The Issue in Brief

Community-based Participatory Research in Practice Based Research Networks

John M. Westfall, MD, MPH , and colleagues

Background Community-based participatory research (CBPR) is aimed at making clinical research more relevant and valuable by involving patients and community members. CBPR is a cooperative process in which researchers and community members learn from each other. One goal of CBPR is to ground clinical research in real-life patient experience. This study looked at whether practice-based research networks (groups of clinicians who conduct research in doctors’ offices) are using CBPR in their research.

What This Study Found In a survey of US practice-based research networks, more than one half of the networks that responded had some mechanism to involve community members in their research. Several networks actively involve community members in generating research ideas, reviewing research plans, and interpreting and distributing research results. Many networks are planning to do more CBPR in the future.

Implications

• Community involvement may strengthen research in practice-based research networks.
• Involving the community of patients may help ensure that networks ask important clinical questions that matter to patients, are relevant to doctors, and are thoroughly studied in a research s

Diabetes: How Are We Diagnosing and Initially Managing It?

Patrick J. O'Connor, MD MPH , and colleagues

Background It is estimated that 35% to 50% of diabetes cases are not diagnosed. This study was designed to determine how diabetes is diagnosed and initially managed by primary care clinicians.

What This Study Found In nearly one half of the 504 diabetes cases studied, the patient’s diabetes was diagnosed when the doctor recognized diabetes symptoms during a visit for another reason. Primary care practices can improve detection of undiagnosed diabetes and improve 1-year results by being alert to symptoms of diabetes, by evaluating those at high risk for this disorder, and by instituting appropriate treatments at the time of diagnosis.

Implications

• Timely diagnosis of diabetes is likely to be beneficial for diabetes patients.
• The authors call for more efforts to diagnose diabetes early.

Management of Type 2 Diabetes in the Primary Care Setting: A Practice-Based Research Network Study

Stephen J. Spann, MD, MBA , and colleagues

Background Primary care clinicians treat many patients with diabetes. This study describes the care provided by primary care clinicians to their patients with type 2 diabetes.

What This Study Found Primary care clinicians provide intense diabetes care, including use of medications to lower glucose and cholesterol levels, and control blood pressure. Only a modest number of the 822 patients in this study (40.5%), however, actually achieved the established targets for diabetes control. More than one third were at or below the target blood pressure recommended by the American Diabetes Association.

Implications

• Patients with type 2 diabetes are commonly treated in primary care settings and have other conditions related to diabetes.
• Although treatment of hyperglycemia (high blood glucose levels) is somewhat successful, control of cardiovascular risk factors is poor and remains a serious challenge.
• These challenges reinforce the need to reorganize primary care practices and improve the systems that support the care of patients with chronic diseases, including diabetes.

Quality of Preventive Care for Diabetes: Effects of Visit Frequency and Competing Demands

Joshua J. Fenton, MD, MPH , and colleagues

Background Regular medical care can prevent many common diabetes complications. Despite the effectiveness of preventive care for diabetes, however, many patients do not receive recommended diabetes services. This study examined how often a group of diabetes patients visited the doctor, and for what reasons, in order to shed light on why some patients do not receive sufficient diabetes care.

What This Study Found Diabetes patients who do not visit the doctor often are less likely to receive timely diabetes-related preventive care. Patients who make frequent doctor visits but for lower-priority health conditions are more likely to have a delay in their diabetes-related preventive services.

Implications

• Office systems and other innovations may help primary care offices increase the delivery of diabetes services to patients who don’t visit the doctor often, and to those who visit for conditions that a

Encounters by Patients With Type 2 Diabetes are Complex and Demanding: An Observational Study

Michael L. Parchman, MD, MPH , and colleagues

Background During most patient visits, doctors have “competing demands,” that is, multiple health conditions and preventive measures that demand their attention. Because of limited time, doctors often prioritize those demands and deal only with the most urgent problems. This study looks at whether competing demands in the primary care doctor visit affect the delivery of medical care for diabetes.

What This Study Found Needed diabetes services are less likely to occur during visits for the competing demand of acute illness. When fewer diabetes services are delivered, follow-up visits are scheduled sooner. More diabetes care is given when visits are longer.

Implications

• Competing demands during visits with patients who have type 2 diabetes can interfere with delivering needed diabetes services. In spite of this, primary care practices often make use of the acute illn
• Changes in the primary care practice setting could improve the quality of diabetes care. New models of care are needed, such as group visits, as well as information technology that allows for manageme

Effects of Enhanced Depression Treatment on Diabetes Self-care

Elizabeth H. B. Lin, MD, MPH , and colleagues

Background Healthy nutrition, physical activity, and use of appropriate medications can slow the progression of diabetes and reduce complications associated with the disease. However, many people with diabetes, particularly those with depression, do not practice these healthy self-care habits. This study looked at whether improved depression treatment in diabetes patients has an influence on self-care behaviors, including taking diabetes medications as prescribed.

What This Study Found Treatment for depression does not improve self-management of diabetes among patients with both illnesses. Increased depression care was not associated with improved diabetes self-care behaviors, such as proper nutrition, physical activity, or stopping smoking, or increased use of medications as prescribed.

Implications

• Patients who manage multiple medical conditions face complex challenges.
• Further study is needed to determine whether combined management of diabetes and depression would help patients achieve better psychological and diabetes results.

Shared Decision Making and the Experience of Partnership in Primary Care

George W. Saba, PhD , and colleagues

Background The goal of this study is to learn more about shared decision making, in which patients and physicians make decisions after openly exchanging information and exploring beliefs. The study looks at how the communication behavior of shared decision making is related to patients’ and physicians’ experience of partnership. The study also tests new research strategies for understanding the relationship between communication skills and personal experience.

What This Study Found Communication behavior and relationship factors influence personal experiences of partnership between patients and doctors. In many (41%) of the decision moments, there was agreement between participants’ perception and the study’s ratings of shared decision making. But for most (59%) decision moments, communication behaviors and personal experience were not aligned. In 38% of decision moments, patients and physicians exchanged information and beliefs and appeared to make joint decisions; however, their relationship was characterized by mistrust, withholding of crucial information, or mutual frustration. In 21% of decision moments, patients and physicians collaborated in decision making despite a limited amount of clear communication.

Implications

• Communication is more complex than a set of communication behaviors.
• Shared decision making can appear successful, but when the process is not truly collaborative, important information can be withheld, and participants may have different intentions about a care plan.
• Efforts to strengthen patient-physician communication, especially among disadvantaged populations, must focus on both communication behavior and personal interactions.

State Anger and the Risk of Injury: a Case-control and Case-crossover Study

Daniel C. Vinson, MD, MSPH , and colleagues

Background Is anger associated with injury? This study looked at the risk of injury during specific episodes of anger (called “state anger”).

What This Study Found Anger greatly increases a person’s chances of injury, especially among men, according to this study of more than 2,500 patients. Based on interviews of patients who had been seriously injured and were seeking care at an emergency department, researchers found that 31.7% reported some degree of irritability just before the injury, 18.1% reported feeling angry, and 13.2% reported feeling hostile. The relationship between anger and injury is stronger in men than women. In addition, risk of injury is higher for greater degrees of anger. For example, the risk is higher for those feeling “quite a bit” or “extremely” angry rather than just “angry.” Anger is much less common among patients with traffic injuries, but in both men and women anger is strongly associated with intentional injuries inflicted by another person.

Implications

• Control of irritability and anger might decrease the risk of injury, especially among men.

Effect of Improved Primary Care Access on Quality of Depression Care

Leif I. Solberg, MD , and colleagues

Background Do patients receive better quality care if they have better access to their personal doctors? This study looked at how increased access to primary care doctors affected the quality of care for patients with depression. The study took place in a medical group that implemented “advanced access,” in which patients are offered the opportunity to have an appointment the same day with their clinician of choice.

What This Study Found Better patient access to primary care doctors is associated with improved care of patients with depression. However, improved patient use of antidepressant medication appears to be related to improvement in the ongoing relationship between patient and doctor rather than to more access to doctor visits.

Implications

• Regular follow-up with patients and more attention to integrating primary care and mental health care could improve the quality of depression care.
• Advanced access should be implemented in ways that strengthen the ongoing relationship between patients and doctors.

The Dark Bridal Canopy

Jeffrey M. Borkan, MD, PhD

Background This true story depicts a challenge faced by the author while serving as a family physician in a desolate, desert region in Israel's Southern Aravah Valley, where he practiced for a decade. The episode, a fatal car crash in which a newlywed Druse woman was killed, involved much more than just the terse details listed in the emergency log. The essay illustrates the important role of narrative in capturing some of the intangible sights, sounds, and emotions that are a part of family medicine and in providing meaningful insights into disease, illness, suffering, and the nature of healing.

Boy Scouts for Henry

Richard E. Allen, MD, MPH

Background A resident physician tells the story of an elderly patient who was kept alive beyond his wishes. He reflects on how the experience shaped his perception of the role of physicians in end-of-life care, suggesting that to fight illness at all cost and prolong life with no quality may be as wrong as assisting in their death. The author contends that patients often need the help and permission of their physicians to die.