Ambulatory Quality Improvement Despite COVID-19: Blueprint for a Successful System for Continuous Improvement.

ABSTRACT: In this article, we describe our experience developing and implementing a multipronged approach to improve performance across a strategic subset of quality measures within primary care. Detailed techniques include data visualization and analytics, process reengineering, team engagement, visual project management, continuous improvement methods and training, and incentives and recognition. We achieved positive change across 12 high priority measures which we deemed the "High Value Framework (HVF)" by fostering a collaborative, nonpunitive, problem-solving culture. We focused on measures that had the greatest potential for impact from a clinical, reimbursement, and reputational perspective. More importantly, we sustained gains despite the challenges posed by the COVID-19 pandemic, thereby demonstrating programmatic resilience and high process reliability. This systematic approach serves as a practical blueprint for other healthcare entities seeking to navigate the complexities of quality improvement in a dynamic environment. The model provides a strategic framework for prioritizing and standardizing quality measures, effectively engaging stakeholders, and managing organizational change. Our model emerged from a need to address real-world operational challenges, rather than as an academic or theoretical exercise, and was developed independently of existing literature on measure prioritization and standardization at the time of its inception.

Peptic Ulcer Disease and H. pylori Infection: Common Questions and Answers.

Peptic ulcer disease is common, affecting 1 out of 12 people in the United States. Approximately 1 in 5 peptic ulcers is associated with Helicobacter pylori infection, with most of the rest due to nonsteroidal anti-inflammatory drug (NSAID) use. The combination of H. pylori infection and NSAID use synergistically increases the risk of bleeding ulcers more than sixfold. The H. pylori test-and-treat strategy is the mainstay of outpatient management. Patients younger than 60 years who have dyspepsia without alarm symptoms should be tested and, if positive, treated to eradicate the infection. If negative, they should be treated empirically with a proton pump inhibitor (PPI). Esophagogastroduodenoscopy is recommended for patients 60 years and older with new symptoms and for anyone with alarm symptoms. Noninvasive testing for H. pylori using a urea breath test or stool antigen test is preferred. Bismuth quadruple therapy or concomitant therapy (nonbismuth quadruple therapy) is the preferred first-line treatment for eradication because of increasing clarithromycin resistance. To lower the risk of ulcers associated with long-term NSAID use, clinicians should consider coadministering a PPI or substituting an NSAID with less effect on gastric mucosa, such as celecoxib. Eradicating H. pylori in NSAID users reduces the likelihood of peptic ulcers by one-half. Potential risks of long-term PPI use include fractures, interaction with antiplatelet medications, chronic kidney disease, Clostridioides difficile infection, dementia, and magnesium, calcium, and vitamin B12 micronutrient deficiencies.

Acute Chest Pain in Adults: Outpatient Evaluation.

Approximately 1% of primary care office visits are for chest pain, and 2% to 4% of these patients will have unstable angina or myocardial infarction. Initial evaluation is based on determining whether the patient needs to be referred to a higher level of care to rule out acute coronary syndrome (ACS). A combination of age, sex, and type of chest pain can predict the likelihood of coronary artery disease as the cause of chest pain. The Marburg Heart Score and the INTERCHEST clinical decision rule can also help estimate ACS risk. Twelve-lead electrocardiography is recommended to look for ST segment changes, new-onset left bundle branch block, presence of Q waves, and new T-wave inversions. Patients with suspicion of ACS or changes on electrocardiography should be transported immediately to the emergency department. Those at low or intermediate risk of ACS can undergo exercise stress testing, coronary computed tomography angiography, or cardiac magnetic resonance imaging. In those with low suspicion for ACS, consider other diagnoses such as chest wall pain or costochondritis, gastroesophageal reflux disease, and panic disorder or anxiety states. Other less common, but important, diagnostic considerations include acute pericarditis, pneumonia, heart failure, pulmonary embolism, and acute thoracic aortic dissection.

Amblyopia: Detection and Treatment.

Amblyopia is the leading cause of monocular vision loss in children. Early recognition and treatment are important to prevent vision loss. The U.S. Preventive Services Task Force recommends vision screening for all children at least once between three and five years of age to detect the presence of amblyopia or its risk factors. The American Association for Pediatric Ophthalmology and Strabismus and the American Academy of Pediatrics recommend routine, age-appropriate red reflex testing, examination for signs of strabismus, and vision chart testing. Photoscreening may be a useful adjunct to traditional vision screening, but there is limited evidence that it improves visual outcomes. Treatments for amblyopia include patching, atropine eye drops, and optical penalization of the nonamblyopic eye. In children with moderate amblyopia, patching for two hours per day is as effective as six hours, and daily atropine is as effective as daily patching. Children younger than seven years receive the most benefit from treatment, but older children may still benefit. Amblyopia recurs in 25% of children, so continued surveillance is important.

Hyperhidrosis: Management Options.

Hyperhidrosis is excessive sweating that affects patients' quality of life, resulting in social and work impairment and emotional distress. Primary hyperhidrosis is bilaterally symmetric, focal, excessive sweating of the axillae, palms, soles, or craniofacial region not caused by other underlying conditions. Secondary hyperhidrosis may be focal or generalized, and is caused by an underlying medical condition or medication use. The Hyperhidrosis Disease Severity Scale is a validated survey used to grade the tolerability of sweating and its impact on quality of life. The score can be used to guide treatment. Topical aluminum chloride solution is the initial treatment in most cases of primary focal hyperhidrosis. Topical glycopyrrolate is first-line treatment for craniofacial sweating. Botulinum toxin injection (onabotulinumtoxinA) is considered first- or second-line treatment for axillary, palmar, plantar, or craniofacial hyperhidrosis. Iontophoresis should be considered for treating hyperhidrosis of the palms and soles. Oral anticholinergics are useful adjuncts in severe cases of hyperhidrosis when other treatments fail. Local microwave therapy is a newer treatment option for axillary hyperhidrosis. Local surgery and endoscopic thoracic sympathectomy should be considered in severe cases of hyperhidrosis that have not responded to topical or medical therapies.

Epididymitis: An Overview.

Inflammation of the epididymis, or epididymitis, is commonly seen in the outpatient setting. Etiology and treatment are based on patient age and the likely causative organisms. Epididymitis presents as the gradual onset of posterior scrotal pain that may be accompanied by urinary symptoms such as dysuria and urinary frequency. Physical findings include a swollen and tender epididymis with the testis in an anatomically normal position. Although the etiology is largely unknown, reflux of urine into the ejaculatory ducts is considered the most common cause of epididymitis in children younger than 14 years. Neisseria gonorrhoeae and Chlamydia trachomatis are the most common pathogens in sexually active males 14 to 35 years of age, and a single intramuscular dose of ceftriaxone with 10 days of oral doxycycline is the treatment of choice in this age group. In men who practice insertive anal intercourse, an enteric organism is also likely, and ceftriaxone with 10 days of oral levofloxacin or ofloxacin is the recommended treatment regimen. In men older than 35 years, epididymitis is usually caused by enteric bacteria transported by reflux of urine into the ejaculatory ducts secondary to bladder outlet obstruction; levofloxacin or ofloxacin alone is sufficient to treat these infections. Because untreated acute epididymitis can lead to infertility and chronic scrotal pain, recognition and therapy are vital to reduce patient morbidity.

Outpatient diagnosis of acute chest pain in adults.

Approximately 1 percent of primary care office visits are for chest pain, and 1.5 percent of these patients will have unstable angina or acute myocardial infarction. The initial goal in patients presenting with chest pain is to determine if the patient needs to be referred for further testing to rule in or out acute coronary syndrome and myocardial infarction. The physician should consider patient characteristics and risk factors to help determine initial risk. Twelve-lead electrocardiography is typically the test of choice when looking for ST segment changes, new-onset left bundle branch block, presence of Q waves, and new-onset T wave inversions. For persons in whom the suspicion for ischemia is lower, other diagnoses to consider include chest wall pain/costochondritis (localized pain reproducible by palpation), gastroesophageal reflux disease (burning retrosternal pain, acid regurgitation, and a sour or bitter taste in the mouth), and panic disorder/anxiety state. Other less common but important diagnostic considerations include pneumonia (fever, egophony, and dullness to percussion), heart failure, pulmonary embolism (consider using the Wells criteria), acute pericarditis, and acute thoracic aortic dissection (acute chest or back pain with a pulse differential in the upper extremities). Persons with a higher likelihood of acute coronary syndrome should be referred to the emergency department or hospital.

Progressive lymphadenopathy and intractable pain in an immunocompetent African-American adult with cat-scratch disease.

Persistent, painful cervical lymphadenopathy associated with malaise that does not respond to oral antibiotics may be cat-scratch disease. This condition is challenging to treat and may require surgical intervention. We present a case report of an immunocompetent 47-year-old African-American woman who was diagnosed with cat-scratch disease and hospitalized after multiple outpatient evaluations for progressive, painful lymphadenopathy. This case report outlines the patient's treatment in the author's urban outpatient clinic followed by an inpatient hospital stay with surgical intervention. Although the reported incidence of cat-scratch disease is higher in whites, primary care physicians should include cat-scratch disease in their differential diagnosis for African-American patients with regional lymphadenopathy, which is a hallmark of the disease. In addition, primary care physicians should be familiar with the atypical presentations of cat-scratch disease and the broad differential diagnosis for regional lymphadenopathy, including sarcoidosis, which is more common in African Americans.

Evolving medical knowledge: moving toward efficiently answering questions and keeping current.

The information needs of clinicians are many and varied; however, these information needs remain largely unmet. This likely diminishes the quality of patient care. Although it is important that physicians be proficient in critically evaluating the medical literature, it is more important that they become proficient in the "applied science of information management." Clinicians must learn the techniques and skills to find, evaluate, and use relevant and valid information both in the care of patients and in their careers of lifelong learning. Clinicians need sources for rapid retrieval of valid information at the point of care.

Outpatient treatment of systolic heart failure.

Optimal outpatient treatment of systolic heart failure has three goals that should be pursued simultaneously: (1) control of risk factors for the development and progression of heart failure, (2) treatment of heart failure, and (3) education of patients. Control of risk factors includes treating hypertension, diabetes, and coronary artery disease, and eliminating the use of alcohol and tobacco. All patients with heart failure should be taking an angiotensin-converting enzyme (ACE) inhibitor or angiotensin-receptor blocker. In the absence of contraindications, an ACE inhibitor is preferred. In most patients, physicians should consider adding a beta blocker to ACE-inhibitor therapy. In patients with severe heart failure, spironolactone is a useful addition to baseline drug therapy, as is carvedilol (substitute carvedilol if patient is already taking a beta blocker). Patients with stable heart failure should be encouraged to begin and maintain a regular aerobic exercise program. Digoxin therapy may reduce the likelihood of hospitalization but does not reduce mortality. It must be monitored closely, with a target dosage level of 0.5 to 1.1 ng per mL. Symptoms may be controlled with the use of diuretics and restricted dietary sodium. Finally, patient education, with the patient's active participation in the care, is a key strategy in the management of heart failure. Periodic follow-up between scheduled office visits, which is essential in the long-term management of heart failure, may include telephone calls from the office nurse, maintenance of a daily symptom and weight diary, and participation in a disease-management program.

Outpatient treatment of heart failure.

Heart failure (HF) affects more than 2 million adults in the United States. This common, costly, and disabling disorder mainly affects the elderly, with prevalence rates up to 10% in patients older than 65 years. The management of HF is responsible for millions of outpatient visits per year, is the most common discharge diagnosis for Medicare beneficiaries, and accounts for more than 5% of total health care dollars spent.