In This Issue: On-the-Ground Advances & High-Level Influences
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* Kurt C. Stange

This issue of *Annals* conveys new knowledge to support practice- and patient-level improvements in practice, and reveals policy-level factors that constrain or enhance on-the-ground work to improve health.

## ON-THE-GROUND ADVANCES

The sweet spot between the easy, usual way of measuring blood pressure and the hassle of 24-hour monitoring is investigated by Bos and colleagues.1 They find that in-office automated blood pressure monitoring over 30 minutes results in a dramatic reduction in the number of patients who meet criteria for treatment intensification. In a related editorial, Green states that routine office blood pressures should no longer be used to diagnose or modify hypertension treatment. He calls for practice-based research and new approaches so that clinicians “get it right” for their patients.2

A prospective study of screening for diabetes compares point-of-care glycosylated hemoglobin testing with standard care, and finds a much higher rate of pre-diabetes diagnosis with systematic use of point-of-care glycosylated hemoglobin testing. The authors conclude that glycosylated hemoglobin “may be the most effective method to identify patients unknowingly living in hyperglycemia.”3

Elmore et al experiment with offering patients in a large primary care safety net clinic the opportunity to type their visit agendas in the electronic visit note prior to seeing their clinician.4 Both patients and clinicians find that this improves communication, and most want to continue having patients type their agendas in the future. They conclude that “Enabling patients to type visit agendas may enhance care by engaging patients and giving clinicians an efficient way to prioritize patients’ concerns.”

Having both patients and physicians wash their hands is found by Doyle et al to be a promising approach to assuring high rates of use of this simple, important infection control practice.5

In a cluster randomized trial, LaPorte and colleagues find that a brief intervention by general practitioners working with young cannabis users has subtle effects in subgroups, but no overall effect on cannabis consumption.6

Parents’ expectations regarding antibiotics for children with acute respiratory infections is evaluated by Hoffmann et al. They find that while most parents recognize potential harms from antibiotics, they overestimate their effect on symptom duration by 5 to 10 times.7

The usefulness of antibiotics for children whose eczema appears infected is examined in a clinical trial by Francis et al. They find no added effect of topical or oral antibiotics over topical steroids and emollients.8

In a reflective personal essay, Ventres offers an internal blueprint for providing person-centered care. Seven “intentions of practice” help him attend to patients as complex human beings.9

Young et al approach patient-centeredness through a different lens. Their essay provides perspectives on the particular challenges of measuring quality in primary medical care.10

## HIGH-LEVEL INFLUENCES

Care coordination across 11 countries is examined by Penm et al.11 They find that patients are less likely to experience poor care coordination if their primary care physician knows their history well, spends sufficient time with them, involves them in care, and explains things well. Among 11 high income countries, care coordination is poorest in the United States.

Rhodes and colleagues test the hypothesis that the Patient Protection and Affordable Care Act’s expansion of access—now threatened—might overwhelm primary care by increasing access for millions of new patients. In 10 diverse states, by the measure of median wait times for new appointments, there was no evidence of being overwhelmed.12 Multiple other studies show that primary care is stretched dangerously thin. This study shows that despite being stretched, primary care has the ability to adapt to meet demands when policy changes bring additional opportunities for service.

In a study of the long-term “imprint” of training, Phillips and colleagues find that the spending pattern of physicians training in high cost vs low cost Hospital Service Areas persists long after training.13

An article by authors from the Patient-Centered Outcomes Research Institute (PCORI) shares an Engagement Rubric developed from multiple sources. Building on decades of prior work in participatory research by others, the PCORI Engagement Rubric provides a framework for involving patients and other stakeholders in all phases of research.14

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

## GRATITUDE AND TRANSITIONS

The *Annals’* Editorial Advisory Board provides crucial strategic advice about the journal’s direction, connections, and the conversations in which we participate. They also provide critical connections to diverse people and ideas served by *Annals*. We would like to thank the following outgoing Board members for their years of guidance and insights: 

*   Richard Antonelli, MD

*   Ed Bope, MD

*   Carolyn Clancy, MD

*   Nicole Gentile, MD

*   Ann Louise Kinmonth, MD

*   Steve Reid, MD

*   Moira Stewart, PhD

*   Richard “Mort” Wasserman, MD

*   Jack Westfall, MD

We are delighted to welcome four new members to the Board: 

*   Sarah Burbank, BS, Rush Medical College (student member)

*   Alexander Fiks, MD, MSCE, Children’s Hospital of Philadelphia and Pediatric Research in Office Settings

*   Robert McNellis, MPH, PA, Agency for Health Care Research and Quality

*   Sally Okun, RN, MMHS, PatientsLikeMe

Over the past year, the *Annals* team has benefitted greatly from the service of 2 Editorial Fellows who, in addition to learning about the processes of editing and publishing a journal and undertaking special projects, have functioned as editors. We are grateful for their outstanding work with us: 

*   Alan Adelman, MD, MS

*   Michael Johansen, MD

Finally, we are happy to welcome Ahmed Rashid, MBChB, MSc, MRCGP as the new *Annals* Editorial Fellow. Ahmed currently is a clinical teaching fellow at the University College of London Medical School and brings clinical, teaching, research, and social media expertise to his work with us.

## Footnotes

*   Conflict of interest: Kurt Stange has been a member of the National Commission of Prevention Priorities since it began.

*   © 2017 Annals of Family Medicine, Inc.

## References

1.  Bos MJ, Buis S. Thirty-minute office blood pressure monitoring in primary care. Ann Fam Med. 2017;15(2):120–123.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTUvMi8xMjAiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzE1LzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

2.  Green LA. It is time to change how we measure blood pressures in the office. Ann Fam Med. 2017;15(2):105–106.
    
    [FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTUvMi8xMDUiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzE1LzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

3.  Whitley HP, Hanson C, Parton JM. Systematic diabetes screening using point-of-care A1c testing facilitates identification of prediabetes. Ann Fam Med. 2017;15(2):162–164.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTUvMi8xNjIiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzE1LzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

4.  Anderson MO, Jackson SL, Oster NV, et al. Patients typing their own visit agendas into an electronic medical record: pilot in a safety-net clinic. Ann Fam Med. 2017;15(2):158–161.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTUvMi8xNTgiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzE1LzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

5.  Doyle GA, Xiang J, Zaman H, et al. Patient attitudes and participation in hand co-washing in an outpatient clinic before and after a prompt. Ann Fam Med. 2017;15(2):155–157.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTUvMi8xNTUiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzE1LzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

6.  Laporte C, Vaillant-Roussel H, Pereira B, et al. Cannabis and young users—a brief intervention to reduce their consumption (CANABIC): a cluster randomized controlled trial in primary care. Ann Fam Med. 2017;15(2):131–139.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTUvMi8xMzEiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzE1LzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

7.  Coxeter PD, Del Mar C, Hoffmann TC. Parents’ expectations and experiences of antibiotics for acute respiratory infections in primary care. Ann Fam Med. 2017;15(2):149–154.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTUvMi8xNDkiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzE1LzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

8.  Francis NA, Ridd MJ, Thomas-Jones E, et al. Oral and topical antibiotics for clinically infected eczema in children: a pragmatic randomized controlled trial in ambulatory care. Ann Fam Med. 2017;15(2):124–130.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTUvMi8xMjQiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzE1LzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

9.  Ventres WB. Looking within: intentions of practice for person-centered care. Ann Fam Med. 2017;15:171–174.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTUvMi8xNzEiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzE1LzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

10. Young RA, Roberts RG, Holden RJ. The challenges of measuring, improving, and reporting quality in primary care. Ann Fam Med. 2017;15(2):175–182.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTUvMi8xNzUiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzE1LzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

11. Penm J, MacKinnon NJ, Strakowski SM, Ying J, Doty MM. Minding the gap: factors associated with primary care coordination of adults in 11 countries. Ann Fam Med. 2017;15(2):113–119.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTUvMi8xMTMiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzE1LzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

12. Rhodes KV, Basseyn S, Friedman AB, Kenney GM, Wissoker D, Polsky D. Access to primary care appointments following 2014 insurance expansions. Ann Fam Med. 2017;15(2):107–112.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTUvMi8xMDciO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzE1LzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

13. Phillips RL, Petterson SM, Bazemore AW, Wingrove P, Puffer JC. The effects of training institution practice costs, quality, and other characteristics on future practice. Ann Fam Med. 2017;15(2):140–148.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTUvMi8xNDAiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzE1LzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

14. Sheridan S, Schrandt S, Forsythe L, Hilliard TS, Paez KA. The PCORI Engagement Rubric: promising practices for partnering in research. Ann Fam Med. 2017;15(2):165–170.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTUvMi8xNjUiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzE1LzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==)