In This Issue: Critical Topics in Primary Care

LIMITS AND POTENTIAL OF UNIVERSAL HEALTH COVERAGE

In a study set in Ontario, Canada, Glazier et al investigate the extent to which universal coverage of physician services reduces socioeconomic disparities in care.¹ They find that although income is not associated with inequities in physician contact or frequency of visits, higher education is inversely associated with frequent visits to primary care and directly associated with visits to specialty care. In the Ontario system, universal insurance appears to be successful in achieving income equity in physician visits, but it does not eliminate education-related differences in specialist care.

A study by DeVoe et al helps make the case for universal health insurance coverage in the United States and contributes to the hotly debated issue of health system reform.² The study examines the relationship between parental insurance coverage and children’s access to care and finds that, when parents lack health insurance, their children are more likely to go without necessary medical and preventive services. As the authors point out, “If the current trend continues, the majority of US children will soon live in families with discordant and disrupted patterns of family health insurance.”²

One of the missing links in US health policy is an integrative perspective. The fourth in a series of editorials on generalism presents a framework for integrating health care components, an approach that can foster the development of comprehensive, relationship-centered systems of care.³

DIABETES, DEPRESSION, AND RISK

Two articles in this issue address the challenges of screening for diabetes and depression. In an investigation of the yield of opportunistic targeted screening for diabetes in primary care, Klein Woolthuis et al find that the strongest predictor of undiagnosed diabetes is obesity.⁴ When targeting high-risk individuals, the number needed to screen was 37 (vs 233 for low-risk individuals). In a systematic review of an at-risk population, Reuland et al conclude that there is fair evidence to support the use of 5 commonly used instruments to accurately screen for depression in Spanish-speaking patients.⁵

Lin et al examine the association of diabetes with depression and other causes of mortality. They find that patients with both diabetes and depression have higher mortality risks beyond cardiovascular deaths.⁶

A SOCIAL AND CULTURAL LENS

Studies in this issue focus a social and cultural lens on issues of health and health care. Mainous et al find that antibiotics are widely available on the Internet without prescription.⁷ Given the unregulated nature of the Internet, these findings may have serious implications for patient health, quality of care, and efforts to reduce antibiotic resistance.

A randomized controlled trial by Barnet et al shows that a community-based home visiting intervention is effective in reducing rapid repeat births among low-income teenaged mothers.⁸ This innovative approach uses a computer-assisted motivational intervention conducted by paraprofessionals in community settings.

REALITIES OF CLINICAL PRACTICE

Research from the Netherlands provides insights into clinical practice. In a study of 21 Dutch general practices, diagnostic category, duration of complaints, and functional limitations are key variables in management decisions for nontraumatic complaints of arm, neck, and shoulder.⁹

In a poignant essay, Blevins reminds us that research is a valuable but distant source of knowledge. When it comes to clinical practice, patients remain our greatest teachers.¹⁰