George Valko

Eczema Herpeticum: Making the diagnosis in the Emergency Department

Eczema herpeticum (EH), a form of Kaposis varicelliform eruption, is the dissemination of herpes simplex virus in the setting of preexisting eczema. We discuss the case of an 18-year-old woman with underlying atopic dermatitis (AD) who presented to an Emergency Department complaining of malaise, fever, and a spreading, burning, vesiculopapular facial rash. She was treated for both presumed impetigo and a flare of her underlying AD with cephalexin, bacitracin ointment, topical steroids, and diphenhydramine. Her condition worsened, and she was seen 3 days later by her primary care physician, who recognized the superimposition of a herpetic infection on her underlying AD and revised the diagnosis to EH. An oral regimen of acyclovir led to prompt resolution of the patients rash and symptoms. Recognition of EH in the acute care setting is essential for the provision of timely and specific treatment and to avoid the serious sequelae of this condition.

A "How To" Guide to Creating a Patient-Centered Medical Home

The concept of the patient-centered medical home (PCMH) has been widely embraced as a foundation for the transformation of health care delivery. Recent evaluations of PCMH pilots validate the initial hypothesis that care provided in the PCMH has the potential to result in better health outcomes at lower cost. However, earning recognition or certification as a PCMH can be a daunting task. This article discusses the process of developing the potential to function as a PCMH, earning formal recognition, and implementing a system of continuous quality improvement to enable the establishment of a mature, sustainable PCMH.

Evaluating a Multipayer Medical Home Intervention

Evaluating a Multipayer Medical Home Intervention To the Editor As physicians involved in the Pennsylvania Chronic Care Initiative (PACCI), a medical home pilot, we are concerned that the evaluation of the first phase had many inadequacies that steered Dr Friedberg and colleagues1 to the wrong conclusions. These conclusions have the potential to impede further payment reform and block continued redesign of primary care practices. This study examined data from the first 3 years of the initiative, a time frame that is too short to detect changes resulting from the intervention. Phase 1 of this program was devoted to building the infrastructure and culture to earn National Committee for Quality Assurance (NCQA) Patient-Centered Medical Home (PCMH) recognition and become a true medical home; reduction in costs of care was not a goal. In phase 2, pilot practices added case management and other quality interventions to the PCMH model. Our practice is just starting to observe reductions in emergency department visits, hospitalizations (including reductions in 30-day readmissions), and costs of care attributable to PCMH changes and the PACCI. The use of claims data has significant limitations. For example, one of our laboratories does not report to the payers any claims for blood work done for capitated patients; physicians instead complete gap reports via electronic medical record registries for the payers and submit results to the PACCI. These reports were not included in the analysis. Friedberg et al1 stated that “[p]oint estimates suggested improved performance among pilot practices relative to comparison practices.” However, in the propensity-weighted analyses, many more patients were included in pilot vs comparison practices. It is more difficult to get a larger cohort to goal than a smaller cohort. The smaller number of patients in comparison practices therefore makes it more difficult to find statistically significant differences in outcomes. The authors reported that there was not a strict 1:1 match of pilot vs comparison practices, but they did not adequately highlight potentially important implications of this mismatch. Other factors, such as insurance mix, number of trainees in a practice, and number of new patients enrolling in a practice, may have had a substantial effect on results. Our practice enrolls a large number of new patients monthly, many with poor control of hypertension, diabetes, and cholesterol. Getting new patients to goal is more challenging than keeping a stable cohort at goal. It is unclear if comparison practices faced similar challenges or if the authors accounted for these differences.

Endometriosis As A Cause Of Colonic Obstruction

Case Report A 41-year-old woman with a family history of colon cancer in her father complained to her family physician of a 4-month history of crampy lower abdominal pain and a change of bowel habits from regularity to intermittent constipation and loose stools. There was no particular pattern to the bowel movements, and she could not recall what would aggravate the pain, but having a bowel movement provided temporary relief. The stool had not changed in color or odor and did not appear bloody or tarry. She had no fever, chills, night sweats, anorexia, weight loss, nausea, or vomiting. Her menstrual periods were irregular and were accompanied by cramps and heavy flow. She did have a recent travel history to an area once endemic to Giardia lamblia; however, no one else in her travel party had any symptoms. She did not eat any new or unusual foods. She had a medical history notable for a Clark level I melanoma, fibrocystic breast disease, a benign thyroid adenoma, hypothyroidism, and dysfunctional uterine bleeding. A recent work-up for her dysfunctional uterine bleeding included a Papanicolaou smear and endometrial biopsy, the results of which were normal. Leiomyomas, suspected on pelvic examination, were confirmed by sonography, and magnetic resonance imaging obtained in response to a mildly elevated CA 125 revealed normal ovaries. Findings on a hysterosalpingogram to assess infertility were also normal. Past surgery included excisional biopsies of the melanoma and breast