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Richard W. Grant, MD, MPH; Jeffrey M. Ashburner, MPH; Clemens S. Hong, MD, MPH; Yuchiao Chang, PhD; Michael J. Barry, MD; and Steve J. Atlas, MD, MPH

Patients with complex health needs are increasingly the focus of health system redesign, and understanding factors that contribute to this complexity is essential. Researchers asked 40 primary care physicians (PCPs) to rate the complexity of 120 of their patients and to document the characteristics associated with complexity. The PCPs defined more than one quarter of patients as complex. Medical, social, and behavioral factors contributed to their assessments, which differed substantially from 3 often-used comorbidity measures. Patient complexity is multidimensional and is not adequately captured in measures that focus only on comorbidity.

Topics: pentachlorophenol, primary health care, comorbidity
  
Donna M. Zulman, MD, MS; Kim M. Nazi, MA; Carolyn L. Turvey, PhD, MS; Todd H. Wagner, PhD; Susan S. Woods, MD, MPH; and Larry C. An, MD

Electronic personal health record systems are being implemented with little understanding of how patients want their information used. In this survey of veterans who use an electronic system containing their medical records and health information, 4 of 5 respondents wanted someone outside of the health system, especially family members and other health care providers, to have access to at least some of their information. The survey response rate was low, so results may not be generalizable to all users. Electronic health record systems should enable secure information sharing with patient-designated users outside of the health system.

Topics: personal health record, veterans, health personnel
  
Jan Walker, RN, MBA; Suzanne G. Leveille, PhD, RN; Long Ngo, PhD; Elisabeth Vodicka, BA; Jonathan D. Darer, MD, MPH; Shireesha Dhanireddy, MD; Joann G. Elmore, MD, MPH; Henry J. Feldman, MD; Marc J. Lichtenfeld, PhD; Natalia Oster, MPH; James D. Ralston, MD, MPH; Stephen E. Ross, MD; and Tom Delbanco, MD

Whether patients and physicians anticipate benefits or harms from allowing patients to have access to physicians' office notes is unknown. In this survey of physicians and patients at 3 institutions, most physicians who planned to participate in a pilot program that provided patients with electronic access to their office notes anticipated benefits to their patients. Physicians who chose not to participate in the program more often worried about potential harms. Patients expected overall benefits more frequently than harms. Further study is needed to assess the benefits and harms of patients' access to their physicians' office notes.

Topics: pentachlorophenol, attitude, demography, privacy
  
Cora McGreevy, MB, BCh, BAO; and David Williams, MB, BAO, BCh, PhD

Vitamin D deficiency is prevalent worldwide and has been linked with hypertension, myocardial infarction, and stroke, as well as diabetes, congestive heart failure, peripheral vascular disease, atherosclerosis, and endothelial dysfunction. This review discusses the physiology and definition of vitamin D deficiency, evaluates its worldwide prevalence, and discusses recent evidence for the association between hypovitaminosis D and cardiovascular disease.

Topics: cardiovascular diseases, vitamin d deficiency, vitamin d, narrative review
  
Mei Chung, PhD, MPH; Jounghee Lee, PhD; Teruhiko Terasawa, MD, PhD; Joseph Lau, MD; and Thomas A. Trikalinos, MD, PhD

This updated systematic review supports the forthcoming U.S. Preventive Services Task Force recommendations on vitamin D with or without calcium supplements for preventing cancer and fractures. The review of 19 trials and 28 observational studies reports that combined vitamin D and calcium supplementation reduces fracture risk in older persons, optimum dosing regimens are unclear, effects of vitamin D supplementation on cancer risk are uncertain, and supplementation may increase the risk for renal and urinary tract stones. Vitamin D supplementation can reduce fracture risk, but the optimal doses and effects on cancer risk are uncertain.

Topics: calcium, cancer, fracture, vitamin d, cancer prevention
  
Dimitri M. Drekonja, MD, MS; Mary Butler, PhD, MBA; Roderick MacDonald, MS; Donna Bliss, PhD, RN; Gregory A. Filice, MD; Thomas S. Rector, PhD; and Timothy J. Wilt, MD, MPH

The incidence and severity of Clostridium difficile infections are increasing, and several antibiotics are available for treatment. This comparative effectiveness review of 11 randomized trials involving adults with C. difficile found that initial cure rates did not significantly differ for fidaxomicin, vancomycin, and metronidazole. Recurrent disease was common with all agents but less frequent with fidaxomicin (15%) than with vancomycin (25%). Any of several agents could be used for initial treatment of C. difficile infection, but fidaxomicin may be a superior agent for recurrent infection.

Topics: vancomycin, diarrhea, metronidazole, infection, comparative effectiveness research, clostridium difficile (bacteria), lipiarmycin, toxins, ...
  
Anupam B. Jena, MD, PhD; Dana P. Goldman, PhD; Susan E. Foster, MSW; and Joseph A. Califano Jr., LLB

Although they are available through traditional channels, controlled prescription medications can also be purchased on the Internet without a prescription. This issue has gained the attention of federal regulators, law enforcement, and the media, but physician awareness of the problem is scarce. This article describes the nature and magnitude of the problem, the challenges to federal and private efforts in combating illegitimate online pharmacies, and strategies for physicians to recognize and minimize the effects of such pharmacies.

Topics: internet, pharmacies, prescription drug abuse, prescription drug, substance abuse
  
Barbara J. Turner, MD, MSEd, MA; and Leona Cuttler, MD

In this issue, Grant and colleagues asked PCPs for their subjective assessment of clinical complexity among a random sample of their own patients. The editorialists discuss the challenges in measuring clinical complexity, describe the study's findings and limitations, and conclude that the article broadens our understanding of patient complexity.

Topics: primary care physicians, substance abuse, comorbidity, elderly, hospitals, pediatric
  

Two articles in this issue focus on providing patients and others with access to a patient's electronic health information. Walker and colleagues surveyed patients and their PCPs about their attitudes before initiation of a voluntary program of sharing physicians' notes with patients, and Zulman and coworkers solicited views from veterans about sharing the contents of their personal health record with their caregivers and providers outside of the system. The editorialists conclude that electronic health records should be used to engage patients and their caregivers. However, they pose critical questions about sharing electronic health records that must be addressed as we move forward.

Topics: medical records, cancer care facilities
  
Julie R. Rosenbaum, MD

As a primary care physician, sometimes it is the smallest request that can create the most trying challenge.

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Jeremy D. Graham, MA, DO; Darryl K. Potyk, MD; and Elise D. Raimi, MSPH
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Carlos O. Weiss, MD; Maia Holden, NP; and Matthew McNabney, MD
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Topics: inpatient, comprehensive geriatric assessment
  
Topics: mediterranean diet, cardiovascular disease risk factors, fat-restricted diet, overweight
  
Topics: diabetes mellitus, type 2, glucose, mortality
  
Topics: ischemic stroke, insulin
  
Topics: acute cerebrovascular accidents, transient ischemic attack, statins
  
Topics: antidepressive agents, irritable bowel syndrome, antispasmodics
  
Topics: hiv-1, anti-retroviral agents
  
Topics: alteplase, deoxyribonuclease i, pleura, treatment outcome, pleural infections and inflammations
  
Topics: hypertension
  
Topics: myocardial infarction, rheumatoid arthritis, diabetes mellitus
  
Topics: kidney failure, chronic, hematuria, microscopic
  
Topics: clopidogrel, stent, genotype, cyp2c19 protein, human
  
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