Challenges in the Era of Coding and Corporatization.

The past 40 years have witnessed a major redesign of health care, largely driven by rampantly increasing costs and the perception of lack of better outcomes to justify those costs. Many demographic changes have also challenged the women's health care provider workforce, and evolving new payment systems are likewise a source of angst for these providers. Managed care is seeking to cut costs, and the challenge is to do so without sacrificing quality. Burnout is a new challenge in the present environment. There is now an opportunity to meet these challenges and provide the excellent care our patients deserve.

Patient Safety in Outpatient Procedures.

The past 4 decades have seen a remarkable re-engineering of health care, particularly with respect to surgical services and the formalization of patient safety protocols. As various forces drove many surgical procedures to the ambulatory setting, many advantages, and perhaps several disadvantages, quickly became apparent. In some studies, adverse events were found to be more common in office settings for instance, and it was quickly recognized that the formal quality controls that had evolved in the hospital setting were not always transferred to the outpatient facility. This article traces the development of health care's response to this challenge.

Hereditary Cancer Risk Assessment and Genetic Testing in the Community-Practice Setting.

OBJECTIVE: To evaluate the feasibility and results of incorporating routine hereditary cancer risk assessment, counseling, and follow-up genetic testing in the community obstetrics and gynecology practice setting without referral to a genetic counselor. METHODS: This prospective process intervention study was conducted with two obstetrics and gynecology practice groups (five sites). The intervention included baseline process assessment, refinement of clinic-specific patient screening workflows and tools, and training in hereditary cancer risk screening and follow-up. Outcomes related to hereditary cancer assessment and testing were measured during an 8-week postintervention period. Patients and health care providers were surveyed about satisfaction with the process. Data also were collected during the 8 weeks before the intervention to assess the effects of screening process improvements. RESULTS: A total of 4,107 patients were seen during the postintervention period, and 92.8% (3,811) were assessed for hereditary cancer risk. Among those assessed, 906 of 3,811 (23.8%) women met National Comprehensive Cancer Network guidelines for genetic testing, and 813 of 906 (89.7%) eligible patients were offered genetic testing. A total of 165 of 4,107 (4.0%) women completed genetic testing and received a final test result. This represents a fourfold increase over genetic testing immediately before the intervention (1.1%) and an eightfold increase over the previous year (0.5%). Testing identified pathogenic variants in 9 of 165 (5.5%) tested women. All health care providers (15/15) reported that they will continue to use the established hereditary cancer risk assessment process. In addition, 98.8% (167/169) of patients who submitted a sample for genetic testing and completed a patient satisfaction survey stated that they were able to understand the information provided, and 97.6% (165/169) expressed satisfaction with the overall process. CONCLUSION: It is feasible to incorporate hereditary cancer risk assessment, education, and testing into community obstetrics and gynecology practices. As a result, multigene panel testing identified significant cancer risks that otherwise would not have been recognized.

Obesity and Tobacco Cessation Toolkits: Practical Tips and Tools to Save Lives.

Both obesity and smoking are public health burdens that together contribute to approximately one third of the deaths annually in the United States. In 2015, under the direction of Dr. Mark DeFrancesco, the American College of Obstetricians and Gynecologists convened two workgroups with the purpose of creating toolkits that bring together information that the obstetrician-gynecologist can use to address these preventable health problems. An Obesity Prevention and Treatment Workgroup and a Tobacco and Nicotine Cessation Workgroup developed toolkits on Obesity Prevention and Treatment (www.acog.org/ObesityToolkit)andTobaccoandNicotineCessation(www.acog.org/TobaccoToolkit). The toolkits contain specific talking points, counseling methods, and algorithms to address these health concerns in a supportive, efficient, and effective manner. By including these methods in practice, clinicians can help prevent the tragedy of early deaths caused by obesity, tobacco, and nicotine use.

International Federation of Gynecology and Obstetrics opinion on reproductive health impacts of exposure to toxic environmental chemicals.

Exposure to toxic environmental chemicals during pregnancy and breastfeeding is ubiquitous and is a threat to healthy human reproduction. There are tens of thousands of chemicals in global commerce, and even small exposures to toxic chemicals during pregnancy can trigger adverse health consequences. Exposure to toxic environmental chemicals and related health outcomes are inequitably distributed within and between countries; universally, the consequences of exposure are disproportionately borne by people with low incomes. Discrimination, other social factors, economic factors, and occupation impact risk of exposure and harm. Documented links between prenatal exposure to environmental chemicals and adverse health outcomes span the life course and include impacts on fertility and pregnancy, neurodevelopment, and cancer. The global health and economic burden related to toxic environmental chemicals is in excess of millions of deaths and billions of dollars every year. On the basis of accumulating robust evidence of exposures and adverse health impacts related to toxic environmental chemicals, the International Federation of Gynecology and Obstetrics (FIGO) joins other leading reproductive health professional societies in calling for timely action to prevent harm. FIGO recommends that reproductive and other health professionals advocate for policies to prevent exposure to toxic environmental chemicals, work to ensure a healthy food system for all, make environmental health part of health care, and champion environmental justice.

Obstetricians and gynecologists' practice and opinions of expanded carrier testing and noninvasive prenatal testing.

OBJECTIVE: The objective of this study is to assess the opinions of Fellows of the American College of Obstetricians and Gynecologists on expanded carrier testing (molecular detection of >100 genetic diseases of variable severity) and noninvasive prenatal testing (NIPT). METHODS: A survey conducted between March and August 2012, assessed current use of testing, provision of genetic counseling, types of disorders that should be identified, preferences for future use, ethical aspects, and views on regulatory oversight. RESULTS: Expanded carrier testing was offered to all patients by 15% of the responders and 52.1% upon patient request. Most (67.3%) favored testing only for mutations of known significance. In this study, 79.1% supported the use of NIPT as a screen for Down syndrome for all women with 47.9% viewing NIPT as a complete substitution for invasive testing. Most supported expansion to other aneuploidies (97.5%) and severe early-onset Mendelian disorders (90.4%) but not for adult-onset disorders (29.8%) or nonmedical sex identification (15.7%). A majority (73.2%) believed that NIPT would increase pregnancy terminations for mild disease states. Respondents favored a role for professional societies in providing regulatory oversight. CONCLUSION: Rapid incorporation of new genetic technologies may be limited by the availability of genetic counseling, concerns regarding inclusion of clinically mild disorders, results of unknown significance, and costs.

Executive summary of the American College of Obstetricians and Gynecologists Presidential Task Force on Patient Safety in the Office Setting: reinvigorating safety in office-based gynecologic surgery.

The American College of Obstetricians and Gynecologists Presidential Task Force on Patient Safety in the Office Setting was convened to identify patient safety concerns, develop tools, and provide guidance for physicians performing invasive surgical procedures in the office setting. Physicians who serve as office medical directors have a myriad of responsibilities related to clinical and patient safety, including evaluating staff competency, encouraging office team communication, promoting patient partnership, and ensuring safety in the use of analgesia or anesthesia. Activities and tools used in the inpatient setting, such as multidisciplinary team meetings, checklists, time-outs, mock emergency drills, and measurement and reporting systems, can easily be tailored and applied to any office practice.

Practice smarter... not harder!

The American College of Obstetricians and Gynecologists (ACOG) Presidential Task Force on Changing Practice in the 21st Century developed a list of practical goals or recommendations that ACOG or our members can implement, to improve practice satisfaction and ensure survival in the twenty-first century. Three areas of focus were 1) Patient Safety and Risk Management; 2) Practice Economics and Efficiencies; and 3) Workforce Changes. Recommendations in each area were subdivided into what ACOG might implement and what members can do themselves. Recommendations for ACOG to consider include enhancing the ACOG Web site; developing model protocols, informed consents, and electronic medical records templates; continue lobbying for tort reform, but also work on alternative concepts; help develop "reentry" guidelines; expand the Practice Management division to provide more tools for practices; and help develop models to allow more practice style diversity. Recommendations for ACOG members were to reduce variation in practice patterns, using standard tools; automate routine tasks with electronic tools; work cooperatively with other providers and practices; participate in emergency drills, "time-outs," and other risk reduction training; mentor new associates; and learn from them too.