The use of Collagenase Clostridium Histolyticum in the management of Dupuytren's contracture-outcomes of a pilot study in a District General Hospital setting.

INTRODUCTION: Collagenase Clostridium Histolyticum (CCH) is a recognised treatment option for adult patients presenting with Dupuytren's contracture (DC). PATIENTS AND METHODS: Twenty male patients with established DC were treated using CCH. The average metacarpophalangeal (MCP) joint and proximal interphalangeal joint (PIP) contractures pre-treatment were 520 (range, 0 - 750) and 350 (range, 0 - 840) respectively. The average DASH score pre-treatment was 24.2 points (range, 0 - 68.2 points). Patients were reviewed at lmonth, 3months and at an average of 23 months (17 to 27 months). RESULTS: MCP joint contractures significantly improved compared to pre-treatment and the improvement was maintained at latest follow up. PIP joint contractures did significantly improve but to a lesser degree and there was no significant improvement compared to pre-treatment beyond 3months. A trend for MCP and PIP joint contracture recurrence was observed at latest follow up but did not reach statistical significance. DASH scores significantly improved from pre-treatment and the improvement was maintained at latest follow up. At 3months, the average patient satisfaction score was 9.5 (range, 6 - 10), which decreased to 8.6 (range, 6 - 10) at latest follow up. We estimated a potential cost saving of approximately £70,000 by treating 20 patients using CCH compared to inpatient operative fasciectomy. CONCLUSION: CCH is a useful option in the management of DC in appropriately selected patients. Cost-effectiveness in the treatment of DC should be carefully considered.

Exceptions to outpatient quality measures for coronary artery disease in electronic health records.

BACKGROUND: Physicians report outpatient quality measures from data in electronic health records to facilitate care improvement and qualify for incentive payments. OBJECTIVE: To determine the frequency and validity of exceptions to quality measures and to test a system for classifying the reasons for these exceptions. DESIGN: Cross-sectional observational study. SETTING: 5 internal medicine or cardiology practices. PARTICIPANTS: 47,075 patients with coronary artery disease between 2006 and 2007. MEASUREMENTS: Counts of adherence with and exceptions to 4 quality measures, on the basis of automatic reports of recommended drug therapy by computer software and separate manual reviews of electronic health records. RESULTS: 3.5% of patients who had a drug recommended had an exception to the drug and were not prescribed it (95% CI, 3.4% to 3.7%). Clinicians did prescribe the recommended drug for many other patients with exceptions. In 538 randomly selected records, 92.6% (CI, 90.3% to 94.9%) of the exceptions reported automatically by computer software were also exceptions during manual review. Most medical exceptions were clinical contraindications, drug allergies, or drug intolerances. In 592 randomly selected records, an unreported exception or a drug prescription was found during manual review for 74.6% (CI, 71.1% to 78.1%) of patients for whom automatic reporting recorded a quality failure. LIMITATION: The study used a convenience sample of practices, nonstandardized data extraction methods, only drug-related quality measures, and no financial incentives. CONCLUSION: Exceptions to recommended therapy occur infrequently and are usually valid. Physicians frequently prescribed drugs even when exceptions were present. Automated reports of quality failure often miss critical information. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

Nonprimary care physicians' views on office-based quality incentive and improvement programs.

The current pay-for-performance movement in health care has continued to evolve despite the absence of input from physicians and empirical evidence of its effectiveness. The majority of existing quality incentive programs related to physician services is limited to primary care physicians. There is an increasing movement among payers to broaden pay for performance to include nonprimary care physicians. This article reports the results of a survey of nonprimary care physicians' views on office-based quality incentive and improvement programs. Data were collected from surveys completed by nonprimary care physicians practicing cardiology, hematology, oncology, obstetrics and gynecology, orthopedic surgery, and urology. Findings indicate that nonprimary care physicians recognize some value in office-based quality incentive and improvement programs. Specialty societies played a significant role in influencing physicians' views on office-based quality improvements. Physicians indicated support for incentive designs that included infrastructure grants to implement improvements in their office such as an electronic medical record.