On TRACK: Comorbidity and External Validity, Exemplary Practice, Postpartum Support
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* Kurt C. Stange

## COMORBIDITY AND EXTERNAL VALIDITY

The online discussion advances understanding of the effect of comorbidity on the interpretation and application of clinical trial findings.1–6 The discussion supports recent calls for greater focus on documenting and presenting the information needed to assess external validity in clinical trials.7,8 In addition, guidelines based on clinical trials that don’t adequately consider comorbidity can result in polypharmacy1 and impractical recommendations.5,6 Bayliss proposes classifying comorbidity on the basis of the effect of comorbid conditions on the “condition of interest.”3 Her 3 categories of comorbidities have different implications for understanding and applying clinical trial data to the care of patients with complex conditions. These categories are (1) pathophysiologically related conditions that require congruent treatment plans, (2) conditions that have discordant and potentially competing treatments, and (3) conditions that do not affect the primary disease or treatment.

## EXEMPLARY PRACTICE

“Exemplary practice research gives us information and, frankly, gives us hope.”9 The article by Solberg et al in the last issue of *Annals* not only prompted readers to define a field of research that focuses on exemplary practices, but elicited further observations of what makes a practice exemplary.10 These features include shared understanding of mission, vision, and values; consistent leadership; an egalitarian spirit; openness to conversations about change; and a culture of caring.9 A related set of features is leadership that focuses on a mission which encompasses both business and clinical activities, supporting but not micromanaging leaders of practice components, 2-way communication at all levels of the practice, a team model, and focusing on practice-patient relationships.11

Other online discussions relate pearls for minimizing unintended consequences of the electronic health record on relationship-centered care12,13 and for developing skills and systems to integrate care of addicted patients into primary care.14,15

The essay on facilitating collaboration among the generalist disciplines elicited calls for leadership that moves beyond competition to bring the disciplines together to solve important problems.16–19

## POSTPARTUM SUPPORT

The study by McGovern et al in the last issue of *Annals* stimulated reporting of new data and recommendations on postpartum needs.20–22 The discussion also related important contextual information on public and work-place policies in different countries.23–26 “In cultures that care for mothers after birth, mothers are allowed adequate rest, they have ongoing breastfeeding support from their care providers and family members, and their transition to motherhood is honored with rituals that celebrate this major life change.”26

Please join the discussion at [http://www.AnnFamMed.org](http://www.AnnFamMed.org).

*   © 2006 Annals of Family Medicine, Inc.

## REFERENCES

1.  van den Akker M. Invited commentary: Comorbidity and multimorbidity in family medicine: also relevant for research [eletter]. [http://www.annfammed.org/cgi/eletters/4/2/101#3888](http://www.annfammed.org/cgi/eletters/4/2/101#3888), 3 April 2006.
    
    

2.  Beasley J. Bravo for raising the issue [eletter]. [http://www.annfammed.org/cgi/eletters/4/2/104#3920](http://www.annfammed.org/cgi/eletters/4/2/104#3920), 16 April 2006.
    
    

3.  Bayliss E. A methodological suggestion for the management of comorbidities in randomized controlled trials [eletter]. [http://www.annfammed.org/cgi/eletters/4/2/104#3914](http://www.annfammed.org/cgi/eletters/4/2/104#3914), 11 April 2006.
    
    

4.  Hogg WE. Randomized controlled trials: do they have external validity for patients with multiple comorbidity [eletter]? [http://www.annfammed.org/cgi/eletters/4/2/104#3910](http://www.annfammed.org/cgi/eletters/4/2/104#3910), 9 April 2006.
    
    

5.  Wright NMJ. Randomised controlled trials: do they have external validity for patients with multiple comorbidities? Invited commentary [eletter]. [http://www.annfammed.org/cgi/eletters/4/2/104#3852](http://www.annfammed.org/cgi/eletters/4/2/104#3852), 31 March 2006.
    
    

6.  Soubhi H. Too tall for the bed [eletter]? [http://www.annfammed.org/cgi/eletters/4/2/104#3828](http://www.annfammed.org/cgi/eletters/4/2/104#3828), 31 March 2006.
    
    

7.  Glasgow RE, Green LW, Klesges LM, et al. External validity: we need to do more. Ann Behav Med. 2006;31:105–108.
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1207/s15324796abm3102_1&link_type=DOI) 
    
    [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=16542124&link_type=MED&atom=%2Fannalsfm%2F4%2F3%2F269.atom) 
    
    [Web of Science](http://www.annfammed.org/lookup/external-ref?access_num=000236708600001&link_type=ISI) 

8.  Green LW, Glasgow RE. Evaluating the relevance, generalization, and applicability of research: issues in external validation and translation methodology. Eval Health Prof. 2006;29:126–153.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToic3BlaHAiO3M6NToicmVzaWQiO3M6ODoiMjkvMS8xMjYiO3M6NDoiYXRvbSI7czoyMjoiL2FubmFsc2ZtLzQvMy8yNjkuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

9.  Craigie FC. Organizational culture and exemplary practices [eletter]. [http://www.annfammed.org/cgi/eletters/4/2/109#3874](http://www.annfammed.org/cgi/eletters/4/2/109#3874), 2 April 2006.
    
    

10. Solberg LI, Hroscikoski MC, Sperl-Hillen JM, Harper PG, Crabtree BF. Transforming medical care: case study of an exemplar small medical group. Ann Fam Med. 2006;4:109–116.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiNC8yLzEwOSI7czo0OiJhdG9tIjtzOjIyOiIvYW5uYWxzZm0vNC8zLzI2OS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

11. Stello B. Lessons for every practice in exemplary medical group [eletter]. [http://www.annfammed.org/cgi/eletters/4/2/109#3876](http://www.annfammed.org/cgi/eletters/4/2/109#3876), 2 April 2006.
    
    

12. Scherger JE. Relationship centered care using the EHR [eletter]. [http://www.annfammed.org/cgi/eletters/4/2/124#3883](http://www.annfammed.org/cgi/eletters/4/2/124#3883), 3 April 2006.
    
    

13. Haq CL. Complexity [eletter]. [http://www.annfammed.org/cgi/eletters/4/2/124#3833](http://www.annfammed.org/cgi/eletters/4/2/124#3833), 31 April 2006.
    
    

14. Parran TV. Strong endorsement for generalists considering buprenorphine training [eletter]. [http://www.annfammed.org/cgi/eletters/4/2/168#3895](http://www.annfammed.org/cgi/eletters/4/2/168#3895), 5 April 2006.
    
    

15. Chirayath HT. A rare perspective [eletter]. [http://www.annfammed.org/cgi/eletters/4/2/168#3841](http://www.annfammed.org/cgi/eletters/4/2/168#3841), 31 March 2006.
    
    

16. Green LA. Next steps [eletter]. [http://www.annfammed.org/cgi/eletters/4/2/172#3925](http://www.annfammed.org/cgi/eletters/4/2/172#3925), 22 April 2006.
    
    

17. Kuo D. CME: Low hanging fruit and a first step toward collaboration [eletter]. [http://www.annfammed.org/cgi/eletters/4/2/172#3918](http://www.annfammed.org/cgi/eletters/4/2/172#3918), 16 April 2006.
    
    

18. Katerndahl DA. Recognize and support current multidisciplinary actions [eletter]. [http://www.annfammed.org/cgi/eletters/4/2/172#3854](http://www.annfammed.org/cgi/eletters/4/2/172#3854), 31 March 2006.
    
    

19. Khan OA. Collaboration in primary care is not just necessary but right [eletter]. [http://www.annfammed.org/cgi/eletters/4/2/172#3844](http://www.annfammed.org/cgi/eletters/4/2/172#3844), 31 March 2006.
    
    

20. McGovern PM, Dowd B, Gjerdingen D, et al. The postpartum health of employed mothers five weeks after childbirth. Ann Fam Med. 2006;4:159–167.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiNC8yLzE1OSI7czo0OiJhdG9tIjtzOjIyOiIvYW5uYWxzZm0vNC8zLzI2OS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

21. Sakala C, et al. Let’s help women improve their chances for good postpartum health [eletter]. [http://www.annfammed.org/cgi/eletters/4/2/159#3901](http://www.annfammed.org/cgi/eletters/4/2/159#3901), 6 April 2006.
    
    

22. McGovern PM. RE: “Glad to see this” by Dr. Marily Culp [eletter]. [http://www.annfammed.org/cgi/eletters/4/2/159#3879](http://www.annfammed.org/cgi/eletters/4/2/159#3879), 2 April 2006.
    
    

23. Dagher RK. A wakeup call for employers [eletter]! [http://www.annfammed.org/cgi/eletters/4/2/159#3935](http://www.annfammed.org/cgi/eletters/4/2/159#3935), 24 April 2006.
    
    

24. Harper D. Why is something so natural, so hard for society to understand [eletter]? [http://www.annfammed.org/cgi/eletters/4/2/159#3892](http://www.annfammed.org/cgi/eletters/4/2/159#3892), 5 April 2006.
    
    

25. Yawn N. Demedicalize labor and delivery but assess the health care needs of postpartum women [eletter]. [http://www.annfammed.org/cgi/eletters/4/2/159#3890](http://www.annfammed.org/cgi/eletters/4/2/159#3890), 3 April 2006.
    
    

26. Kendall-Tackett KA. Inadequate postpartum support for U.S. mothers [eletter]. [http://www.annfammed.org/cgi/eletters/4/2/159#3863](http://www.annfammed.org/cgi/eletters/4/2/159#3863), 31 March 2006.