflections on Leadership By Ian Douglas Couper, B.A., M.B.B.Ch., MFamMed
Annals of Family Medicine is a peer-reviewed, indexed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care disciplines. Annals is sponsored by six family medical organizations, including the American Academy of Family Physicians, the American Board of Family Medicine, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors and the North American Primary Care Research Group. Annals is published six times each year and contains original research from the clinical, biomedical, social and health services areas, as well as contributions on methodology and theory, selected reviews, essays and editorials. Complete editorial content and interactive discussion groups for each published article can be accessed free of charge on the journal’s Web site, www.annfammed.org.
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The Annals of Family Medicine