University Hospitals: creating the infrastructure for quality and value through accountable care.

University Hospitals Health System Inc. (UH), in Cleveland, Ohio, like many hospitals and healthcare systems, sought to anticipate the dramatic changes of healthcare reform, including its increased focus on quality and outcomes. UH evaluated incentives to keep patients out of hospital and to ease mounting pressures on reimbursement and costs. During UH's strategic planning sessions in 2009 and 2010, we identified value--the combination of quality and efficiency--to be a key driver of our future success. Ahead of the enactment of the Affordable Care Act, in early 2010 we chose to proceed with the formation of an accountable care organization (ACO). We believed the ACO was a novel vehicle by which to improve the efficient delivery of our high-quality healthcare to maximize the value of the services we provide. We also believed that the most successful strategy, if it can be achieved, is to build on success. A major success, or a series of smaller successes, will go a long way toward achieving operational buy-in, enhancing respect for strategic initiatives, and convincing physicians of the need for change. Through thoughtful governance, effective plan design, customized data analytics, physician networks and incentives, innovative patient engagement, and supplemental coordination resources, our ACOs have succeeded in improving population health and delivering value.

A randomized comparison of print and web communication on colorectal cancer screening.

BACKGROUND: New methods to enhance colorectal cancer (CRC) screening rates are needed. The web offers novel possibilities to educate patients and to improve health behaviors, such as cancer screening. Evidence supports the efficacy of health communications that are targeted and tailored to improve the uptake of recommendations. METHODS: We identified unscreened women at average risk for CRC from the scheduling databases of obstetrics and gynecology practices in 2 large health care systems. Participants consented to a randomized controlled trial that compared CRC screening uptake after receipt of CRC screening information delivered via the web or in print form. Participants could also be assigned to a control (usual care) group. Women in the interventional arms received tailored information in a high- or low-monitoring Cognitive Social Information Processing model-defined attentional style. The primary outcome was CRC screening participation at 4 months. RESULTS: A total of 904 women were randomized to the interventional or control group. At 4 months, CRC screening uptake was not significantly different in the web (12.2%), print (12.0%), or control (12.9%) group. Attentional style had no effect on screening uptake for any group. Some baseline participant factors were associated with greater screening, including higher income (P = .03), stage of change (P < .001), and physician recommendation to screen (P < .001). CONCLUSIONS: A web-based educational intervention was no more effective than a print-based one or control (no educational intervention) in increasing CRC screening rates in women at average risk of CRC. Risk messages tailored to attentional style had no effect on screening uptake. In average-risk populations, use of the Internet for health communication without additional enhancement is unlikely to improve screening participation. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00459030.

Sexual function in elderly women: a review of current literature.

Although sexuality remains an important component of emotional and physical intimacy that most men and women desire to experience throughout their lives, sexual dysfunction in women is a problem that is not well studied. The prevalence of sexual dysfunction among all women is estimated to be between 25% and 63%; the prevalence in postmenopausal women is even higher, with rates between 68% and 86.5%. Increasing recognition of this common problem and future research in this field may alter perceptions about sexuality, dismiss taboo and incorrect thoughts on sexual dysfunction, and spark better management for patients, allowing them to live more enjoyable lives.

Build it, and will they come? Unexpected findings from a study on a Web-based intervention to improve colorectal cancer screening.

Given the extensive use of the Internet for health information, Web-based health promotion interventions are widely perceived as an effective communication channel. The authors conducted this study to determine use of a Web-based intervention intended to improve colorectal cancer screening in a population of women who are at average risk and noncompliant to current screening recommendations. The study was a randomized controlled trial designed to compare the effectiveness of colorectal cancer screening educational materials delivered using the Internet versus a printed format. In 3 years, 391 women seen for routine obstetrics/gynecology follow-up at 2 academic centers provided relevant survey information. Of these, 130 were randomized to the Web intervention. Participants received voluntary access to a password-protected, study-specific Web site that provided information about colorectal cancer and colorectal cancer screening options. The main outcome measures were self-reported and actual Web site use. Only 24.6% of women logged onto the Web site. Age was the only variable that differentiated users from nonusers (p = .03). In contrast, 16% of participants self-reported Web use. There was significant discordance between the veracity of actual and self-reported use (p = .004). Among true users, most (81%) logged on once only. These findings raise questions about how to increase use of important health communication interventions.

Secondary amenorrhea attributed to occlusion of microperforate transverse vaginal septum.

OBJECTIVE: To present a case of secondary amenorrhea after occlusion of microperforate transverse vaginal septum. DESIGN: Case report. SETTING: Academic teaching hospital. PATIENT(S): A 19-year-old woman with new onset of irregular menses and pelvic pain, with history of menarche at age 14. INTERVENTION(S): Surgical evaluation and treatment, including laparoscopy, hysteroscopy, and excision of septum, followed by repeat surgery with lysis of adhesions due to agglutination of the area previously excised. MAIN OUTCOME MEASURE(S): Awareness of the possibility of secondary amenorrhea occurring due to septal scarring of a perforate transverse vaginal septum. RESULT(S): Imaging revealed a hematometra and hematocolpos. Examination revealed a transverse vaginal septum. Ultrasound scans and magnetic resonance imaging revealed an enlarged uterus and an endometrial cavity and cervix distended with fluid and debris. Examination under anesthesia revealed a septum approximately 5 mm thick, which was revealed to be benign fibromuscular tissue with chronic nonspecific inflammation. CONCLUSION(S): This case demonstrates the evolution from a microperforate transverse vaginal septum with regular menses for over 4 years to an occluded septum. Although transverse vaginal septa causing amenorrhea are usually diagnosed at menarche, perforate septa have been shown to lead to hypomenorrhea, dysmenorrhea, dyspareunia, infertility, and issues with vaginal childbirth. We present a case in which a perforate transverse vaginal septum led to secondary amenorrhea.

Case of accessory ovary in the round ligament with associated endometriosis.

The phenomenon of accessory ovary, initially described in 1864, is extremely rare. We report a case of an accessory ovary in a round ligament with endometriosis. At the time of laparoscopy a firm 2- to 3-cm mass was noted within the round ligament with a normal ovary visualized. Dissection and removal of the mass was performed. Histopathology revealed ovarian stroma and dense connective tissue with endometriosis. This case fulfills the criteria established in 1959 for accessory ovary and is the first case of an accessory ovary reported within the round ligament. A unique finding with the accessory ovary in this case is the presence of endometriosis. No reported cases exist of endometriosis within an accessory ovary. This information may be pertinent for evaluation of dysmenorrhea when no endometrial implants are present, or with the persistence or recurrence of endometriosis and pain after a bilateral salpingo-oophorectomy.

Case of sisters with complete androgen insensitivity syndrome and discordant Müllerian remnants.

OBJECTIVE: Presentation of complete androgen insensitivity in two members of the same family with differing residual Müllerian tissue. DESIGN: Case report. SETTING: Rural hospital setting. PATIENT(S): Two siblings with 46,XY karyotype and female phenotype presented at different points in time with primary amenorrhea. Laparoscopy of sister 1 revealed bilateral elongated gonads and remnants of uterine tissue. Laparoscopy of sister 2 demonstrated both gonads, but no uterus was identified. INTERVENTION(S): Sister 1: bilateral gonadectomy and hysterectomy. Sister 2: bilateral gonadectomy. MAIN OUTCOME MEASURE(S): Gonadectomy for cancer prophylaxis, counseling in affected/unaffected family members. RESULT(S): Sister 1: pathology revealed portions of immature testicles and fragments of smooth muscle. Sister 2: pathology reported two testicular and epididymal-like structures with benign Sertoli cell adenomas entirely in testicular parenchyma. CONCLUSION(S): This case demonstrates the presentation and laparoscopic photos of complete androgen insensitivity syndrome discovered in two siblings. Both girls are genotypically male, but differ in the presence of vestigial Müllerian tissue. This case demonstrates that siblings with androgen resistance may express varying amounts of Müllerian tissue.

The diagnostic challenge of identifying isolated fallopian tube torsion: a case report of laparoscopic management.

Torsion of adnexal structures is a relatively uncommon occurrence. Isolated fallopian tube torsion is an even rarer gynecologic cause of acute low abdominal pain. Diagnosis of this condition is frequently delayed because of the rarity of its occurrence and prolonged investigations to rule out more common causes of acute abdominal pain on a differential diagnosis. A case of a 32-year-old woman with isolated right fallopian tube torsion managed laparoscopically is presented.

Modulation of the expression of vascular endothelial growth factor in human fibroblasts.

OBJECTIVE: To examine the up-regulation of vascular endothelial growth factor (VEGF) expression by hypoxia, a crucial event leading to neovascularization, as the reduction in VEGF expression may facilitate minimization of adhesion development. DESIGN: Prospective experimental study. SETTING: University medical center. PATIENT(S): Five patients with adhesions undergoing laparotomy with excision of adhesions and normal peritoneum. INTERVENTION(S): Adhesion and normal peritoneal fibroblasts were treated with dichloroacetic acid (DCA) or NS-398 (a cyclooxygenase-2 [COX-2] inhibitor) for 24 to 48 hours. MAIN OUTCOME MEASURE(S): A real-time reverse transcriptase polymerase chain reaction (RT-PCR) to quantify relative changes in mRNA levels of VEGF from each treatment. RESULT(S): In both normal peritoneal and adhesion fibroblasts, VEGF mRNA was present with statistically significantly higher levels in adhesion fibroblasts (32%). The DCA treatment resulted in a statistically significant decrease in VEGF mRNA levels in adhesion (20%) and normal peritoneal (18%) fibroblasts. The NS-398 treatment resulted in a statistically significant decrease in VEGF mRNA levels in adhesion (25%) and normal peritoneal (16%) fibroblasts. CONCLUSION(S): Stimulation of aerobic metabolism by DCA or inhibition of COX-2 by NS-398 reduces VEGF expression. Angiogenesis, which is an integral component in the development of dense vascular adhesions, may be reduced by either COX-2 inhibitors or stimulation of aerobic metabolism by DCA.