One of the challenges of clinical practice inprimary care is the need to apply scientific evidence from studies of the many to care of the individual. Both numbers and narratives are important. The challenge is to integrate general evidence-based guidelines and what Ian McWhinney1 called “an acquaintance with particulars.” One reason that scientific evidence is often not translated into practice is the lack of fit with the particular patient, family, community, or practice setting in which the evidence is being applied. In primary care practice, context matters. Yet, most of our scientific evidence is generated using methods that specifically isolate a phenomenon from its context, so that it can be studied “objectively.”
What if we could have scientific objectivity and an understanding of context? What if we could both objectify a phenomenon for study and retain an understanding of local meaning? This is the goal of multimethod research: investigation that integrates quantitative methods that isolate a phenomenon from its context, with qualitative methods that emphasize meaning and an acquaintance with the particulars.
In this issue, Borkan2 lays out the argument that multimethod research is an essential tool for the generation of knowledge relevant to primary care practice. His editorial stands as a piece of scholarship, as well as an introduction to two research articles in this issue. The study by Creswell and colleagues3 identifies criteria to analyze mixed methods studies, and applies these criteria to a sample of studies from the primary care literature. They identify frameworks for integrating quantitative and qualitative data to inform primary care practice. The study by Schillaci et al4 uses an epidemiological approach to evaluate the effect of a Medicaid policy change in decreasing immunization rates in New Mexico. Using ethnographic methods, the researchers show the effect of these changes on local funding and the process of care in public health clinics, where many of the most vulnerable patients receive their care. The multimethod approach closes the loop in understanding the effect of a policy change on immunization rates and on the lives of frontline clinicians and the vulnerable populations they serve.
This issue also contains two studies from the HealthPartners Research Foundation that inform efforts to reduce tobacco use. The study by Boyle and Solberg5 finds that implementing smoking status as a vital sign increases documentation of tobacco use, but does not increase provision of smoking cessation advice. Making smoking a vital sign is widely recommended and makes sense. But like many widely recommended actions that make sense, its benefit does not stand up to scientific scrutiny. The study by Solberg et al6 finds that diabetic patients who smoke are more likely to report poor health and feeling depressed, as well as poorer diabetes self-care and health care. Smoking appears to be a marker for higher risk diabetes-related behavior and implies the need for different or more intensive clinical interventions.
A timely study for this season is Hueston and Benich’s cost-benefit analysis of 3 different testing strategies for influenza in high-risk adults.7 Their findings show the need for different clinical approaches based on the prevalence of influenza and the treatment option that is being considered.
Another seasonally relevant study is an evaluation of factors affecting pneumococcal vaccine use among the elderly. The study by Santibanez et al8 is unique in ascertaining both the physician and the patient perspective and identifies the importance of systems to support in-office provision of vaccination.
Two other papers in this issue are important to the care of the elderly. Daaleman et al9 finds that spirituality, but not religiosity, is associated with better self-reported health status among geriatric outpatients. A study by Jerant and colleagues10 presents an important new model of palliative care for older people. This TLC model, if put into practice, has great potential to improve chronic illness care among the elderly. The authors’ preliminary data support the feasibility of its implementation.
A study of great importance is the multisite retrospective cohort study of adult survivors of childhood cancer reported by Oeffinger et al.11 Among more than 9,000 survivors, the majority of care is provided by primary care physicians. The study identifies several groups at high risk for low levels of follow-up care, and advocates greater communication between cancer centers and primary care physicians.
The study by Phillips et al12 carefully assesses the effects of the Balanced Budget Act of 1997 on the financial health of teaching hospitals. The findings are of interest both to those concerned about graduate medical education and those interested in the outcomes of Medicare policy changes.
Finally, an essay in our Reflections feature13 describes both the positive and negative aspects of the recent “industrialization” of health care. We look forward to an active online discussion from those who have experienced these health care system changes as patients, clinicians, policy makers, researchers, and educators.
With this issue we also expand the Annals in two important ways. The size of the Annals has been increased by 50%. The Annals Board, which is comprised of representatives of the sponsoring organizations, has taken this step in response to the large number and high quality of manuscripts submitted and to the high quality of the online discussions. The additional pages will allow us to make more papers available more quickly to our readers, and we are grateful to all who have made this possible. We have also expanded the Annals editorial team to meet the steady demand and expanding opportunities. Laura McLellan, MLS, has been working as editorial assistant for several months. Her experience in library science brings to the team important expertise from the perspective of end-users of published information. We are also delighted to announce that Paul A. Nutting, MD, MSPH, has agreed to become an associate editor. Paul brings a wealth of expertise in health care, community health, practice-based research, and medical editing.
Please join the online discussion of Annals articles at http://www.annfammed.org.
- © 2004 Annals of Family Medicine, Inc.
