Organizing Health Care for Value ================================ * Kurt C. Stange The thoughtfulness and diversity of the *Annals* online discussion continues to greatly enrich the interpretation and action steps from the articles that are published. Some online comments, such as Nouwen’s critique of whether diabetes doubles the risk of depression1 or Dunlop’s well-referenced elucidation of the relationship between activity and youth obesity,2 put the studies on which they comment into a larger context of literature and experience. Other discussion provides evidence for how to focus health care reform.3–6 One comment shares a clinical pearl about when and how to consider thoracic outlet syndrome as a cause for arm, neck or shoulder pain.7 Other lines of discussion, such as those surrounding Valderas’ analysis of multimorbidity8 or reflections on the editorial series on generalism and high-value health care,9,10 appear to be helping to define and focus emerging directions for the field. The continuing discussion of Hahn’s analysis11 of evidence grading and the process of guideline implementation advances the field of clinical guideline development. The discussion puts into context the methods, politics, and quality of evidence used to establish clinical guidelines.12 A group of 20 family medicine residents that used this article for their journal club13 found Hahn’s analysis to be “an ‘eye opener’ that evidence-grading guidelines in use have many flaws.” These journal club participants concluded that “as a group we decided to not take evidence grading guidelines at face value, but to do our own research and be better informed.”14 When an article particularly resonates or challenges, I would ask readers to consider periodically checking on and contributing to the online discussion.15 Well-referenced comments and analysis are welcomed, but so are short, simple responses that add a single point, whether they are challenges, questions, interpretation, or exhortation.16 Please join the conversation at [http://www.AnnFamMed.org](http://www.AnnFamMed.org). * © 2009 Annals of Family Medicine, Inc. ## REFERENCES 1. Nouwen A. Does diabetes double the risk of depression? Comment on O’Connor, et al [eletter]. [http://www.annfammed.org/cgi/eletters/7/4/328#11171](http://www.annfammed.org/cgi/eletters/7/4/328#11171), 4 Sep 2009. 2. Dunlop AL. Barriers to physical activity are afoot for overweight youth [eletter]. [http://www.annfammed.org/cgi/eletters/7/4/352#11128](http://www.annfammed.org/cgi/eletters/7/4/352#11128), 28 Aug 2009. 3. Allin SM. Inequity in health care use—what are the causes and solutions [eletter]? [http://www.annfammed.org/cgi/eletters/7/5/396#11264](http://www.annfammed.org/cgi/eletters/7/5/396#11264), 22 Sep 2009. 4. Guendelman S. Health care reform should consider the same health plan for children and their parents [eletter]. [http://www.annfammed.org/cgi/eletters/7/5/406#11312](http://www.annfammed.org/cgi/eletters/7/5/406#11312), 13 Oct 2009. 5. Sommers BD. Covering entire families is better for both children and adults [eletter]. [http://www.annfammed.org/cgi/eletters/7/5/406#11249](http://www.annfammed.org/cgi/eletters/7/5/406#11249), 18 Sep 2009. 6. Russell GM. Context, practices and individuals [eletter]. [http://www.annfammed.org/cgi/eletters/7/4/309#11067](http://www.annfammed.org/cgi/eletters/7/4/309#11067), 25 Aug 2009. 7. Selmonosky CA. An ignored common cause of arm, neck and shoulder pain [eletter]. [http://www.annfammed.org/cgi/eletters/7/5/446#11288](http://www.annfammed.org/cgi/eletters/7/5/446#11288), 24 Sep 2009. 8. TRACK discussion in response to: Valderas JM, Starfield B, Sibbald B, Salisbury C, Roland M. Defining comorbidity: implications for understanding health and health services. Ann Fam Med. 2009;7(4):357–363. [http://www.annfammed.org/cgi/eletters/7/4/357](http://www.annfammed.org/cgi/eletters/7/4/357). Accessed Oct 16, 2009. [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiNy80LzM1NyI7czo0OiJhdG9tIjtzOjIyOiIvYW5uYWxzZm0vNy82LzU1OS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 9. TRACK discussion in response to: Stange KC. The problem of fragmentation and the need for integrative solutions. Ann Fam Med. 2009;7(2):100–103. [http://www.annfammed.org/cgi/eletters/7/2/100](http://www.annfammed.org/cgi/eletters/7/2/100). Accessed Oct 15, 2009. [FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiNy8yLzEwMCI7czo0OiJhdG9tIjtzOjIyOiIvYW5uYWxzZm0vNy82LzU1OS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 10. TRACK discussion in response to: Stange KC, Ferrer RL. The paradox of primary care. Ann Fam Med. 2009;7(4):293–299. [http://www.annfammed.org/cgi/eletters/7/4/293](http://www.annfammed.org/cgi/eletters/7/4/293). Accessed Oct 15, 2009. [FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiNy80LzI5MyI7czo0OiJhdG9tIjtzOjIyOiIvYW5uYWxzZm0vNy82LzU1OS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 11. Hahn DL. Importance of evidence grading for guideline implementation: the example of asthma. Ann Fam Med. 2009;7(4):364–369. [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiNy80LzM2NCI7czo0OiJhdG9tIjtzOjIyOiIvYW5uYWxzZm0vNy82LzU1OS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 12. TRACK discussion in response to: Hahn DL. Importance of evidence grading for guideline implementation: the example of asthma. Ann Fam Med. 2009;7(4):364–369. [http://www.annfammed.org/cgi/eletters/7/4/364](http://www.annfammed.org/cgi/eletters/7/4/364). Accessed Oct 15, 2009. [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiNy80LzM2NCI7czo0OiJhdG9tIjtzOjIyOiIvYW5uYWxzZm0vNy82LzU1OS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 13. Stange KC. Symbiosis instead of competing demands: a tale of 2 preventive services. [*Annals* Journal Club]. Ann Fam Med. 2009;7(4):iii. [FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiNy8xL2lpaSI7czo0OiJhdG9tIjtzOjIyOiIvYW5uYWxzZm0vNy82LzU1OS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 14. Coray AK. Eye opening article about evidence grading [eletter]. [http://www.annfammed.org/cgi/eletters/7/4/364#11133](http://www.annfammed.org/cgi/eletters/7/4/364#11133), 28 Aug 2009. 15. Stange KC. On TRACK: How to use the *Annals* online discussion. Ann Fam Med. 2004;2(6):611–612. [FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiMi82LzYxMSI7czo0OiJhdG9tIjtzOjIyOiIvYW5uYWxzZm0vNy82LzU1OS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 16. Stange KC. On TRACK: Questions, interpretation, exhortation. Ann Fam Med. 2004;2(5):514–517. [FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiMi81LzUxNCI7czo0OiJhdG9tIjtzOjIyOiIvYW5uYWxzZm0vNy82LzU1OS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=)