The Journal of Family Practice

ABSTRACT

Purpose Medical scribes are known to increase revenue by increasing visits to a medical practice. We examined whether medical scribes are associated with markers of financial benefit independent of increased visits.

Methods We conducted a pre- and post-­observational study with a control group, examining changes in the percentage of visits (1) coded as level of service 4 or 5, (2) with at least 1 hierarchical condition category code billed, and (3) at which orders for 3 pay-for-performance quality measures (screening for breast, cervical, and colon cancer) were placed, if due. We looked at changes in outcomes among scribed providers and compared them to nonscribed providers. We used generalized estimating equations with robust standard errors to account for repeated measures and the hierarchical nature of the data, controlling for patient demographics.

Results We examined 41,371 visits to 17 scribed providers and 230,297 visits to 78 nonscribed providers. In adjusted analyses, and compared to nonscribed providers, scribes were associated with an increase of:

• Frutiger LT Std9.2 percentage points in level-of-­service 4 or 5 billing (Frutiger LT StdP < .001)
• 3.6 percentage points in hierarchical condition category coding (Frutiger LT StdP < .001)
• 4.0 percentage points in breast cancer screening orders (Frutiger LT StdP = .01)
• 4.9 percentage points in colon cancer screening orders (Frutiger LT StdPFrutiger LT Std = .04).

Conclusions This study suggests that scribes are associated with financial benefit in addition to increased visit volume. Primary care practices should consider the financial benefit of scribes independent of their ability to add patient volume.

Increasingly, medical scribes are used in ambulatory care settings across the United States.¹ Scribes are trained personnel who accompany providers during visits to provide documentation support and assist with other administrative tasks. They are associated with reduced documentation time for providers^2-6 and improved provider satisfaction,^7-11 without detriment to^4-16 (or with possible improvement in^17-20) patient satisfaction in ambulatory care settings. At the same time, concerns remain that using scribes might inhibit patient communication, harm clinical reasoning, reduce the effectiveness of clinical decision-support tools, and simply serve as a work-around to fixing inefficiencies in the electronic medical record (EMR).^21-23

A driving force for the increased use of medical scribes is the expectation that they reduce the cost of providing care. Cost-­efficiency is typically described as resulting from a reduction in physician time per patient seen, which allows increased patient volume and, in turn, drives increased physician productivity.^{2,8,10,18,24-27} Whether scribes result in cost savings remains unclear; some papers suggest that scribes are cost efficient in ambulatory care,^2,10,18 while others have been unable to identify cost savings, particularly in primary care.⁴

One reason why scribes might not be associated with cost savings is that their financial benefit might be undercounted. Studies that focus on increased volume miss the opportunity to capture financial benefits conferred through mechanisms that are independent of seeing more patients:

• Scribes might help providers address and document more, and more complex, medical problems, allowing higher level-of-service (LOS) billing. For example, a provider chooses a lower LOS because they have insufficiently documented a visit to support a higher LOS; by assisting with documentation, the scribe might allow the provider to choose a higher LOS.
• Scribes might prompt a provider to use decision-support tools for risk coding (using appropriate medical codes to capture the patient’s level of medical complexity), thereby increasing reimbursement.
• Scribes might extend the time available during the visit for the provider to address pay-for-performance quality measures, such as cancer screening.

Continue to: Making visits count, not counting visits

Making visits count, not counting visits. In this study, we examined whether medical scribes in primary care are associated with improved markers of revenue that are independent of seeing more patients. Specifically, we examined whether scribes are associated with increased LOS coding, risk coding, and orders for pay-for-performance measures for all primary care visits and for nonpreventive primary care visits.

Methods

Design

This observational study compared the change in outcomes before implementation of scribes and during implementation of scribes, between scribed providers and nonscribed providers. We compared visits during the year prior to the implementation of scribes (July 2017–June 2018) with the year during their implementation (July 2018–2019).

The Cambridge Health Alliance Institutional Review Board considered this study exempt from review.

Setting

This study was conducted at a safety-net community academic health system that uses an EMR developed by Epic Systems [Verona, WI]. This EMR includes decision-support tools that prompt providers when pay-for-performance quality measures are due and when hierarchical condition category (HCC) codes—ie, specific diagnoses used by Medicare and other payers to reimburse providers for the complexity of their patients—might apply to the visit.

Primary care practices should consider the financial benefit of scribes, independent of their ability to add patient volume.

These EMR decision-support tools use algorithms that draw on age, gender, diagnoses that were billed previously or are on the problem list, laboratory findings, and prior imaging. They alert physicians when a patient is due for pay-for-performance quality measures, such as cancer screenings, and when HCC codes might be applicable.

Continue to: During the study period...

During the study period, the EMR ­decision-support tool for HCC coding underwent several changes designed to improve HCC coding. In addition, systematic changes to primary care visits took place, leading to an increase in the number of patients seen and screenings required.

Outcomes

We examined 2 categories of outcomes that confer financial benefit to many institutions: billing measures and pay-for-performance measures.

Billing measures included the percentage of visits (1) coded as LOS 4 or 5 and (2) with at least 1 HCC code billed (among those for which the decision-support tool identified at least 1 potential HCC code).

Pay-for-performance measures. We examined whether any of 3 pay-for-­performance quality measures were addressed during the visit, selecting 3 that are commonly addressed by primary care providers (PCPs) and that require PCPs to sign an order for screening during a primary care visit: breast cancer (mammography order), cervical cancer (Papanicolaou smear order), and colon cancer (an order for fecal occult blood testing or colonoscopy).

Intervention

Scribes were employees of Cambridge Health Alliance who had recently graduated from college and were interested in a career as a health care professional. Scribes received 3 days of training on how to function effectively in their role; 1 day of training in EMR functionality; and 2 hours of training on decision-support tools for pay-for-performance quality measures and risk coding. Scribes continued learning on the job through feedback from supervising PCPs. Scribes documented patient encounters, recording histories and findings on the physical exam and transcribing discussion of treatment plans and the PCP’s instructions to patients.

Continue to: The 14 scribes worked with 17 physician...

The 14 scribes worked with 17 physician and nurse practitioner PCPs beginning in July 2018. Participation by PCPs was voluntary; they received no compensation for participating in the scribe program. PCPs were not required to see additional patients to participate. PCPs who chose to work with a scribe were similar to those who declined a scribe, as regards gender, race, type of provider (MD or NP), tenure at the institution, and percentage of time in clinical work (see Table W-1).

The control group comprised providers who elected not to work with a scribe but who worked in the same clinics as the intervention providers.

Scribes might extend the time available during the visit for the provider to address pay-forperformance quality measures, such as cancer screening.

Scribes were assigned to a PCP based on availability during the PCP’s scheduled hours and worked with 1 PCP throughout the intervention (except for 1 PCP who worked with 2 scribes). All PCPs worked with their scribe(s) part time; on average, 49% of intervention PCPs’ visits were scribed.

Inclusion and exclusion criteria

Because the first year at an institution is a learning period for PCPs, we excluded those who worked at the institution for < 1 year before the start of the scribe program (n = 12). Based on the extensive clinical experience of 1 PCP (WA) with scribes, we excluded the first 200 visits or 6 weeks (whichever occurred first) with a scribe among all scribed providers, to account for an initial learning period (n = 2202, of 15,372 scribed visits [14%]). We also excluded 2 providers who left during the pre-intervention period or were in the intervention period for < 1 month.

To ensure that we captured visits to providers with clinically significant exposure to scribes, we required scribed providers to have ≥ 20% of their visits scribed during the intervention period. To minimize the potential for contamination, we excluded nonscribed visits to scribed providers during the intervention period (n = 2211), because such nonscribed visits were largely due to visits outside the scribe’s scheduled time.

Continue to: Analysis

We compared demographic characteristics for patients and providers using the chi-square test for categorical variables and the t test for continuous variables. We compared the change in outcomes from before implementation of scribes to during implementation of scribes among scribed providers, compared to nonscribed providers, using generalized estimating equations with robust standard errors to account for repeated measures (ie, multiple visits by the same patients) and the hierarchical nature of the data (ie, patients nested within providers). We then recalculated these estimates, controlling for patient demographics (age, gender, race, and ethnicity). We repeated these analyses for patients presenting for nonpreventive visits.

Results

Visit characteristics

We examined 271,768 visits, including 41,371 visits to 17 scribed providers and 230,397 visits to 78 nonscribed providers (Table 1). Patients were most likely to be female, > 21 years of age, have English as their language of care, and be non-White. Most visits were by established patients and were nonpreventive.

We noted no clinically significant differences in characteristics between visits with scribed providers and visits with nonscribed providers, and over time. Patient complexity measures, including care management enrollment and hospital admissions, were also similar between groups, and over time.

Billing measures

HCC coding. In 28.6% of visits, the decision-support tool identified at least 1 potential HCC code. Among these, the percentage of visits with at least 1 HCC code billed increased by 10.1 percentage points (from 3.9% before implementation of scribes to 14.0%) among scribed providers, compared to increasing by 6.5 percentage points (from 2.9% before implementation to 9.3%) among nonscribed providers (TABLE 2). Scribes were therefore associated with an additional 3.6 percentage-point increase in visits with at least 1 HCC code billed (P < .0001)—a difference that remained significant after adjusting for patient demographics (P < .0001).

LOS coding. Scribed providers increased the number of visits billed as LOS 4 or 5 by 9.6 percentage points (from 47.3% before implementation to 56.8%); during the same period, nonscribed providers increased the number of visits billed as LOS 4 or 5 by 1.3 percentage points (from 46.5% before implementation to 47.8%) (TABLE 2). Scribes were therefore associated with an additional 8.3 percentage points in LOS 4 or 5 billing (P < .001) (TABLE 2). This difference remained significant after adjusting for patient demographics (P < .001).

Continue to: Pay-for-performance quality measures

Breast cancer screening. Scribed providers increased the number of visits at which breast cancer screening was ordered by 2.7 percentage points (from 17.3% before implementation of scribes to 20.0%); during the same period, the number of visits at which breast cancer screening was ordered by nonscribed providers decreased by 1.9 percentage points (from 19.5% to 17.6%). Scribes were therefore associated with an increase of 4.6 percentage points in breast cancer screening orders, compared to nonscribed providers (P < .003) (TABLE 2). That difference remained significant after adjusting for patient demographics (P = .01).

Colon cancer screening. Similarly, scribed providers increased the number of visits at which colon cancer screening was ordered by 1.2 percentage points (from 19.2% before implementation of scribes to 20.3%); during the same period, the number of visits at which colon cancer screening was ordered by nonscribed providers decreased by 2.7 percentage points (from 18.5% to 15.9%) (P = .112). After adjusting for patient demographics, scribes were associated with an increase of 4.9 percentage points in colon cancer screening orders, compared to nonscribed providers (P = .044) (TABLE 2).

Cervical cancer screening. The rate at which cervical cancer screening was ordered did not change among scribed providers and decreased (by 2.5 percentage points) among nonscribed providers—a difference that was not statistically significant (P = .26).

Nonpreventive visits. Our findings overall did not change in analyses focused on nonpreventive visits, in which scribes were associated with an increase of 8.2 percentage points in LOS 4 or 5 billing (P < .001); an increase of 3.1 percentage points in HCC coding (P < .001); and an increase of 3.2 percentage points in breast cancer screening orders (P = .03) (TABLE 3). Although scribes were associated with an increase of 1.5 percentage points in cervical cancer screening orders and an increase of 3.1 percentage points in colon cancer screening orders, these increases did not reach statistical significance.

Discussion

We found that implementation of scribes is associated with (1) an increase in LOS coding and risk coding and (2) a higher frequency of addressing 2 of 3 pay-for-performance quality measures in primary care. In adjusted analyses in our study, and compared to nonscribed providers, scribes were associated with an additional 9.2 percentage points in LOS 4 or 5 billing; 3.6 percentage points in HCC coding; 4.0 percentage points in breast cancer screening orders; and 4.9 percentage points in colon cancer screening orders. Cervical cancer screening orders followed a similar pattern, with an increase of 2.3 percentage points in the adjusted screening order rate among scribed providers, compared to nonscribed providers, during implementation of scribes—although the increase was not significant. These findings did not change in analyses focused on nonpreventive visits.

Continue to: Our findings are consistent

Our findings are consistent with those of earlier studies. Prior examinations in ambulatory specialties found that scribes increased HCC coding,⁴ LOS billing,²⁴ and pay-for-performance metrics.¹⁸ The only study to examine these areas in primary care found that scribes were associated with increased pay-for-performance measure documentation,²⁰ a change that is necessary but insufficient to realize increased pay-for-­performance revenue. Therefore, our study confirms, for the first time, that PCPs can better address pay-for-performance measures, LOS billing, and HCC coding when working with a scribe in primary care.

Providers who used a scribe during the intervention period of our study increased the number of visits billed as LOS 4 or 5 by 9.6 percentage points.

Demands on primary care visits are increasing.²⁸ Physicians are required to provide more documentation; there is greater emphasis on PCPs meeting pay-for-­performance measures; and there are more data in the EMR to review. In this context, addressing pay-for-performance measures and gaps in risk coding is likely to be increasingly challenging. Our study suggests that scribes might provide a mechanism to increase risk coding, LOS billing, and pay-for-performance measures, despite increased demands on primary care visits.

Increase in LOS billing. In the settings in which we work, a fee-for-service LOS 4 primary care visit generates, on average, $20 to $75 more in revenue than an LOS 3 visit. Using an average of $50 additional revenue for LOS 4 billing, we estimate that a full-time scribe is associated with roughly $7,000 in additional revenue annually. We arrived at this estimate using an average of 1500 visits at LOS ≤ 3 for every PCP full-time equivalent. A 9.2 percentage–point increase in LOS 4 billing would lead to roughly 140 additional LOS 4 visits, with each visit generating an additional $50 in revenue.

This analysis does not account for increased revenue associated with increased pay for HCC coding identified in our study.

Our study also suggests that scribes might provide a mechanism to increase risk coding and payfor-performance, despite increased demands on primary care visits.

Furthermore, in our conservative assumption, the entire increase in LOS billing was from level 3 to level 4; in fact, a small percentage of that increase would be from level 2 and another small percentage would be to level 5—both of which would generate additional revenue. Our assumption therefore underestimates the full financial value associated with scribes in the absence of increased patient volume. Nonetheless, the assumption suggests that increases in LOS billing offset a substantial percentage of a scribe’s salary.

Continue to: Limitations of this study

Limitations of this study. Our study should be interpreted in the context of several limitations:

• The study was conducted at 1 institution. Our findings might not be generalizable beyond this setting.
• The study measures the impact of scribes when providers work with scribes part time. Because providers who utilize a scribe for all, or nearly all, their visits are likely to use a scribe more efficiently, our study might underestimate the full impact of a scribe.
• In some settings, team members such as medical assistants are trained to assist with documentation and other responsibilities (such as closing care gaps) in addition to other patient care responsibilities.^29-32 The extent to which our findings transfer to other models is unclear; studies comparing the impact of other models (which might provide even stronger outcomes) to the impact of medical scribes would be an interesting area for further research.
• In addition to the variability of models, there is likely variability in the quality and interactions of medical scribes, which might impact outcomes. We did not examine the qualities of scribes that led to outcomes in this study.
• We examined the impact of scribes on quality measure–ordering behaviors of providers, not on whether quality measures actually improved. Because scribes are associated with more face-to-face time with patients,²⁷ they might allow for increased attention being paid by physicians to barriers to pay-for-performance measures (eg, patient education). This could increase the likelihood that patients complete a multitude of screenings, and thus improve adherence and follow-up. However, the impact of scribes on quality measures is a topic for future study.

Value beyond volume. Any limitations notwithstanding, our study suggests that scribes are associated with financial benefit in addition to the benefit of increased volume. Primary care practices should therefore consider the financial benefit of scribes independent of their ability to add patient volume. By recognizing this additive value, primary care practices might more fully capture the benefit of scribes, which might then allow practices to employ scribes with less demand to increase volume. This added support without increased volume would, in turn, likely reduce provider burnout (and the costly associated turnover) and increase patient satisfaction, leading to a synergistic financial benefit.

CORRESPONDENCE
Wayne Altman, MD, FAAFP, Tufts University School of Medicine, 200 Harrison Avenue, Boston, MA 02111; wayne. altman@tufts.edu

ABSTRACT

Purpose Medical scribes are known to increase revenue by increasing visits to a medical practice. We examined whether medical scribes are associated with markers of financial benefit independent of increased visits.

Methods We conducted a pre- and post-­observational study with a control group, examining changes in the percentage of visits (1) coded as level of service 4 or 5, (2) with at least 1 hierarchical condition category code billed, and (3) at which orders for 3 pay-for-performance quality measures (screening for breast, cervical, and colon cancer) were placed, if due. We looked at changes in outcomes among scribed providers and compared them to nonscribed providers. We used generalized estimating equations with robust standard errors to account for repeated measures and the hierarchical nature of the data, controlling for patient demographics.

Results We examined 41,371 visits to 17 scribed providers and 230,297 visits to 78 nonscribed providers. In adjusted analyses, and compared to nonscribed providers, scribes were associated with an increase of:

• Frutiger LT Std9.2 percentage points in level-of-­service 4 or 5 billing (Frutiger LT StdP < .001)
• 3.6 percentage points in hierarchical condition category coding (Frutiger LT StdP < .001)
• 4.0 percentage points in breast cancer screening orders (Frutiger LT StdP = .01)
• 4.9 percentage points in colon cancer screening orders (Frutiger LT StdPFrutiger LT Std = .04).

Conclusions This study suggests that scribes are associated with financial benefit in addition to increased visit volume. Primary care practices should consider the financial benefit of scribes independent of their ability to add patient volume.

Increasingly, medical scribes are used in ambulatory care settings across the United States.¹ Scribes are trained personnel who accompany providers during visits to provide documentation support and assist with other administrative tasks. They are associated with reduced documentation time for providers^2-6 and improved provider satisfaction,^7-11 without detriment to^4-16 (or with possible improvement in^17-20) patient satisfaction in ambulatory care settings. At the same time, concerns remain that using scribes might inhibit patient communication, harm clinical reasoning, reduce the effectiveness of clinical decision-support tools, and simply serve as a work-around to fixing inefficiencies in the electronic medical record (EMR).^21-23

A driving force for the increased use of medical scribes is the expectation that they reduce the cost of providing care. Cost-­efficiency is typically described as resulting from a reduction in physician time per patient seen, which allows increased patient volume and, in turn, drives increased physician productivity.^{2,8,10,18,24-27} Whether scribes result in cost savings remains unclear; some papers suggest that scribes are cost efficient in ambulatory care,^2,10,18 while others have been unable to identify cost savings, particularly in primary care.⁴

One reason why scribes might not be associated with cost savings is that their financial benefit might be undercounted. Studies that focus on increased volume miss the opportunity to capture financial benefits conferred through mechanisms that are independent of seeing more patients:

• Scribes might help providers address and document more, and more complex, medical problems, allowing higher level-of-service (LOS) billing. For example, a provider chooses a lower LOS because they have insufficiently documented a visit to support a higher LOS; by assisting with documentation, the scribe might allow the provider to choose a higher LOS.
• Scribes might prompt a provider to use decision-support tools for risk coding (using appropriate medical codes to capture the patient’s level of medical complexity), thereby increasing reimbursement.
• Scribes might extend the time available during the visit for the provider to address pay-for-performance quality measures, such as cancer screening.

Continue to: Making visits count, not counting visits

Making visits count, not counting visits. In this study, we examined whether medical scribes in primary care are associated with improved markers of revenue that are independent of seeing more patients. Specifically, we examined whether scribes are associated with increased LOS coding, risk coding, and orders for pay-for-performance measures for all primary care visits and for nonpreventive primary care visits.

Methods

Design

This observational study compared the change in outcomes before implementation of scribes and during implementation of scribes, between scribed providers and nonscribed providers. We compared visits during the year prior to the implementation of scribes (July 2017–June 2018) with the year during their implementation (July 2018–2019).

The Cambridge Health Alliance Institutional Review Board considered this study exempt from review.

Setting

This study was conducted at a safety-net community academic health system that uses an EMR developed by Epic Systems [Verona, WI]. This EMR includes decision-support tools that prompt providers when pay-for-performance quality measures are due and when hierarchical condition category (HCC) codes—ie, specific diagnoses used by Medicare and other payers to reimburse providers for the complexity of their patients—might apply to the visit.

Primary care practices should consider the financial benefit of scribes, independent of their ability to add patient volume.

These EMR decision-support tools use algorithms that draw on age, gender, diagnoses that were billed previously or are on the problem list, laboratory findings, and prior imaging. They alert physicians when a patient is due for pay-for-performance quality measures, such as cancer screenings, and when HCC codes might be applicable.

Continue to: During the study period...

During the study period, the EMR ­decision-support tool for HCC coding underwent several changes designed to improve HCC coding. In addition, systematic changes to primary care visits took place, leading to an increase in the number of patients seen and screenings required.

Outcomes

We examined 2 categories of outcomes that confer financial benefit to many institutions: billing measures and pay-for-performance measures.

Billing measures included the percentage of visits (1) coded as LOS 4 or 5 and (2) with at least 1 HCC code billed (among those for which the decision-support tool identified at least 1 potential HCC code).

Pay-for-performance measures. We examined whether any of 3 pay-for-­performance quality measures were addressed during the visit, selecting 3 that are commonly addressed by primary care providers (PCPs) and that require PCPs to sign an order for screening during a primary care visit: breast cancer (mammography order), cervical cancer (Papanicolaou smear order), and colon cancer (an order for fecal occult blood testing or colonoscopy).

Intervention

Scribes were employees of Cambridge Health Alliance who had recently graduated from college and were interested in a career as a health care professional. Scribes received 3 days of training on how to function effectively in their role; 1 day of training in EMR functionality; and 2 hours of training on decision-support tools for pay-for-performance quality measures and risk coding. Scribes continued learning on the job through feedback from supervising PCPs. Scribes documented patient encounters, recording histories and findings on the physical exam and transcribing discussion of treatment plans and the PCP’s instructions to patients.

Continue to: The 14 scribes worked with 17 physician...

The 14 scribes worked with 17 physician and nurse practitioner PCPs beginning in July 2018. Participation by PCPs was voluntary; they received no compensation for participating in the scribe program. PCPs were not required to see additional patients to participate. PCPs who chose to work with a scribe were similar to those who declined a scribe, as regards gender, race, type of provider (MD or NP), tenure at the institution, and percentage of time in clinical work (see Table W-1).

The control group comprised providers who elected not to work with a scribe but who worked in the same clinics as the intervention providers.

Scribes might extend the time available during the visit for the provider to address pay-forperformance quality measures, such as cancer screening.

Scribes were assigned to a PCP based on availability during the PCP’s scheduled hours and worked with 1 PCP throughout the intervention (except for 1 PCP who worked with 2 scribes). All PCPs worked with their scribe(s) part time; on average, 49% of intervention PCPs’ visits were scribed.

Inclusion and exclusion criteria

Because the first year at an institution is a learning period for PCPs, we excluded those who worked at the institution for < 1 year before the start of the scribe program (n = 12). Based on the extensive clinical experience of 1 PCP (WA) with scribes, we excluded the first 200 visits or 6 weeks (whichever occurred first) with a scribe among all scribed providers, to account for an initial learning period (n = 2202, of 15,372 scribed visits [14%]). We also excluded 2 providers who left during the pre-intervention period or were in the intervention period for < 1 month.

To ensure that we captured visits to providers with clinically significant exposure to scribes, we required scribed providers to have ≥ 20% of their visits scribed during the intervention period. To minimize the potential for contamination, we excluded nonscribed visits to scribed providers during the intervention period (n = 2211), because such nonscribed visits were largely due to visits outside the scribe’s scheduled time.

Continue to: Analysis

We compared demographic characteristics for patients and providers using the chi-square test for categorical variables and the t test for continuous variables. We compared the change in outcomes from before implementation of scribes to during implementation of scribes among scribed providers, compared to nonscribed providers, using generalized estimating equations with robust standard errors to account for repeated measures (ie, multiple visits by the same patients) and the hierarchical nature of the data (ie, patients nested within providers). We then recalculated these estimates, controlling for patient demographics (age, gender, race, and ethnicity). We repeated these analyses for patients presenting for nonpreventive visits.

Results

Visit characteristics

We examined 271,768 visits, including 41,371 visits to 17 scribed providers and 230,397 visits to 78 nonscribed providers (Table 1). Patients were most likely to be female, > 21 years of age, have English as their language of care, and be non-White. Most visits were by established patients and were nonpreventive.

We noted no clinically significant differences in characteristics between visits with scribed providers and visits with nonscribed providers, and over time. Patient complexity measures, including care management enrollment and hospital admissions, were also similar between groups, and over time.

Billing measures

HCC coding. In 28.6% of visits, the decision-support tool identified at least 1 potential HCC code. Among these, the percentage of visits with at least 1 HCC code billed increased by 10.1 percentage points (from 3.9% before implementation of scribes to 14.0%) among scribed providers, compared to increasing by 6.5 percentage points (from 2.9% before implementation to 9.3%) among nonscribed providers (TABLE 2). Scribes were therefore associated with an additional 3.6 percentage-point increase in visits with at least 1 HCC code billed (P < .0001)—a difference that remained significant after adjusting for patient demographics (P < .0001).

LOS coding. Scribed providers increased the number of visits billed as LOS 4 or 5 by 9.6 percentage points (from 47.3% before implementation to 56.8%); during the same period, nonscribed providers increased the number of visits billed as LOS 4 or 5 by 1.3 percentage points (from 46.5% before implementation to 47.8%) (TABLE 2). Scribes were therefore associated with an additional 8.3 percentage points in LOS 4 or 5 billing (P < .001) (TABLE 2). This difference remained significant after adjusting for patient demographics (P < .001).

Continue to: Pay-for-performance quality measures

Breast cancer screening. Scribed providers increased the number of visits at which breast cancer screening was ordered by 2.7 percentage points (from 17.3% before implementation of scribes to 20.0%); during the same period, the number of visits at which breast cancer screening was ordered by nonscribed providers decreased by 1.9 percentage points (from 19.5% to 17.6%). Scribes were therefore associated with an increase of 4.6 percentage points in breast cancer screening orders, compared to nonscribed providers (P < .003) (TABLE 2). That difference remained significant after adjusting for patient demographics (P = .01).

Colon cancer screening. Similarly, scribed providers increased the number of visits at which colon cancer screening was ordered by 1.2 percentage points (from 19.2% before implementation of scribes to 20.3%); during the same period, the number of visits at which colon cancer screening was ordered by nonscribed providers decreased by 2.7 percentage points (from 18.5% to 15.9%) (P = .112). After adjusting for patient demographics, scribes were associated with an increase of 4.9 percentage points in colon cancer screening orders, compared to nonscribed providers (P = .044) (TABLE 2).

Cervical cancer screening. The rate at which cervical cancer screening was ordered did not change among scribed providers and decreased (by 2.5 percentage points) among nonscribed providers—a difference that was not statistically significant (P = .26).

Nonpreventive visits. Our findings overall did not change in analyses focused on nonpreventive visits, in which scribes were associated with an increase of 8.2 percentage points in LOS 4 or 5 billing (P < .001); an increase of 3.1 percentage points in HCC coding (P < .001); and an increase of 3.2 percentage points in breast cancer screening orders (P = .03) (TABLE 3). Although scribes were associated with an increase of 1.5 percentage points in cervical cancer screening orders and an increase of 3.1 percentage points in colon cancer screening orders, these increases did not reach statistical significance.

Discussion

We found that implementation of scribes is associated with (1) an increase in LOS coding and risk coding and (2) a higher frequency of addressing 2 of 3 pay-for-performance quality measures in primary care. In adjusted analyses in our study, and compared to nonscribed providers, scribes were associated with an additional 9.2 percentage points in LOS 4 or 5 billing; 3.6 percentage points in HCC coding; 4.0 percentage points in breast cancer screening orders; and 4.9 percentage points in colon cancer screening orders. Cervical cancer screening orders followed a similar pattern, with an increase of 2.3 percentage points in the adjusted screening order rate among scribed providers, compared to nonscribed providers, during implementation of scribes—although the increase was not significant. These findings did not change in analyses focused on nonpreventive visits.

Continue to: Our findings are consistent

Our findings are consistent with those of earlier studies. Prior examinations in ambulatory specialties found that scribes increased HCC coding,⁴ LOS billing,²⁴ and pay-for-performance metrics.¹⁸ The only study to examine these areas in primary care found that scribes were associated with increased pay-for-performance measure documentation,²⁰ a change that is necessary but insufficient to realize increased pay-for-­performance revenue. Therefore, our study confirms, for the first time, that PCPs can better address pay-for-performance measures, LOS billing, and HCC coding when working with a scribe in primary care.

Providers who used a scribe during the intervention period of our study increased the number of visits billed as LOS 4 or 5 by 9.6 percentage points.

Demands on primary care visits are increasing.²⁸ Physicians are required to provide more documentation; there is greater emphasis on PCPs meeting pay-for-­performance measures; and there are more data in the EMR to review. In this context, addressing pay-for-performance measures and gaps in risk coding is likely to be increasingly challenging. Our study suggests that scribes might provide a mechanism to increase risk coding, LOS billing, and pay-for-performance measures, despite increased demands on primary care visits.

Increase in LOS billing. In the settings in which we work, a fee-for-service LOS 4 primary care visit generates, on average, $20 to $75 more in revenue than an LOS 3 visit. Using an average of $50 additional revenue for LOS 4 billing, we estimate that a full-time scribe is associated with roughly $7,000 in additional revenue annually. We arrived at this estimate using an average of 1500 visits at LOS ≤ 3 for every PCP full-time equivalent. A 9.2 percentage–point increase in LOS 4 billing would lead to roughly 140 additional LOS 4 visits, with each visit generating an additional $50 in revenue.

This analysis does not account for increased revenue associated with increased pay for HCC coding identified in our study.

Our study also suggests that scribes might provide a mechanism to increase risk coding and payfor-performance, despite increased demands on primary care visits.

Furthermore, in our conservative assumption, the entire increase in LOS billing was from level 3 to level 4; in fact, a small percentage of that increase would be from level 2 and another small percentage would be to level 5—both of which would generate additional revenue. Our assumption therefore underestimates the full financial value associated with scribes in the absence of increased patient volume. Nonetheless, the assumption suggests that increases in LOS billing offset a substantial percentage of a scribe’s salary.

Continue to: Limitations of this study

Limitations of this study. Our study should be interpreted in the context of several limitations:

• The study was conducted at 1 institution. Our findings might not be generalizable beyond this setting.
• The study measures the impact of scribes when providers work with scribes part time. Because providers who utilize a scribe for all, or nearly all, their visits are likely to use a scribe more efficiently, our study might underestimate the full impact of a scribe.
• In some settings, team members such as medical assistants are trained to assist with documentation and other responsibilities (such as closing care gaps) in addition to other patient care responsibilities.^29-32 The extent to which our findings transfer to other models is unclear; studies comparing the impact of other models (which might provide even stronger outcomes) to the impact of medical scribes would be an interesting area for further research.
• In addition to the variability of models, there is likely variability in the quality and interactions of medical scribes, which might impact outcomes. We did not examine the qualities of scribes that led to outcomes in this study.
• We examined the impact of scribes on quality measure–ordering behaviors of providers, not on whether quality measures actually improved. Because scribes are associated with more face-to-face time with patients,²⁷ they might allow for increased attention being paid by physicians to barriers to pay-for-performance measures (eg, patient education). This could increase the likelihood that patients complete a multitude of screenings, and thus improve adherence and follow-up. However, the impact of scribes on quality measures is a topic for future study.

Value beyond volume. Any limitations notwithstanding, our study suggests that scribes are associated with financial benefit in addition to the benefit of increased volume. Primary care practices should therefore consider the financial benefit of scribes independent of their ability to add patient volume. By recognizing this additive value, primary care practices might more fully capture the benefit of scribes, which might then allow practices to employ scribes with less demand to increase volume. This added support without increased volume would, in turn, likely reduce provider burnout (and the costly associated turnover) and increase patient satisfaction, leading to a synergistic financial benefit.

CORRESPONDENCE
Wayne Altman, MD, FAAFP, Tufts University School of Medicine, 200 Harrison Avenue, Boston, MA 02111; wayne. altman@tufts.edu

ABSTRACT

Purpose Medical scribes are known to increase revenue by increasing visits to a medical practice. We examined whether medical scribes are associated with markers of financial benefit independent of increased visits.

Methods We conducted a pre- and post-­observational study with a control group, examining changes in the percentage of visits (1) coded as level of service 4 or 5, (2) with at least 1 hierarchical condition category code billed, and (3) at which orders for 3 pay-for-performance quality measures (screening for breast, cervical, and colon cancer) were placed, if due. We looked at changes in outcomes among scribed providers and compared them to nonscribed providers. We used generalized estimating equations with robust standard errors to account for repeated measures and the hierarchical nature of the data, controlling for patient demographics.

Results We examined 41,371 visits to 17 scribed providers and 230,297 visits to 78 nonscribed providers. In adjusted analyses, and compared to nonscribed providers, scribes were associated with an increase of:

• Frutiger LT Std9.2 percentage points in level-of-­service 4 or 5 billing (Frutiger LT StdP < .001)
• 3.6 percentage points in hierarchical condition category coding (Frutiger LT StdP < .001)
• 4.0 percentage points in breast cancer screening orders (Frutiger LT StdP = .01)
• 4.9 percentage points in colon cancer screening orders (Frutiger LT StdPFrutiger LT Std = .04).

Conclusions This study suggests that scribes are associated with financial benefit in addition to increased visit volume. Primary care practices should consider the financial benefit of scribes independent of their ability to add patient volume.

Increasingly, medical scribes are used in ambulatory care settings across the United States.¹ Scribes are trained personnel who accompany providers during visits to provide documentation support and assist with other administrative tasks. They are associated with reduced documentation time for providers^2-6 and improved provider satisfaction,^7-11 without detriment to^4-16 (or with possible improvement in^17-20) patient satisfaction in ambulatory care settings. At the same time, concerns remain that using scribes might inhibit patient communication, harm clinical reasoning, reduce the effectiveness of clinical decision-support tools, and simply serve as a work-around to fixing inefficiencies in the electronic medical record (EMR).^21-23

A driving force for the increased use of medical scribes is the expectation that they reduce the cost of providing care. Cost-­efficiency is typically described as resulting from a reduction in physician time per patient seen, which allows increased patient volume and, in turn, drives increased physician productivity.^{2,8,10,18,24-27} Whether scribes result in cost savings remains unclear; some papers suggest that scribes are cost efficient in ambulatory care,^2,10,18 while others have been unable to identify cost savings, particularly in primary care.⁴

One reason why scribes might not be associated with cost savings is that their financial benefit might be undercounted. Studies that focus on increased volume miss the opportunity to capture financial benefits conferred through mechanisms that are independent of seeing more patients:

• Scribes might help providers address and document more, and more complex, medical problems, allowing higher level-of-service (LOS) billing. For example, a provider chooses a lower LOS because they have insufficiently documented a visit to support a higher LOS; by assisting with documentation, the scribe might allow the provider to choose a higher LOS.
• Scribes might prompt a provider to use decision-support tools for risk coding (using appropriate medical codes to capture the patient’s level of medical complexity), thereby increasing reimbursement.
• Scribes might extend the time available during the visit for the provider to address pay-for-performance quality measures, such as cancer screening.

Continue to: Making visits count, not counting visits

Making visits count, not counting visits. In this study, we examined whether medical scribes in primary care are associated with improved markers of revenue that are independent of seeing more patients. Specifically, we examined whether scribes are associated with increased LOS coding, risk coding, and orders for pay-for-performance measures for all primary care visits and for nonpreventive primary care visits.

Methods

Design

This observational study compared the change in outcomes before implementation of scribes and during implementation of scribes, between scribed providers and nonscribed providers. We compared visits during the year prior to the implementation of scribes (July 2017–June 2018) with the year during their implementation (July 2018–2019).

The Cambridge Health Alliance Institutional Review Board considered this study exempt from review.

Setting

This study was conducted at a safety-net community academic health system that uses an EMR developed by Epic Systems [Verona, WI]. This EMR includes decision-support tools that prompt providers when pay-for-performance quality measures are due and when hierarchical condition category (HCC) codes—ie, specific diagnoses used by Medicare and other payers to reimburse providers for the complexity of their patients—might apply to the visit.

Primary care practices should consider the financial benefit of scribes, independent of their ability to add patient volume.

These EMR decision-support tools use algorithms that draw on age, gender, diagnoses that were billed previously or are on the problem list, laboratory findings, and prior imaging. They alert physicians when a patient is due for pay-for-performance quality measures, such as cancer screenings, and when HCC codes might be applicable.

Continue to: During the study period...

During the study period, the EMR ­decision-support tool for HCC coding underwent several changes designed to improve HCC coding. In addition, systematic changes to primary care visits took place, leading to an increase in the number of patients seen and screenings required.

Outcomes

We examined 2 categories of outcomes that confer financial benefit to many institutions: billing measures and pay-for-performance measures.

Billing measures included the percentage of visits (1) coded as LOS 4 or 5 and (2) with at least 1 HCC code billed (among those for which the decision-support tool identified at least 1 potential HCC code).

Pay-for-performance measures. We examined whether any of 3 pay-for-­performance quality measures were addressed during the visit, selecting 3 that are commonly addressed by primary care providers (PCPs) and that require PCPs to sign an order for screening during a primary care visit: breast cancer (mammography order), cervical cancer (Papanicolaou smear order), and colon cancer (an order for fecal occult blood testing or colonoscopy).

Intervention

Scribes were employees of Cambridge Health Alliance who had recently graduated from college and were interested in a career as a health care professional. Scribes received 3 days of training on how to function effectively in their role; 1 day of training in EMR functionality; and 2 hours of training on decision-support tools for pay-for-performance quality measures and risk coding. Scribes continued learning on the job through feedback from supervising PCPs. Scribes documented patient encounters, recording histories and findings on the physical exam and transcribing discussion of treatment plans and the PCP’s instructions to patients.

Continue to: The 14 scribes worked with 17 physician...

The 14 scribes worked with 17 physician and nurse practitioner PCPs beginning in July 2018. Participation by PCPs was voluntary; they received no compensation for participating in the scribe program. PCPs were not required to see additional patients to participate. PCPs who chose to work with a scribe were similar to those who declined a scribe, as regards gender, race, type of provider (MD or NP), tenure at the institution, and percentage of time in clinical work (see Table W-1).

The control group comprised providers who elected not to work with a scribe but who worked in the same clinics as the intervention providers.

Scribes might extend the time available during the visit for the provider to address pay-forperformance quality measures, such as cancer screening.

Scribes were assigned to a PCP based on availability during the PCP’s scheduled hours and worked with 1 PCP throughout the intervention (except for 1 PCP who worked with 2 scribes). All PCPs worked with their scribe(s) part time; on average, 49% of intervention PCPs’ visits were scribed.

Inclusion and exclusion criteria

Because the first year at an institution is a learning period for PCPs, we excluded those who worked at the institution for < 1 year before the start of the scribe program (n = 12). Based on the extensive clinical experience of 1 PCP (WA) with scribes, we excluded the first 200 visits or 6 weeks (whichever occurred first) with a scribe among all scribed providers, to account for an initial learning period (n = 2202, of 15,372 scribed visits [14%]). We also excluded 2 providers who left during the pre-intervention period or were in the intervention period for < 1 month.

To ensure that we captured visits to providers with clinically significant exposure to scribes, we required scribed providers to have ≥ 20% of their visits scribed during the intervention period. To minimize the potential for contamination, we excluded nonscribed visits to scribed providers during the intervention period (n = 2211), because such nonscribed visits were largely due to visits outside the scribe’s scheduled time.

Continue to: Analysis

We compared demographic characteristics for patients and providers using the chi-square test for categorical variables and the t test for continuous variables. We compared the change in outcomes from before implementation of scribes to during implementation of scribes among scribed providers, compared to nonscribed providers, using generalized estimating equations with robust standard errors to account for repeated measures (ie, multiple visits by the same patients) and the hierarchical nature of the data (ie, patients nested within providers). We then recalculated these estimates, controlling for patient demographics (age, gender, race, and ethnicity). We repeated these analyses for patients presenting for nonpreventive visits.

Results

Visit characteristics

We examined 271,768 visits, including 41,371 visits to 17 scribed providers and 230,397 visits to 78 nonscribed providers (Table 1). Patients were most likely to be female, > 21 years of age, have English as their language of care, and be non-White. Most visits were by established patients and were nonpreventive.

We noted no clinically significant differences in characteristics between visits with scribed providers and visits with nonscribed providers, and over time. Patient complexity measures, including care management enrollment and hospital admissions, were also similar between groups, and over time.

Billing measures

HCC coding. In 28.6% of visits, the decision-support tool identified at least 1 potential HCC code. Among these, the percentage of visits with at least 1 HCC code billed increased by 10.1 percentage points (from 3.9% before implementation of scribes to 14.0%) among scribed providers, compared to increasing by 6.5 percentage points (from 2.9% before implementation to 9.3%) among nonscribed providers (TABLE 2). Scribes were therefore associated with an additional 3.6 percentage-point increase in visits with at least 1 HCC code billed (P < .0001)—a difference that remained significant after adjusting for patient demographics (P < .0001).

LOS coding. Scribed providers increased the number of visits billed as LOS 4 or 5 by 9.6 percentage points (from 47.3% before implementation to 56.8%); during the same period, nonscribed providers increased the number of visits billed as LOS 4 or 5 by 1.3 percentage points (from 46.5% before implementation to 47.8%) (TABLE 2). Scribes were therefore associated with an additional 8.3 percentage points in LOS 4 or 5 billing (P < .001) (TABLE 2). This difference remained significant after adjusting for patient demographics (P < .001).

Continue to: Pay-for-performance quality measures

Breast cancer screening. Scribed providers increased the number of visits at which breast cancer screening was ordered by 2.7 percentage points (from 17.3% before implementation of scribes to 20.0%); during the same period, the number of visits at which breast cancer screening was ordered by nonscribed providers decreased by 1.9 percentage points (from 19.5% to 17.6%). Scribes were therefore associated with an increase of 4.6 percentage points in breast cancer screening orders, compared to nonscribed providers (P < .003) (TABLE 2). That difference remained significant after adjusting for patient demographics (P = .01).

Colon cancer screening. Similarly, scribed providers increased the number of visits at which colon cancer screening was ordered by 1.2 percentage points (from 19.2% before implementation of scribes to 20.3%); during the same period, the number of visits at which colon cancer screening was ordered by nonscribed providers decreased by 2.7 percentage points (from 18.5% to 15.9%) (P = .112). After adjusting for patient demographics, scribes were associated with an increase of 4.9 percentage points in colon cancer screening orders, compared to nonscribed providers (P = .044) (TABLE 2).

Cervical cancer screening. The rate at which cervical cancer screening was ordered did not change among scribed providers and decreased (by 2.5 percentage points) among nonscribed providers—a difference that was not statistically significant (P = .26).

Nonpreventive visits. Our findings overall did not change in analyses focused on nonpreventive visits, in which scribes were associated with an increase of 8.2 percentage points in LOS 4 or 5 billing (P < .001); an increase of 3.1 percentage points in HCC coding (P < .001); and an increase of 3.2 percentage points in breast cancer screening orders (P = .03) (TABLE 3). Although scribes were associated with an increase of 1.5 percentage points in cervical cancer screening orders and an increase of 3.1 percentage points in colon cancer screening orders, these increases did not reach statistical significance.

Discussion

We found that implementation of scribes is associated with (1) an increase in LOS coding and risk coding and (2) a higher frequency of addressing 2 of 3 pay-for-performance quality measures in primary care. In adjusted analyses in our study, and compared to nonscribed providers, scribes were associated with an additional 9.2 percentage points in LOS 4 or 5 billing; 3.6 percentage points in HCC coding; 4.0 percentage points in breast cancer screening orders; and 4.9 percentage points in colon cancer screening orders. Cervical cancer screening orders followed a similar pattern, with an increase of 2.3 percentage points in the adjusted screening order rate among scribed providers, compared to nonscribed providers, during implementation of scribes—although the increase was not significant. These findings did not change in analyses focused on nonpreventive visits.

Continue to: Our findings are consistent

Our findings are consistent with those of earlier studies. Prior examinations in ambulatory specialties found that scribes increased HCC coding,⁴ LOS billing,²⁴ and pay-for-performance metrics.¹⁸ The only study to examine these areas in primary care found that scribes were associated with increased pay-for-performance measure documentation,²⁰ a change that is necessary but insufficient to realize increased pay-for-­performance revenue. Therefore, our study confirms, for the first time, that PCPs can better address pay-for-performance measures, LOS billing, and HCC coding when working with a scribe in primary care.

Providers who used a scribe during the intervention period of our study increased the number of visits billed as LOS 4 or 5 by 9.6 percentage points.

Demands on primary care visits are increasing.²⁸ Physicians are required to provide more documentation; there is greater emphasis on PCPs meeting pay-for-­performance measures; and there are more data in the EMR to review. In this context, addressing pay-for-performance measures and gaps in risk coding is likely to be increasingly challenging. Our study suggests that scribes might provide a mechanism to increase risk coding, LOS billing, and pay-for-performance measures, despite increased demands on primary care visits.

Increase in LOS billing. In the settings in which we work, a fee-for-service LOS 4 primary care visit generates, on average, $20 to $75 more in revenue than an LOS 3 visit. Using an average of $50 additional revenue for LOS 4 billing, we estimate that a full-time scribe is associated with roughly $7,000 in additional revenue annually. We arrived at this estimate using an average of 1500 visits at LOS ≤ 3 for every PCP full-time equivalent. A 9.2 percentage–point increase in LOS 4 billing would lead to roughly 140 additional LOS 4 visits, with each visit generating an additional $50 in revenue.

This analysis does not account for increased revenue associated with increased pay for HCC coding identified in our study.

Our study also suggests that scribes might provide a mechanism to increase risk coding and payfor-performance, despite increased demands on primary care visits.

Furthermore, in our conservative assumption, the entire increase in LOS billing was from level 3 to level 4; in fact, a small percentage of that increase would be from level 2 and another small percentage would be to level 5—both of which would generate additional revenue. Our assumption therefore underestimates the full financial value associated with scribes in the absence of increased patient volume. Nonetheless, the assumption suggests that increases in LOS billing offset a substantial percentage of a scribe’s salary.

Continue to: Limitations of this study

Limitations of this study. Our study should be interpreted in the context of several limitations:

• The study was conducted at 1 institution. Our findings might not be generalizable beyond this setting.
• The study measures the impact of scribes when providers work with scribes part time. Because providers who utilize a scribe for all, or nearly all, their visits are likely to use a scribe more efficiently, our study might underestimate the full impact of a scribe.
• In some settings, team members such as medical assistants are trained to assist with documentation and other responsibilities (such as closing care gaps) in addition to other patient care responsibilities.^29-32 The extent to which our findings transfer to other models is unclear; studies comparing the impact of other models (which might provide even stronger outcomes) to the impact of medical scribes would be an interesting area for further research.
• In addition to the variability of models, there is likely variability in the quality and interactions of medical scribes, which might impact outcomes. We did not examine the qualities of scribes that led to outcomes in this study.
• We examined the impact of scribes on quality measure–ordering behaviors of providers, not on whether quality measures actually improved. Because scribes are associated with more face-to-face time with patients,²⁷ they might allow for increased attention being paid by physicians to barriers to pay-for-performance measures (eg, patient education). This could increase the likelihood that patients complete a multitude of screenings, and thus improve adherence and follow-up. However, the impact of scribes on quality measures is a topic for future study.

Value beyond volume. Any limitations notwithstanding, our study suggests that scribes are associated with financial benefit in addition to the benefit of increased volume. Primary care practices should therefore consider the financial benefit of scribes independent of their ability to add patient volume. By recognizing this additive value, primary care practices might more fully capture the benefit of scribes, which might then allow practices to employ scribes with less demand to increase volume. This added support without increased volume would, in turn, likely reduce provider burnout (and the costly associated turnover) and increase patient satisfaction, leading to a synergistic financial benefit.

CORRESPONDENCE
Wayne Altman, MD, FAAFP, Tufts University School of Medicine, 200 Harrison Avenue, Boston, MA 02111; wayne. altman@tufts.edu

A 31-year-old Hispanic man presented for evaluation of numerous disfiguring growths on his scalp. They first appeared when he was 19 years old. A review of his family history revealed that his father had 2 “cysts” on his body.

The patient had 10 nodules on his scalp and upper back (Figures 1A and 1B). The ones on his scalp lacked puncta and appeared in a “turban tumor” configuration. The lesions were pink, smooth, and semisoft, and ranged in size from 1 to 6 cm.

Six years earlier, the patient had been seen for evaluation of 20 protuberant nodules. At the time, he had been referred to plastic surgery, where 15 lesions were excised. No other treatment was reported by the patient during the 6-year gap between exams.

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

Pilar cysts (PC), also known as trichilemma cysts, wen, or isthmus-catagen cysts, are benign cysts that manifest as smooth, firm, well-­circumscribed, pink nodules. PCs originate from the follicular isthmus of the hair’s external root sheath¹ and are found in 5% to 10% of the US population.² Possible sites of appearance include the face, neck, trunk, and extremities, although 90% of PCs develop on the scalp.¹ They tend to have an autosomal dominant pattern of inheritance with linkages to the short arm of chromosome 3.³ PCs can occasionally become inflamed following infection or trauma.

Characteristic histology of PCs demonstrates semisolid, keratin-filled, subepidermal cysts lined by stratified epithelium without a granular layer (trichilemmal keratinization). Lesions excised from this patient’s scalp showed 2 subtypes of PCs: nonproliferating (FIGURE 2A) and proliferating (FIGURE 2B). Subtypes appear similar on exam but can be differentiated on histology.

With gradual growth, proliferating PCs can reach up to 25 cm in diameter.¹ Rapid growth, size > 5 cm, infiltration, or a non-scalp location may indicate malignancy.⁴

Differential diagnosis includes lipomas

The differential diagnosis for a lesion such as this includes epidermal inclusion cysts, dermoid cysts, and lipomas. Epidermal inclusion cysts have a punctum, whereas PCs do not. Dermoid cysts are single congenital lesions that manifest much earlier than PCs. Lipomas are easily movable rubbery bulges that appear more frequently in lipid-dense areas of the body.

For this patient, the striking turban ­tumor–like presentation, with numerous large cysts on the scalp, initially inspired a differential diagnosis including several genetic tumor syndromes. However, unlike the association between Gardner syndrome and numerous epidermoid cysts or Brooke-Spiegler syndrome and spiradenomas, no syndromes have been linked to numerous trichilemmal cysts.

Continue to: Excision is effective

Excision is the treatment of choice for both proliferating and nonproliferating PCs.⁵ The local recurrence rate of proliferating PCs is 3.7% with a rare likelihood of transformation to trichilemmal carcinoma.⁶

Our patient continues to be followed in clinic for monitoring and periodic excision of bothersome cysts.

A 31-year-old Hispanic man presented for evaluation of numerous disfiguring growths on his scalp. They first appeared when he was 19 years old. A review of his family history revealed that his father had 2 “cysts” on his body.

The patient had 10 nodules on his scalp and upper back (Figures 1A and 1B). The ones on his scalp lacked puncta and appeared in a “turban tumor” configuration. The lesions were pink, smooth, and semisoft, and ranged in size from 1 to 6 cm.

Six years earlier, the patient had been seen for evaluation of 20 protuberant nodules. At the time, he had been referred to plastic surgery, where 15 lesions were excised. No other treatment was reported by the patient during the 6-year gap between exams.

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

Pilar cysts (PC), also known as trichilemma cysts, wen, or isthmus-catagen cysts, are benign cysts that manifest as smooth, firm, well-­circumscribed, pink nodules. PCs originate from the follicular isthmus of the hair’s external root sheath¹ and are found in 5% to 10% of the US population.² Possible sites of appearance include the face, neck, trunk, and extremities, although 90% of PCs develop on the scalp.¹ They tend to have an autosomal dominant pattern of inheritance with linkages to the short arm of chromosome 3.³ PCs can occasionally become inflamed following infection or trauma.

Characteristic histology of PCs demonstrates semisolid, keratin-filled, subepidermal cysts lined by stratified epithelium without a granular layer (trichilemmal keratinization). Lesions excised from this patient’s scalp showed 2 subtypes of PCs: nonproliferating (FIGURE 2A) and proliferating (FIGURE 2B). Subtypes appear similar on exam but can be differentiated on histology.

With gradual growth, proliferating PCs can reach up to 25 cm in diameter.¹ Rapid growth, size > 5 cm, infiltration, or a non-scalp location may indicate malignancy.⁴

Differential diagnosis includes lipomas

The differential diagnosis for a lesion such as this includes epidermal inclusion cysts, dermoid cysts, and lipomas. Epidermal inclusion cysts have a punctum, whereas PCs do not. Dermoid cysts are single congenital lesions that manifest much earlier than PCs. Lipomas are easily movable rubbery bulges that appear more frequently in lipid-dense areas of the body.

For this patient, the striking turban ­tumor–like presentation, with numerous large cysts on the scalp, initially inspired a differential diagnosis including several genetic tumor syndromes. However, unlike the association between Gardner syndrome and numerous epidermoid cysts or Brooke-Spiegler syndrome and spiradenomas, no syndromes have been linked to numerous trichilemmal cysts.

Continue to: Excision is effective

Excision is the treatment of choice for both proliferating and nonproliferating PCs.⁵ The local recurrence rate of proliferating PCs is 3.7% with a rare likelihood of transformation to trichilemmal carcinoma.⁶

Our patient continues to be followed in clinic for monitoring and periodic excision of bothersome cysts.

A 31-year-old Hispanic man presented for evaluation of numerous disfiguring growths on his scalp. They first appeared when he was 19 years old. A review of his family history revealed that his father had 2 “cysts” on his body.

The patient had 10 nodules on his scalp and upper back (Figures 1A and 1B). The ones on his scalp lacked puncta and appeared in a “turban tumor” configuration. The lesions were pink, smooth, and semisoft, and ranged in size from 1 to 6 cm.

Six years earlier, the patient had been seen for evaluation of 20 protuberant nodules. At the time, he had been referred to plastic surgery, where 15 lesions were excised. No other treatment was reported by the patient during the 6-year gap between exams.

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

Pilar cysts (PC), also known as trichilemma cysts, wen, or isthmus-catagen cysts, are benign cysts that manifest as smooth, firm, well-­circumscribed, pink nodules. PCs originate from the follicular isthmus of the hair’s external root sheath¹ and are found in 5% to 10% of the US population.² Possible sites of appearance include the face, neck, trunk, and extremities, although 90% of PCs develop on the scalp.¹ They tend to have an autosomal dominant pattern of inheritance with linkages to the short arm of chromosome 3.³ PCs can occasionally become inflamed following infection or trauma.

Characteristic histology of PCs demonstrates semisolid, keratin-filled, subepidermal cysts lined by stratified epithelium without a granular layer (trichilemmal keratinization). Lesions excised from this patient’s scalp showed 2 subtypes of PCs: nonproliferating (FIGURE 2A) and proliferating (FIGURE 2B). Subtypes appear similar on exam but can be differentiated on histology.

With gradual growth, proliferating PCs can reach up to 25 cm in diameter.¹ Rapid growth, size > 5 cm, infiltration, or a non-scalp location may indicate malignancy.⁴

Differential diagnosis includes lipomas

The differential diagnosis for a lesion such as this includes epidermal inclusion cysts, dermoid cysts, and lipomas. Epidermal inclusion cysts have a punctum, whereas PCs do not. Dermoid cysts are single congenital lesions that manifest much earlier than PCs. Lipomas are easily movable rubbery bulges that appear more frequently in lipid-dense areas of the body.

For this patient, the striking turban ­tumor–like presentation, with numerous large cysts on the scalp, initially inspired a differential diagnosis including several genetic tumor syndromes. However, unlike the association between Gardner syndrome and numerous epidermoid cysts or Brooke-Spiegler syndrome and spiradenomas, no syndromes have been linked to numerous trichilemmal cysts.

Continue to: Excision is effective

Excision is the treatment of choice for both proliferating and nonproliferating PCs.⁵ The local recurrence rate of proliferating PCs is 3.7% with a rare likelihood of transformation to trichilemmal carcinoma.⁶

Our patient continues to be followed in clinic for monitoring and periodic excision of bothersome cysts.

The ivory white appearance and slight atrophy of the lesions raised the possibility of extragenital lichen sclerosus (LS). A 4-mm punch biopsy confirmed the diagnosis.

LS occurs in all races and is an uncommon, chronic inflammatory disease that most often affects the vulva and perianal mucosa in postmenopausal women.¹ That said, it can also affect men and children, and manifest in places such as the trunk and neck. Extragenital lesions may appear ivory white, as in this case, or may resemble ecchymoses and raise alarm for possible abuse.

When LS is present on the extremities, a complete skin surface exam, including external genitalia, is warranted. LS is thought to be an autoimmune disease and is associated with vitiligo, autoimmune thyroid disease, and morphea.

In cases of suspected LS, it’s important to biopsy the full thickness of the skin and subcutaneous tissue. It is helpful to include an area of normal skin in the sample, as the findings are subtle and best contrasted with the architecture of unaffected skin. For this patient, a 4-mm punch biopsy was sufficient, but an incisional biopsy would be more appropriate for a larger patch or plaque.

Treatment options are based on a small case series and a few small randomized controlled trials. Medications include topical steroids, topical calcineurin inhibitors, systemic retinoids, and topical estrogens.

In this case, the patient was advised to apply topical clobetasol 0.05% cream bid to the affected area for 2 weeks, then twice weekly for 4 weeks. She had partial clearance with this approach, but small macules later appeared on her dorsal foot; the treatment was repeated.

‌

Text and photos courtesy of Jonathan Karnes, MD, medical director, MDFMR Dermatology Services, Augusta, ME. (Photo copyright retained.)

The ivory white appearance and slight atrophy of the lesions raised the possibility of extragenital lichen sclerosus (LS). A 4-mm punch biopsy confirmed the diagnosis.

LS occurs in all races and is an uncommon, chronic inflammatory disease that most often affects the vulva and perianal mucosa in postmenopausal women.¹ That said, it can also affect men and children, and manifest in places such as the trunk and neck. Extragenital lesions may appear ivory white, as in this case, or may resemble ecchymoses and raise alarm for possible abuse.

When LS is present on the extremities, a complete skin surface exam, including external genitalia, is warranted. LS is thought to be an autoimmune disease and is associated with vitiligo, autoimmune thyroid disease, and morphea.

In cases of suspected LS, it’s important to biopsy the full thickness of the skin and subcutaneous tissue. It is helpful to include an area of normal skin in the sample, as the findings are subtle and best contrasted with the architecture of unaffected skin. For this patient, a 4-mm punch biopsy was sufficient, but an incisional biopsy would be more appropriate for a larger patch or plaque.

Treatment options are based on a small case series and a few small randomized controlled trials. Medications include topical steroids, topical calcineurin inhibitors, systemic retinoids, and topical estrogens.

In this case, the patient was advised to apply topical clobetasol 0.05% cream bid to the affected area for 2 weeks, then twice weekly for 4 weeks. She had partial clearance with this approach, but small macules later appeared on her dorsal foot; the treatment was repeated.

‌

Text and photos courtesy of Jonathan Karnes, MD, medical director, MDFMR Dermatology Services, Augusta, ME. (Photo copyright retained.)

The ivory white appearance and slight atrophy of the lesions raised the possibility of extragenital lichen sclerosus (LS). A 4-mm punch biopsy confirmed the diagnosis.

LS occurs in all races and is an uncommon, chronic inflammatory disease that most often affects the vulva and perianal mucosa in postmenopausal women.¹ That said, it can also affect men and children, and manifest in places such as the trunk and neck. Extragenital lesions may appear ivory white, as in this case, or may resemble ecchymoses and raise alarm for possible abuse.

When LS is present on the extremities, a complete skin surface exam, including external genitalia, is warranted. LS is thought to be an autoimmune disease and is associated with vitiligo, autoimmune thyroid disease, and morphea.

In cases of suspected LS, it’s important to biopsy the full thickness of the skin and subcutaneous tissue. It is helpful to include an area of normal skin in the sample, as the findings are subtle and best contrasted with the architecture of unaffected skin. For this patient, a 4-mm punch biopsy was sufficient, but an incisional biopsy would be more appropriate for a larger patch or plaque.

Treatment options are based on a small case series and a few small randomized controlled trials. Medications include topical steroids, topical calcineurin inhibitors, systemic retinoids, and topical estrogens.

In this case, the patient was advised to apply topical clobetasol 0.05% cream bid to the affected area for 2 weeks, then twice weekly for 4 weeks. She had partial clearance with this approach, but small macules later appeared on her dorsal foot; the treatment was repeated.

‌

Text and photos courtesy of Jonathan Karnes, MD, medical director, MDFMR Dermatology Services, Augusta, ME. (Photo copyright retained.)

THE CASE

An 18-year-old woman with no significant past medical history presented to the emergency department complaining of midsternal chest pain and mild shortness of breath, which had been intermittent for the past several months. She denied any history of deep vein thrombosis or pulmonary embolism risk factors, such as oral contraceptive use.

Laboratory values were within normal limits. An electrocardiogram (EKG), however, showed T-wave inversions in leads V₁ and V₂, and physical examination revealed decreased breath sounds in the right lung base. A chest radiograph and subsequent chest computed tomography (CT) were ordered.

The initial radiograph (FIGURE 1) showed a large right anterior mediastinal mass; the CT revealed fat, fluid, soft tissue, and ossification within the mass (FIGURE 2). The CT also showed evidence of local mass effect on the right atrium, as well as compressive atelectasis in the adjacent right lung, contributing to the patient’s EKG abnormality and physical exam findings.

THE DIAGNOSIS

Based on the patient’s clinical history and imaging findings, which were consistent with a benign well-differentiated teratoma, she was given a diagnosis of anterior mediastinal teratoma.

DISCUSSION

Teratomas are tumors composed of pluripotent stem cells that carry elements from all 3 of the embryologic layers (ectoderm, mesoderm, and endoderm).¹ There are 3 classifications of teratomas: mature (well-differentiated), immature (poorly differentiated), and malignant.

Tumors of germ cell origin are rare within the anterior mediastinum, accounting for 1% to 3% of total reported cases.² Among anterior mediastinal masses, germ cell tumors such as teratomas, seminomas, and nonseminomatous tumors comprise approximately 15% of adult and 24% of pediatric anterior mediastinal tumors.³

It is reported that up to 60% of patients with mediastinal teratomas present with no signs or symptoms upon diagnosis.⁴ When the mass is large, patients can develop chest pain or shortness of breath relating to tumor mass effect. In rare instances, there can be hemoptysis or trichoptysis, pathognomonic for teratomas with bronchial communication.⁵ Physical exam findings are also nonspecific and may include decreased breath sounds secondary to compressive atelectasis with large tumor burden.

Continue to: Radiographic imaging...

Radiographic imaging is essential to elucidate the diagnosis. Chest radiograph can show an intrathoracic mass, and CT can provide further characterization, such as density and precise location.

Location of mass guides differential

Localizing an intrathoracic mass in the anterior, middle, or posterior mediastinum allows for narrowing of the differential diagnosis (TABLE⁶). The main diagnostic consideration for a middle mediastinal or hilar mass is primary carcinoma. Posterior mediastinal masses, on the other hand, are generally of benign etiology and may include neurogenic tumors, foregut duplication cysts, or, in rare cases, extramedullary hematopoiesis.

The differential diagnosis of anterior mediastinal masses can be separated into 4 main categories of disease, colloquially known as the “4 Ts”:

Teratoma. Mixed tissue densities seen on CT relate to the multiple tissue types originating from the embryologic germ cell layers.Frequently, there will be fat, fluid, and calcifications.

Thyroid pathology. A goiter or thyroid cancer can manifest with endocrine dysfunction, such as thyroid-stimulating hormone and T3/T4 abnormalities. A thyroid mass tends to sit more superiorly than do other anterior mediastinal masses and may be confirmed using a nuclear scan looking for increased radioactive iodine uptake.

Continue to: Thymoma

Thymoma. The diagnostic features include parathymic syndromes such as myasthenia gravis (30%-50% of thymoma cases^7,8) and pure red cell aplasia (5% of thymoma cases⁹).

“Terrible” lymphoma. The most effective way to differentiate an anterior mediastinal mass due to lymphadenopathy (secondary to lymphoma) is to perform a tissue sample biopsy.

Also consider, as part of the differential for anterior mediastinal masses, such things as mesenchymal tumors, Morgagni hernia (anterior diaphragmatic defect), and pericardial cysts (fluid attenuating and usually located at the right cardiophrenic angle).

Surgical resection is effective

The treatment for anterior mediastinal teratoma is surgical resection.¹⁰ A complete surgical resection is typically curative and provides adequate therapy for symptom resolution.

The standard surgical approach involves gaining access to the anterior mediastinum via a median sternotomy. When there is extensive tumor involvement of the hemithorax, clamshell thoracotomy is preferred, requiring incisions in both the left and right hemithoraxes.¹¹

Continue to: Our patient

Our patient underwent resection of the tumor; the subsequent pathology report for the specimen (FIGURE 3) confirmed the diagnosis. There was no abnormal enhancement or vascular invasion to suggest aggressive or malignant potential.

THE TAKEAWAY

Patients frequently present with nonspecific and vague chest complaints. This case points to the importance of obtaining a thorough clinical history and conducting a complete physical examination to guide additional work-up and radiographic imaging.

CORRESPONDENCE
Cassie Tran, MD, 320 E North Avenue, Pittsburgh, PA 15212; tran.cassie@gmail.com

THE CASE

An 18-year-old woman with no significant past medical history presented to the emergency department complaining of midsternal chest pain and mild shortness of breath, which had been intermittent for the past several months. She denied any history of deep vein thrombosis or pulmonary embolism risk factors, such as oral contraceptive use.

Laboratory values were within normal limits. An electrocardiogram (EKG), however, showed T-wave inversions in leads V₁ and V₂, and physical examination revealed decreased breath sounds in the right lung base. A chest radiograph and subsequent chest computed tomography (CT) were ordered.

The initial radiograph (FIGURE 1) showed a large right anterior mediastinal mass; the CT revealed fat, fluid, soft tissue, and ossification within the mass (FIGURE 2). The CT also showed evidence of local mass effect on the right atrium, as well as compressive atelectasis in the adjacent right lung, contributing to the patient’s EKG abnormality and physical exam findings.

THE DIAGNOSIS

Based on the patient’s clinical history and imaging findings, which were consistent with a benign well-differentiated teratoma, she was given a diagnosis of anterior mediastinal teratoma.

DISCUSSION

Teratomas are tumors composed of pluripotent stem cells that carry elements from all 3 of the embryologic layers (ectoderm, mesoderm, and endoderm).¹ There are 3 classifications of teratomas: mature (well-differentiated), immature (poorly differentiated), and malignant.

Tumors of germ cell origin are rare within the anterior mediastinum, accounting for 1% to 3% of total reported cases.² Among anterior mediastinal masses, germ cell tumors such as teratomas, seminomas, and nonseminomatous tumors comprise approximately 15% of adult and 24% of pediatric anterior mediastinal tumors.³

It is reported that up to 60% of patients with mediastinal teratomas present with no signs or symptoms upon diagnosis.⁴ When the mass is large, patients can develop chest pain or shortness of breath relating to tumor mass effect. In rare instances, there can be hemoptysis or trichoptysis, pathognomonic for teratomas with bronchial communication.⁵ Physical exam findings are also nonspecific and may include decreased breath sounds secondary to compressive atelectasis with large tumor burden.

Continue to: Radiographic imaging...

Radiographic imaging is essential to elucidate the diagnosis. Chest radiograph can show an intrathoracic mass, and CT can provide further characterization, such as density and precise location.

Location of mass guides differential

Localizing an intrathoracic mass in the anterior, middle, or posterior mediastinum allows for narrowing of the differential diagnosis (TABLE⁶). The main diagnostic consideration for a middle mediastinal or hilar mass is primary carcinoma. Posterior mediastinal masses, on the other hand, are generally of benign etiology and may include neurogenic tumors, foregut duplication cysts, or, in rare cases, extramedullary hematopoiesis.

The differential diagnosis of anterior mediastinal masses can be separated into 4 main categories of disease, colloquially known as the “4 Ts”:

Teratoma. Mixed tissue densities seen on CT relate to the multiple tissue types originating from the embryologic germ cell layers.Frequently, there will be fat, fluid, and calcifications.

Thyroid pathology. A goiter or thyroid cancer can manifest with endocrine dysfunction, such as thyroid-stimulating hormone and T3/T4 abnormalities. A thyroid mass tends to sit more superiorly than do other anterior mediastinal masses and may be confirmed using a nuclear scan looking for increased radioactive iodine uptake.

Continue to: Thymoma

Thymoma. The diagnostic features include parathymic syndromes such as myasthenia gravis (30%-50% of thymoma cases^7,8) and pure red cell aplasia (5% of thymoma cases⁹).

“Terrible” lymphoma. The most effective way to differentiate an anterior mediastinal mass due to lymphadenopathy (secondary to lymphoma) is to perform a tissue sample biopsy.

Also consider, as part of the differential for anterior mediastinal masses, such things as mesenchymal tumors, Morgagni hernia (anterior diaphragmatic defect), and pericardial cysts (fluid attenuating and usually located at the right cardiophrenic angle).

Surgical resection is effective

The treatment for anterior mediastinal teratoma is surgical resection.¹⁰ A complete surgical resection is typically curative and provides adequate therapy for symptom resolution.

The standard surgical approach involves gaining access to the anterior mediastinum via a median sternotomy. When there is extensive tumor involvement of the hemithorax, clamshell thoracotomy is preferred, requiring incisions in both the left and right hemithoraxes.¹¹

Continue to: Our patient

Our patient underwent resection of the tumor; the subsequent pathology report for the specimen (FIGURE 3) confirmed the diagnosis. There was no abnormal enhancement or vascular invasion to suggest aggressive or malignant potential.

THE TAKEAWAY

Patients frequently present with nonspecific and vague chest complaints. This case points to the importance of obtaining a thorough clinical history and conducting a complete physical examination to guide additional work-up and radiographic imaging.

CORRESPONDENCE
Cassie Tran, MD, 320 E North Avenue, Pittsburgh, PA 15212; tran.cassie@gmail.com

THE CASE

An 18-year-old woman with no significant past medical history presented to the emergency department complaining of midsternal chest pain and mild shortness of breath, which had been intermittent for the past several months. She denied any history of deep vein thrombosis or pulmonary embolism risk factors, such as oral contraceptive use.

Laboratory values were within normal limits. An electrocardiogram (EKG), however, showed T-wave inversions in leads V₁ and V₂, and physical examination revealed decreased breath sounds in the right lung base. A chest radiograph and subsequent chest computed tomography (CT) were ordered.

The initial radiograph (FIGURE 1) showed a large right anterior mediastinal mass; the CT revealed fat, fluid, soft tissue, and ossification within the mass (FIGURE 2). The CT also showed evidence of local mass effect on the right atrium, as well as compressive atelectasis in the adjacent right lung, contributing to the patient’s EKG abnormality and physical exam findings.

THE DIAGNOSIS

Based on the patient’s clinical history and imaging findings, which were consistent with a benign well-differentiated teratoma, she was given a diagnosis of anterior mediastinal teratoma.

DISCUSSION

Teratomas are tumors composed of pluripotent stem cells that carry elements from all 3 of the embryologic layers (ectoderm, mesoderm, and endoderm).¹ There are 3 classifications of teratomas: mature (well-differentiated), immature (poorly differentiated), and malignant.

Tumors of germ cell origin are rare within the anterior mediastinum, accounting for 1% to 3% of total reported cases.² Among anterior mediastinal masses, germ cell tumors such as teratomas, seminomas, and nonseminomatous tumors comprise approximately 15% of adult and 24% of pediatric anterior mediastinal tumors.³

It is reported that up to 60% of patients with mediastinal teratomas present with no signs or symptoms upon diagnosis.⁴ When the mass is large, patients can develop chest pain or shortness of breath relating to tumor mass effect. In rare instances, there can be hemoptysis or trichoptysis, pathognomonic for teratomas with bronchial communication.⁵ Physical exam findings are also nonspecific and may include decreased breath sounds secondary to compressive atelectasis with large tumor burden.

Continue to: Radiographic imaging...

Radiographic imaging is essential to elucidate the diagnosis. Chest radiograph can show an intrathoracic mass, and CT can provide further characterization, such as density and precise location.

Location of mass guides differential

Localizing an intrathoracic mass in the anterior, middle, or posterior mediastinum allows for narrowing of the differential diagnosis (TABLE⁶). The main diagnostic consideration for a middle mediastinal or hilar mass is primary carcinoma. Posterior mediastinal masses, on the other hand, are generally of benign etiology and may include neurogenic tumors, foregut duplication cysts, or, in rare cases, extramedullary hematopoiesis.

The differential diagnosis of anterior mediastinal masses can be separated into 4 main categories of disease, colloquially known as the “4 Ts”:

Teratoma. Mixed tissue densities seen on CT relate to the multiple tissue types originating from the embryologic germ cell layers.Frequently, there will be fat, fluid, and calcifications.

Thyroid pathology. A goiter or thyroid cancer can manifest with endocrine dysfunction, such as thyroid-stimulating hormone and T3/T4 abnormalities. A thyroid mass tends to sit more superiorly than do other anterior mediastinal masses and may be confirmed using a nuclear scan looking for increased radioactive iodine uptake.

Continue to: Thymoma

Thymoma. The diagnostic features include parathymic syndromes such as myasthenia gravis (30%-50% of thymoma cases^7,8) and pure red cell aplasia (5% of thymoma cases⁹).

“Terrible” lymphoma. The most effective way to differentiate an anterior mediastinal mass due to lymphadenopathy (secondary to lymphoma) is to perform a tissue sample biopsy.

Also consider, as part of the differential for anterior mediastinal masses, such things as mesenchymal tumors, Morgagni hernia (anterior diaphragmatic defect), and pericardial cysts (fluid attenuating and usually located at the right cardiophrenic angle).

Surgical resection is effective

The treatment for anterior mediastinal teratoma is surgical resection.¹⁰ A complete surgical resection is typically curative and provides adequate therapy for symptom resolution.

The standard surgical approach involves gaining access to the anterior mediastinum via a median sternotomy. When there is extensive tumor involvement of the hemithorax, clamshell thoracotomy is preferred, requiring incisions in both the left and right hemithoraxes.¹¹

Continue to: Our patient

Our patient underwent resection of the tumor; the subsequent pathology report for the specimen (FIGURE 3) confirmed the diagnosis. There was no abnormal enhancement or vascular invasion to suggest aggressive or malignant potential.

THE TAKEAWAY

Patients frequently present with nonspecific and vague chest complaints. This case points to the importance of obtaining a thorough clinical history and conducting a complete physical examination to guide additional work-up and radiographic imaging.

CORRESPONDENCE
Cassie Tran, MD, 320 E North Avenue, Pittsburgh, PA 15212; tran.cassie@gmail.com

ILLUSTRATIVE CASE

A 45-year-old woman with no chronic medical illness presents to your office for her annual physical examination. After a medical assistant (MA) applies an automatic BP cuff to the patient’s left arm, the BP reading is 155/92 mm Hg. The MA then rechecks the BP, and this time it reads 160/98 mm Hg. The MA performs a manual BP reading, which is 158/90 mm Hg (left arm) and 162/100 mm Hg (right arm). The patient denies any headache, visual changes, chest pain, or difficulty breathing and tells the MA that her BP is always high during a doctor visit. You are wondering if she has hypertension or if is this the white-coat effect.

Depending on the definition of hypertension, its prevalence among US adults 18 years or older varies from 46%, based on the American College of Cardiology guideline (≥ 130/80 mm Hg), to 29%, based on the Eighth Joint National Committee (JNC-8) guideline (≥ 140/90 mm Hg for adults ages 18–59 years and ≥ 150/90 mm Hg for adults ≥ 60 years without diabetes and/or chronic kidney disease).^2,3

According to JNC-8, the prevalence is similar among men (30.2%) and women (27.7%) and increases with age: 18 to 39 years, 7.5%; 40 to 59 years, 33.2%; and ≥ 60 years, 63.1%.^3,4 When ranked by risk-attributable ­disability-adjusted life-years (DALYs), high systolic blood pressure (SBP) is the leading risk factor, accounting for 10.4 million deaths and 218 million DALYs globally in 2017.⁵ National medical costs associated with hypertension are estimated to account for about $131 billion in annual health care expenditures, averaged over 12 years from 2003 to 2014.⁶

When performed correctly, the auscultatory method using a mercury sphygmomanometer correlates well with simultaneous intra-arterial BP and was considered the gold standard for office-based measurements for many years.^7,8 However, significant ­observer-related differences in auditory acuity and terminal digit rounding are sources of inaccurate measurement. White-coat hypertension cannot be detected with this method—another significant limitation. The inaccuracy of office-based BP readings leads to concerns about hypertension being inappropriately diagnosed in patients or delays in diagnosis occurring.⁹

A proposed solution to this problem is measurement using an oscillometric sphygmomanometer. This device uses a pressure transducer to assess the oscillations of pressure in a cuff during gradual deflation; it provides accurate BP measurements when fully automated and programmed to complete several BP measurements at appropriate intervals while the patient rests alone in a quiet room.¹⁰

The accuracy of this new method was tested in a 2009 cohort study of 309 patients referred to an ambulatory blood pressure (ABP) monitoring unit at an academic hospital for diagnosis or management of hypertension.¹¹ The study compared mean awake ABP, which continuously measures patients’ BP throughout the day, manual sphygmomanometer readings taken by the patient’s own physician, and an automated office blood pressure (AOBP) device called BpTRU (an automated oscillometric sphygmomanometer) while the patient rested alone in the exam room.¹¹ The awake ABP is a federally approved standard for the diagnosis of white-coat hypertension.¹² In this study, the white-coat response was negated with the use of the automated BpTRU device.¹¹

A 2019 meta-analysis that included 26 studies (N = 7116) comparing AOBP with other BP measurement techniques concluded that the use of automated oscillometric BP readings is more accurate for diagnosing hypertension and assists in negating the white-coat hypertension effect.⁹

Continue to: STUDY SUMMARY

STUDY SUMMARY

Automated office BP devices are just as accurate as more expensive ABP studies

This systematic review and meta-analysis (N = 9279; 23 cross-sectional, 1 cohort, and 7 randomized controlled trials [N = 1304], of which 17 studies overlapped with those included in the previously mentioned meta-analysis⁹) compared SBP and diastolic blood pressure measured by an oscillometric AOBP device to awake or daytime ABP (continuously monitoring BP while awake, used as a standard for BP measurement), routine manual office BP, or research BP measurements.

The study also explored the protocol by which the best AOBP results could be obtained. For AOBP measurement, the included trials had no more than 2 minutes of elapsed time between individual AOBP measurements and had at least 3 AOBP readings to calculate the mean.

Compared with AOBP, in samples with an SBP of ≥ 130 mm Hg, SBP readings were significantly higher for both routine office visits (mean difference [MD] = 14.5 mm Hg; 95% CI, 11.8–17.2) and research (MD = 7 mm Hg; 95% CI, 4.9–9.1). However, no difference was found between AOBP and awake ambulatory SBP values (MD = 0.3 mm Hg; 95% CI, −1.1 to 1.7). In all cases, heterogeneity of the included studies was high (I² was > 75%). There was no evidence of small-study effect or publication bias, and little evidence of potential financial bias. The most accurate methodology for AOBP measurements included multiple BP readings and the patient resting alone in a quiet location.

This meta-analysis supports the use of an automated office blood pressure device to accurately screen for hypertension and avoid the white-coat effect.

Although there was statistical heterogeneity, the results were confirmed in the authors’ analysis of studies with high methodologic quality. In addition, researchers performed multiple meta-regression analyses to evaluate the statistical heterogeneity and found no significant differences based on age, body mass index, number of treated patients, gender, measurement interval, or added rest before AOBP.

WHAT'S NEW

Study confirms unattended, automated office BP as preferred technique

This is the second recent comprehensive systematic review and meta-analysis to directly compare AOBP with other common techniques of BP measurement in screening for and diagnosing hypertension in the clinical setting. ⁹

Continue to: This meta-analysis...

This meta-analysis emphasized the technique (see below) by which to obtain the best AOBP vs ABP results, whereas the other ­meta-analysis⁹ did not. Thus the study provides practice-based settings with the information they need to more closely replicate the results of the studies included in the meta-analysis.

Also, the equivalency comparison with the more expensive and intrusive ABP monitoring may save money, improve patient adherence, and increase patient satisfaction. Given these advantages, along with its demonstrated accuracy, AOBP should be adopted in routine clinical practice to screen patients for hypertension.

CAVEATS

Close adherence to measurementprocedures is a necessity

Effective use of AOBP in clinical practice requires close adherence to the AOBP study procedures described in this meta-analysis. These include taking multiple (at least 3) BP readings, 1 to 2 minutes apart, recorded with a fully automated oscillometric sphygmomanometer while the patient rests alone in a quiet place.

CHALLENGES TO IMPLEMENTATION

Adjusting workflows, addressing cost

Physicians may be reluctant to adopt this technique because they may not be convinced of its advantages compared with the traditional methods of recording BP and because of difficulties with implementing new rooming workflows.¹² The cost of AOBP devices used in this study (Omron 907 and BpTRU; BpTRU ceased operations in 2017) were not disclosed, which may be a hindrance, as devices may cost $1000 or more.

Effective use of automated office blood pressure requires that one take multiple (at least 3) BP readings, 1 to 2 minutes apart, while the patient rests alone in a quiet place.

An online search for “automated oscillometric BP monitor” by one of the PURL authors (RCM) found oscillometric AOBP devices ranging from $150 to > $1000, depending on whether the device was medical grade; a search for “Omron 907” found devices for ≤ $599 on multiple sites. However, none of the lower-cost devices indicated the ability to take multiple, unattended BP readings.

ACKNOWLEDGEMENT

The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center for Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.

ILLUSTRATIVE CASE

A 45-year-old woman with no chronic medical illness presents to your office for her annual physical examination. After a medical assistant (MA) applies an automatic BP cuff to the patient’s left arm, the BP reading is 155/92 mm Hg. The MA then rechecks the BP, and this time it reads 160/98 mm Hg. The MA performs a manual BP reading, which is 158/90 mm Hg (left arm) and 162/100 mm Hg (right arm). The patient denies any headache, visual changes, chest pain, or difficulty breathing and tells the MA that her BP is always high during a doctor visit. You are wondering if she has hypertension or if is this the white-coat effect.

Depending on the definition of hypertension, its prevalence among US adults 18 years or older varies from 46%, based on the American College of Cardiology guideline (≥ 130/80 mm Hg), to 29%, based on the Eighth Joint National Committee (JNC-8) guideline (≥ 140/90 mm Hg for adults ages 18–59 years and ≥ 150/90 mm Hg for adults ≥ 60 years without diabetes and/or chronic kidney disease).^2,3

According to JNC-8, the prevalence is similar among men (30.2%) and women (27.7%) and increases with age: 18 to 39 years, 7.5%; 40 to 59 years, 33.2%; and ≥ 60 years, 63.1%.^3,4 When ranked by risk-attributable ­disability-adjusted life-years (DALYs), high systolic blood pressure (SBP) is the leading risk factor, accounting for 10.4 million deaths and 218 million DALYs globally in 2017.⁵ National medical costs associated with hypertension are estimated to account for about $131 billion in annual health care expenditures, averaged over 12 years from 2003 to 2014.⁶

When performed correctly, the auscultatory method using a mercury sphygmomanometer correlates well with simultaneous intra-arterial BP and was considered the gold standard for office-based measurements for many years.^7,8 However, significant ­observer-related differences in auditory acuity and terminal digit rounding are sources of inaccurate measurement. White-coat hypertension cannot be detected with this method—another significant limitation. The inaccuracy of office-based BP readings leads to concerns about hypertension being inappropriately diagnosed in patients or delays in diagnosis occurring.⁹

A proposed solution to this problem is measurement using an oscillometric sphygmomanometer. This device uses a pressure transducer to assess the oscillations of pressure in a cuff during gradual deflation; it provides accurate BP measurements when fully automated and programmed to complete several BP measurements at appropriate intervals while the patient rests alone in a quiet room.¹⁰

The accuracy of this new method was tested in a 2009 cohort study of 309 patients referred to an ambulatory blood pressure (ABP) monitoring unit at an academic hospital for diagnosis or management of hypertension.¹¹ The study compared mean awake ABP, which continuously measures patients’ BP throughout the day, manual sphygmomanometer readings taken by the patient’s own physician, and an automated office blood pressure (AOBP) device called BpTRU (an automated oscillometric sphygmomanometer) while the patient rested alone in the exam room.¹¹ The awake ABP is a federally approved standard for the diagnosis of white-coat hypertension.¹² In this study, the white-coat response was negated with the use of the automated BpTRU device.¹¹

A 2019 meta-analysis that included 26 studies (N = 7116) comparing AOBP with other BP measurement techniques concluded that the use of automated oscillometric BP readings is more accurate for diagnosing hypertension and assists in negating the white-coat hypertension effect.⁹

Continue to: STUDY SUMMARY

STUDY SUMMARY

Automated office BP devices are just as accurate as more expensive ABP studies

This systematic review and meta-analysis (N = 9279; 23 cross-sectional, 1 cohort, and 7 randomized controlled trials [N = 1304], of which 17 studies overlapped with those included in the previously mentioned meta-analysis⁹) compared SBP and diastolic blood pressure measured by an oscillometric AOBP device to awake or daytime ABP (continuously monitoring BP while awake, used as a standard for BP measurement), routine manual office BP, or research BP measurements.

The study also explored the protocol by which the best AOBP results could be obtained. For AOBP measurement, the included trials had no more than 2 minutes of elapsed time between individual AOBP measurements and had at least 3 AOBP readings to calculate the mean.

Compared with AOBP, in samples with an SBP of ≥ 130 mm Hg, SBP readings were significantly higher for both routine office visits (mean difference [MD] = 14.5 mm Hg; 95% CI, 11.8–17.2) and research (MD = 7 mm Hg; 95% CI, 4.9–9.1). However, no difference was found between AOBP and awake ambulatory SBP values (MD = 0.3 mm Hg; 95% CI, −1.1 to 1.7). In all cases, heterogeneity of the included studies was high (I² was > 75%). There was no evidence of small-study effect or publication bias, and little evidence of potential financial bias. The most accurate methodology for AOBP measurements included multiple BP readings and the patient resting alone in a quiet location.

This meta-analysis supports the use of an automated office blood pressure device to accurately screen for hypertension and avoid the white-coat effect.

Although there was statistical heterogeneity, the results were confirmed in the authors’ analysis of studies with high methodologic quality. In addition, researchers performed multiple meta-regression analyses to evaluate the statistical heterogeneity and found no significant differences based on age, body mass index, number of treated patients, gender, measurement interval, or added rest before AOBP.

WHAT'S NEW

Study confirms unattended, automated office BP as preferred technique

This is the second recent comprehensive systematic review and meta-analysis to directly compare AOBP with other common techniques of BP measurement in screening for and diagnosing hypertension in the clinical setting. ⁹

Continue to: This meta-analysis...

This meta-analysis emphasized the technique (see below) by which to obtain the best AOBP vs ABP results, whereas the other ­meta-analysis⁹ did not. Thus the study provides practice-based settings with the information they need to more closely replicate the results of the studies included in the meta-analysis.

Also, the equivalency comparison with the more expensive and intrusive ABP monitoring may save money, improve patient adherence, and increase patient satisfaction. Given these advantages, along with its demonstrated accuracy, AOBP should be adopted in routine clinical practice to screen patients for hypertension.

CAVEATS

Close adherence to measurementprocedures is a necessity

Effective use of AOBP in clinical practice requires close adherence to the AOBP study procedures described in this meta-analysis. These include taking multiple (at least 3) BP readings, 1 to 2 minutes apart, recorded with a fully automated oscillometric sphygmomanometer while the patient rests alone in a quiet place.

CHALLENGES TO IMPLEMENTATION

Adjusting workflows, addressing cost

Physicians may be reluctant to adopt this technique because they may not be convinced of its advantages compared with the traditional methods of recording BP and because of difficulties with implementing new rooming workflows.¹² The cost of AOBP devices used in this study (Omron 907 and BpTRU; BpTRU ceased operations in 2017) were not disclosed, which may be a hindrance, as devices may cost $1000 or more.

Effective use of automated office blood pressure requires that one take multiple (at least 3) BP readings, 1 to 2 minutes apart, while the patient rests alone in a quiet place.

An online search for “automated oscillometric BP monitor” by one of the PURL authors (RCM) found oscillometric AOBP devices ranging from $150 to > $1000, depending on whether the device was medical grade; a search for “Omron 907” found devices for ≤ $599 on multiple sites. However, none of the lower-cost devices indicated the ability to take multiple, unattended BP readings.

ACKNOWLEDGEMENT

The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center for Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.

ILLUSTRATIVE CASE

A 45-year-old woman with no chronic medical illness presents to your office for her annual physical examination. After a medical assistant (MA) applies an automatic BP cuff to the patient’s left arm, the BP reading is 155/92 mm Hg. The MA then rechecks the BP, and this time it reads 160/98 mm Hg. The MA performs a manual BP reading, which is 158/90 mm Hg (left arm) and 162/100 mm Hg (right arm). The patient denies any headache, visual changes, chest pain, or difficulty breathing and tells the MA that her BP is always high during a doctor visit. You are wondering if she has hypertension or if is this the white-coat effect.

Depending on the definition of hypertension, its prevalence among US adults 18 years or older varies from 46%, based on the American College of Cardiology guideline (≥ 130/80 mm Hg), to 29%, based on the Eighth Joint National Committee (JNC-8) guideline (≥ 140/90 mm Hg for adults ages 18–59 years and ≥ 150/90 mm Hg for adults ≥ 60 years without diabetes and/or chronic kidney disease).^2,3

According to JNC-8, the prevalence is similar among men (30.2%) and women (27.7%) and increases with age: 18 to 39 years, 7.5%; 40 to 59 years, 33.2%; and ≥ 60 years, 63.1%.^3,4 When ranked by risk-attributable ­disability-adjusted life-years (DALYs), high systolic blood pressure (SBP) is the leading risk factor, accounting for 10.4 million deaths and 218 million DALYs globally in 2017.⁵ National medical costs associated with hypertension are estimated to account for about $131 billion in annual health care expenditures, averaged over 12 years from 2003 to 2014.⁶

When performed correctly, the auscultatory method using a mercury sphygmomanometer correlates well with simultaneous intra-arterial BP and was considered the gold standard for office-based measurements for many years.^7,8 However, significant ­observer-related differences in auditory acuity and terminal digit rounding are sources of inaccurate measurement. White-coat hypertension cannot be detected with this method—another significant limitation. The inaccuracy of office-based BP readings leads to concerns about hypertension being inappropriately diagnosed in patients or delays in diagnosis occurring.⁹

A proposed solution to this problem is measurement using an oscillometric sphygmomanometer. This device uses a pressure transducer to assess the oscillations of pressure in a cuff during gradual deflation; it provides accurate BP measurements when fully automated and programmed to complete several BP measurements at appropriate intervals while the patient rests alone in a quiet room.¹⁰

The accuracy of this new method was tested in a 2009 cohort study of 309 patients referred to an ambulatory blood pressure (ABP) monitoring unit at an academic hospital for diagnosis or management of hypertension.¹¹ The study compared mean awake ABP, which continuously measures patients’ BP throughout the day, manual sphygmomanometer readings taken by the patient’s own physician, and an automated office blood pressure (AOBP) device called BpTRU (an automated oscillometric sphygmomanometer) while the patient rested alone in the exam room.¹¹ The awake ABP is a federally approved standard for the diagnosis of white-coat hypertension.¹² In this study, the white-coat response was negated with the use of the automated BpTRU device.¹¹

A 2019 meta-analysis that included 26 studies (N = 7116) comparing AOBP with other BP measurement techniques concluded that the use of automated oscillometric BP readings is more accurate for diagnosing hypertension and assists in negating the white-coat hypertension effect.⁹

Continue to: STUDY SUMMARY

STUDY SUMMARY

Automated office BP devices are just as accurate as more expensive ABP studies

This systematic review and meta-analysis (N = 9279; 23 cross-sectional, 1 cohort, and 7 randomized controlled trials [N = 1304], of which 17 studies overlapped with those included in the previously mentioned meta-analysis⁹) compared SBP and diastolic blood pressure measured by an oscillometric AOBP device to awake or daytime ABP (continuously monitoring BP while awake, used as a standard for BP measurement), routine manual office BP, or research BP measurements.

The study also explored the protocol by which the best AOBP results could be obtained. For AOBP measurement, the included trials had no more than 2 minutes of elapsed time between individual AOBP measurements and had at least 3 AOBP readings to calculate the mean.

Compared with AOBP, in samples with an SBP of ≥ 130 mm Hg, SBP readings were significantly higher for both routine office visits (mean difference [MD] = 14.5 mm Hg; 95% CI, 11.8–17.2) and research (MD = 7 mm Hg; 95% CI, 4.9–9.1). However, no difference was found between AOBP and awake ambulatory SBP values (MD = 0.3 mm Hg; 95% CI, −1.1 to 1.7). In all cases, heterogeneity of the included studies was high (I² was > 75%). There was no evidence of small-study effect or publication bias, and little evidence of potential financial bias. The most accurate methodology for AOBP measurements included multiple BP readings and the patient resting alone in a quiet location.

This meta-analysis supports the use of an automated office blood pressure device to accurately screen for hypertension and avoid the white-coat effect.

Although there was statistical heterogeneity, the results were confirmed in the authors’ analysis of studies with high methodologic quality. In addition, researchers performed multiple meta-regression analyses to evaluate the statistical heterogeneity and found no significant differences based on age, body mass index, number of treated patients, gender, measurement interval, or added rest before AOBP.

WHAT'S NEW

Study confirms unattended, automated office BP as preferred technique

This is the second recent comprehensive systematic review and meta-analysis to directly compare AOBP with other common techniques of BP measurement in screening for and diagnosing hypertension in the clinical setting. ⁹

Continue to: This meta-analysis...

This meta-analysis emphasized the technique (see below) by which to obtain the best AOBP vs ABP results, whereas the other ­meta-analysis⁹ did not. Thus the study provides practice-based settings with the information they need to more closely replicate the results of the studies included in the meta-analysis.

Also, the equivalency comparison with the more expensive and intrusive ABP monitoring may save money, improve patient adherence, and increase patient satisfaction. Given these advantages, along with its demonstrated accuracy, AOBP should be adopted in routine clinical practice to screen patients for hypertension.

CAVEATS

Close adherence to measurementprocedures is a necessity

Effective use of AOBP in clinical practice requires close adherence to the AOBP study procedures described in this meta-analysis. These include taking multiple (at least 3) BP readings, 1 to 2 minutes apart, recorded with a fully automated oscillometric sphygmomanometer while the patient rests alone in a quiet place.

CHALLENGES TO IMPLEMENTATION

Adjusting workflows, addressing cost

Physicians may be reluctant to adopt this technique because they may not be convinced of its advantages compared with the traditional methods of recording BP and because of difficulties with implementing new rooming workflows.¹² The cost of AOBP devices used in this study (Omron 907 and BpTRU; BpTRU ceased operations in 2017) were not disclosed, which may be a hindrance, as devices may cost $1000 or more.

Effective use of automated office blood pressure requires that one take multiple (at least 3) BP readings, 1 to 2 minutes apart, while the patient rests alone in a quiet place.

An online search for “automated oscillometric BP monitor” by one of the PURL authors (RCM) found oscillometric AOBP devices ranging from $150 to > $1000, depending on whether the device was medical grade; a search for “Omron 907” found devices for ≤ $599 on multiple sites. However, none of the lower-cost devices indicated the ability to take multiple, unattended BP readings.

ACKNOWLEDGEMENT

The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center for Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.