The online discussion advances understanding of the effect of comorbidity on the interpretation and application of clinical trial findings.1–6 The discussion supports recent calls for greater focus on documenting and presenting the information needed to assess external validity in clinical trials.7,8 In addition, guidelines based on clinical trials that don’t adequately consider comorbidity can result in polypharmacy1 and impractical recommendations.5,6 Bayliss proposes classifying comorbidity on the basis of the effect of comorbid conditions on the "condition of interest."3 Her 3 categories of comorbidities have different implications for understanding and applying clinical trial data to the care of patients with complex conditions. These categories are (1) pathophysiologically related conditions that require congruent treatment plans, (2) conditions that have discordant and potentially competing treatments, and (3) conditions that do not affect the primary disease or treatment.
EXEMPLARY PRACTICE
"Exemplary practice research gives us information and, frankly, gives us hope."9 The article by Solberg et al in the last issue of Annals not only prompted readers to define a field of research that focuses on exemplary practices, but elicited further observations of what makes a practice exemplary.10 These features include shared understanding of mission, vision, and values; consistent leadership; an egalitarian spirit; openness to conversations about change; and a culture of caring.9 A related set of features is leadership that focuses on a mission which encompasses both business and clinical activities, supporting but not micromanaging leaders of practice components, 2-way communication at all levels of the practice, a team model, and focusing on practice-patient relationships.11
Other online discussions relate pearls for minimizing unintended consequences of the electronic health record on relationship-centered care12,13 and for developing skills and systems to integrate care of addicted patients into primary care.14,15
The essay on facilitating collaboration among the generalist disciplines elicited calls for leadership that moves beyond competition to bring the disciplines together to solve important problems.16–19
POSTPARTUM SUPPORT
The study by McGovern et al in the last issue of Annals stimulated reporting of new data and recommendations on postpartum needs.20–22 The discussion also related important contextual information on public and work-place policies in different countries.23–26 "In cultures that care for mothers after birth, mothers are allowed adequate rest, they have ongoing breastfeeding support from their care providers and family members, and their transition to motherhood is honored with rituals that celebrate this major life change."263113
REFERENCES
van den Akker M. Invited commentary: Comorbidity and multimorbidity in family medicine: also relevant for research .
Beasley J. Bravo for raising the issue.
Bayliss E. A methodological suggestion for the management of comorbidities in randomized controlled trials.
Hogg WE. Randomized controlled trials: do they have external validity for patients with multiple comorbidity.
Wright NMJ. Randomised controlled trials: do they have external validity for patients with multiple comorbidities? Invited commentary .
Soubhi H. Too tall for the bed.
Glasgow RE, Green LW, Klesges LM, et al. External validity: we need to do more. Ann Behav Med. 2006;31:105–108.
Green LW, Glasgow RE. Evaluating the relevance, generalization, and applicability of research: issues in external validation and translation methodology. Eval Health Prof. 2006;29:126–153.
Craigie FC. Organizational culture and exemplary practices.
Solberg LI, Hroscikoski MC, Sperl-Hillen JM, Harper PG, Crabtree BF. Transforming medical care: case study of an exemplar small medical group. Ann Fam Med. 2006;4:109–116.
Stello B. Lessons for every practice in exemplary medical group.
Scherger JE. Relationship centered care using the EHR .
Haq CL. Complexity.
Parran TV. Strong endorsement for generalists considering buprenorphine training.
Chirayath HT. A rare perspective.
Green LA. Next steps.
Kuo D. CME: Low hanging fruit and a first step toward collaboration.
Katerndahl DA. Recognize and support current multidisciplinary actions.
Khan OA. Collaboration in primary care is not just necessary but right.
McGovern PM, Dowd B, Gjerdingen D, et al. The postpartum health of employed mothers five weeks after childbirth. Ann Fam Med. 2006;4:159–167.
Sakala C, et al. Let’s help women improve their chances for good postpartum health .
McGovern PM. RE: "Glad to see this" by Dr. Marily Culp.
Dagher RK. A wakeup call for employers.
Harper D. Why is something so natural, so hard for society to understand.
Yawn N. Demedicalize labor and delivery but assess the health care needs of postpartum women.
Kendall-Tackett KA. Inadequate postpartum support for U.S. mothers.
(文章出处：《家庭医学史册》)齐康网
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