Christopher Nabors

Experience with faculty supervision of an electronic resident sign-out system.

The Association of Professors of Medicine (APM) is the national organization of departments of internal medicine at the US medicalschools and numerous affiliated teaching hospitals as represented by chairs and appointed leaders. As the official sponsor of TheAmerican Journal of Medicine, the association invites authors to publish commentaries on issues concerning academic internalmedicine.For the latest information about departments of internal medicine, please visit APM’s website at www.im.org/APM.

Mobile physician reporting of clinically significant events-a novel way to improve handoff communication and supervision of resident on call activities.

Objectives Reporting of clinically significant events represents an important mechanism by which patient safety problems may be identified and corrected. However, time pressure and cumbersome report entry procedures have discouraged the full participation of physicians. To improve the process, our internal medicine training program developed an easy-to-use mobile platform that combines the reporting process with patient sign-out. Methods Between August 25, 2011, and January 25, 2012, our trainees entered clinically significant events into i-touch/i-phone/i-pad based devices functioning in wireless-synchrony with our desktop application. Events were collected into daily reports that were sent from the handoff system to program leaders and attending physicians to plan for rounds and to correct safety problems. Results Using the mobile module, residents entered 31 reportable events per month versus the 12 events per month that were reported via desktop during a previous 6-month study period. Conclusions Advances in information technology now permit clinically significant events that take place during “off hours” to be identified and reported (via handoff) to next providers and to supervisors via collated reports. This information permits hospital leaders to correct safety issues quickly and effectively, while attending physicians are able to use information gleaned from the reports to optimize rounding plans and to provide additional oversight of trainee on call patient management decisions.

Faculty Supervision of the House Staff Handoff Process: The Time Has Come

t q t b v m m a o t c m m p b The Accreditation Council for Graduate Medical Education is taking bold new initiatives to make residency education more accountable to the public. If this is not done by the Accreditation Council for Graduate Medical Education, it will surely be legislated by governmental agencies that are paying the bill for Graduate Medical Education training, which would include requirements for more direct observation of a trainee’s performance, documentation of the trainee’s individual clinical outcomes, and educational outcomes of the residency training program. The creation of “the milestones” makes it easier to document specific behaviors and performance on specific tasks. Previously, some of our faculty ratings were a result of supervisory “gestalt” rather than direct observation of the task by the trainee/learner. Direct observation is the only way to discern the difference between what the learner “can do” versus what the learner “actually does.” This has been well described in faculty development sessions at our institution with Dr Eric Holmboe of the American Board of Internal Medicine, as well as by Dr Louis Pangaro at the Clerkship Directors of Internal Medicine meeting in October, 2005. The fact that a learner has the knowledge, skills, and attitude of a particular task does not mean this automatically translates into desired behaviors at the bedside, thus the need for more direct supervision and direct observation in all of our training programs. This is the essence of competency-based education. This direct observation will be applied to the Entrustable Patient Activities. No Entrustable Patient Activity is more important than the process of “handoffs.” No Entrustable Patient Activity requires more direct observation and supervision than the handoff process if we are to increase the patient safety culture and environments in our teaching hospitals. The process of handoffs has been studied for some time. As a consequence of the mandated changes in house taff duty hours, we have an average of 5.2 handoffs per day per patient in the United States. This number is chilling in the mathematic calculation of risk for each patient in the

Milestones: a rapid assessment method for the Clinical Competency Committee

Introduction Educational milestones are now used to assess the developmental progress of all U.S. graduate medical residents during training. Twice annually, each program’s Clinical Competency Committee (CCC) makes these determinations and reports its findings to the Accreditation Council for Graduate Medical Education (ACGME). The ideal way to conduct the CCC is not known. After finding that deliberations reliant upon the new milestones were time intensive, our internal medicine residency program tested an approach designed to produce rapid but accurate assessments. Material and methods For this study, we modified our usual CCC process to include pre-meeting faculty ratings of resident milestones progress with in-meeting reconciliation of their ratings. Data were considered largely via standard report and presented in a pre-arranged pattern. Participants were surveyed regarding their perceptions of data management strategies and use of milestones. Reliability of competence assessments was estimated by comparing pre-/post-intervention class rank lists produced by individual committee members with a master class rank list produced by the collective CCC after full deliberation. Results Use of the study CCC approach reduced committee deliberation time from 25 min to 9 min per resident (p < 0.001). Committee members believed milestones improved their ability to identify and assess expected elements of competency development (p = 0.026). Individual committee member assessments of trainee progress agreed well with collective CCC assessments. Conclusions Modification of the clinical competency process to include pre-meeting competence ratings with in-meeting reconciliation of these ratings led to shorter deliberation times, improved evaluator satisfaction and resulted in reliable milestone assessments.

Association of corrected QT interval with long-term mortality in patients with syncope

Introduction The electrocardiographic parameters QRS duration, QRS-T angle and QTc can predict mortality in patients with cardiovascular disease. The prgnostic value of these parameters in hospitalized patients with syncope needs investigation. Material and methods We retrospectively studied 590 consecutive patients hospitalized with syncope. After excluding patients with baseline abnormal rhythm, QT- prolonging medications, and missing data, 459 patients were analyzed. Baseline demographic characteristics, co-morbidities, medication use, San Francisco Syncope Rule (SFSR) and Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL) score and data on mortality were collected. The categorical variables and continuous variables of the 2 groups of patients with prolonged QTc and normal QTc interval were analyzed by Fischers exact test and Mann-Whitney Test. A stepwise Cox regression model was used for time to death analysis. Results Of 459 patients, prolonged QTc interval was observed in 122 (27%). Mean follow-up was 41 months. Patients with prolonged QTc interval had higher prevalence of cardiovascular disease, OESIL score, high risk SFSR, hypertension, dyslipidemia, coronary artery disease, congestive heart failure, and increased mortality. Stepwise Cox regression analysis showed that significant independent prognostic factors for time to death were prolonged QTc interval (p = 0.005), age (p = 0.001), diabetes mellitus (p = 0.001) and history of malignancy (p = 0.006). QRS duration and QRS-T angle were not independent predictors of mortality. Conclusions A prolonged QTc interval is an independent predictor of long-term mortality in hospitalized patients with syncope.

Continuity Clinic Model and Diabetic Outcomes in Internal Medicine Residencies: Findings of the Educational Innovations Project Ambulatory Collaborative.

BACKGROUND Efforts to improve diabetes care in residency programs are ongoing and in the midst of continuity clinic redesign at many institutions. While there appears to be a link between resident continuity and improvement in glycemic control for diabetic patients, it is uncertain whether clinic structure affects quality measures and patient outcomes. METHODS This multi-institutional, cross-sectional study included 12 internal medicine programs. Three outcomes (glycemic control, blood pressure control, and achievement of target low-density lipoprotein [LDL]) and 2 process measures (A1C and LDL measurement) were reported for diabetic patients. Traditional, block, and combination clinic models were compared using analysis of covariance (ANCOVA). Analysis was adjusted for continuity, utilization, workload, and panel size. RESULTS No significant differences were found in glycemic control across clinic models (P = .06). The percentage of diabetic patients with LDL < 100 mg/dL was 60% in block, compared to 54.9% and 55% in traditional and combination models (P = .006). The percentage of diabetic patients with blood pressure < 130/80 mmHg was 48.4% in block, compared to 36.7% and 36.9% in other models (P < .001). The percentage of diabetic patients with HbA1C measured was 92.1% in block compared to 75.2% and 82.1% in other models (P < .001). Also, the percentage of diabetic patients with LDL measured was significantly different across all groups, with 91.2% in traditional, 70.4% in combination, and 83.3% in block model programs (P < .001). CONCLUSIONS While high scores on diabetic quality measures are achievable in any clinic model, the block model design was associated with better performance.

Association Between Opioid Abuse/Dependence and Outcomes in Hospitalized Heart Failure Patients.

Opioid use is associated with unintentional and intentional overdose and is one of the leading causes of emergency room visits and accidental deaths. However, the association between opioid abuse/dependence and outcomes in hospitalized patients has not been well studied. Congestive heart failure (HF) is the fourth most common cause of hospitalization in the United States. The purpose of this study was to examine the effect of opioid abuse/dependence on outcomes in patients hospitalized with HF. We queried the 2002–2010 Nationwide Inpatient Sample databases to identify all patients aged 18 years and older admitted with the primary diagnosis of HF. Multivariate logistic regression analysis was used to compare the frequency of hospital-acquired conditions (HACs) and in-hospital mortality between patients with and without a history of opioid abuse/dependence. Of 9,993,240 patients with HF, 29,014 had a history of opioid abuse or dependence. Opioid abusers/dependents were likely to be younger men of poor socioeconomic background with self pay or Medicaid as their primary payer. They had a lower prevalence of dyslipidemia, diabetes mellitus, coronary artery disease, prior myocardial infarction, and peripheral vascular disease (P < 0.001 for all). They were more likely to be smokers and have chronic pulmonary disease, depression, liver disease, and obesity (P < 0.001 for all). Patients with a history of opioid abuse/dependence had lower incidence of HACs (14.8% vs. 16.5%, adjusted odds ratio: 0.71, P < 0.001) and lower in-hospital mortality (1.3% vs. 3.6%, adjusted odds ratio: 0.64, P < 0.001) as compared with patients without prior opioid abuse/dependence. In conclusion, among adult patients aged 18 years and older hospitalized with HF, opioid abuse/dependence was associated with lower frequency of HACs and lower in-hospital mortality.

Tracking outpatient continuity and chronic disease indicators-a novel use of the new innovations clinic module.

The Accreditation Council for Graduate Medical Education common program requirements for Practice-based Learning and Improvement in Internal Medicine specify that trainees must “systematically analyze [his/her] practice using quality improvement methods, and implement changes with the goal of practice improvement” and that the training program “must include use of performance data” in the assessment of the residents practice. Before implementation of an electronic health record at our academic medical center, we found meeting these requirements to be challenging. This prompted us to set up the New Innovations (New Innovations, Inc, Uniontown, OH) Software Suites Patient Continuity module to permit analysis and tracking of both quality of care indicators and patient continuity. By using the system, our residents were better able to monitor their patient panel sizes and composition and to correlate their practices with quality of care data. Residency programs, which currently utilize New Innovations software but lack an electronic health record, may find the continuity clinic module useful for engaging their house staff in structured practice improvement initiatives and in satisfying the Accreditation Council for Graduate Medical Educations common program requirements for practice-based learning.

Use of Statins for Primary Prevention – Selection of Risk Threshold and Implications across Race and Gender.

BACKGROUND The 2016 U.S. Preventive Services Task Force (USPSTF) guidelines for primary prevention statin therapy are more restrictive than the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines. There are important differences in how application of the risk thresholds from these guidelines would impact particular segments of the U.S. POPULATION METHODS Data from the National Health and Nutrition Examination Survey (2005-14) were used to determine statin eligibility across age, gender, and racial or ethnic group using criteria from the 2013 ACC/AHA and 2016 USPSTF guidelines. Proportions of the study population eligible for statins under the ACC/AHA 5% and 7.5% risk thresholds were compared with those eligible under the 2016 USPSTF 10% guidelines. RESULTS Of the 5388 study participants, 34% were eligible for statin therapy under the USPSTF guideline compared with 43% under the Class I (7.5%) ACC/AHA treatment threshold and 53% under the Class IIa (5%) ACC/AHA treatment threshold. Moving from the USPSTF 10% threshold to the ACC/AHA 5% threshold increased statin eligibility for males ages 40-59 from 26%-48% (whites), from 19%-43% (Hispanics), and from 33%-74% (blacks). A similar disproportionate but less pronounced effect was seen when different risk thresholds were used for statin eligibility among women ages 40-59 across differing races and ethnicities. CONCLUSIONS In this sample of U.S. adults from the National Health and Nutrition Examination Survey database, full implementation of the higher USPSTF statin treatment threshold could lead to less overall statin use and disproportionately lower statin use among non-Hispanic blacks.

Drug treatment of hypertension in older patients with diabetes mellitus

ABSTRACT Introduction: Hypertension is more prevalent in the elderly (age>65 years) diabetic population than in the general population and shows an increasing prevalence with advancing age. Both diabetes mellitus (DM) and hypertension are independent risk factors for cardiovascular (CV) related morbidity and mortality. Optimal BP targets were not identified in elderly patients with DM and hypertension. Areas covered: In this review article, the authors briefly discuss the pathophysiology of hypertension in elderly diabetics, present evidence with various antihypertensive drug classes supporting the treatment of hypertension to reduce CV events in older diabetics, and then discuss the optimal target BP goals in these patients. Expert opinion: Clinicians should have a BP goal of less than 130/80 mm in all elderly patients with hypertension and DM, especially in those with high CV-risk. When medications are required for optimal BP control in addition to lifestyle measures, either thiazide diuretics, angiotensin-converting-enzyme inhibitors, angiotensin receptor blockers, or calcium channel blockers should be considered as initial therapy. Combinations of medications are usually required in these patients because BP control is more difficult to achieve in diabetics than those without DM.