Bundled payment for actinic keratosis management: Pilot evaluation of developed models.

BACKGROUND: There is an opportunity to explore alternate payment models in dermatology. OBJECTIVE: To pilot 2 bundled payment models for actinic keratosis (AK) management. METHODS: A prospective cohort study was conducted during September 2013-June 2016. Consecutive patients were recruited from clinics of 5 dermatologists. Patients had to be adults, have ≥1 year of care at the department, and have a history of AK. A bundled payment strategy was prospectively piloted for 1 year and compared with costs in the prior year. RESULTS: Overall, 400 participants were enrolled, and complete data was collected for 254 participants. During the year of bundled payments, actual total annual spending on claims was $70,557, whereas model 1 and model 2 bundled payment models would have totaled $67,310 and $74,422, respectively, for the patient cohort. Patient satisfaction surveys showed no difference in the quality of care. LIMITATIONS: Single-center study and limited sample size. International Classification of Diseases 9 and 10 codes were used to identify claims and might be inaccurate. Costs were modeled rather than fully implemented. CONCLUSION: Dermatologists should be aware of bundled payment models. More work is needed to elucidate the optimal formulation of a bundled payment for AK management, including the services covered, time delimitation, and risk stratification factors.

Patient and physician views of shared decision making in cancer.

CONTEXT: Engaging patients in shared decision making involves patient knowledge of treatment options and physician elicitation of patient preferences. OBJECTIVE: Our aim was to explore patient and physician perceptions of shared decision making in clinical encounters for cancer care. DESIGN: Patients and physicians were asked open-ended questions regarding their perceptions of shared decision making throughout their cancer care. Transcripts of interviews were coded and analysed for shared decision-making themes. SETTING AND PARTICIPANTS: At an academic medical centre, 20 cancer patients with a range of cancer diagnoses, stages of cancer and time from diagnosis, and eight physicians involved in cancer care were individually interviewed. DISCUSSION AND CONCLUSIONS: Most physicians reported providing patients with written information. However, most patients reported that written information was too detailed and felt that the physicians did not assess the level of information they wished to receive. Most patients wanted to play an active role in the treatment decision, but also wanted the physician's recommendation, such as what their physician would choose for him/herself or a family member in a similar situation. While physicians stated that they incorporated patient autonomy in decision making, most provided data without making treatment recommendations in the format preferred by most patients. We identified several communication gaps in cancer care. While patients want to be involved in the decision-making process, they also want physicians to provide evidence-based recommendations in the context of their individual preferences. However, physicians often are reluctant to provide a recommendation that will bias the patient.

Mycobacterium abscessus Causes Highly Resistant Infection as a Breast Abscess.

Mycobacterium abscessus is an increasing threat to public health due to its multi-drug resistance and increasing prevalence. The pathogen most commonly causes chronic respiratory infections, but it may also invade locally through the skin and soft tissue damage caused by trauma, piercings, or tattoos. A 58-year-old African American female presented with a five-month history of recurrent abscesses in the right breast. She had previously been treated with doxycycline and ceftriaxone injections at an outside clinic with minimal improvement. Following incision and drainage, cultures and susceptibilities showed M. abscessus infection with a high level of drug resistance. Due to financial barriers, the patient received a suboptimal antibiotic regimen and required multiple surgical procedures, resulting in only temporary wound healing. At the time of this report, the patient is recovering from her fourth incision and drainage, with cultures and susceptibilities pending and discussions of a total mastectomy. M. abscessus is a highly resistant bacteria capable of causing skin and soft tissue infections of the breast. Such infections may occur without an inciting event and require extensive surgical and antimicrobial management.

Vacuoles in the Breast: A Histologic Clue for an Unusual Presentation of an Atypical Organism.

Infections with nontuberculous mycobacteria (NTM) are increasing in prevalence worldwide, and this group of organisms is emerging as significant clinical pathogens. We present a case of a 58-year-old female with persistent furuncles of the breast who was found to have an NTM infection. This case is unique for the lack of risk factors for NTM in the patient's history, the location of the infection in the breast, and the close cooperation needed across disciplines to arrive at the diagnosis. This multi-disciplinary discussion considers the classic clinical presentation of NTM, it is a characteristic morphological appearance on histopathology, the differential diagnosis, treatment, and the ultimate outcome of the case. This case report and discussion will assist both clinicians and pathologists in the diagnosis of this important infectious disease.