In This Issue: Views from Above and Below

Abstract

An interesting array of articles in this issue provides both high-level and on-the-ground perspectives on how policy and particulars interact to affect health. Two articles identify novel risk factors. Chou and colleagues use a nationwide database to discover that sleep apnea more than doubles the risk of subsequently developing panic disorder.1 Using a nationally representative database, Skeldon et al find that erectile dysfunction, already known to be a marker for future cardiovascular disease, doubles the odds of having undiagnosed diabetes.2 For an average middle-aged man, the probability of undiagnosed diabetes jumps from 1 in 50 to 1 in 10 in men with erectile dysfunction. A nationally representative study of women aged 28 to 84 years examines sexual activity and satisfaction in mid-life and older women.3 Among older women who are sexually active, sexual satisfaction is not related to age, but to higher relationship satisfaction, better communication, and higher importance placed on sex. Bupropion, a drug with a favorable side-effect profile that often is helpful in treating depression and for quitting smoking, also has abuse potential, mimicking crack cocaine or amphetamines when crushed and snorted or injected. Steele and colleagues find evidence of a dramatic increase in duplicitous prescriptions for bupropion in Ontario between 2000 and 2013, suggesting a need for prescribing vigilance against growing misuse.4 A mixed methods study explores barriers to implementing HPV vaccinations.5 Tailoring counseling strategies and tracking/distributing patient reminders are among the challenges faced by primary care clinicians. Using data from a novel policy experiment and a network of community health centers, Bailey and colleagues find that patients randomly assigned to apply for Medicaid use a wider variety of services than do uninsured patients, suggesting the need for growing support of primary care for the underserved.6 Another policy analysis finds that compensation arrangements are similar for primary care physicians in and outside of accountable care organizations, but physician compensation by salary is higher in practices that bear at least some financial risk. The many evolving payment changes represent a large, uncontrolled experiment worthy of ongoing evaluation.7 A special report form Tiperneni et al proposes using lessons from community-oriented primary care to move from the current narrowly health care–focused accountable care organizations toward “accountable communities for health” that address health from a community perspective that includes the total investment in health across all sectors.8 This approach is more inclusive of the diverse determinants of health, and thus has much greater potential to improve population health than that of current accountable care organizations. An unintended consequence from a well-meaning and evidence-based clinical guideline change is examined by Ruffin et al in a study featured in Annals Journal Club.9 The authors find a dramatic reduction in chlamydia screening among young women after guidelines changed recommend beginningcervical cancer screening at age 21.10 Another study is interesting because it brings together both patient and staff experiences in primary care for people with chronic illnesses and either no insurance or Medicaid. Both patients and staff members highly value personal relationships, but find information flow and misaligned goals and expectations to be challenges.11 A research brief describes the development and validation of online medical database search filters to identify research studies of relevance to family medicine. Two filters balance specificity and sensitivity.12 A series of insightful essays make real the importance of access and relationships for health care and health,13 the value of openness to teachable moments,14 and the potential of integration into primary care to make genomic medicine helpful to patients.15 We welcome your reflections at AnnFamMed.org.