In This Issue: An Abundance of Interventions and Observations to Improve Care
=============================================================================

* Kurt C. Stange

Wow! The opportunities to improve practice based on new information from research are stunning. Based on research published in this issue of *Annals*, a family physician might:

*   Train patients in mindfulness meditation and sustained exercise of moderate intensity.

Both of these interventions are associated with reduced illness severity and fewer days of missed work from acute respiratory infections in a clinical trial by Barrett and colleagues. This study also is featured in the *Annals* Journal Club.1

*   Provide patients with access to an interactive preventive health record.

In a clinical trial by Krist et al, despite fairly low rates of use among 4,500 patients in 8 primary care practices, an interactive preventive health record that provides access to the medical record, explains information in lay language, and provides individualized recommendations, resources, and reminders is associated with a greater rate of being up-to-date on recommended preventive services.2

*   Offer postpartum depression screening and management.

In a randomized clinical trial by Yawn et al, physicians given postpartum screening tools and education are more likely to diagnose and treat postpartum depression, and their patients have lower depressive symptoms at 6 and 12 months of follow-up.3

*   Engage in practice audit and targeted education about assessment and management of depression and self-harm in later life.

In a clinical trial by Almeida at al, this intervention had varied effects, but it reduced a composite outcome of self-harm behavior or clinically significant depression at 12 or 24 months.4

## SPACE IS NEEDED

What might it take to make these interventions a reality in practice? Providing a transitional platform from the hamster wheel5 of fee-for-service payment,6–9 supporting time for reflection to balance and inform action,10–14 and involving patients in designing practice15–19 would be a good start. Capitalizing primary care practices not only to meet accreditation and performance standards but also to innovate to meet patient needs could be transformative, if practices could move from drinking from the fire hose to building adaptive reserve20 and collaborative connections,12,21–23 rather than just getting through the day.24–29

With time to reflect together and to plan, test, and learn from emerging observational research, primary care practices, their patients, and community partners might use observations from other research and reflections in this issue to strengthen patient care. They might:

*   Learn from the observations of their colleagues on how to rely more on open communication and longstanding relationships than on drugs to reduce suffering in their palliative care patients.30

*   Identify chemical intolerance and its comorbidities among a surprisingly high percentage of patients.31

*   Work together with patients, practice colleagues, and system support to reduce opioid misuse by looking for depression32 and objective evidence of disease.33 An editorial by Von Korff provides an update on what is known and what remains to be learned, about the effectiveness and safety of opioids for chronic noncancer pain.34 In another editorial, Rosenblatt and Catlin35 provide a very helpful perspective on this challenging topic.

With some investment in time, space, and support for reflection, as well as action, and with a focus on developing adaptive reserve, communication, and partnership, the promising interventions and ideas in this issue, and ten thousand more, have a chance to make health care and health better.

We welcome your reflections at [http://www.AnnFamMed.org](http://www.AnnFamMed.org).

*   © 2012 Annals of Family Medicine, Inc.

## References

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    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTAvNC8zMzciO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzEwLzQvMjk4LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

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    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTAvNC8zMTIiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzEwLzQvMjk4LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

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    [FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTAvNC8zMDIiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzEwLzQvMjk4LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

35. Rosenblatt RA, Catlin M. Opioids for chronic pain: first do no harm. Ann Fam Med. 2012;10(4):300–301.
    
    [FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTAvNC8zMDAiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzEwLzQvMjk4LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==)