Performance measurement part I: Foundational knowledge for measure development.

As medicine is moving toward performance and outcome-based payment and is transitioning away from productivity-based systems, value is now being appraised in healthcare through "performance measures." Over the past few decades, assessment of clinical performance in health care has been essential in ensuring safe and cost-effective patient care. The Centers for Medicare & Medicaid Services is further driving this change with measurable, outcomes-based national payer incentive payment systems. With the continually evolving requirements in health care reform focused on value-based care, there is a growing concern that clinicians, particularly dermatologists, may not understand the scientific rationale of health care quality measurement. As such, in order to help dermatologists understand the health care measurement science landscape to empower them to engage in the performance measure development and implementation process, the first article in this 2-part continuing medical education series reviews the value equation, historic and evolving policy issues, and the American Academy of Dermatology's approach to performance measurement development to provide the required foundational knowledge for performance measure developers.

Performance measurement part II: A guide to developing dermatology performance measures.

Throughout the 21st century, national and local governments, private health sectors, health insurance companies, healthcare professionals, labor unions, and consumers have been striving to develop an effective approach to evaluate, report, and improve the quality of healthcare. As medicine improves and health systems grow to meet patient needs, the performance measurement system of care effectiveness must also evolve. Continual efforts should be undertaken to effectively measure quality of care to create a more informed public, improve health outcomes, and reduce healthcare costs. As such, recent policy reform has necessitated that performance systems be implemented in healthcare, with the "performance measure" being the foundation of the system in which all of healthcare must be actively engaged in to ensure optimal care for patients. The development of performance measures can be highly complex, particularly when creating specialty-specific performance measures. To help dermatologists understand the process of creating dermatology-specific performance measures to engage in creating or implementing performance measures at the local or national levels, this article in the two-part continuing medical education series reviews the types, components, and process of developing, reviewing, and implementing performance measures.

Subcorneal Pustular Dermatosis Following SARS-CoV-2 Infection.

Subcorneal pustular dermatosis (SPD), also called Sneddon-Wilkinson disease, is a rare, relapsing pustular dermatosis.1 SPD has been associated with multiple myeloma, IgA Gammopathy, pyoderma gangrenosum and certain autoimmune diseases.2 However, SPD occurrence following SARS-COV-2 has not yet been reported. Herein, we report a case of SPD occurring after SARS-CoV-2 infection in a 52-year-old male. We hypothesize that the occurrence of SPD shortly following SARS-CoV-2 infection suggests the viral illness may have precipitated onset of SPD, and the patient may remain at risk for future flares of disease despite appropriate treatment and current remission status.

Metastatic Gallbladder Melanoma Presenting as Acute Emphysematous Cholecystitis.

Malignant melanoma is an aggressive tumor with a high potential for distant metastases, including spread to the gallbladder where it represents more than half of all metastases detected at autopsy. Yet, it is rarely symptomatic in life and is a rare cause of acute cholecystitis. Emphysematous cholecystitis is a rare, potentially fatal variant of acute cholecystitis characterized by the presence of gas in the gallbladder lumen or wall. We report a 77-year-old woman with acute emphysematous cholecystitis as the initial feature of recurrent melanoma metastatic to the gallbladder. This exceptional association highlights the need to consider a relapse of malignancy when assessing unexplained abdominal symptoms in any patient with a prior history of melanoma.

Porokeratotic eccrine duct and hair follicle nevus (PEHFN) associated with keratitis-ichthyosis-deafness (KID) syndrome.

Porokeratotic eccrine ostial and dermal duct nevus is a rare hamartomatous malformation, histologically characterized by cornoid lamellae overlying dilated eccrine ostia. The nevus most commonly presents in the form of multiple filiform keratotic spines in a linear arrangement, usually on the distal extremities. Porokeratotic eccrine and hair follicle nevus is thought to be a variant of porokeratotic eccrine ostial and dermal duct nevus that additionally involves hair follicle infundibula. We report a case of widespread Porokeratotic eccrine and hair follicle nevus that developed in a 15-year-old woman with keratitis-ichthyosis-deafness syndrome.

Preoperative methicillin-resistant Staphylococcus aureus screening in Mohs surgery appears to decrease postoperative infections.

BACKGROUND: Colonization with methicillin-resistant Staphylococcus aureus (MRSA) places patients at risk for postoperative MRSA wound infections. OBJECTIVE: To determine the effect of a decontamination and prophylaxis protocol on postoperative MRSA wound infections in patients with nasal MRSA. METHODS & MATERIALS: Wound cultures over a 23-month period were reviewed before and 11 months after implementation of a screening and decontamination protocol. After preoperative MRSA screening with nasal swabs, carriers were instructed to use intranasal mupirocin for 5 to 7 days before surgery and 5 to 7 days of trimethoprim-sulfamethoxazole starting the day before surgery. RESULTS: During the 23 months before prescreening evaluation, we performed 3,633 Mohs surgical cases, and 12 postoperative MRSA wound infections (0.3%) occurred. Subsequently, 963 patients underwent screening for MRSA, and 23 MRSA carriers were identified (2.4%). Of the 22 who underwent the decontamination and treatment protocol, none developed postoperative wound infections. One MRSA carrier did not receive preoperative treatment and subsequently developed a MRSA wound infection. There were no other MRSA infections. CONCLUSION: Preoperative MRSA screening and implementation of a decontamination protocol appears to decrease postoperative MRSA wound infections after Mohs surgery. Although an interesting observation, controlled studies of clinical and cost effectiveness are required before general implementation. The authors have indicated no significant interest with commercial supporters.

Cyberdermatoethics II: a case-based approach to teledermatology ethics.

Teledermatology is the use of telecommunication for medical diagnosis and patient care in dermatology. The visual nature of diagnosis in dermatology makes it particularly well suited to the practice of telemedicine. The differences between the two basic types of teledermatology, real-time and store-and-forward, are reviewed. Case scenarios are used to examine some of the ethical and clinical issues that can occur, such as the nature of the doctor-patient relationship, follow-up of incidental diagnoses, limitations of telemedicine, privacy issues, and licensing. Guidelines for the use of telemedicine in dermatology are reviewed.

A range of histologic findings in infantile digital fibromatosis.

Infantile digital fibromatosis is a benign proliferation of myofibroblasts with characteristic eosinophilic intracytoplasmic inclusion bodies. Clinically, patients present in the first several years of life with asymptomatic, smooth, flesh-colored nodules located on the dorsal or lateral aspect of the fingers or toes. The lesions have a tendency for spontaneous regression and recur over 60% of the time following excision. Observation is often recommended, while surgery is reserved for cases of rapid growth or functional impairment. We report three patients, ranging in age from 8 months to 8 years, with infantile digital fibromatosis. All three patients presented with nodules on the hands or feet and all shared histologic findings of spindle cells with characteristic inclusion bodies. Pathologic features ranged from a haphazard arrangement of spindle cells with few inclusion bodies and numerous lymphocytes to a well-organized arrangement of spindle cells with abundant inclusion bodies and rare lymphocytes. All three patients underwent excision for diagnosis or treatment of their tumors with two of the patients experiencing a recurrence.

Nonpalpable purpura within a setting of anticoagulant therapy and metastatic carcinoma.

The anticoagulant warfarin can produce a skin necrosis that is clinically indistinguishable from the skin necrosis caused by purpura fulminans associated with disseminated intravascular coagulation (DIC) and heparin-induced thrombocytopenia (HIT). The similar clinical and histologic findings observed in each of these skin necroses create a challenge for diagnosis and eventual treatment. The authors report a patient with significant risk factors for warfarin-induced skin necrosis, DIC, and HIT presenting with painful, purpuric patches beginning on her feet and extending proximally before becoming hemorrhagic bullae on her lower extremities.