Most current strategies to improve quality and efficiency in health-care delivery focus on measuring and improving physician practice. A new "second generation" of physician profiling--episode-based profiling--is moving beyond legacy "first-generation" physician profiles based on population health and preventive services measures. Episode-based profiling measures physician practice at the "episode of care" level with sophisticated analytic methods and tools using data from claim and other administrative data sets, and it has an underlying "theory of change" consistent with the evolution of the US health-care marketplace. While offering potential advantages in informing consumer choice and enabling practice improvement, episode-based profiling also has limitations and challenges, both analytically and in the process of physician engagement and improvement. Nonetheless, episode-based profiling is likely to continue to spread and have growing influence, and it has significant implications for research, policy, and clinical stakeholders.

To investigate whether asymptomatic shedding of herpes simplex virus occurs in women with recurrent genital herpes, six women with documented disease were followed up twice weekly with viral cultures and pelvic examination. During the study period of 1330 patient days and 452 patient visits, 26 episodes of genital herpesvirus infection were recorded. Twenty-three (88 %) episodes were accompanied by signs and symptoms. Three (14 %) of the culture-positive recurrences were asyrnptomatic. In one episode an asymptomatic lesion was noted, and in two instances viral shedding from the vulva or cervix occurred in the absence of visible herpetic lesions. Three of the six women had evidence of recurrent cervical herpesvirus infection. No relationships between menstrual cycle and sexual activity and the onset of recurrence were noted.

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Lymphocyte transformation and production of lymphocyte-derived chemotactic factor in response to herpes simplex virus antigen were studied in 15 patients with initial genital herpes and 10 controls. The patients underwent frequent genital examinations, viral cultures, and weekly immunological studies for a period of 11 weeks. The production of lymphocyte-derived chemotactic factor was maximal in week 1 of the disease and declined to control levels by week 6. In contrast, lymphocyte transformation was lowest in week 1, reached a maximum by week 4, and declined to control levels by week 11. Production of lymphocyte-derived chemotactic factor in week 1 was significantly lower in nine patients who developed signs or symptoms of systemic herpes infection than in six who had localized disease. In addition, a marked but transient decline in the production of this lymphokine was observed in patients at the time of clinical recurrence. Virus-specific lymphocyte transformation correlated inversely with the duration of genital pain and lesions and did not correlate with the presence of systemic signs or symptoms. These findings indicate that during initial genital herpes infection the dynamics of lymphocyte transformation and those of lymphocyte-derived chemotactic factor production are different, and that the generation of this lymphokine is an early component of the cellular immune response in this disease. Furthermore, adequate produce of lymphocyte-derived chemotactic factor may be important in restricting herpes simplex virus to the genital area and preventing disease recurrence.

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