Effect of comorbid depression on outcomes in diabetes and its relationship to quality of care and patient adherence: a statewide primary care ambulatory research and resources consortium study.

OBJECTIVE: To determine whether current depression was associated with poorer quality of care and poorer patient adherence to treatment regimens and whether current depression was associated with patient diabetes outcomes independent of its relationships to quality of care and patient adherence among patients with diabetes. METHOD: This study was conducted in the offices of family physicians who belong to the Statewide Primary Care Ambulatory Research and Resources Consortium from March 2006 to March 2011. Seven primary care physicians enrolled 10 to 20 English- or Spanish-speaking patients with diabetes presenting for routine follow-up visits. Subjects included 106 patients who completed a questionnaire documenting their depressive symptoms, compliance with diabetes therapy, diabetes-related quality of life, and patient satisfaction. The physicians completed a 4-item questionnaire concerning whether the patient had depression and any depression treatments that they ordered. All questions were answered either "yes" or "no." A practice research coordinator evaluated the quality of diabetes care provided and ordered hemoglobin A(1c) (HbA(1c)) testing for the patient. RESULTS: Depression was associated with poorer compliance, quality of care, diabetes-related quality of life, and patient satisfaction; only HbA(1c) levels did not correlate with depression. When adjusting for compliance and quality of care, depression was still associated with poorer quality of life and satisfaction (P ≤ .001). While physician recognition and treatment of depression were less than optimal, depression severity was a significant predictor of receiving some form of mental health intervention (P ≤ .05) except for the provision of mental health counseling. Poor diabetes control was associated with the provision of counseling (P ≤ .10), while poor quality of life was associated with recognition of depression (P ≤ .10). CONCLUSION: Depression was independently associated with satisfaction and quality of life but not diabetes control. Although depression severity was an important predictor of depression recognition and treatment, poor quality of life was a predictor of recognition, and poor diabetes control was a predictor of receiving mental health counseling.

Practice-based research networks (PBRNs): meeting the challenges of the future.

Practice-based research networks (PBRNs) are useful tools for conducting studies in the busy primary care setting, but their continued existence is threatened by a range of challenges. PBRNs must position themselves now to be prepared to face the challenges ahead. For example, experience with the Clinical Translational Science Awards has placed PBRNs at the center of university efforts toward greater community engagement. Networks must use this opportunity to solicit infrastructure support and partner with experienced principal investigators from other disciplines. Successful networks must make greater use of health information technology to solicit clinician involvement, identify and recruit potential subjects, and disseminate key findings. To maintain the active participation of busy clinicians in the clinical research enterprise, networks must find new ways to engage their members and simplify study participation. Networks should pursue clinically relevant projects that create meaning and connect busy practitioners to the larger agenda of primary care research. Finally, collaborating with other networks in a structured and ongoing manner is one way for PBRNs to extend their reach while making maximal use of their unique resources and local expertise.

Evaluation of patients presenting with knee pain: Part II. Differential diagnosis.

Knee pain is a common presenting complaint with many possible causes. An awareness of certain patterns can help the family physician identify the underlying cause more efficiently. Teenage girls and young women are more likely to have patellar tracking problems such as patellar subluxation and patellofemoral pain syndrome, whereas teenage boys and young men are more likely to have knee extensor mechanism problems such as tibial apophysitis (Osgood-Schlatter lesion) and patellar tendonitis. Referred pain resulting from hip joint pathology, such as slipped capital femoral epiphysis, also may cause knee pain. Active patients are more likely to have acute ligamentous sprains and overuse injuries such as pes anserine bursitis and medial plica syndrome. Trauma may result in acute ligamentous rupture or fracture, leading to acute knee joint swelling and hemarthrosis. Septic arthritis may develop in patients of any age, but crystal-induced inflammatory arthropathy is more likely in adults. Osteoarthritis of the knee joint is common in older adults.

Evaluation of patients presenting with knee pain: Part I. History, physical examination, radiographs, and laboratory tests.

Family physicians frequently encounter patients with knee pain. Accurate diagnosis requires a knowledge of knee anatomy, common pain patterns in knee injuries, and features of frequently encountered causes of knee pain, as well as specific physical examination skills. The history should include characteristics of the patient's pain, mechanical symptoms (locking, popping, giving way), joint effusion (timing, amount, recurrence), and mechanism of injury. The physical examination should include careful inspection of the knee, palpation for point tenderness, assessment of joint effusion, range-of-motion testing, evaluation of ligaments for injury or laxity, and assessment of the menisci. Radiographs should be obtained in patients with isolated patellar tenderness or tenderness at the head of the fibula, inability to bear weight or flex the knee to 90 degrees, or age greater than 55 years.

Barriers to and benefits of leisure time physical activity in the elderly: differences across cultures.

The purpose of this study was to compare ethnic differences in attitudes toward barriers and benefits of leisure-time physical activity (LTPA) in sedentary elderly Mexican (MAs) and European Americans (EAs). An in-home, cross-sectional survey was performed on 210 community-dwelling elders from 10 primary care practices in south Texas that are part of the South Texas Ambulatory Research Network, a practice-based research network. Analytical variables included ethnicity, age, sex, income, education, marital status, and LTPA. Fisher exact test was used to analyze the 100 sedentary elders (LTPA <500 kcal/wk; 63 MAs and 37 EAs). Self-consciousness and lack of self-discipline, interest, company, enjoyment, and knowledge were found to be the predominant barriers to LTPA in both groups. Both groups held similar beliefs about benefits gained from exercise, such as improved self-esteem, mood, shape, and health, but the beliefs about the positive benefits of exercise were more prevalent in MAs. These findings remained after adjusting for age, income, education, marital status, and sex. Some might think that a major barrier lies in misconception about benefits of LTPA, but in this study, both ethnic groups were accurate in their perceived benefits of LTPA. When attempting to engage elderly in LTPA, it is important not only to consider what barriers exist but also what beliefs about the benefits exist.