In This Issue: The Patient Voice, Clinical Research, Clustered Data, and the Wonca Research Conference

CLUSTERED DATA

Clustered data (such as patients nested within clinicians within practices) are common in primary care research. Two articles^1,2 and an editorial³ in this issue show how recognition and management of the relevant statistical issues are critical to the validity of much of this research. This is important reading for practice-based network researchers and others analyzing¹ and calculating sample sizes² in clustered data, as well as for those reading and applying their findings.

SYSTEMATIC REVIEWS

Recommendations from the US Preventive Services Task Force bring together and interpret the best evidence for two important clinical decisions. The finding that screening for ovarian cancer is harmful⁴ will be disconcerting to concerned patients and for clinicians caring for them. Such rigorous reviews of available science are important, however, to keep us from allowing wishful thinking to move us away from the dictum to “first do no harm.”

The Task Force finding of sufficient evidence to recommend screening children younger than age 5 for amblyopia, strabismus, and visual acuity⁵ reinforces the need to develop office systems to assure that all children coming for care receive this consequential screening service and appropriate referral when a problem is discovered. This evidence should also strengthen our resolve to assure that children, and all Americans, have access to basic medical care.

A systematic review by researchers from New Zealand⁶ finds good evidence to support some nonsurgical treatments for carpal tunnel syndrome, and weaker but still useful evidence for other treatments.

CLINICAL AND TECHNOLOGY RESEARCH

Tierney et al,⁷ in a study of 5,825 patients with an average follow-up of 5.6 years, find that a single measurement of pulse and blood pressure conveys important information about the risk for stroke, heart and kidney disease, and death. This strong evidence linking simple measures and major outcomes should influence us to act on this routinely available information.

Gill and colleagues⁸ evaluate a new technology for screening for diabetic retinopathy. The reasonable performance characteristics of the PanOptic ophthalmoscope appear to justify use by family physicians to conduct screening among patients for whom referral to an ophthalmologist is not feasible.

Flushing the prostatic end of the vas deferens has been hypothesized to shorten the time needed to reach azoospermia after vasectomy. In this randomized clinical trial that overcomes some of the methodological limitations of previous studies, however, a saline flush did not increase the rate of azoospermia.⁹

THE PATIENT VOICE: IMPROVING CARE FOR PAIN, INTIMATE PARTNER VIOLENCE, AND SPIRITUAL DIMENSIONS

The clinical dictum to “listen to the patient” is too infrequently applied to the research that guides our approach to patients. Three studies in this issue specifically seek the patient voice and find information that can be used to improve patient care.

In a qualitative study, Zink et al¹⁰ find that women who are victims of intimate partner violence exhibit different stages of readiness to change that can be used to tailor screening and intervention by clinicians. The specific insights shared by these women demonstrate the importance of clinician awareness and of openness, affirmation, local knowledge, and education in helping victims to move along the continuum toward action.

The study by Bertakis and colleagues¹¹ goes beyond many studies showing low rates of recognition of pain by clinicians to identify factors associated with pain recognition. Knowing the two clinician styles and two patient characteristics associated with greater recognition of pain may help to increase the identification and treatment of pain.

HEALTH SERVICES RESEARCH: OTC MEDICATION USE; WORKING WITH OTHER CLINICIANS

Phenazopyridine is a commonly used bladder analgesic, which is available without a prescription. Shi et al¹² find low levels of consumer knowledge that may result in poor-quality care or lack of care. The pattern of these knowledge deficits raises concern about poorer care among the traditionally underserved.

Referral patterns are important to the quality of patient care. The study by Kinchen et al¹³ finds that patient convenience, previous experience, board certification, and insurance coverage are important in referral decisions, but their importance varies with the race and sex of the referring physician.

Studies show that primary care patients frequently visit practitioners of complementary and alternative medicine (CAM). The study by Barrett et al¹⁴ finds that CAM practitioners report taking a holistic, empowering, person-centered approach, and most express a desire to work with clinicians providing mainstream health care.

ANNALS’ 1-YEAR ANNIVERSARY

In this issue, Larry Green¹⁵ asks the “So what and who cares?” questions about the Annals first anniversary. George Lundberg, when he was editor of JAMA, was fond of saying that these are the two questions that guide an editor’s decision about accepting a manuscript for publication. It is therefore fitting that they are used to evaluate the Annals.

As editors, we wish to provide a few additional reflections. Primary care research is coming of age. Our community of inquiry and scholarship is broader and richer than many of us imagined. The first full year for the Annals of Family Medicine is primary evidence, and the result has been a journey of exciting surprise and challenge. As we reflect over this initial year, 3 themes emerge. We are seeing excellent manuscripts that represent a comprehensive diversity of content and methods. The potential for creating an online, cross-disciplinary community of dialogue through TRACK is apparent but still emerging.

From the beginning, we have received an abundance of high-quality manuscripts, and the flow has only quickened and deepened. The first year brought us more than 451 submissions, and an acceptance rate of 21% that is trending down. Our goal is to manage this volume efficiently, equitably, and effectively, while continuing to build research capacity and promote excellence. Our average turnaround time from initial submission to initial editorial response is 46 days overall. With recent changes to our editorial process, turnaround has been reduced to 35 days since January 2004. We are greatly helped by your encouragement, shared excitement, and patience; by the beneficence and wisdom of more than 600 reviewers; and by the remarkable support of our sponsoring organizations and publishers. The sponsors have increased the number of pages in the Annals, from 64 to 96 pages beginning with volume 2, and with additional noncommercial support, we have have published 2 supplements. The American Academy of Family Physicians Foundation has generously agreed to support an expansion of the September/October 2004 issue to include a cluster of 9 papers on practice-based research, in addition to the usual complement of papers on diverse other topics. When appropriate, we are encouraging the shortening of articles in print with accompanying supportive materials as an appendix online. All this is helping us to reduce the time from acceptance to publication in the coming months.

The maturity of primary care research is represented not only by its quality and abundance, but also by its diversity. Nearly every part of the primary care universe of inquiry and knowledge¹⁶ is touched in the first 6 issues. The perspectives of clinicians, patients, families, and communities are presented along with studies of the clinician-patient relationship. Health services research, policy analysis, cost-effectiveness, and issues of justice and values are investigated. The Annals also has many articles presenting the results of observational epidemiology studies and randomized controlled trials, along with systematic reviews of evidence by the United States Preventive Services Task Force and others. These studies represent a broad range of disciplines, methods, and countries, and they have highlighted some of the core values and emerging understandings of primary care. These include comorbidity and the importance of generalism, the ecology of care and the role of information systems, equity and access to care, continuity of care as an outcome, the use of mixed methods, and the feasibility and value of community-oriented primary care. Nonetheless, there remain some areas where we want to encourage more inquiry and submissions. We are especially eager to receive more natural history and interventional studies of the common acute and chronic conditions seen by primary care clinicians. Research on hypertension, back pain, emotional distress, and acute respiratory illness, for example, should not be left only to the specialists. This research needs to be informed by a generalist frame and by the perspective of primary care settings.

More than 200 readers have submitted thoughtful and thought-provoking comments in TRACK, the Annals online discussion forum. We list and thank these participants in this issue and encourage you to jump into this stream by sharing concerns, ideas, reactions, and enthusiasms about articles and about others’ online comments. Please invite others to participate, including patients, clinicians, policy makers, researchers, and educators. Informal and brief comments are as welcome as well-reasoned, referenced responses. These interactions are essential if the TRACK discussion and its synthesis, On TRACK, are to serve as a catalyst for growing a community of inquiry and learning. Primary care research may have come of age, but we have only begun to develop the power of bringing new generalist knowledge to bear on important problems in health and health care.

Thank you, for your contributions and your support.

SUPPLEMENT FROM THE WONCA INTERNATIONAL FAMILY MEDICINE RESEARCH CONFERENCE

The conference, Improving Health Globally: Family Medicine Research, represents a watershed event for Wonca, the international organization for family doctors, and for general practice and family medicine around the globe. For the first time, family physicians and general practitioners from 34 countries came together to recognize their collective responsibility for generating new knowledge. For a discipline that has traditionally emphasized the application of what is known over systematically advancing the boundaries of knowledge, this step is powerful. Participants recognized the need to remain grounded in the wisdom of local knowledge and practice, while engaging those on the front lines of health care in generating relevant information from the generalist perspective, the community and relationship context, and the settings in which most people live and receive their medical care. Contributors called for integrating the patient and clinician voice in research, developing research networks, working to resolve inequalities, and providing the knowledge needed to enhance health and inform high-quality health care. In the process the discipline, particularly in countries in which family medicine is just getting started, has the opportunity to establish research as an essential component of general and family practice from the beginning—not as an add-on, but a vital organ in the body of general practice—the brain of relevant knowledge that is built on the heart of caring for the whole person and community.

The 9 papers from this conference, an additional paper summarizing the deliberations and recommendations, and an introductory editorial by the organizers make up the Annals second supplement, which is available online at http://www.annfammed.org/content/vol2/suppl_2. We are grateful to the authors, conference participants, and to Wonca and its organizational partners for sponsoring this supplement. We are indebted to Drs. Chris vanWeel and Walter Rosser, two senior statesmen of general practice and family medicine research, who put in countless hours as organizers of the conference and guest editors of the supplement. We encourage readers from all nationalities and walks of life to consider the implications of family medicine research for improving health care and health, and to offer your comments in the online discussion on the Annals Web site, http://www.annfammed.org.