A 10-step program to successfully reduce low-value care.

The cost of health care in the United States is approaching 18% of the gross national product, an expenditure that is competing with dollars being used for other purposes. One way to reduce the cost of care is by identifying and reducing low-value care (LVC): patient care that offers little to no benefit in specific clinical scenarios, adds cost, and may, through adverse effects or adverse outcomes, actually harm patients. The authors have been involved in identifying and reducing LVC for more than 15 years and have created a practical, 10-step approach to effectively integrate LVC reduction programs into medical systems.

"Won't You Be My Doctor?": Four Keys to a Satisfying Relationship in an Increasingly Virtual World.

Despite rapid technological advances in healthcare, medicine is still largely practiced in a doctor's office This reality is changing rapidly during the COVID-19 pandemic as face-to-face conversations with primary care practitioners are being replaced by virtual visits conducted by phone or video conferencing. Communication challenges in patient-practitioner relationships exist in face-to-face visits and they are accentuated in virtual ones. Absent a physical examination and other sensory data, conversation is the primary means by which safe, satisfying care depends.

Physicians' perceptions of autonomy support during transition to value-based reimbursement: A multi-center psychometric evaluation of six-item and three-item measures.

Background: Successive health system reforms have steadily eroded physician autonomy. Escalating accountability demands placed on physicians concurrent with diminishing autonomy plus widespread "cost cutting" endanger clinical work-life quality and, in turn, threaten patient-care quality, safety, and continuity. This has engendered a renewed emphasis on bettering physician work-life to safeguard patient care.

Job satisfaction and guideline adherence among physicians: Moderating effects of perceived autonomy support and job control.

Value-based purchasing of physician services aims to incentivize greater adherence to clinical practice guidelines. By increasing job demands, new reimbursement models could adversely affect job satisfaction and, indirectly, clinical performance. Studies of satisfaction-performance associations among healthcare practitioners have yielded inconsistent findings.

A community-wide quality improvement initiative to improve hypertension control and reduce disparities.

Initiatives to improve hypertension control within academic medical centers and closed health systems have been extensively studied, but large community-wide quality improvement (QI) initiatives have been both less common and less successful in the United States. The authors examined a community-wide QI initiative across 226 843 patients from 198 practices in nine counties across upstate New York to improve hypertension control and reduce disparities. The QI initiative focused on (a) providing population and practice-level comparative data, (b) community engagement, especially in underserved communities, and (c) practice-level quality improvement assistance, but was not designed to examine causality of specific components.

The Moderating Effect of Job Satisfaction on Physicians' Motivation to Adhere to Financially Incentivized Clinical Practice Guidelines.

We examined moderating effects of professional satisfaction on physicians' motivation to adhere to diabetes guidelines associated with pay-for-performance incentives. We merged cross-sectional survey data on attitudes, from 156 primary physicians, with prospective medical record-sourced data on guideline adherence and census data on ambulatory-care population characteristics. We examined moderating effects by testing theory-driven models for satisfied versus discontented physicians, using partial least squares structural equation modeling.

The role of medical culture in the journey to resilience.

There is growing concern about the difficulty primary care practices are experiencing both recruiting and retaining practitioners. Frustrations stemming from integrating electronic medical records, satisfying external documentation requirements for oversight and billing, and the divide created between inpatient and ambulatory care teams all contribute to practitioner and staff burnout. Addressing the current culture of medical education and primary care is clearly an essential issue for health care leaders and medical educators.

Raman spectroscopy differentiates squamous cell carcinoma (SCC) from normal skin following treatment with a high-powered CO2 laser.

Background And Objectives: The number of cases of non-melanoma skin cancer (NMSC), which include squamous cell carcinoma (SCC) and basal cell carcinoma (BCC), continues to rise as the aging population grows. Mohs micrographic surgery has become the treatment of choice in many cases but is not always necessary or feasible. Ablation with a high-powered CO2 laser offers the advantage of highly precise, hemostatic tissue removal.

Motivators and hygiene factors among physicians responding to explicit incentives to improve the value of care.

Background: Physician's dissatisfaction is reported to be increasing, especially in primary care. The transition from fee-for-service to outcome-based reimbursements may make matters worse.

Purpose/objective: To investigate influences of provider attitudes and practice settings on job satisfaction/dissatisfaction during transition to quality-based payment models, we assessed self-reported satisfaction/dissatisfaction with practice in a Rochester (New York)-area physician practice association in the process of implementing pay-for-performance.

Building bridges: future directions for medical error disclosure research.

Objective: The disclosure of medical errors has attracted considerable research interest in recent years. However, the research to date has lacked interdisciplinary dialog, making translation of findings into medical practice challenging. This article lays out the disciplinary perspectives of the fields of medicine, ethics, law and communication on medical error disclosure and identifies gaps and tensions that occur at these interdisciplinary boundaries.

Molecular mechanism of hepcidin-mediated ferroportin internalization requires ferroportin lysines, not tyrosines or JAK-STAT.

Ferroportin is the primary means of cellular iron efflux and a key component of iron metabolism. Hepcidin regulates Fpn activity by inducing its internalization and degradation. The mechanism of internalization is reported to require JAK2 activation, phosphorylation of Fpn tyrosine residues 302 and 303, and initiation of transcription through STAT3 phosphorylation.

The impact of a program in mindful communication on primary care physicians.

Purpose: In addition to structural transformations, deeper changes are needed to enhance physicians' sense of meaning and satisfaction with their work and their ability to respond creatively to a dynamically changing practice environment. The purpose of this research was to understand what aspects of a successful continuing education program in mindful communication contributed to physicians' well-being and the care they provide.

Method: In 2008, the authors conducted in-depth, semistructured interviews with primary care physicians who had recently completed a 52-hour mindful communication program demonstrated to reduce psychological distress and burnout while improving empathy.

Creating community collaboration to improve the care of patients with high blood pressure: lessons from Rochester, New York.

Over the past two years, the business community of Monroe County, which includes Rochester, New York, has been engaging in a collaborative to improve outcomes for people with high blood pressure. As the employers examined the costs of care in the community, they recognized two important factors. First, the costs of care for the uninsured, the underinsured, and the Medicare population influence the business community's cost of care.

Recurrent meningococcal sepsis in a presumptive immunocompetent host shown to be complement C5 deficient-a case report.

Invasive meningococcal disease is a world wide challenge. Most cases occur in immunocompetent children and young adults, but some immunodeficiencies are linked to a greater risk of invasive neisserial infections. One of these is complement component deficiencies, particularly deficiency of properdin and the terminal complement components.

Lost in translation: physicians' struggle with cost-reduction programs.

Relationships between health plans and the medical profession are often strained, leading to the inability to create a shared vision for the health care redesign needed to more effectively care for our population. Because of their respective stakeholders, health plans and providers naturally differ in perspective. However, this article suggests that it is the inability of stakeholders to find a common language to effectively communicate interests, needs, and proposed interventions that often derails progress toward common goals.

Engaging physicians in change: results of a safety net quality improvement program to reduce overuse.

Identifying, understanding, and addressing clinical variation is a useful tool to promote appropriate care while helping control health care costs. Although accurate, relevant, and useful data are important in the process, successfully engaging physicians to change behavior is often the most significant challenge. Using a commercially available variation analysis process, a California Medicaid managed care plan identified significant network practice pattern variation.

Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians.

Context: Primary care physicians report high levels of distress, which is linked to burnout, attrition, and poorer quality of care. Programs to reduce burnout before it results in impairment are rare; data on these programs are scarce.

Objective: To determine whether an intensive educational program in mindfulness, communication, and self-awareness is associated with improvement in primary care physicians' well-being, psychological distress, burnout, and capacity for relating to patients.

Provider attitudes associated with adherence to evidence-based clinical guidelines in a managed care setting.

In a cross-sectional observational study of Rochester (New York) primary care physicians (PCPs) enrolled in a pay-for-performance (P4P) collaboration, the authors investigated attitudinal factors associated with provider adherence to evidence-based clinical guidelines targeted by explicit incentives. The multivariable adherence model linked guideline adherence rates to provider attitudes among 186 survey respondents, adjusting for individual, practice, and community characteristics. Adherence was defined as the percentage of expected services that were delivered.

Beyond the efficiency index: finding a better way to reduce overuse and increase efficiency in physician care.

Current strategies for addressing health care costs stress physician performance measurement and commonly use an efficiency index (EI). During seven years of conducting individual practitioner pay-for-performance (P4P), we found that using EIs hindered our work on reducing overuse of services. This paper offers an alternative approach through the identification of variation in key cost drivers.

Physician self-disclosure in primary care visits: enough about you, what about me?

Background: The value of physician self-disclosure (MD-SD) in creating successful patient-physician partnerships has not been demonstrated.

Methods: To describe antecedents, delivery, and effects of MD-SD in primary care visits, we conducted a descriptive study using sequence analysis of transcripts of 113 unannounced, undetected, standardized patient visits to primary care physicians. Our main outcome measures were the number of MD-SDs per visit; number of visits with MD-SDs; word count; antecedents, timing, and effect of MD-SD on subsequent physician and patient communication; content and focus of MD-SD.

Effects of paying physicians based on their relative performance for quality.

Background: Studies examining the effectiveness of pay-for-performance programs to improve quality of care primarily have been confined to bonus-type arrangements that reward providers for performance above a predetermined threshold. No studies to date have evaluated programs placing providers at financial risk for performance relative to other participants in the program.

Objective: The objective of the study is to evaluate the impact of an incentive program conferring limited financial risk to primary care physicians.