Allan H. Goroll

Multifactorial Index of Cardiac Risk in Noncardiac Surgical Procedures

To determine which preoperative factors might affect the development of cardiac complications after major noncardiac operations, we prospectively studied 1001 patients over 40 years of age. By multivariate discriminant analysis, we identified nine independent significant correlates of life-threatening and fatal cardiac complications: preoperative third heart sound or jugular venous distention; myocardial infarction in the preceding six months; more than five premature ventricular contractions per minute documented at any time before operation; rhythm other than sinus or presence of premature atrial contractions on preoperative electrocardiogram; age over 70 years; intraperitoneal, intrathoracic or aortic operation; emergency operation; important valvular aortic stenosis; and poor general medical condition. Patients could be separated into four classes of significantly different risk. Ten of the 19 postoperative cardiac fatalities occurred in the 18 patients at highest risk. If validated by prospective application, the multifactorial index may allow preoperative estimation of cardiac risk independent of direct surgical risk.

Heart failure in outpatients: a randomized trial of digoxin versus placebo.

The view that digitalis clinically benefits patients with heart failure and sinus rhythm lacks support from a well-controlled study. Using a randomized, double-blind, crossover protocol, we compared the effects of oral digoxin and placebo on the clinical courses of 25 outpatients without atrial fibrillation. According to a clinicoradiographic scoring system, the severity of heart failure was reduced by digoxin in 14 patients; in nine of these 14, improvement was confirmed by repeated trials (five patients) or right-heart catheterization (four patients). The other 11 patients had no detectable improvement from digoxin. Patients who responded to digoxin had more chronic and more severe heart failure, greater left ventricular dilation and ejection-fraction depression, and a third heart sound. Multivariate analysis showed that the third heart sound was the strongest correlate of the response to digoxin (P less than 0.0001). These data suggest that long-term digoxin therapy is clinically beneficial in patients with heart failure unaccompanied by atrial fibrillation whose failure persists despite diuretic treatment and who have a third heart sound.

Cardiac risk factors and complications in non-cardiac surgery.

In an attempt to assess cardiac risk in non-cardiac surgery, 1001 patients over 40 years of age who underwent major operative procedures were examined preoperatively, observed through surgery, studied with at least one postoperative electrocardiogram, and followed until hospital discharge or death. Documented postoperative myocardial infarction occurred in only 18 patients; though most of these patients had some pre-existing heart disease, there were few preoperative factors which were statistically correlated with postoperative infarction. Postoperative pulmonary edema was strongly correlated with preoperative heart failure, but 21 of the 36 patients who developed pulmonary edema did not have any prior history of heart failure. Nearly all of these 21 patients were elderly, had abnormal preoperative electrocardiograms, and had intraabdominal or intrathoracic surgery. In the absence of an acute infarction, bifascicular conduction defects, with or without PR interval prolongation, never progressed to complete heart block. Spinal anesthesia protected against postoperative heart failure but not against other cardiac complication. By multivariate regression analysis, postoperative cardiac death was significantly correlated with (a) myocardial infarction in the previous 6 months; (b) third heart sound or jugular venous distention immediately preoperatively; (c) more than five premature ventricular contractions per minute documented at any time preoperatively; (d) rhythm other than sinus, or premature atrial contractions on preoperative electrocardiogram; (e) age over 70 years; (f) significant valvular aortic stenosis; (g) emergency operation; (h) a 33% or greater fall in systolic blood pressure for more than 10 minutes intraoperatively. Notably unimportant factors included smoking, glucose intolerance, hyperlipidemia, hypertension, peripheral atherosclerotic vascular disease, angina, and distant myocardial infarction.

An analysis of physicians' reasons for prescribing long-term digitalis therapy in outpatients☆

We examined by medical-record review why long-term digitalis therapy was prescribed in 150 outpatients, the reasons were: supraventricular tachyarrhythmias (35): supraventricular tachyarrhythmias and heart failure (33); and heart failure with sinus rhythm (82). In the patients without supraventricular tachyarrhythmias we scrutinized the diagnosis of heart failure using a clinicoradiographic scoring system and found the diagnosis unlikely in 32 patients. When these 32 patients are combined with the 31 patients who had only one occurrence of supraventricular tachyarrhythmias or heart failure, 42% of the patients were on long-term digitalis therapy for a questionable reason. We conclude that a substantial fraction of general medical outpatients might benefit from digitalis withdrawal, if evidence for heart failure is lacking or if the reason prompting digitalis therapy is isolated to the distant past.

Fundamental Reform of Payment for Adult Primary Care: Comprehensive Payment for Comprehensive Care

Primary care is essential to the effective and efficient functioning of health care delivery systems, yet there is an impending crisis in the field due in part to a dysfunctional payment system. We present a fundamentally new model of payment for primary care, replacing encounter-based imbursement with comprehensive payment for comprehensive care. Unlike former iterations of primary care capitation (which simply bundled inadequate fee-for-service payments), our comprehensive payment model represents new investment in adult primary care, with substantial increases in payment over current levels. The comprehensive payment is directed to practices to include support for the modern systems and teams essential to the delivery of comprehensive, coordinated care. Income to primary physicians is increased commensurate with the high level of responsibility expected. To ensure optimal allocation of resources and the rewarding of desired outcomes, the comprehensive payment is needs/risk-adjusted and performance-based. Our model establishes a new social contract with the primary care community, substantially increasing payment in return for achieving important societal health system goals, including improved accessibility, quality, safety, and efficiency. Attainment of these goals should help offset and justify the costs of the investment. Field tests of this and other new models of payment for primary care are urgently needed.

A New Model for Accreditation of Residency Programs in Internal Medicine

Medical education is experiencing a back-to-basics movement, with increased emphasis on mastery of core clinical competencies (1-3). Debates over curricular time, clinical rotations, and conferences are being replaced by discussions about clinical competence and its assessment (4-8). The change is driven largely by evolving societal mandates for quality, safety, and accountability in health care (9-11) and is resulting in re-examinations of priorities and programs not only by medical schools and residency training programs but also by certifying, licensing, and accrediting bodies (12, 13). As the accrediting body for the nations medical residency programs, the Accreditation Council for Graduate Medical Education (ACGME) bears responsibility for the quality of graduate medical education (14). Through its accrediting authority, the ACGME has the potential to serve as a constructive force for reform of graduate medical education by better aligning accreditation standards with desired medical education outcomes (5, 6). This paper describes a new outcomes-based model for residency program accreditation in internal medicine initiated by the ACGMEs Residency Review Committee for Internal Medicine (RRC-IM). The RRC-IMs Long-Range Planning Committee (LRPC) was asked to perform a blue sky examination of residency program accreditation in internal medicine, taking up the ACGME charge to make the system more outcomes based (that is, focused on trainee clinical competence) (5). In response, the LRPC developed a new accreditation model that is designed to serve as a long-range plan and template for advancing graduate medical education in internal medicine through reform of the accreditation process. Related goals included 1) enhancing the validity, reliability, and efficiency of the accreditation system; 2) encouraging continuous program improvement; and 3) stimulating educational innovation. Current Approach to Accreditation in Internal Medicine and Its Shortcomings The current approach relies on documentation of compliance with an extensive list of requirements in such areas as facilities, faculty, teaching program, and methods of evaluation. There are nearly 400 specific requirements listed (15), and educational processes account for the vast majority. The only objective outcome measure is the 3-year rolling-average aggregate pass rate of program graduates on the American Board of Internal Medicine (ABIM) certification examination. While substantive improvements have been made to this accreditation system (for example, use of standardized computer-based resident questionnaires and constant updating and revision of program requirements in close consultation with stakeholders), the system remains a largely passive process for the training programs, relying on periodic external audit. Shortcomings include extensive documentation that must be prepared by training program directors, hundreds of hours of review required annually by RRC members, little incentive for program directors to monitor key educational outcomes or to continuously improve educational programs between audits, and absence of comprehensive objective measurements of program effectiveness. These limitations leave some program directors and reviewers questioning the value of the current accreditation process and others concerned about the accountability and societal responsiveness of our training system in internal medicine (12, 13). Toward a New Accreditation System: Basing Program Accreditation on Aggregate Clinical Competence and Essential Educational and Clinical Infrastructures The LRPC accreditation model shifts the focus of accreditation from intermittent external audit of educational process to continuous internal monitoring and improvement of trainee clinical competence. In addition, the model specifies essential resident and patient care protections that foster a safe and effective training environment. Rationale The main reason for changing to a competency-based accreditation system is to better align the accreditation process with desired educational outcomes. By making clinical competence the principal basis for residency program accreditationa high-stakes determinationthe model redirects attention to and reinforces the primary educational mission. The existing accreditation systems concentration on educational process prompts the question of whether a programs compliance with current requirements ensures the graduation of skilled internists and enables differentiation between good-quality training programs and substandard ones (12, 13). An accreditation system that makes aggregate trainee clinical competence the prime basis for accreditation should enhance program accountability and provide a powerful stimulus to improve training. In addition, by emphasizing outcomes over process, the new model gives program directors considerably more freedom to innovate. As important as aggregate clinical competence is for judging the educational effectiveness of a residency program, it is insufficient to ensure fundamental patient and trainee protections. Consequently, the proposed model specifies the inclusion of a limited set of patient care and educational infrastructure requirements that foster safe, well-functioning systems of care and training. If this reform is to achieve the goal of continuous program improvement, the audit process associated with accreditation needs to become more continuous and internal to the program rather than infrequent and predominantly external. For this reason, the current review process of extensive documentation and periodic external audits for compliance with process requirements is largely replaced by regular ongoing internal (faculty) assessment of trainee clinical performance. Continuous program self-monitoring provides the opportunity for real-time feedback that can be applied both to improving an individual trainees clinical performance and to strengthening the overall educational program. The alternative, a periodic external evaluation of trainee competence, while appealing for its potential objectivity and uniformity, cannot deliver the necessary information in timely fashion and would be very expensive and difficult to carry out without disrupting training and patient care. Despite the emphasis on local assessment of trainee competence as the principal basis for accreditation, the model proposes a balanced approach to program evaluation that recognizes the need to have complementary external oversights and national performance standards. Included in the external oversight would be certification and audit of the local evaluation process. In addition, some measures of clinical competence, such as assessment of medical knowledge and reasoning, will continue to be performed by external testing (for example, through the secured ABIM examination). Moreover, external peer review is retained in this model, relying on the RRC to examine all data and use its judgment to render the final accreditation decision. An outcomes-based system will require time and much developmental work before it can be universally implemented; however, the LRPC views immediate pilot implementation as a desirable first step. On the basis of the models potential to stimulate continuous program improvement, the LRPC has recommended that programs with a strong accreditation history be able to opt out of the current accreditation system in return for 1) achieving a higher minimum ABIM pass rate, 2) meeting a strengthened set of infrastructure standards, and 3) implementing a comprehensive (possibly home-grown) competency assessment program that includes critical review of evaluation methods and use of clinical performance data to continuously improve the teaching program. Developing and implementing assessment methods and setting performance standards represent major undertakings that will require years of shared work and pooled resources. Although the RRC-IM has ultimate responsibility for setting aggregate trainee competency standards for program accreditation, its goal of fundamentally changing the accreditation system will need to be a collaborative process that solicits detailed input from all stakeholders (including the public). Working with stakeholders and using its accrediting authority, the RRC-IM can stimulate development and testing of clinical competency measures and help bring about a sound, acceptable, publically responsive outcomes-based accreditation system. The Outcome Requirements: Mastery of Core Competencies The proposed outcome measures are the clinical competencies that all residents should master by the end of their training. A set of such competencies has been identified through an ACGME initiative (5) and refined by stakeholders in internal medicine into a set of working definitions expressed in behavioral terms (Table 1) (16). The ABIM incorporated these 6 competencies into its resident evaluation forms (17), and the ACGME has asked all of its RRCs to begin making reference to the competencies in their program requirements (18). Performance standards for the competencies will need to be specified and might be stated in terms of outcome statements that define safe, patient-centered, efficient, effective, and appropriate care (similar to the Institute of Medicines Aims [19]). Table 1. The Core Clinical Competencies for Internal Medicine* The Infrastructure Requirements: Essential Trainee and Patient Protections Complementing the competency standards in this model would be requirements for institutional and program infrastructures essential to safe and effective education and patient care. Examples of educational infrastructure requirements might include workload standards, duty-hour limits, faculty qualifications, and procedures ensuring regular evaluation and timely feedback. Requirements to ensure patient safety might encompass electronic medical records, order-entry and tracking systems, and well-organized and adequa

Community-wide implementation of health information technology: the Massachusetts eHealth Collaborative experience.

The Massachusetts eHealth Collaborative (MAeHC) was formed to improve patient safety and quality of care by promoting the use of health information technology through community-based implementation of electronic health records (EHRs) and health information exchange. The Collaborative has recently implemented EHRs in a diverse set of competitively selected communities, encompassing nearly 500 physicians serving over 500,000 patients. Targeting both EHR implementation and health information exchange at the community level has identified numerous challenges and strategies for overcoming them. This article describes the formation and implementation phases of the Collaborative, focusing on barriers identified, lessons learned, and policy issues.

Clinical decisions. American Board of Internal Medicine maintenance of certification program.

This interactive feature allows readers to make a decision on the basis of a vignette that is followed by specific options, none of which can be considered either correct or incorrect. In short essays, experts in thefield then arguefor each of the options. In the online version of this feature, available at NEJM.org, readers can participate in forming community opinion by choosing one of the options and, if they like, providing their reasons.

Health Care IT Collaboration in Massachusetts: The Experience of Creating Regional Connectivity

The state of Massachusetts has significant early experience in planning for and implementing interoperability networks for exchange of clinical and financial data. Members of our evolving data-sharing organizations gained valuable experience that is of potential benefit to others regarding the governance, policies, and technologies underpinning regional health information organizations. We describe the history, roles, and evolution of organizations and their plans for and success with pilot projects.

Do Clerkship Directors Think Medical Students Are Prepared for the Clerkship Years

Purpose Educators have begun to question whether medical students are adequately prepared for the core clerkships. Inadequate preclerkship preparation may hinder learning and may be predictive of future achievement. This study assessed and compared the views of clerkship directors regarding student preparation for the core clinical clerkships in six key competencies. Method In 2002, a national survey was conducted of 190 clerkship directors in internal medicine, family medicine, pediatrics, surgery, obstetrics/gynecology, and psychiatry from 32 U.S. medical schools. Clerkship directors were asked to report their views on the appropriate level of student preparation needed to begin the core clinical clerkships (none, minimal, intermediate, advanced), and the adequacy of that preparation (ranging from “much less” to “much more than necessary”) in six key clinical competencies. Results A total of 140 clerkship directors responded (74%). The majority reported that students need at least intermediate ability in five of six competencies: communication (96%), professionalism (96%), interviewing/physical examination (78%), life-cycle stages (57%), epidemiology/probabilistic thinking (56%), and systems of care (27%). Thirty to fifty percent of clerkship directors felt students are less prepared than necessary in the six competencies. Views were similar across all specialties and generally did not differ by other clerkship director characteristics. Conclusions Almost half of clerkship directors were concerned that students do not receive adequate preparation in key competencies before starting the core clinical clerkships. Many medical schools may need to give more attention to the preclerkship preparation of students in these high-priority areas.