Clinical Quality Measures: A Challenge for-and to-Family Physicians.

INTRODUCTION: Improving design, selection and implementation of appropriate clinical quality measures can reduce harms and costs of health care and improve the quality and experience of care delivery. These measures have not been evaluated for appropriateness for use in performance measurement in a systematic, reproducible, and widely accepted manner. METHODS: We defined 10 criteria for evaluation of measure appropriateness in 4 domains: Patient-centeredness of outcomes, specification of population measured and measure detail, reliable evidence that benefits likely outweigh harms, and independence from significant confounders. We applied these criteria to 24 measures under consideration for statewide use in Massachusetts in public and private incentive-based programs. We appraised each measure as Appropriate or Not Appropriate for such use. RESULTS: We rated 15 measures as Appropriate (62.5%). Three measures (12.5%) were considered Appropriate only if applied at a system level but not for patient-provider assessment and 6 measures (25%) were rated Not Appropriate. Reasons for designation as "Not Appropriate" included benefits not clearly outweighing harms, lack of preservation of patient autonomy, inappropriate specification of population and measure detail, confounding by locus of control, and confounding by social determinants of health. CONCLUSIONS: Using this consensus-driven, 10-criteria methodology we were able to evaluate appropriateness of clinical quality measures. This methodology may improve measure design and inform selection of the most appropriate measures for use in quality measurement, financial incentives, and reporting.

Colposcopic endocervical brushing cytology appears to be more sensitive than histologic endocervical curettage for detecting endocervical adenocarcinoma.

INTRODUCTION: Colposcopic endocervical brushing cytology (CEB) is more sensitive than endocervical curettage (ECC) for detecting squamous intraepithelial lesions. There are no data on performance of CEB for detecting endocervical adenocarcinoma. MATERIALS AND METHODS: A total of 151 patients were identified in a word search for "endocervical adenocarcinoma" in surgical pathology reports from January 2007 to June 2019. To measure sensitivity, reports of CEB or ECC samples within 1 year preceding the first surgical pathology diagnosis of at least endocervical adenocarcinoma in situ (AIS+) were examined. Specificity was measured in a cohort in which at least atypical glandular cells (AGC+) was reported in CEB or ECC. RESULTS: Seven CEB preceding diagnosis of AIS were identified: 6 of 7 were positive or suspicious for AIS+. One of 7 was negative and it was negative on re-review. Three of 6 positive CEB cases used cell blocks with immunohistochemistry. Seventy ECC samples preceding diagnosis of AIS were identified: 40 of 70 were diagnosed as AGC+. The sensitivities of CEB and ECC for detecting AIS+ at a threshold of AGC+ are 86% and 57% (too few patients for statistics), respectively. For specificity, 12 of 18 CEB and 9 of 25 ECC reports with AGC+ were false positive by follow-up surgical pathology. The specificities of CEB and ECC are 99.4% and 99.9%, respectively. CONCLUSION: Sensitivity of CEB for detecting AIS+ (86%) is at least as high as ECC (57%). Specificity of CEB is similar to ECC. Addition of a cell block to CEB may be useful. CEB appears to be an appropriate test for follow-up of atypical glandular cells reported on Papanicolaou tests.

Transformation Support Provided Remotely to a National Cohort of Optometry Practices.

PURPOSE: We describe the results of a practice transformation project conducted within a national cohort of optometry practices participating in the Southern New England Practice Transformation Network. METHODS: Participants were 2,997 optometrists in 1,706 practices in 50 states. The multicomponent intervention entailed curriculum dissemination through a preexisting network of optometrists supported by specialized staff and resources, and data collection through a web portal providing real-time feedback. Outcomes included practices reporting data, urgent optometry visits for target conditions, and projected cost savings achieved by reducing emergency department (ED) use through increased provision of urgent care for conditions amenable to management in optometry practices. RESULTS: Over 13 months, 69.9% of practices reported data for a mean of 6.7 months. Beginning with the fourth month, the number of urgent optometry visits increased steadily. Among reporting practices, the total cost savings were estimated at $152 million (176,703 ED visits avoided at an average cost differential of $860 per visit). Monthly projected cost savings per optometrist were substantially greater in rural vs urban practices ($10,800 vs $7,870; P <.001). CONCLUSIONS: Technical assistance to promote practice transformation can be provided remotely and at scale at low per-practice cost. Through the provision of timely, easily accessed ambulatory care, optometrists can improve the patient experience and reduce ED use, thereby reducing costs. The cost savings opportunities are immense because of the large volume and high expense of ED visits for ocular conditions that might otherwise be managed in ambulatory optometry practices.

Diabetes: 8 strategies to put into practice.

In search of ways to improve the way you approach diabetes care in your practice? Consider these strategies, which have worked for us-- and have evidence to support them.