Quality Improvement in Otolaryngology-Head and Neck Surgery: Developing Registry-Enabled Quality Measures From Guidelines for Cerumen Impaction and Allergic Rhinitis Through a Transparent and Systematic Process.

BACKGROUND AND SIGNIFICANCE: Quality measurement can drive improvement in clinical care and allow for easy reporting of quality care by clinicians, but creating quality measures is a time-consuming and costly process. ECRI (formerly Emergency Care Research Institute) has pioneered a process to support systematic translation of clinical practice guidelines into electronic quality measures using a transparent and reproducible pathway. This process could be used to augment or support the development of electronic quality measures of the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) and others as the Centers for Medicare and Medicaid Services transitions from the Merit-Based Incentive Payment System (MIPS) to the MIPS Value Pathways for quality reporting. METHODS: We used a transparent and reproducible process to create electronic quality measures based on recommendations from 2 AAO-HNSF clinical practice guidelines (cerumen impaction and allergic rhinitis). Steps of this process include source material review, electronic content extraction, logic development, implementation barrier analysis, content encoding and structuring, and measure formalization. Proposed measures then go through the standard publication process for AAO-HNSF measures. RESULTS: The 2 guidelines contained 29 recommendation statements, of which 7 were translated into electronic quality measures and published. Intermediate products of the guideline conversion process facilitated development and were retained to support review, updating, and transparency. Of the 7 initially published quality measures, 6 were approved as 2018 MIPS measures, and 2 continued to demonstrate a gap in care after a year of data collection. CONCLUSION: Developing high-quality, registry-enabled measures from guidelines via a rigorous reproducible process is feasible. The streamlined process was effective in producing quality measures for publication in a timely fashion. Efforts to better identify gaps in care and more quickly recognize recommendations that would not translate well into quality measures could further streamline this process.

SMAP L-Band Microwave Radiometer: Instrument Design and First Year on Orbit.

The Soil Moisture Active-Passive (SMAP) L-band microwave radiometer is a conical scanning instrument designed to measure soil moisture with 4% volumetric accuracy at 40-km spatial resolution. SMAP is NASA's first Earth Systematic Mission developed in response to its first Earth science decadal survey. Here, the design is reviewed and the results of its first year on orbit are presented. Unique features of the radiometer include a large 6-m rotating reflector, fully polarimetric radiometer receiver with internal calibration, and radio-frequency interference detection and filtering hardware. The radiometer electronics are thermally controlled to achieve good radiometric stability. Analyses of on-orbit results indicate that the electrical and thermal characteristics of the electronics and internal calibration sources are very stable and promote excellent gain stability. Radiometer NEDT < 1 K for 17-ms samples. The gain spectrum exhibits low noise at frequencies >1 MHz and 1/f noise rising at longer time scales fully captured by the internal calibration scheme. Results from sky observations and global swath imagery of all four Stokes antenna temperatures indicate that the instrument is operating as expected.

Clinical practice guideline: Allergic rhinitis.

OBJECTIVE: Allergic rhinitis (AR) is one of the most common diseases affecting adults. It is the most common chronic disease in children in the United States today and the fifth most common chronic disease in the United States overall. AR is estimated to affect nearly 1 in every 6 Americans and generates $2 to $5 billion in direct health expenditures annually. It can impair quality of life and, through loss of work and school attendance, is responsible for as much as $2 to $4 billion in lost productivity annually. Not surprisingly, myriad diagnostic tests and treatments are used in managing this disorder, yet there is considerable variation in their use. This clinical practice guideline was undertaken to optimize the care of patients with AR by addressing quality improvement opportunities through an evaluation of the available evidence and an assessment of the harm-benefit balance of various diagnostic and management options. PURPOSE: The primary purpose of this guideline is to address quality improvement opportunities for all clinicians, in any setting, who are likely to manage patients with AR as well as to optimize patient care, promote effective diagnosis and therapy, and reduce harmful or unnecessary variations in care. The guideline is intended to be applicable for both pediatric and adult patients with AR. Children under the age of 2 years were excluded from the clinical practice guideline because rhinitis in this population may be different than in older patients and is not informed by the same evidence base. The guideline is intended to focus on a limited number of quality improvement opportunities deemed most important by the working group and is not intended to be a comprehensive reference for diagnosing and managing AR. The recommendations outlined in the guideline are not intended to represent the standard of care for patient management, nor are the recommendations intended to limit treatment or care provided to individual patients. ACTION STATEMENTS: The development group made a strong recommendation that clinicians recommend intranasal steroids for patients with a clinical diagnosis of AR whose symptoms affect their quality of life. The development group also made a strong recommendation that clinicians recommend oral second-generation/less sedating antihistamines for patients with AR and primary complaints of sneezing and itching. The panel made the following recommendations: (1) Clinicians should make the clinical diagnosis of AR when patients present with a history and physical examination consistent with an allergic cause and 1 or more of the following symptoms: nasal congestion, runny nose, itchy nose, or sneezing. Findings of AR consistent with an allergic cause include, but are not limited to, clear rhinorrhea, nasal congestion, pale discoloration of the nasal mucosa, and red and watery eyes. (2) Clinicians should perform and interpret, or refer to a clinician who can perform and interpret, specific IgE (skin or blood) allergy testing for patients with a clinical diagnosis of AR who do not respond to empiric treatment, or when the diagnosis is uncertain, or when knowledge of the specific causative allergen is needed to target therapy. (3) Clinicians should assess patients with a clinical diagnosis of AR for, and document in the medical record, the presence of associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media. (4) Clinicians should offer, or refer to a clinician who can offer, immunotherapy (sublingual or subcutaneous) for patients with AR who have inadequate response to symptoms with pharmacologic therapy with or without environmental controls. The panel recommended against (1) clinicians routinely performing sinonasal imaging in patients presenting with symptoms consistent with a diagnosis of AR and (2) clinicians offering oral leukotriene receptor antagonists as primary therapy for patients with AR. The panel group made the following options: (1) Clinicians may advise avoidance of known allergens or may advise environmental controls (ie, removal of pets; the use of air filtration systems, bed covers, and acaricides [chemical agents formulated to kill dust mites]) in patients with AR who have identified allergens that correlate with clinical symptoms. (2) Clinicians may offer intranasal antihistamines for patients with seasonal, perennial, or episodic AR. (3) Clinicians may offer combination pharmacologic therapy in patients with AR who have inadequate response to pharmacologic monotherapy. (4) Clinicians may offer, or refer to a surgeon who can offer, inferior turbinate reduction in patients with AR with nasal airway obstruction and enlarged inferior turbinates who have failed medical management. (5) Clinicians may offer acupuncture, or refer to a clinician who can offer acupuncture, for patients with AR who are interested in nonpharmacologic therapy. The development group provided no recommendation regarding the use of herbal therapy for patients with AR.

Clinical practice guideline: allergic rhinitis executive summary.

The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) has published a supplement to this issue featuring the new Clinical Practice Guideline: Allergic Rhinitis. To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 14 recommendations developed address the evaluation of patients with allergic rhinitis, including performing and interpretation of diagnostic testing and assessment and documentation of chronic conditions and comorbidities. It will then focus on the recommendations to guide the evaluation and treatment of patients with allergic rhinitis, to determine the most appropriate interventions to improve symptoms and quality of life for patients with allergic rhinitis.

Medical malpractice and rhinology.

BACKGROUND: Physicians facing malpractice litigation are in uncharted territory. The language, concepts, rules, and strategies of the legal system are foreign to science-based physicians. Understanding the statistics of rhinology malpractice litigation may aid the physician to cope with the assault of a claim. METHODS: Information from the 2006 Physician Insurers Association of America (PIAA) and the 2006 PIAA Risk Management Report (RMR)-Otorhinolaryngology were searched for claims data referable to the nose, nasal chamber, and paranasal sinuses. The PIAA data sharing report (DSR) is the largest single resource of malpractice claims data containing both settlement and trial judgment information. RESULTS: The nose, nasal cavity, and paranasal sinuses represent nearly two-thirds of the total indemnity paid for improper performance from otolaryngology head and neck surgery (Oto-HNS) medical malpractice claims between 1985 and 2005 based on claims information. Improper performance accounts for 50.3% of total monies paid ($107.6 million of $213.6 million) to resolve Oto-HNS claims in this period. Of nearly 2400 operative claims closed in the period of 1985-2005, 34.1% involved procedures on the nose and sinuses. In the past 6 years, $103.5 million indemnity has been added to the otolaryngology total. CONCLUSION: The area of endoscopic sinus surgery has substantially contributed to Oto-HNS claims in the PIAA DSR. Despite malpractice being a cost of medical practice, every claim is perceived as an assault on the surgeon's competence. Ensuring informed consent and complete documentation may assist the provider in defending their care.

Best practice forum: standard high level disinfection protocol development.

Gluteraldehyde-based high-level disinfection (HLD) poses significant safety risks for staff and patients as well as institutional cost concerns. A value analysis team reviewed HLD practices, available products, and environmental requirements in view of the literature and standards developed by the Occupational Safety and Health Administration (OSHA). Institutional areas were identified and standardized unit-specific educational and competency programs were established. The overall use of gluteraldehyde-based HLD was decreased in this institution based on the findings and policy and procedure modification.