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September/October 2009 Annals of Family Medicine tip sheet

Universal Health Insurance Reduces Some Socioeconomic Disparities in Care
The experience of Ontario, Canada

Universal health insurance appears to reduce income inequities but not education-related disparities in health care according to Canadian researchers. Analyzing nationally representative claims data on more than 25,558 residents of Ontario, where necessary physician and hospital services are fully covered by government, researchers find patient income levels are not associated with inequities in physician contact or frequency of visits. They do find, however, that those with higher levels of education are more likely to see specialists, to be frequent visitors and to bypass primary care to reach specialists than are those with lower educational attainment. They assert that these patterns may be explained by better health knowledge and health attitudes, which lead to greater demand for care and better ability to navigate the system. They conclude that policy makers should consider the advantage of providing universal physician coverage as a means to reduce income inequities, but they point out that this strategy alone is unlikely to eliminate education gradients in use of physician services.

Universal Health Insurance and Equity in Primary Care and Specialist Office Visits: A Population-Based Study
By Richard H. Glazier, M.D., M.P.H., et al
Institute for Clinical Evaluative Sciences, Toronto, Canada

Insured Children Have Unmet Health Care Needs if Parents Are Uninsured
Researchers call for universal health insurance coverage

Examining the relationship between parental insurance coverage and children's access to care, researchers find that when parents lack health insurance, their insured children are more likely to go without necessary medical and preventive services. Analyzing nationally representative data on 43,509 U.S. children aged 2-17 years, researchers found that insured children with uninsured parents had higher odds of an insurance coverage gap (2.45 odds ratio), no usual source of care (1.31 odds ratio), unmet health care needs (1.11 odds ratio) and having not received at least one preventive counseling service (1.20 odds ratio) when compared with insured children with insured parents. Insured children with mixed parental insurance had similar vulnerabilities. The authors point out that if the current trend continues, the majority of U.S. children will soon live in families with discordant and disrupted patterns of family health insurance. They call for policy makers to look beyond child-only insurance models, asserting that these findings support the urgent need to replace the current patchwork of public insurance and private insurance with a new comprehensive model that provides a basic level of stable coverage to all families and everyone in the family.

Children's Receipt of Health Care Services and Family Health Insurance Patterns
By Jennifer E. DeVoe, M.D. D.Phil., et al
Oregon Health and Science University, Portland

Antibiotics Widely Available on the Internet Without Prescription

Antibiotics are freely available for purchase on the Internet without a prescription despite ongoing initiatives to control antibiotic resistance. Using a simple search with the keywords "purchase antibiotics without a prescription" and "online" on the top two Internet search engines, Google and Yahoo, researchers found 138 unique vendors selling antibiotics without a prescription. Of those vendors, 36 percent sold antibiotics without a prescription. The other 64 percent provided an online diagnosis and corresponding prescription without a physical exam or ongoing relationship with a doctor. Specifically, they found that penicillins were available on 94 percent of the sites, macrolides on 96 percent, fluoroquinolones on 62 percent and cephalosporins on 57 percent. Nearly all (99 percent), shipped to the United States with a mean delivery time of eight days. Researchers note that the vendors who sold antibiotics without a prescription were more likely to sell in quantities greater than a single course and more likely to take more than seven days for the antibiotics to reach the customer than were vendors who required a medical interview, suggesting that these transactions would likely be used by individuals storing the drugs for future self-diagnosis and treatment. The authors call for public health officials to expand their efforts to control antibiotic resistance beyond initiatives focused on physician prescribing behavior to include education directed to patients and the community, as well as increased regulation and enforcement of existing regulations.

Availability of Antibiotics for Purchase Without a Prescription on the Internet
By Arch G. Mainous, III, Ph.D., et al
Medical University of South Carolina, Charleston

Other Studies in this Issue:

Depressed Diabetic Patients Face Substantially Elevated All-Cause Mortality Risks

Analyzing a cohort of 4,184 patients with type 2 diabetes, researchers find that patients with both diabetes and depression face substantially elevated mortality risks beyond cardiovascular-related death (the focus of most research on depression and mortality since the two were first linked). Specifically, after adjustment or demographic and clinical characteristics and health habits, major depression was significantly associated with all-cause mortality (hazard ratio 1.52) and with noncardiovascular, noncancer-related mortality (hazard ratio 2.15). The authors call for a reexamination of the causal mechanisms underlying the link between depression and excess mortality. They point out that obesity, smoking, physical inactivity and negative biologic factors (e.g. higher inflammatory markers) are more common among patients with diabetes and depression compared with diabetes patients who do not have depression, which may help explain the ubiquitous association of depression with a wide array of death causes. Depression and Increased Mortality in Diabetes: Unexpected Causes of Death

By Elizabeth H.B. Lin, M.D., M.P.H., et al
University of Washington, Seattle

Motivational Intervention Reduces Rapid Subsequent Birth Among Adolescent Mothers

With data indicating that almost one-quarter of adolescent mothers give birth to another child within two years of having a baby, researchers offer evidence that an innovative computer-assisted motivational intervention conducted by paraprofessionals in community-based settings is effective in reducing the likelihood of rapid subsequent birth. The randomized controlled trial of 235 pregnant teenagers from urban prenatal clinics serving low-income, predominantly African American communities finds that those who received the intervention show a 44 percent reduction in repeat birth. Similar to other samples of adolescent mothers receiving usual care, one-quarter of adolescent mothers in the control group experienced a rapid repeat birth.

Motivational Intervention to Reduce Rapid Subsequent Birth to Adolescent Mothers: A Community-Based Randomized Trial
By Beth Barnet, M.D., et al
University of Maryland, Baltimore

The Primary Care Paradox and the Need to Integrate Primary and Specialty Care to Improve the Quality of Health Care
The fourth in a seven-part series of commentaries to understand health and health care

Amid the ongoing health care reform debate in Washington, D.C., Annals of Family Medicine editor Kurt Stange, M.D., Ph.D., continues his seven-part series of commentaries designed to help make sense of the problems and opportunities we face for understanding and improving health care and health. The September/October issue of the Annals features the series' fourth installment, which explores an integrated way of understanding how the components of health care can work together to balance access, cost and quality. He outlines a "holarchy" of health care, in which the components of health care (services, structures and relationships) are more than isolated commodities to be delivered, bought and sold, but are integrated and related to each other in important ways. He asserts that understanding the holarchy of health care can help us to organize health care more effectively, changing it from isolated commodities into a relationship-centered continuum that maximizes integration, prioritization, and, when needed, healing and transcendence. With this framework in mind, Stange offers a number of implications for understanding the nature of health care and for organizing and improving care.

A Science of Connectedness
By Kurt C. Stange, M.D., Ph.D.
Case Western Reserve University, Ohio

Diabetes Screening Approach Has Fair Yield; Obesity Strongest Predictor

Investigating the yield of opportunistic targeted screening for diabetes among primary care patients in 11 family practices in The Netherlands, researchers found that when targeting high-risk individuals, 37 people needed to be screened to detect one case of undiagnosed diabetes, compared to 233 for low-risk individuals. Of the American Diabetes Association diabetes risk factors, obesity was the strongest predictor of undiagnosed type 2 diabetes. The authors conclude that opportunistic screening for type 2 diabetes in primary care could target middle-aged and older adults with obesity.

Yield of Opportunistic Targeted Screening for Type 2 Diabetes in Primary Care: The Diabscreen Study By Erwin P. Klein Woolthuis, M.D., et al Radboud University Nijmegen Medical Centere, The Netherlands

Accuracy of Spanish Language Depression Screening Instruments

In a systematic review of the literature, Reuland et al conclude there is fair evidence to support the use of five commonly used instruments to accurately screen for depression in Spanish-speaking patients. The review identifies the need for future studies to evaluate the accuracy of ultra-short, practical depression-screening instruments that can be used in the primary care setting.

Diagnostic Accuracy of Spanish Language Depression-Screening Instruments
By Daniel S. Reuland, M.D., M.P.H., et al
University of North Carolina at Chapel Hill

What Influences How Physicians Treat Arm, Neck and Shoulder Complaints

Evaluating what impacts physicians' management decisions for nontraumatic complaints of the arm, neck and shoulder, Dutch researchers find that having a long duration of complaints and reporting many functional limitations were most frequently associated with the choice of a management option. The observational study of 682 patients seen in 21 Dutch general practices also identifies several physician characteristics that appear to play a role in determining the course of treatment.

Management Decisions in Nontraumatic Complaints of Arm, Neck, and Shoulder in General Practice
By Anita Feleus, Ph.D., et al
Erasmus Medical Centre Rotterdam, The Netherlands

How One Patient's Struggle with Parkinson's Disease Became One Physician's Solace

In a poignant essay, a primary care physician reminds us that when it comes to clinical practice, patients are physicians' greatest teachers. Blevins reflects on how his longtime patient's experience with advanced Parkinson's disease offered him solace, inspiration and a glimpse into the future when he himself was diagnosed with the disease.

Gazing at the Future
By Steve M. Blevins, M.D.
University of Oklahoma, Oklahoma City


Contact: Angela Sharma
American Academy of Family Physicians

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