Jan/Feb Annals of Family Medicine tip sheet

January 31, 2006

Anger greatly increases a person's chances of injury, especially among men, according to this study of more than 2,500 patients. Based on interviews of people who had been seriously injured and were seeking care at an emergency department, researchers found that 31.7 percent reported some degree of irritability just before the injury, 18.1 percent reported feeling angry and 13.2 percent reported feeling hostile. Moreover, the association between anger and injury was stronger in men than women. Researchers also found that risk of injury was notably higher for greater degrees of anger. For example, the risk was higher for those feeling "quite a bit" or "extremely" angry, compared with lesser degress of "angry." Surprisingly, the authors found that anger was significantly less common among patients with traffic injuries. In contrast, anger was strongly associated with intentional injuries inflicted by another person in both men and women. These findings provide insights into the complex associations between state anger and injury risk.
State Anger and the Risk of Injury: A Case-Control and Case-Crossover Study
Daniel C. Vinson, M.D., M.S.P.H.

With 20.8 million people in the United States, or 7 percent of the population, struggling with diabetes, this issue of the Annals of Family Medicine features five studies that address diabetes quality of care from innovative viewpoints.

Primary care practices can improve detection of undiagnosed diabetes and improve one-year outcomes by being vigilant in detecting symptoms of diabetes, by evaluating those at high risk for this disorder and by instituting appropriate treatments at the time of diagnosis. The researchers found that for nearly half of the 504 patients studied, diagnosis of diabetes was accomplished not by screening asymptomatic patients, but by clinical recognition of classic short- and long term diabetes-related symptoms at visits scheduled for reasons unrelated to diabetes. The authors assert that timely diagnosis of diabetes is likely to lead to better control of blood pressure, lipids, weight and aspirin use as well as substantial improvement in glucose control. They call for more aggressive and systematic efforts for early diabetes diagnosis and for consideration as clinical policy.
Diabetes: How Are We Diagnosing and Initially Managing It?
By Patrick J. O'Connor, M.D., M.P.H., et al

This study of diabetic patients illustrates the challenges inherent in delivering optimal diabetes care, especially for patients with multiple chronic health problems. Even with intense diabetes care by experienced primary care clinicians, including glucose-lowering medications, antihypertensives and lipid-lowering agents, only a modest number of the 822 patients in this study (40.5 percent) actually achieved the established targets for blood sugar control. These findings suggest that to substantially improve chronic illness care, reengineering primary care practice through practice redesign may be necessary.
Management of Type 2 Diabetes in the Primary Care Setting: A Practice-Based Research Network Study
By Stephen J. Spann, M.D., M.B.A., et al

Competing demands during visits with patients who have type 2 diabetes may be a major barrier to delivering indicated diabetes services. Based on observations of office visits for 211 patients with type 2 diabetes, the researchers found that needed diabetes services were less likely to occur during encounters for acute illness, the percentage of indicated services delivered increased as the duration of visits increased and follow-up visits were scheduled sooner if fewer of the indicated services were delivered. The authors conclude that competing demands require prioritizing and sometimes deferring services to follow-up visits to improve quality of diabetes care.
Encounters by Patients With Type 2 Diabetes - Complex and Demanding: An Observational Study
By Michael L. Parchman, M.D., M.P.H., et al

Treatment for depression does not improve self-management of diabetes among patients with both illnesses according to a randomized clinical trial of 329 patients in nine primary care clinics. During the 12-month intervention period, enhanced depression care was not associated with improved diabetes self-care behaviors, such as proper nutrition, physical activity or smoking cessation. The authors call for further research to assess whether self-care interventions tailored for specific conditions - in addition to enhanced depression care - can achieve better diabetes and depression outcomes.
Effects of Enhanced Depression Treatment on Diabetes Self-Care
By Elizabeth H. B. Lin, M.D., M.P.H., et al

Patients who make infrequent visits to their physician or who make frequent visits for minor health conditions are more likely to receive substandard preventive care for diabetes. According to an analysis of data for 4,463 diabetic patients, those who make infrequent visits are less likely to receive timely diabetes-related preventive care, and those patients who make frequent visits for lower-priority health conditions are at increased risk for delayed diabetes-related preventive services. The authors contend that primary care-based interventions which include office systems that help with patient follow-up, opportunistic prevention and guideline adherence might improve rates of diabetes preventive care among patients who make infrequent outpatient visits.
Quality of Preventive Care for Diabetes: Effects of Visit Frequency and Competing Demands
By Joshua J. Fenton, M.D., M.P.H., et al


Better access to primary care is associated with improvement in care for patients with depression. This study of 6,000 patients with depression receiving care from a large multispecialty medical group finds that care is improved when patients have better access to their physician. Furthermore, personal physician continuity appeared to be the mechanism for this improvement in care. The authors conclude that when advanced access to care is implemented, it must be done in such a way that continuity of care is enhanced rather than harmed.
Effect of Improved Primary Care Access on Quality of Depression Care
By Leif I. Solberg, M.D., et al

Although shared decision making is common in a patient-physician relationship, it is as likely to be associated with a negative subjective experience as a positive one. According to thematic analysis of a sample of 18 patient visits in three clinics, the study revealed that both relationship factors, such as trust and power, and communication behavior influenced subjective experience of partnership among the patient and physician. The authors conclude that attempts to enhance patient-physician partnerships must attend to effective communication style and affective relationship dynamics.
Shared Decision Making and the Experience of Partnership in Primary Care
By George W. Saba, Ph.D., et al

Some practice-based research networks (PBRNs) are involving community members and patients in their research in an effort to enhance the relevance and value of clinical research. Surveying identified practice-based research networks in the United States, the researchers found that more than half had some mechanism to involve community members in their research. The authors believe that community involvement will enhance the relevance of PBRN research. An accompanying editorial highlights the potential for bringing together practice-based research networks and community-based participatory research to provide unforeseen solutions to many of the most difficult problems in health and the health care system today.
Community-Based Participatory Research in Practice-Based Research Networks
By John M. Westfall, M.D., M.P.H., et al
Moving the Frontiers Forward: Incorporating Community-Based Participatory Research into Practice-Based Research Networks
By Ann C. Macaulay, M.D., C.C.F.P., F.C.F.P, et al

This physician narrative of a compelling medical and social drama illustrates the important difference between personal accounts and the facts outlined in the medical log. Narratives, the author asserts, capture some of the intangible sights, sounds and emotions that are so much a part of family medicine and that might provide meaningful insights into disease, illness, suffering and the nature of healing.
The Dark Bridal Canopy
By Jeffrey Borkan, M.D., Ph.D.

A resident physician tells the story of an elderly patient who was kept alive beyond his wishes. He reflects on how the experience shaped his perception of the role of physicians in end-of-life care, suggesting that to fight illness at all cost and prolong life with no quality may be as wrong as assisting in their death. He contends that patients often need the help and permission of their physicians to die.
Boy Scouts for Henry
By Richard E. Allen, M.D., M.P.H.

American Academy of Family Physicians

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