In This Issue: Finding the Sweet Spot in Health Care
====================================================

* Kurt C. Stange

Superb and subtle health care involves balancing risk and benefit, person and population, individual decision and data, and system support of that decision and the resulting action. Optimizing the nuances in this balancing act is the challenge, joy, and opportunity of both health care and health policy making. Finding the sweet spot between all these trade-offs is the theme of this issue of *Annals*.

Two articles 1,2 help us to balance the positive and negative effects of screening: Brodersen et al by finding the substantial 6-month and 3-year psychological harm of false-positive mammograms1; Garrison and colleagues by comparing the sensitivity and specificity of measuring blood pressure at each patient visit vs limiting blood pressure measurement to once a year.2

The sweet spot in designing care for people with diabetes ironically involves reducing blood glucose levels, among other outcomes. Thom and colleagues’ clinical trial finds that clinic-based health coaching improves the glycemic control of patients seen in urban public health clinics.3 Multiple outcomes among African American diabetics seen in rural fee-for-service practices are improved by a team approach at the point of care in a study by Bray and colleagues.4

The trade-offs in balancing the population and individual risks of antibiotic side effects and resistance and the potential small benefit of antibiotics for selected people with respiratory tract infections are found in two studies. In a large cohort of patients consulting their physicians for respiratory infections, Meropol and colleagues find a small reduction in subsequent hospitalization for pneumonia and no increase in severe adverse drug reactions for those prescribed antibiotics.5 Cals et al assess the long-term effects on office visit rates and antibiotic prescribing from a pragmatic trial of family physicians’ use of C-reactive protein point-of care-testing and/or training in enhanced communication skills. They find no effect for C-reactive protein, but they did find reductions in antibiotic use during the 3.5 years of follow-up among patients of physicians receiving communication training.6

One study provides information to help optimize the referral and consultation process. A Web-based consultation system between family physicians and nephrologists reduces the number of referrals and appears to improve treatment appropriateness among patients with chronic kidney disease.7

Licciardone et al provide clinical trial evidence of the short-term efficacy of osteopathic manual treatment for nonspecific chronic low back pain and the inefficacy of ultrasound therapy.8

The multiple factors affecting physicians’ likelihood of prescribing long-acting reversible contraception to adolescents are identified by Rubin et al.9

The large opportunity and policy imperative of using the Primary Care Extension Program provision of the Affordable Care Act10 are articulated in an analysis from the Robert Graham Center for Policy Studies in Family Medicine and Primary Care.11

And in an analysis of the practices of general medical journals, the authors find that a quarter of journals at least occasionally receive previous peer-review reports from authors submitting manuscripts. Editors report both pros and cons.12 The *Annals* is among the journals that periodically finds courageous authors submitting other editors’ rejection letters and prior peer reviews along with their manuscript submission to us. We try to take a fresh look at the manuscript, but find that the additional information does sometimes help to expedite the decision process.

In balancing our work on the *Annals* editorial team, we are delighted to announce that Bijal Balasubramanian, MBBS, PhD, has joined us as an associate editor. Dr Balasubramanian is an assistant professor at the University of Texas School of Public Health in Dallas. Her research relates to the quality of health care provided to primary care patients and to practice/clinician/ patient interactions that contribute to the quality and equity of care across the cancer control continuum. She brings strong methodological skills in addition to content expertise to the editorial team.

Finally, we are delighted to announce for the first time an editorial internship at the *Annals of Family Medicine*. The specific call for applications for a March 30, 2013, deadline is available on the *Annals* homepage at [http://annfammed.org](http://annfammed.org). The editorial intern will gain experience in diverse aspects of the process of editing an international journal, and will have the opportunity to work on a project to improve the *Annals’* ability to meet its mission of advancing knowledge essential to understanding and improving health and primary care. We are excited about this opportunity to add to the talent of the *Annals* team and to contribute to the editorial capacity of the field, and we look forward to receiving applications from qualified and enthusiastic candidates.

We welcome your reflections at [http://www.AnnFamMed.org](http://www.AnnFamMed.org).

*   © 2013 Annals of Family Medicine, Inc.

## References

1.  Brodersen J, Siersma VD. Long-term psychosocial consequences of false-positive screening mammography. Ann Fam Med. 2013; 11(2):106–115.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTEvMi8xMDYiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzExLzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

2.  Garrison GM, Oberhelman S. Screening for hypertension annually compared with current practice. Ann Fam Med. 2013;11(2):116–121.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTEvMi8xMTYiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzExLzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

3.  Thom DH, Ghorob A, Hessler D, De Vore D, Chen E, Bodenheimer TA. Impact of peer health coaching on glycemic control in lowincome patients with diabetes: a randomized controlled trial. Ann Fam Med. 2013;11(2):137–144.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTEvMi8xMzciO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzExLzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

4.  Bray P, Cummings DM, Morrissey S, et al. Improved outcomes in diabetes care for rural African Americans. Ann Fam Med. 2013;11 (2):145–150.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTEvMi8xNDUiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzExLzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

5.  Meropol SB, Localio AR, Metlay JP. Risks and benefits associated with antibiotic use for acute respiratory infections: a cohort study. Ann Fam Med. 2013;11(2):165–172.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTEvMi8xNjUiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzExLzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

6.  Cals JWL, de Bock L, Beckers PHW, et al. Enhanced communication skills and C-reactive protein point-of-care testing for respiratory tract infection: 3.5-year follow-up of a cluster randomized trial. Ann Fam Med. 2013;11(2):157–164.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTEvMi8xNTciO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzExLzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

7.  Scherpbier-de Haan ND, van Gelder VA, van Weel C, Vervoort GMM, Wetzels JFM, de Grauw WJC. Initial implementation of a Web-based consultation process for patients with chronic kidney disease. Ann Fam Med. 2013;11(2):151–156.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTEvMi8xNTEiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzExLzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

8.  Licciardone JC, Minotti DE, Gatchel RJ, Kearns CM, Singh KP. Osteopathic manual treatment and ultrasound therapy for relief of chronic low back pain: a randomized controlled trial. Ann Fam Med. 2013;11(2):122–129.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTEvMi8xMjIiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzExLzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

9.  Rubin SE, Davis K, McKee MD. New York City physicians’ views of providing long-acting reversible contraception to adolescents. Ann Fam Med. 2013;11(2):130–136.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTEvMi8xMzAiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzExLzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

10. Grumbach K, Mold JW. A health care cooperative extension service: transforming primary care and community health. JAMA. 2009;301(24):2589–2591.
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1001/jama.2009.923&link_type=DOI) 
    
    [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=19549977&link_type=MED&atom=%2Fannalsfm%2F11%2F2%2F102.atom) 
    
    [Web of Science](http://www.annfammed.org/lookup/external-ref?access_num=000267266500025&link_type=ISI) 

11. Phillips RL Jr., Kaufman A, Mold JW, et al. The primary care extension program: a catalyst for change. Ann Fam Med. 2013;11(2):173–178.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTEvMi8xNzMiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzExLzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

12. Cals JWL, Mallen CD, Glynn LG, Kotz D. Should authors submit previous peer-review reports when submitting research papers? Views of general medical journal editors. Ann Fam Med. 2013;11(2):179–181.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTEvMi8xNzkiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzExLzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==)