Successful Behavioral Interventions, International Comparisons, and a Wonderful Variety of Topics for Clinical Practice

Behavioral Interventions—With Success!

A successful obesity intervention! We have a very important article—one with amazing outcomes: improvement in obesity among children that persisted for a year resulted from a group visit intervention at a family medicine residency that included the parents and the children (third through fifth grades), both separately and together.¹ The intervention was based on positive psychology and resiliency. This intervention seems feasible, so please repeat it and study the outcomes!

Dickinson et al² report a computer-based interactive behavior change intervention that positively assisted patients with health behavior change. They also note difficulties with patient recruitment and suggest that the intervention might work better if it was integrated into the interaction between primary care clinicians and patients, rather than as a separate intervention. Then, just as if it was ordered up (perhaps by all hopeful clinicians and patients), Goodyear-Smith et al³ report an innovation in New Zealand called eChat. This programmatic innovation provides an electronically completed set of questionnaires before a family physician visit, with the results available for use during the visit. eChat reviews a variety of behavioral and preventive topics, provides self-help, as well as prioritization and request for assistance from the physicians. This has great potential to assist both physicians and patients toward the goal of improving patient engagement and targeted interventions, and we look forward to reports on the overall outcomes.

In another helpful report, Strayer et al⁴ created a handheld personal digital assistant software program that incorporates the major methods recommended to enhance smoking cessation by patients. A group of residents and attending physicians used it, on average, just more than once per month (ie, not with most of their smokers). They reported that use of eChat increased their reported comfort with and use of specific techniques, which are the first steps toward adoption by physicians.

So how to get these changes to happen in practice? Part IV of Maintenance of Certification (MOC) is related to improving quality and practice. Part IV portion of the MOC process has proven far more successful than many would have predicted, including myself (MAB). This MOC requirement has led to a tremendous amount of quality improvement (QI) work within groups and across practices as well as new thinking about how to improve quality and practices. Fisher et al⁵ report process and outcomes with group QI projects within a large, regional, family medicine MOC collaboration; their findings are instructive and provide optimism for ongoing improvement.

The Message from Cross- International Comparisons: More Primary Health Care Teams!

Neggers and Crowe⁶ take on an international comparison of the rate of low birth weight. Smoking and anemia are higher in Cuba, yet low birth weight is significantly lower than in the United States (particularly Alabama) and is decreasing. What gives? The authors visited Cuba and provide information about some major differences in prenatal care, with a heavy dose of responsibility for family physicians, which might be an important explanation for the cross-national differences. Ventres⁷ also has visited south of the border, particularly to Cuba and El Salvador, and notes the increasing emphasis on primary health care, frequently with the use of physician, nurse, and community health workers. Both of these articles provide interesting examples from international perspectives on how far behind the United States is in providing team primary care.

In a further emphasis on prevention, Warner and Frey⁸ provide a review of preconception health care for men. While a preconception visit is widely viewed as important for women, the importance for men often has been overlooked.

Wonderful Variety (or Wonderful Family Doc Miscellany)

Many physicians look at new drugs with cynicism, appropriately so, because of previously distressing experiences with increased costs without increased benefit. Painter et al,⁹ who report no conflicting interest, review one of the newer medications, an extended release version of exenatide (to be taken once a week). The authors' review of the data indicates that there are some advantages for this long-acting over the previous shorter-acting version of the drug at similar cost, and they provide other information about its use.

The Canadian Hypertension Education Program has a list of 13 recommendations on how to measure blood pressure. While many family physicians report they regularly adhere to the recommendations, there are several that they did not believe were important or else the time-consuming nature did not seem worth it. Furthermore, we challenge you: do you truly follow every one of these recommendations for every patient for whom you are measuring blood pressure? We suspect very few blood pressure readings happen to follow all recommendations. In addition, do we truly know how much difference each of these recommendations make in the diagnosis, treatment, and outcomes of high blood pressure?

There is some literature suggesting differences in the practice styles of male and female physician providers. The question is, “Is the sex of the physician associated with differential patient outcomes, including the ultimate outcome—death?” Read Jerant et al¹⁰ to see what these authors found by analyzing a national database.

Just look at the photograph of a red, intertriginous rash that appears in the Wilmer and Hatch¹¹ detailed case report; what would be your diagnosis? The authors discuss the diagnosis of this rash, which had been understandably misdiagnosed. Consider the hints next time you see a rash similar to this one.

Fluid in mastoid cells can be seen on various radiology studies, including magnetic resonance imaging, computed tomography, or radiographs. In fact, as McDonald et al¹² note, this can be seen in many patients with otitis media. The authors clearly review the key issue: When is it serious and urgent?

Van dijk et al¹³ review the megatrials of bronchodilators in chronic obstructive pulmonary disease and note the lack of evidence for improved outcomes, particularly death.

Primary care researchers are eager to use electronic medical record (EMR) databases to identify patients with chronic conditions. Kadhim-Saleh et al¹⁴ provide a methods article to explore the quality of data and the validity of diagnostic algorithms for 5 chronic diagnoses. They conducted a retrospective validation study of EMR-based diagnostic algorithms, comparing the concordance of data from a primary abstraction of patients' EMRs within the Canadian Primary Care Sentinel Surveillance Network national database. The diabetes algorithm had excellent test characteristics and provides confidence that this would be a reliable method for identifying patients with diabetes.

Xierali et al¹⁵ report that family physicians provide a lot of mental health care—even more so in rural areas, where there are so few psychiatrists. Family physicians will do whatever they can to help their patients, including stretching their knowledge to their patients' needs in rural America.

Communities of Solution Theme Issue

In May we will publish our special theme issue focused on articles that take a “community of solution” approach to improving care. We had a wonderful response to our call for papers, and this upcoming issue will include excellent, innovative articles.