Challenges of Practice Transformation

ACP Practice Transformation Resources

Reflections on Practice Transformation

Watch ACP members describe their experiences and successes with preparing their practices for value-based payment. These videos explore topics as diverse as the unique role internists play in practice transformation, the shift to value-based care, the importance of patient engagement, and resources ACP has to assist with transformation. Success Story: Strategies to Reduce Inappropriate Antibiotic Prescribing, featuring Rebecca Andrews, MD, FACP

Practice Transformation

Payment reform and the rapid transition to telehealth is forcing medical practices to transform many aspects of how they deliver care.

Patient and Family Engagement (PFE) Webinar Series Recordings

This three-part webinar series on key PFE topics, including health literacy, collaborative medication management, and patient and family engagement, was developed as a collaboration between the ACP SAN and the Institute for Patient- and Family-Centered Care (IPFCC). [block:block=88]

ACP SAN Clinical Webinar Series Recordings

This four-part webinar series on key clinical topics, including diabetes, hypertension, and opioid management, was developed by the ACP Support and Alignment Network to promote several new or newly updated ACP Practice Advisor modules.

Private Payers

ACP provides a wealth of resources and guides on coding for and getting paid by commercial payers.

How to Bill Medicare’s Annual Wellness Visit | ACP

Visit ACP for information on how to bill Medicare's Annual Wellness Visit (AWV) and to access a Practice Checklist, Patient Letter & Checklist, and more.

Medicare Improper Payment Review - Recovery Auditor Contractors(RAC)

Summary of Program

Medicare Improper Payment Review - Overview

CMS considers any payment to the wrong provider, for the wrong services or in the wrong amount an improper payment. This includes overpayments and underpayments. These improper payments are most often because statutory coverage requests were not met, medically necessity requirements were not met, the claim was improperly coded or there was not sufficient documentation submitted with the claim. Improper payment review is the evaluation of claims to determine whether the items/services are covered, correctly coded and medically necessary.

Understanding How Older Adults Use the U.S. Health Care System: From Measurement to Meaning

Quality Health Communication Is Critical to Optimal Adult Immunization

Beyond One-Size-Fits-All: Testing Insomnia Treatments in Special Populations

Excessive Alcohol Use and Alcohol Use Disorders: A Policy Brief of the American College of Physicians

Alcohol is used by more people in the United States than tobacco, electronic nicotine delivery systems, or illicit drugs. Several health conditions, including cancer, cardiovascular disease, and liver disease, are associated with excessive alcohol use and alcohol use disorder. Nearly 30 million people aged 12 years or older in the United States reported past-year alcohol use disorder in 2022, but—despite its prevalence—alcohol use disorder is undertreated. In this policy brief, the American College of Physicians outlines the health effects of excessive alcohol use and alcohol use disorder, calls for policy changes to increase the availability of treatment of alcohol use disorder and excessive alcohol use, and recommends alcohol-related public health interventions.

Diagnostic Strategy Using Color Doppler Ultrasound of Temporal Arteries in Patients With High Clinical Suspicion of Giant Cell Arteritis: A Prospective Cohort Study: Annals of Internal Medicine: Vol 177, No 6

Background: Giant cell arteritis (GCA) is the most prevalent systemic vasculitis in people older than 50 years. Any delay in diagnosis impairs patients' quality of life and can lead to permanent damage, particularly vision loss. Objective: To evaluate a diagnostic strategy for GCA using color Doppler ultrasound of the temporal artery as a first-line diagnostic test, temporal artery biopsy (TAB) as a secondary test, and physician expertise as the reference method. Design: Prospective multicenter study with a 2-year follow-up. (ClinicalTrials.gov: NCT02703922) Setting: Patients were referred by their general practitioner or ophthalmologist to a physician with extensive experience in GCA diagnosis and management in one of the participating centers: 4 general and 2 university hospitals. Patients: 165 patients with high clinical suspicion of GCA, aged 79 years (IQR, 73 to 85 years). Intervention: The diagnostic procedure was ultrasound, performed less than 7 days after initiation of corticosteroid therapy. Only ultrasound-negative patients underwent TAB. Measurements: Bilateral temporal halo signs seen on ultrasound were considered positive. Ultrasound and TAB results were compared with physician-diagnosed GCA based on clinical findings and other imaging. Results: Diagnosis of GCA was confirmed in 44%, 17%, and 21% of patients by ultrasound, TAB, and clinical expertise and/or other imaging tests, respectively. Their diagnosis remained unchanged at 1 month, and 2 years for those with available follow-up data. An alternative diagnosis was made in 18% of patients. The proportion of ultrasound-positive patients among patients with a clinical GCA diagnosis was 54% (95% CI, 45% to 62%). Limitation: Small sample size, no blinding of ultrasound and TAB results, lack of an objective gold-standard comparator, and single diagnostic strategy. Conclusion: By using ultrasound of the temporal arteries as a first-line diagnostic tool in patients with high clinical suspicion of GCA, further diagnostic tests for patients with positive ultrasound were avoided. Primary Funding Source: Tender “Recherche CH-CHU Poitou-Charentes 2014.”

Weighing In on the Body Mass Index: Addressing Criticisms and Embracing Purpose

Sensitivity and Specificity of Using GPT-3.5 Turbo Models for Title and Abstract Screening in Systematic Reviews and Meta-analyses

Background: Systematic reviews are performed manually despite the exponential growth of scientific literature. Objective: To investigate the sensitivity and specificity of GPT-3.5 Turbo, from OpenAI, as a single reviewer, for title and abstract screening in systematic reviews. Design: Diagnostic test accuracy study. Setting: Unannotated bibliographic databases from 5 systematic reviews representing 22 665 citations. Participants: None. Measurements: A generic prompt framework to instruct GPT to perform title and abstract screening was designed. The output of the model was compared with decisions from authors under 2 rules. The first rule balanced sensitivity and specificity, for example, to act as a second reviewer. The second rule optimized sensitivity, for example, to reduce the number of citations to be manually screened. Results: Under the balanced rule, sensitivities ranged from 81.1% to 96.5% and specificities ranged from 25.8% to 80.4%. Across all reviews, GPT identified 7 of 708 citations (1%) missed by humans that should have been included after full-text screening at the cost of 10 279 of 22 665 false-positive recommendations (45.3%) that would require reconciliation during the screening process. Under the sensitive rule, sensitivities ranged from 94.6% to 99.8% and specificities ranged from 2.2% to 46.6%. Limiting manual screening to citations not ruled out by GPT could reduce the number of citations to screen from 127 of 6334 (2%) to 1851 of 4077 (45.4%), at the cost of missing from 0 to 1 of 26 citations (3.8%) at the full-text level. Limitations: Time needed to fine-tune prompt. Retrospective nature of the study, convenient sample of 5 systematic reviews, and GPT performance sensitive to prompt development and time. Conclusion: The GPT-3.5 Turbo model may be used as a second reviewer for title and abstract screening, at the cost of additional work to reconcile added false positives. It also showed potential to reduce the number of citations before screening by humans, at the cost of missing some citations at the full-text level. Primary Funding Source: None.

Talking With Patients About the New Anti-amyloid Alzheimer Disease Medications

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Food Insecurity in the COVID-19 Era: A National Wake-up Call to Strengthen SNAP Policy

MKSAP Quiz: Follow-up visit for hypertension

Model including hepatitis B viral load accurately predicts HCC risk in untreated patients

Atrial fibrillation rates rose even more than predicted

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Article, podcast address impact of physician-patient relationships on adult vaccination rates

ACP, Annals of Internal Medicine host forum on H5N1 influenza

MRAs appear effective for heart failure across the range of ejection fractions

MKSAP Quiz: 2-day history of cough, fever

Naming animals during gait test effectively distinguishes cognitive decline

Medications may help vaginal menopause symptoms, but data limited, reviews find

Beta-lactams noninferior to fluoroquinolones, trim-sulfa for uncomplicated gram-negative bacteremia | ACP Hospitalist

Thoracentesis didn't improve outcomes in heart failure with pleural effusion | ACP Hospitalist

Take a quiz about the April 2 issue! | ACP Hospitalist

Parenteral, enteral, and malnutrition in the hospital | ACP Hospitalist

New studies highlight importance of intervening on OUD during hospitalization | ACP Hospitalist

Invasive group A strep incidence up sharply in the U.S. over last decade | ACP Hospitalist

First national practice standards for hospital at home developed | ACP Hospitalist

Beefing up on BCNE | ACP Hospitalist

Take a quiz about the March 26 issue! | ACP Hospitalist

Hospitalizations common among patients with substance use disorder | ACP Hospitalist

Hydroxychloroquine-Induced Dilated Cardiomyopathy: A Case Report | Annals of Internal Medicine: Clinical Cases

Hydroxychloroquine (HCQ) cardiomyopathy (CM) usually presents with a hypertrophic or restrictive pattern. We present a patient case of dilated HCQ-CM with normal wall thickness in young woman with systemic lupus erythematosus and end-stage kidney disease. In patients undergoing renal replacement therapy, the daily dose should be lower than recommended by the manufacturer to avoid toxic effects.

Long-Term Use of Metronidazole Mimicking Hepatic Encephalopathy | Annals of Internal Medicine: Clinical Cases

Metronidazole, a widely used antibiotic is associated with a rare but serious set of adverse effects termed Metronidazole Induced Encephalopathy. This condition can be related to both short as well as long term use of the drug and manifests itself as a constellation of symptoms of neurotoxicity, which can include cerebellar dysfunction, speech abnormalities, seizures and an altered sensorium. In addition to a history and physical exam the backbone of diagnosis for this condition is a set of specific findings seen on Magnetic resonance imaging of the brain.

Abdominal Epilepsy as Sequelae of COVID-19 in a Patient With Granulomatosis and Polyangiitis | Annals of Internal Medicine: Clinical Cases

Abdominal epilepsy is characterized by chronic abdominal pain, and an epileptogenic focus in the temporal lobe is found in most patients. Here, we present a patient case of a 60-year-old woman hospitalized because of several episodes of epigastric pain preceded by visual and auditory hallucinations 1 month after having had COVID-19. The electroencephalogram obtained during an episode of pain showed temporo-occipital epileptiform activity. Infection by SARS-CoV-2 has been associated with neurologic disorders including epilepsy and, in this case, abdominal epilepsy.

A Case of Steroid-Responsive Multisystem Inflammatory Syndrome in Adults With SARS-CoV-2 | Annals of Internal Medicine: Clinical Cases

While the COVID-19 pandemic continues to evolve, different phenotypic variants of the disease are being recognized. Multisystem inflammatory syndrome in adults is an emerging entity that has yet to be fully characterized. The syndrome involves extrapulmonary multiorgan failure with hyperinflammation that typically affects young healthy males, approximately 2 to 12 weeks after infection with SARS-CoV-2. There are no formal guidelines for management, although the syndrome appears responsive to immunomodulators and supportive care. Clinicians should be aware of this unusual and severe clinical entity and the general principles of its management.

Spontaneous Ectopic Paraumbilical Variceal Bleeding in a Patient With Cirrhosis | Annals of Internal Medicine: Clinical Cases

Ectopic variceal hemorrhage is a rare sequela of portal hypertension, accounting for 5% of variceal bleeding events. Although mortality rates are high for this condition, there is no established management protocol. We present a patient case of spontaneous external hemorrhage from an ectopic paraumbilical varicosity in the setting of portal hypertension secondary to decompensated alcoholic cirrhosis that was treated effectively with transjugular intrahepatic portosystemic shunt placement.

Acquired Thrombotic Thrombocytopenic Purpura After ChAdOx1 nCoV-19 Vaccine: A Case Report | Annals of Internal Medicine: Clinical Cases

COVID-19, the illness caused by SARS-CoV-2, continues to cause significant morbidity and mortality across the world. An important step in overcoming SARS-CoV-2 is the global vaccination plan. Cases of acquired thrombotic thrombocytopenic purpura (aTTP) have been recently described after SARS-CoV-2 vaccination. We describe a patient case of aTTP occurring 25 days after ChAdOx1 nCov-19 (Vaxzervria/AstraZeneca) vaccination that was promptly treated with plasma exchange, corticosteroids, rituximab, and caplacizumab. Remission of aTTP was achieved in 2 weeks and the patient is currently in complete remission.

A Rare Manifestation of Chronic Gastric Ischemia With Ulceration | Annals of Internal Medicine: Clinical Cases

We present the patient case of a woman with significant cardiovascular disease, chronic abdominal pain, and repeated episodes of gastrointestinal bleeding, who was ultimately diagnosed with chronic gastric ischemia with recurrent gastric ulcers. The current literature suggests that gastric ischemia is more common than previously thought. A higher degree of suspicion for this relatively rare presentation may be required in the clinical setting.

Persistent Left Superior Vena Cava Resulting in Right-to-Left Cardiac Shunt: When to Treat? | Annals of Internal Medicine: Clinical Cases

Persistent left superior vena cava (PLSVC) is one of the most common thoracic venous anatomical variations. A PLSVC commonly drains into the right atrium via the coronary sinus. Anomalous drainage of a PLSVC into the left-sided circulation can occur, presenting as a stroke or hypoxia consequent to a right-to-left shunt. Herein, we describe a symptomatic patient with PLSVC communicating to the left upper pulmonary vein who had successful percutaneous closure with clinical improvement.

Multisystem Inflammatory Syndrome in Adults (MIS-A) Associated With COVID-19: A Presentation of Mixed Shock | Annals of Internal Medicine: Clinical Cases

Multisystem inflammatory syndrome in adults (MIS-A) is an uncommon hyperinflammatory complication of COVID-19 that carries significant morbidity. MIS-A cases have been published, but details regarding effective treatment strategies are limited. Here, we describe a 33-year-old woman with no medical history who developed mixed distributive and cardiogenic shock from MIS-A 5 weeks after COVID-19 infection. She received anakinra, intravenous immunoglobulin, steroids, and aggressive supportive care including mechanical ventilation, inotropic and vasopressor support, and diuresis. This patient case highlights the importance of early consideration and recognition of MIS-A and treatment of mixed shock in MIS-A.

Isolated Bilateral Adrenal Histoplasmosis With Addisonian Crisis in an Immunocompetent Host | Annals of Internal Medicine: Clinical Cases

Bilateral adrenal histoplasmosis presenting as an adrenal crisis and being the only site of demonstrable disease in an immunocompetent adult is a rare presentation. The adrenal gland is frequently involved in disseminated histoplasmosis but commonly presents as unilateral mass; isolated bilateral involvement in an immunocompetent patient is rare. We describe a patient case of 38-year-old man presenting with epigastric pain, intermittent low-grade fever, nausea and vomiting, skin darkening, generalized weakness, and weight loss for 6 months. Investigations suggested primary adrenal insufficiency. On imaging, patient was found to have bilateral adrenal masses. The histopathological examination revealed Histoplasma species.