Outcomes of Health System Structures, Highly Pertinent Clinical Information, Idea Stimulators, Clinical Reviews, and Prediction Tools: JABFM Exemplified

Systems of care make a difference. In the United States, areas with more family physicians per population have lower rates of obesity after controlling for other factors.¹ Patient-centered medical homes (PCMHs) are associated with increased rates of colorectal cancer screening compared with another targeted intervention.² Articles from international sources also help us to understand how the structures of health systems contribute to health and illness. We highlight an article herein on a lack of primary care clinicians in the Chinese health care system³ and 2 articles on health care–based systems of care for the frail elderly. The first, from Canada,⁴ found that instituting a specific care system in long-term care facilities reduced trips to the emergency department by one third. The second, from the Netherlands, found that a specific team-based intervention for frail elderly in their homes did not lead to improvements in overall function or mortality.⁵

For our thought piece this month, Howard et al⁶ note that many practices undergoing transformation are using different terminology than are associated nationally with the PCMH initiative. These differences suggest future directions or areas that are inadequately addressed through the classic PCMH model.

Highly pertinent clinical articles reflect on common clinical problems and lack of evidence or disagreements about best treatments. For distal radius closed fractures, there is clearly insufficient evidence on the “best” treatment. These fractures, without complicating features, can be handled without surgery,⁷ thus permitting treatment in the family medicine setting. We have a clinical review article about treating acne during pregnancy.⁸ Whether or not family physicians provide prenatal care, it is common to be asked to treat medical problems that occur during pregnancy. Given family physicians' substantial experience treating acne, doing so for pregnant women would clearly be within the realm of usual care.

While all our JABFM articles are chosen to provide new information to advance the care of patients in family medicine, we also choose articles that could be considered as reminders—such as one about an entity that is not easily recognized, or not well known: reducing unnecessary testing, or the wrong treatment. As an example, “cotton fever”⁹ is an entity that is apparently well known among intravenous drug users (including the patient in this report) but not by many physicians. With this diagnosis, less treatment is better, yet treatment of the underlying drug abuse is paramount. A second reminder article shows us that preoperative diagnosis of preexisting sleep disorders could lead to a more appropriate level of postoperative monitoring and treatment.¹⁰

In the category of new information, did you know that deaf children who fail treatment with a cochlear implant now have a new option? A new technology called an “auditory brainstem implant” offers the potential for some hearing¹¹—yet another avenue to improve lives.

We have two articles that help family physicians decide when testing or treatment is necessary – by predicting vitamin D levels, and predicting osteoporosis. For vitamin D, all that is needed is body mass index and ethnicity; refer to the useful graph in the article by Weishaar et al.¹² For osteoporosis, consider the differences between the commonly available screening tools.¹³ Mainous et al¹⁴ report on lower grip strength, an easy test that predicts diabetes, even in normal-weight adults; however, most readers are probably unaware of this connection. In addition, prediabetes is underdiagnosed.¹⁵ Next time you shake a patient's hand, think about how strong they are!