Editorial

Express Scripts, the contractor that manages the pharmacy benefit for Tricare, the military health insurance program, announced in 2021 that after a 5-year absence, CVS Pharmacy was once more in the network. In 2023, CVS had the largest profits of any pharmacy chain in the United States, about $159 billion, and generated a quarter of the overall revenue of the US pharmacy industry.¹ Tricare officials heralded the return of CVS as a move that would offer US Department of Defense (DoD) beneficiaries more competitive prices, convenient access, and overall quality.²

DOJ Files Lawsuit Against CVS

In December 2024, the US Department of Justice (DoJ) filed a lawsuit alleging that CVS violated both the Controlled Substances Act (CSA) and the False Claims Act (FCA).^3,4 The United States ex rel. Estright v Health Corporation, et al, filed in Rhode Island, charged that CVS “routinely” and “knowingly” filled invalid prescriptions for controlled substances violating the CSA and then billed federal health care programs for payment for these prescriptions, a breach of the FCA.⁵ The DoJ alleged that CVS pharmacies and pharmacists filled prescriptions for controlled substances that (1) lacked a legitimate medical purpose; (2) were not legally valid; and/or (3) were not issued in the usual course of medical practice. ⁶ CVS contests the charges and issued an official response, stating that it disputes the allegations as false, plans to disprove them in litigation, and has nonetheless fully cooperated with the investigation.⁷

The allegations involved prescriptions for drugs like opioids and benzodiazepines, primary culprits in the American overdose epidemic.⁸ The complaint notes that the prescriptions were early refills in excessive quantities and included what has been called the “holy trinity” of dangerous medications: opioids, benzodiazepines, and muscle relaxants. ^5,8 Even worse (if that is possible), as the complaint outlines, CVS had access to data from both inside and outside the company that these prescriptions came from notorious pill mills and were hence unlawful and yet continued to fill them, leading the DoJ to file the more serious charge that the corporation “knowingly” violated the CSA and “prioritized profits over safety in dispensing controlled substances.”^5,6

The Unholy Trinity

The infamous members of what I prefer to call the “unholy trinity” are a benzodiazepine, often alprazolam, an opioid, and the muscle relaxant carisoprodol. The combination amplifies each agent’s independent risk of respiratory depression. The latter is a schedule IV medication with an active metabolite, meprobamate, that also has this adverse effect. All 3 drugs have high abuse potential and, when combined, increase the risk of fatal overdose. The colloquial name holy trinity derives from the synergistic euphoria experienced when taking this triple cocktail of sedative agents.⁹ This pharmacological recipe for disaster is the house specialty of pill mills: infamous storefront practices that generate high profits and exploit persons with chronic pain and addiction by handing out controlled substances with little clinical assessment and even less oversight.¹⁰

When the Means Become the End

The DoJ allegations suggest that the violations resulted from “corporate-mandated performance metrics, incentive compensation, and staffing policies that prioritized corporate profits over patient safety.”⁶ If the allegations are true, why would a company reinvited by Tricare to serve the nation’s heroes seemingly engage in illegal practices? While CVS has not responded in court, their statement argued that “too often, we have seen government agencies and trial lawyers question the good-faith decisions made by pharmacists while a patient waits at the pharmacy counter, often in pain.”⁶

The DoJ complaint offers a cautionary warning for the US health care system, which is increasingly being micromanaged in the pursuit of efficiency. Like many practitioners in and out of the federal system, I get a cold chill when I read the word productivity. “CVS pharmacists described working at CVS as ‘soul crushing’ because it was impossible to meet the company’s expectations,” the complaint alleges, because “CVS set staffing levels so low that it was impossible for pharmacists to comply with their legal obligations and meet CVS’s demanding metrics.”⁵ Did top-down mandates drive the alleged activities by imposing unattainable performance metrics on pharmacists, offering incentives that encouraged and rewarded corner-cutting, and refusing to fund sufficient staffing to ensure patient safety? This may be what happens when the means (efficiency) become the end rather than a mechanism to achieve the goal of more accessible, affordable, high-quality health care.

Ethically, what is most concerning is that leadership intentionally “deprived its pharmacists of crucial information” about specific practitioners known to engage in illegal prescribing practices.⁶ CVS did not provide pharmacists with “information about prescribers’ prescribing habits that CVS routinely collected and reviewed at the corporate level,” and even removed prescriber blocks that were implemented at Target pharmacies before it was acquired by CVS.⁵ The first element of informed consent is providing patients with adequate information upon which to decide whether to accept or decline treatment. ¹¹ In this situation, however, CVS allegedly prevented “pharmacists from warning one another about certain prescribers.”⁶

If true, the company deprived frontline pharmacists of the information they needed to safely and responsibly dispense medications: “The practices alleged contributed to the opioid crisis and opioid-related deaths, and today’s complaint seeks to hold CVS accountable for its misconduct.”⁶ Though the cost in human life that may have resulted from CSA violations must absolutely and always outweigh financial considerations, the economic damage to Tricare from fraudulent billing and the betrayal of its fiduciary responsinility cannot be underestimated.

A Corporate Morality Play

CVS is not the only company, nor is pharmacy the only industry in health care, that has been the subject of watchdog agency lawsuits or variegated forms of wrongdoing, including violations of the CSA and FCA.^10,12 As of this writing, the DoJ case against CVS has not been heard, much less adjudicated in a court of law. It is ironic that both the DoJ claims and the CVS rebuttal describe the manifest conflict of obligation that pharmacists confront between protecting their livelihood and safeguarding patients’ lives as suggested in the epigraph that has been attributed to the 19th-century British physician and medical educator Peter Mere Latham. It is a dilemma that a growing number of health care practitioners face daily in a vocation becoming increasingly commercialized. It is all too easy for an individual physician, nurse, or pharmacist to feel hopeless and helpless before the behemoth might of a large and looming entity. Yet, it was a whistleblower whose moral courage led to the DoJ investigation and subsequent charges.¹³ We must all never doubt the power of a committed person of conscience to withstand the pressure to mutate medications into poison and stand up for the principles of our professions and inspire a community of colleagues to follow their example.

Express Scripts, the contractor that manages the pharmacy benefit for Tricare, the military health insurance program, announced in 2021 that after a 5-year absence, CVS Pharmacy was once more in the network. In 2023, CVS had the largest profits of any pharmacy chain in the United States, about $159 billion, and generated a quarter of the overall revenue of the US pharmacy industry.¹ Tricare officials heralded the return of CVS as a move that would offer US Department of Defense (DoD) beneficiaries more competitive prices, convenient access, and overall quality.²

DOJ Files Lawsuit Against CVS

In December 2024, the US Department of Justice (DoJ) filed a lawsuit alleging that CVS violated both the Controlled Substances Act (CSA) and the False Claims Act (FCA).^3,4 The United States ex rel. Estright v Health Corporation, et al, filed in Rhode Island, charged that CVS “routinely” and “knowingly” filled invalid prescriptions for controlled substances violating the CSA and then billed federal health care programs for payment for these prescriptions, a breach of the FCA.⁵ The DoJ alleged that CVS pharmacies and pharmacists filled prescriptions for controlled substances that (1) lacked a legitimate medical purpose; (2) were not legally valid; and/or (3) were not issued in the usual course of medical practice. ⁶ CVS contests the charges and issued an official response, stating that it disputes the allegations as false, plans to disprove them in litigation, and has nonetheless fully cooperated with the investigation.⁷

The allegations involved prescriptions for drugs like opioids and benzodiazepines, primary culprits in the American overdose epidemic.⁸ The complaint notes that the prescriptions were early refills in excessive quantities and included what has been called the “holy trinity” of dangerous medications: opioids, benzodiazepines, and muscle relaxants. ^5,8 Even worse (if that is possible), as the complaint outlines, CVS had access to data from both inside and outside the company that these prescriptions came from notorious pill mills and were hence unlawful and yet continued to fill them, leading the DoJ to file the more serious charge that the corporation “knowingly” violated the CSA and “prioritized profits over safety in dispensing controlled substances.”^5,6

The Unholy Trinity

The infamous members of what I prefer to call the “unholy trinity” are a benzodiazepine, often alprazolam, an opioid, and the muscle relaxant carisoprodol. The combination amplifies each agent’s independent risk of respiratory depression. The latter is a schedule IV medication with an active metabolite, meprobamate, that also has this adverse effect. All 3 drugs have high abuse potential and, when combined, increase the risk of fatal overdose. The colloquial name holy trinity derives from the synergistic euphoria experienced when taking this triple cocktail of sedative agents.⁹ This pharmacological recipe for disaster is the house specialty of pill mills: infamous storefront practices that generate high profits and exploit persons with chronic pain and addiction by handing out controlled substances with little clinical assessment and even less oversight.¹⁰

When the Means Become the End

The DoJ allegations suggest that the violations resulted from “corporate-mandated performance metrics, incentive compensation, and staffing policies that prioritized corporate profits over patient safety.”⁶ If the allegations are true, why would a company reinvited by Tricare to serve the nation’s heroes seemingly engage in illegal practices? While CVS has not responded in court, their statement argued that “too often, we have seen government agencies and trial lawyers question the good-faith decisions made by pharmacists while a patient waits at the pharmacy counter, often in pain.”⁶

The DoJ complaint offers a cautionary warning for the US health care system, which is increasingly being micromanaged in the pursuit of efficiency. Like many practitioners in and out of the federal system, I get a cold chill when I read the word productivity. “CVS pharmacists described working at CVS as ‘soul crushing’ because it was impossible to meet the company’s expectations,” the complaint alleges, because “CVS set staffing levels so low that it was impossible for pharmacists to comply with their legal obligations and meet CVS’s demanding metrics.”⁵ Did top-down mandates drive the alleged activities by imposing unattainable performance metrics on pharmacists, offering incentives that encouraged and rewarded corner-cutting, and refusing to fund sufficient staffing to ensure patient safety? This may be what happens when the means (efficiency) become the end rather than a mechanism to achieve the goal of more accessible, affordable, high-quality health care.

Ethically, what is most concerning is that leadership intentionally “deprived its pharmacists of crucial information” about specific practitioners known to engage in illegal prescribing practices.⁶ CVS did not provide pharmacists with “information about prescribers’ prescribing habits that CVS routinely collected and reviewed at the corporate level,” and even removed prescriber blocks that were implemented at Target pharmacies before it was acquired by CVS.⁵ The first element of informed consent is providing patients with adequate information upon which to decide whether to accept or decline treatment. ¹¹ In this situation, however, CVS allegedly prevented “pharmacists from warning one another about certain prescribers.”⁶

If true, the company deprived frontline pharmacists of the information they needed to safely and responsibly dispense medications: “The practices alleged contributed to the opioid crisis and opioid-related deaths, and today’s complaint seeks to hold CVS accountable for its misconduct.”⁶ Though the cost in human life that may have resulted from CSA violations must absolutely and always outweigh financial considerations, the economic damage to Tricare from fraudulent billing and the betrayal of its fiduciary responsinility cannot be underestimated.

A Corporate Morality Play

CVS is not the only company, nor is pharmacy the only industry in health care, that has been the subject of watchdog agency lawsuits or variegated forms of wrongdoing, including violations of the CSA and FCA.^10,12 As of this writing, the DoJ case against CVS has not been heard, much less adjudicated in a court of law. It is ironic that both the DoJ claims and the CVS rebuttal describe the manifest conflict of obligation that pharmacists confront between protecting their livelihood and safeguarding patients’ lives as suggested in the epigraph that has been attributed to the 19th-century British physician and medical educator Peter Mere Latham. It is a dilemma that a growing number of health care practitioners face daily in a vocation becoming increasingly commercialized. It is all too easy for an individual physician, nurse, or pharmacist to feel hopeless and helpless before the behemoth might of a large and looming entity. Yet, it was a whistleblower whose moral courage led to the DoJ investigation and subsequent charges.¹³ We must all never doubt the power of a committed person of conscience to withstand the pressure to mutate medications into poison and stand up for the principles of our professions and inspire a community of colleagues to follow their example.

Express Scripts, the contractor that manages the pharmacy benefit for Tricare, the military health insurance program, announced in 2021 that after a 5-year absence, CVS Pharmacy was once more in the network. In 2023, CVS had the largest profits of any pharmacy chain in the United States, about $159 billion, and generated a quarter of the overall revenue of the US pharmacy industry.¹ Tricare officials heralded the return of CVS as a move that would offer US Department of Defense (DoD) beneficiaries more competitive prices, convenient access, and overall quality.²

DOJ Files Lawsuit Against CVS

In December 2024, the US Department of Justice (DoJ) filed a lawsuit alleging that CVS violated both the Controlled Substances Act (CSA) and the False Claims Act (FCA).^3,4 The United States ex rel. Estright v Health Corporation, et al, filed in Rhode Island, charged that CVS “routinely” and “knowingly” filled invalid prescriptions for controlled substances violating the CSA and then billed federal health care programs for payment for these prescriptions, a breach of the FCA.⁵ The DoJ alleged that CVS pharmacies and pharmacists filled prescriptions for controlled substances that (1) lacked a legitimate medical purpose; (2) were not legally valid; and/or (3) were not issued in the usual course of medical practice. ⁶ CVS contests the charges and issued an official response, stating that it disputes the allegations as false, plans to disprove them in litigation, and has nonetheless fully cooperated with the investigation.⁷

The allegations involved prescriptions for drugs like opioids and benzodiazepines, primary culprits in the American overdose epidemic.⁸ The complaint notes that the prescriptions were early refills in excessive quantities and included what has been called the “holy trinity” of dangerous medications: opioids, benzodiazepines, and muscle relaxants. ^5,8 Even worse (if that is possible), as the complaint outlines, CVS had access to data from both inside and outside the company that these prescriptions came from notorious pill mills and were hence unlawful and yet continued to fill them, leading the DoJ to file the more serious charge that the corporation “knowingly” violated the CSA and “prioritized profits over safety in dispensing controlled substances.”^5,6

The Unholy Trinity

The infamous members of what I prefer to call the “unholy trinity” are a benzodiazepine, often alprazolam, an opioid, and the muscle relaxant carisoprodol. The combination amplifies each agent’s independent risk of respiratory depression. The latter is a schedule IV medication with an active metabolite, meprobamate, that also has this adverse effect. All 3 drugs have high abuse potential and, when combined, increase the risk of fatal overdose. The colloquial name holy trinity derives from the synergistic euphoria experienced when taking this triple cocktail of sedative agents.⁹ This pharmacological recipe for disaster is the house specialty of pill mills: infamous storefront practices that generate high profits and exploit persons with chronic pain and addiction by handing out controlled substances with little clinical assessment and even less oversight.¹⁰

When the Means Become the End

The DoJ allegations suggest that the violations resulted from “corporate-mandated performance metrics, incentive compensation, and staffing policies that prioritized corporate profits over patient safety.”⁶ If the allegations are true, why would a company reinvited by Tricare to serve the nation’s heroes seemingly engage in illegal practices? While CVS has not responded in court, their statement argued that “too often, we have seen government agencies and trial lawyers question the good-faith decisions made by pharmacists while a patient waits at the pharmacy counter, often in pain.”⁶

The DoJ complaint offers a cautionary warning for the US health care system, which is increasingly being micromanaged in the pursuit of efficiency. Like many practitioners in and out of the federal system, I get a cold chill when I read the word productivity. “CVS pharmacists described working at CVS as ‘soul crushing’ because it was impossible to meet the company’s expectations,” the complaint alleges, because “CVS set staffing levels so low that it was impossible for pharmacists to comply with their legal obligations and meet CVS’s demanding metrics.”⁵ Did top-down mandates drive the alleged activities by imposing unattainable performance metrics on pharmacists, offering incentives that encouraged and rewarded corner-cutting, and refusing to fund sufficient staffing to ensure patient safety? This may be what happens when the means (efficiency) become the end rather than a mechanism to achieve the goal of more accessible, affordable, high-quality health care.

Ethically, what is most concerning is that leadership intentionally “deprived its pharmacists of crucial information” about specific practitioners known to engage in illegal prescribing practices.⁶ CVS did not provide pharmacists with “information about prescribers’ prescribing habits that CVS routinely collected and reviewed at the corporate level,” and even removed prescriber blocks that were implemented at Target pharmacies before it was acquired by CVS.⁵ The first element of informed consent is providing patients with adequate information upon which to decide whether to accept or decline treatment. ¹¹ In this situation, however, CVS allegedly prevented “pharmacists from warning one another about certain prescribers.”⁶

If true, the company deprived frontline pharmacists of the information they needed to safely and responsibly dispense medications: “The practices alleged contributed to the opioid crisis and opioid-related deaths, and today’s complaint seeks to hold CVS accountable for its misconduct.”⁶ Though the cost in human life that may have resulted from CSA violations must absolutely and always outweigh financial considerations, the economic damage to Tricare from fraudulent billing and the betrayal of its fiduciary responsinility cannot be underestimated.

A Corporate Morality Play

CVS is not the only company, nor is pharmacy the only industry in health care, that has been the subject of watchdog agency lawsuits or variegated forms of wrongdoing, including violations of the CSA and FCA.^10,12 As of this writing, the DoJ case against CVS has not been heard, much less adjudicated in a court of law. It is ironic that both the DoJ claims and the CVS rebuttal describe the manifest conflict of obligation that pharmacists confront between protecting their livelihood and safeguarding patients’ lives as suggested in the epigraph that has been attributed to the 19th-century British physician and medical educator Peter Mere Latham. It is a dilemma that a growing number of health care practitioners face daily in a vocation becoming increasingly commercialized. It is all too easy for an individual physician, nurse, or pharmacist to feel hopeless and helpless before the behemoth might of a large and looming entity. Yet, it was a whistleblower whose moral courage led to the DoJ investigation and subsequent charges.¹³ We must all never doubt the power of a committed person of conscience to withstand the pressure to mutate medications into poison and stand up for the principles of our professions and inspire a community of colleagues to follow their example.

If I can stop one heart from breaking, I shall not live in vain.
Emily Dickinson¹

The celebration of Valentine’s Day has made the association of hearts with the month of February almost automatic. There is, though, another commemoration of hearts in the second month of the year with special significance for federal practice: American Heart Month. President Lyndon B. Johnson proclaimed February as American Heart Month in 1964 to raise awareness of the enormous human and economic cost of cardiovascular diseases (CVD) that impact many Americans in their prime.

The Centers for Disease Control and Prevention estimates that 1 in 5 deaths in the United States is due to CVD, which includes coronary artery disease, heart failure, heart attack, and stroke.² American Heart Month aims to increase public attention to heart disease prevention and promote research to develop better diagnostic treatment methods for the leading cause of death in most populations.

Forty years after this proclamation, the American Heart Association launched Go Red for Women. On the first Friday of American Heart Month, Americans are encouraged to wear red to draw attention to CVD as the leading cause of death among women as well as men.^2,3 A 2024 report from the American Heart Institute and McKinsey Health Institute attributed at least one-third of the overall health care disparities between men and women to inequities in CVD care. These detrimental differences in the management of heart disease in women encompass both diagnostic misadventures and failure to promptly employ effective therapeutics. CVD morbidity and mortality data for Black women are even higher due to multiple and overlapping social determinants of health.⁴

Higher rates of hypertension, hyperlipidemia, and smoking in women veterans compared with civilians have resulted in an increased risk of heart disease and a 26% higher rate of CVD-related mortality. One in 10 women enrolled in US Department of Veterans Affairs (VA) health care has CVD. Research shows that these women are less likely compared to male veterans to receive counseling about exercise or to be prescribed medications such as statins, even when evidence-based treatment guidelines are followed. The increased rates of heart disease and its complications in women veterans are in part due to risk factors related to military service such as posttraumatic stress disorder (PTSD) and depression, which exceed the rates of nonveteran women.⁵

The heart has a long association with psychological health. For millennia, philosophers and physicians alike believed the heart was the center of the self and the locus of sentience. Even William Harvey, whose discovery of the circulation of blood earned him the title of the father of cardiology, viewed the heart as the life force.⁶ The heart has been explicitly linked to American military trauma since the Civil War era diagnosis of Soldier’s Heart. More recently, mutual genetic vulnerabilities to PTSD and CVD have been posited.⁷ Indeed, research with male combat veterans helped establish the association.

Until recently, there has been a dearth of research to establish the same connection between CVD and PTSD in women veterans, who have elevated rates of PTSD in part due to higher rates of homelessness and military sexual trauma.⁵ Due in large part to the work of a group of VA and US Department of Defense (DoD) researchers, this is starting to change. A research group conducted a retrospective longitudinal study using electronic health record data from nearly 400,000 women veterans to determine the propensity scores of associations between a PTSD diagnosis and the incidence of heart disease over nearly 5 years. The hazard ratio (HR) for the incidence of CVD in women with trauma was 1.44 (compared with matched controls) and even higher in younger women (HR, 1.72).⁸ Researchers also compared CVD mortality in civilian and veteran women and found a concerning trend: not only were mortality rates higher in veterans, but they also did not benefit from an overall improved trend in deaths from heart disease over the past 20 years.⁹

Two years later, the same VA/DoD research group conducted additional analysis on the dataset used in the prior study to examine potential mechanisms underlying the epidemiological link between CVD and PTSD in women veterans. Women with and without PTSD were matched on age and traditional CVD risk factor parameters. The findings demonstrated an association of PTSD with higher risks of diabetes, hypertension, hyperlipidemia, and smoking. However, these traditional risk factors only accounted for one-fourth of the total association. About 34% of the risk was attributed to depression, anxiety, and substance use disorders, as well as obesity and neuroendocrine disorders. This leaves slightly more than half of the elevated risk of CVD unexplained.¹⁰

This research, along with other studies, have identified several mechanisms elucidating the link. Promising translational research may lead to new diagnostic techniques or improved treatment modalities for CVD in women. The most established etiology is that veterans with PTSD have a higher prevalence of multiple CVD risk factors, including smoking, substance use disorders, obesity, poor diet, sleep disorders, depression, and inactivity. There is also increased recognition that PTSD involves neuroendocrine dysfunction in the stress-response that triggers a cascade of metabolic responses (eg, chronic inflammation) that contribute to the onset and progression of heart disease.¹¹

This burgeoning scientific work on CVD and its close association with PTSD and the role of both traditional and nontraditional risk factors can inform VA efforts to educate frontline VA and DoD clinicians, leading to better care for women veterans. Whether a practitioner provides primary, specialty, or mental health care, this new knowledge can inform efforts to optimize prevention and treatment for both PTSD and CVD. For example, the VA/DoD researchers recommend prescribing antidepressants that are less likely to cause or worsen hypertension and to employ psychotherapies known to reduce the harmful CVD effects of increased stress acting through the hypothalamic-pituitary axis. These studies empower VA clinicians to realize Emily Dickinson’s aspiration to prevent trauma and reduce damage to both the psyche and the soma. The health of every veteran’s heart and mind matters, as does every effort of federal practitioners to protect and heal it.

If I can stop one heart from breaking, I shall not live in vain.
Emily Dickinson¹

The celebration of Valentine’s Day has made the association of hearts with the month of February almost automatic. There is, though, another commemoration of hearts in the second month of the year with special significance for federal practice: American Heart Month. President Lyndon B. Johnson proclaimed February as American Heart Month in 1964 to raise awareness of the enormous human and economic cost of cardiovascular diseases (CVD) that impact many Americans in their prime.

The Centers for Disease Control and Prevention estimates that 1 in 5 deaths in the United States is due to CVD, which includes coronary artery disease, heart failure, heart attack, and stroke.² American Heart Month aims to increase public attention to heart disease prevention and promote research to develop better diagnostic treatment methods for the leading cause of death in most populations.

Forty years after this proclamation, the American Heart Association launched Go Red for Women. On the first Friday of American Heart Month, Americans are encouraged to wear red to draw attention to CVD as the leading cause of death among women as well as men.^2,3 A 2024 report from the American Heart Institute and McKinsey Health Institute attributed at least one-third of the overall health care disparities between men and women to inequities in CVD care. These detrimental differences in the management of heart disease in women encompass both diagnostic misadventures and failure to promptly employ effective therapeutics. CVD morbidity and mortality data for Black women are even higher due to multiple and overlapping social determinants of health.⁴

Higher rates of hypertension, hyperlipidemia, and smoking in women veterans compared with civilians have resulted in an increased risk of heart disease and a 26% higher rate of CVD-related mortality. One in 10 women enrolled in US Department of Veterans Affairs (VA) health care has CVD. Research shows that these women are less likely compared to male veterans to receive counseling about exercise or to be prescribed medications such as statins, even when evidence-based treatment guidelines are followed. The increased rates of heart disease and its complications in women veterans are in part due to risk factors related to military service such as posttraumatic stress disorder (PTSD) and depression, which exceed the rates of nonveteran women.⁵

The heart has a long association with psychological health. For millennia, philosophers and physicians alike believed the heart was the center of the self and the locus of sentience. Even William Harvey, whose discovery of the circulation of blood earned him the title of the father of cardiology, viewed the heart as the life force.⁶ The heart has been explicitly linked to American military trauma since the Civil War era diagnosis of Soldier’s Heart. More recently, mutual genetic vulnerabilities to PTSD and CVD have been posited.⁷ Indeed, research with male combat veterans helped establish the association.

Until recently, there has been a dearth of research to establish the same connection between CVD and PTSD in women veterans, who have elevated rates of PTSD in part due to higher rates of homelessness and military sexual trauma.⁵ Due in large part to the work of a group of VA and US Department of Defense (DoD) researchers, this is starting to change. A research group conducted a retrospective longitudinal study using electronic health record data from nearly 400,000 women veterans to determine the propensity scores of associations between a PTSD diagnosis and the incidence of heart disease over nearly 5 years. The hazard ratio (HR) for the incidence of CVD in women with trauma was 1.44 (compared with matched controls) and even higher in younger women (HR, 1.72).⁸ Researchers also compared CVD mortality in civilian and veteran women and found a concerning trend: not only were mortality rates higher in veterans, but they also did not benefit from an overall improved trend in deaths from heart disease over the past 20 years.⁹

Two years later, the same VA/DoD research group conducted additional analysis on the dataset used in the prior study to examine potential mechanisms underlying the epidemiological link between CVD and PTSD in women veterans. Women with and without PTSD were matched on age and traditional CVD risk factor parameters. The findings demonstrated an association of PTSD with higher risks of diabetes, hypertension, hyperlipidemia, and smoking. However, these traditional risk factors only accounted for one-fourth of the total association. About 34% of the risk was attributed to depression, anxiety, and substance use disorders, as well as obesity and neuroendocrine disorders. This leaves slightly more than half of the elevated risk of CVD unexplained.¹⁰

This research, along with other studies, have identified several mechanisms elucidating the link. Promising translational research may lead to new diagnostic techniques or improved treatment modalities for CVD in women. The most established etiology is that veterans with PTSD have a higher prevalence of multiple CVD risk factors, including smoking, substance use disorders, obesity, poor diet, sleep disorders, depression, and inactivity. There is also increased recognition that PTSD involves neuroendocrine dysfunction in the stress-response that triggers a cascade of metabolic responses (eg, chronic inflammation) that contribute to the onset and progression of heart disease.¹¹

This burgeoning scientific work on CVD and its close association with PTSD and the role of both traditional and nontraditional risk factors can inform VA efforts to educate frontline VA and DoD clinicians, leading to better care for women veterans. Whether a practitioner provides primary, specialty, or mental health care, this new knowledge can inform efforts to optimize prevention and treatment for both PTSD and CVD. For example, the VA/DoD researchers recommend prescribing antidepressants that are less likely to cause or worsen hypertension and to employ psychotherapies known to reduce the harmful CVD effects of increased stress acting through the hypothalamic-pituitary axis. These studies empower VA clinicians to realize Emily Dickinson’s aspiration to prevent trauma and reduce damage to both the psyche and the soma. The health of every veteran’s heart and mind matters, as does every effort of federal practitioners to protect and heal it.

If I can stop one heart from breaking, I shall not live in vain.
Emily Dickinson¹

The celebration of Valentine’s Day has made the association of hearts with the month of February almost automatic. There is, though, another commemoration of hearts in the second month of the year with special significance for federal practice: American Heart Month. President Lyndon B. Johnson proclaimed February as American Heart Month in 1964 to raise awareness of the enormous human and economic cost of cardiovascular diseases (CVD) that impact many Americans in their prime.

The Centers for Disease Control and Prevention estimates that 1 in 5 deaths in the United States is due to CVD, which includes coronary artery disease, heart failure, heart attack, and stroke.² American Heart Month aims to increase public attention to heart disease prevention and promote research to develop better diagnostic treatment methods for the leading cause of death in most populations.

Forty years after this proclamation, the American Heart Association launched Go Red for Women. On the first Friday of American Heart Month, Americans are encouraged to wear red to draw attention to CVD as the leading cause of death among women as well as men.^2,3 A 2024 report from the American Heart Institute and McKinsey Health Institute attributed at least one-third of the overall health care disparities between men and women to inequities in CVD care. These detrimental differences in the management of heart disease in women encompass both diagnostic misadventures and failure to promptly employ effective therapeutics. CVD morbidity and mortality data for Black women are even higher due to multiple and overlapping social determinants of health.⁴

Higher rates of hypertension, hyperlipidemia, and smoking in women veterans compared with civilians have resulted in an increased risk of heart disease and a 26% higher rate of CVD-related mortality. One in 10 women enrolled in US Department of Veterans Affairs (VA) health care has CVD. Research shows that these women are less likely compared to male veterans to receive counseling about exercise or to be prescribed medications such as statins, even when evidence-based treatment guidelines are followed. The increased rates of heart disease and its complications in women veterans are in part due to risk factors related to military service such as posttraumatic stress disorder (PTSD) and depression, which exceed the rates of nonveteran women.⁵

The heart has a long association with psychological health. For millennia, philosophers and physicians alike believed the heart was the center of the self and the locus of sentience. Even William Harvey, whose discovery of the circulation of blood earned him the title of the father of cardiology, viewed the heart as the life force.⁶ The heart has been explicitly linked to American military trauma since the Civil War era diagnosis of Soldier’s Heart. More recently, mutual genetic vulnerabilities to PTSD and CVD have been posited.⁷ Indeed, research with male combat veterans helped establish the association.

Until recently, there has been a dearth of research to establish the same connection between CVD and PTSD in women veterans, who have elevated rates of PTSD in part due to higher rates of homelessness and military sexual trauma.⁵ Due in large part to the work of a group of VA and US Department of Defense (DoD) researchers, this is starting to change. A research group conducted a retrospective longitudinal study using electronic health record data from nearly 400,000 women veterans to determine the propensity scores of associations between a PTSD diagnosis and the incidence of heart disease over nearly 5 years. The hazard ratio (HR) for the incidence of CVD in women with trauma was 1.44 (compared with matched controls) and even higher in younger women (HR, 1.72).⁸ Researchers also compared CVD mortality in civilian and veteran women and found a concerning trend: not only were mortality rates higher in veterans, but they also did not benefit from an overall improved trend in deaths from heart disease over the past 20 years.⁹

Two years later, the same VA/DoD research group conducted additional analysis on the dataset used in the prior study to examine potential mechanisms underlying the epidemiological link between CVD and PTSD in women veterans. Women with and without PTSD were matched on age and traditional CVD risk factor parameters. The findings demonstrated an association of PTSD with higher risks of diabetes, hypertension, hyperlipidemia, and smoking. However, these traditional risk factors only accounted for one-fourth of the total association. About 34% of the risk was attributed to depression, anxiety, and substance use disorders, as well as obesity and neuroendocrine disorders. This leaves slightly more than half of the elevated risk of CVD unexplained.¹⁰

This research, along with other studies, have identified several mechanisms elucidating the link. Promising translational research may lead to new diagnostic techniques or improved treatment modalities for CVD in women. The most established etiology is that veterans with PTSD have a higher prevalence of multiple CVD risk factors, including smoking, substance use disorders, obesity, poor diet, sleep disorders, depression, and inactivity. There is also increased recognition that PTSD involves neuroendocrine dysfunction in the stress-response that triggers a cascade of metabolic responses (eg, chronic inflammation) that contribute to the onset and progression of heart disease.¹¹

This burgeoning scientific work on CVD and its close association with PTSD and the role of both traditional and nontraditional risk factors can inform VA efforts to educate frontline VA and DoD clinicians, leading to better care for women veterans. Whether a practitioner provides primary, specialty, or mental health care, this new knowledge can inform efforts to optimize prevention and treatment for both PTSD and CVD. For example, the VA/DoD researchers recommend prescribing antidepressants that are less likely to cause or worsen hypertension and to employ psychotherapies known to reduce the harmful CVD effects of increased stress acting through the hypothalamic-pituitary axis. These studies empower VA clinicians to realize Emily Dickinson’s aspiration to prevent trauma and reduce damage to both the psyche and the soma. The health of every veteran’s heart and mind matters, as does every effort of federal practitioners to protect and heal it.

As the movement to improve quality in health care has evolved over the past several decades, organizations whose missions focus on supporting and promoting quality in health care have defined essential concepts, standards, and measures that comprise quality and that can be used to guide quality improvement (QI) work. The World Health Organization (WHO) defines quality in clinical care as safe, effective, and people-centered service.¹ These 3 pillars of quality form the foundation of a quality system aiming to deliver health care in a timely, equitable, efficient, and integrated manner. The WHO estimates that 5.7 to 8.4 million deaths occur yearly in low- and middle-income countries due to poor quality care. Regarding safety, patient harm from unsafe care is estimated to be among the top 10 causes of death and disability worldwide.² A health care QI plan involves identifying areas for improvement, setting measurable goals, implementing evidence-based strategies and interventions, monitoring progress toward achieving those goals, and continuously evaluating and adjusting the plan as needed to ensure sustained improvement over time. Such a plan can be implemented at various levels of health care organizations, from individual clinical units to entire hospitals or even regional health care systems.

The Institute of Medicine (IOM) identifies 5 domains of quality in health care: effectiveness, efficiency, equity, patient-centeredness, and safety.³ Effectiveness relies on providing care processes supported by scientific evidence and achieving desired outcomes in the IOM recommendations. The primary efficiency aim maximizes the quality of health care delivered or the benefits achieved for a given resource unit. Equity relates to providing health care of equal quality to all individuals, regardless of personal characteristics. Moreover, patient-centeredness relates to meeting patients’ needs and preferences and providing education and support. Safety relates to avoiding actual or potential harm. Timeliness relates to obtaining needed care while minimizing delays. Finally, the IOM defines health care quality as the systematic evaluation and provision of evidence-based and safe care characterized by a culture of continuous improvement, resulting in optimal health outcomes. Taking all these concepts into consideration, 4 key attributes have been identified as essential to the global definition of health care quality: effectiveness, safety, culture of continuous improvement, and desired outcomes. This conceptualization of health care quality encompasses the fundamental components and has the potential to enhance the delivery of care. This definition’s theoretical and practical implications provide a comprehensive and consistent understanding of the elements required to improve health care and maintain public trust.

Health care quality is a dynamic, ever-evolving construct that requires continuous assessment and evaluation to ensure the delivery of care meets the changing needs of society. The National Quality Forum’s National Voluntary Consensus Standards for health care provide measures, guidance, and recommendations on achieving effective outcomes through evidence-based practices.⁴ These standards establish criteria by which health care systems and providers can assess and improve their quality performance.

In the United States, in order to implement and disseminate best practices, the Centers for Medicare & Medicaid Services (CMS) developed Quality Payment Programs that offer incentives to health care providers to improve the quality of care delivery. This CMS program evaluates providers based on their performance in the Merit-Based Incentive Payment System performance categories.⁵ These include measures related to patient experience, cost, clinical quality, improvement activities, and the use of certified electronic health record technology. The scores that providers receive are used to determine their performance-based reimbursements under Medicare’s fee-for-service program.

The concept of health care quality is also applicable in other countries. In the United Kingdom, QI initiatives are led by the Department of Health and Social Care. The National Institute for Health and Care Excellence (NICE) produces guidelines on best practices to ensure that care delivery meets established safety and quality standards, reaching cost-effectiveness excellence.⁶ In Australia, the Australian Commission on Quality and Safety in Health Care is responsible for setting benchmarks for performance in health care systems through a clear, structured agenda.⁷ Ultimately, health care quality is a complex and multifaceted issue that requires a comprehensive approach to ensure the best outcomes for patients. With the implementation of measures such as the CMS Quality Payment Programs and NICE guidelines, health care organizations can take steps to ensure their systems of care delivery reflect evidence-based practices and demonstrate a commitment to providing high-quality care.

Implementing a health care QI plan that encompasses the 4 key attributes of health care quality—effectiveness, safety, culture of continuous improvement, and desired outcomes—requires collaboration among different departments and stakeholders and a data-driven approach to decision-making. Effective communication with patients and their families is critical to ensuring that their needs are being met and that they are active partners in their health care journey. While a health care QI plan is essential for delivering high-quality, safe patient care, it also helps health care organizations comply with regulatory requirements, meet accreditation standards, and stay competitive in the ever-evolving health care landscape.

Corresponding author: Ebrahim Barkoudah, MD, MPH; Ebrahim.Barkoudah@baystatehealth.org

As the movement to improve quality in health care has evolved over the past several decades, organizations whose missions focus on supporting and promoting quality in health care have defined essential concepts, standards, and measures that comprise quality and that can be used to guide quality improvement (QI) work. The World Health Organization (WHO) defines quality in clinical care as safe, effective, and people-centered service.¹ These 3 pillars of quality form the foundation of a quality system aiming to deliver health care in a timely, equitable, efficient, and integrated manner. The WHO estimates that 5.7 to 8.4 million deaths occur yearly in low- and middle-income countries due to poor quality care. Regarding safety, patient harm from unsafe care is estimated to be among the top 10 causes of death and disability worldwide.² A health care QI plan involves identifying areas for improvement, setting measurable goals, implementing evidence-based strategies and interventions, monitoring progress toward achieving those goals, and continuously evaluating and adjusting the plan as needed to ensure sustained improvement over time. Such a plan can be implemented at various levels of health care organizations, from individual clinical units to entire hospitals or even regional health care systems.

The Institute of Medicine (IOM) identifies 5 domains of quality in health care: effectiveness, efficiency, equity, patient-centeredness, and safety.³ Effectiveness relies on providing care processes supported by scientific evidence and achieving desired outcomes in the IOM recommendations. The primary efficiency aim maximizes the quality of health care delivered or the benefits achieved for a given resource unit. Equity relates to providing health care of equal quality to all individuals, regardless of personal characteristics. Moreover, patient-centeredness relates to meeting patients’ needs and preferences and providing education and support. Safety relates to avoiding actual or potential harm. Timeliness relates to obtaining needed care while minimizing delays. Finally, the IOM defines health care quality as the systematic evaluation and provision of evidence-based and safe care characterized by a culture of continuous improvement, resulting in optimal health outcomes. Taking all these concepts into consideration, 4 key attributes have been identified as essential to the global definition of health care quality: effectiveness, safety, culture of continuous improvement, and desired outcomes. This conceptualization of health care quality encompasses the fundamental components and has the potential to enhance the delivery of care. This definition’s theoretical and practical implications provide a comprehensive and consistent understanding of the elements required to improve health care and maintain public trust.

Health care quality is a dynamic, ever-evolving construct that requires continuous assessment and evaluation to ensure the delivery of care meets the changing needs of society. The National Quality Forum’s National Voluntary Consensus Standards for health care provide measures, guidance, and recommendations on achieving effective outcomes through evidence-based practices.⁴ These standards establish criteria by which health care systems and providers can assess and improve their quality performance.

In the United States, in order to implement and disseminate best practices, the Centers for Medicare & Medicaid Services (CMS) developed Quality Payment Programs that offer incentives to health care providers to improve the quality of care delivery. This CMS program evaluates providers based on their performance in the Merit-Based Incentive Payment System performance categories.⁵ These include measures related to patient experience, cost, clinical quality, improvement activities, and the use of certified electronic health record technology. The scores that providers receive are used to determine their performance-based reimbursements under Medicare’s fee-for-service program.

The concept of health care quality is also applicable in other countries. In the United Kingdom, QI initiatives are led by the Department of Health and Social Care. The National Institute for Health and Care Excellence (NICE) produces guidelines on best practices to ensure that care delivery meets established safety and quality standards, reaching cost-effectiveness excellence.⁶ In Australia, the Australian Commission on Quality and Safety in Health Care is responsible for setting benchmarks for performance in health care systems through a clear, structured agenda.⁷ Ultimately, health care quality is a complex and multifaceted issue that requires a comprehensive approach to ensure the best outcomes for patients. With the implementation of measures such as the CMS Quality Payment Programs and NICE guidelines, health care organizations can take steps to ensure their systems of care delivery reflect evidence-based practices and demonstrate a commitment to providing high-quality care.

Implementing a health care QI plan that encompasses the 4 key attributes of health care quality—effectiveness, safety, culture of continuous improvement, and desired outcomes—requires collaboration among different departments and stakeholders and a data-driven approach to decision-making. Effective communication with patients and their families is critical to ensuring that their needs are being met and that they are active partners in their health care journey. While a health care QI plan is essential for delivering high-quality, safe patient care, it also helps health care organizations comply with regulatory requirements, meet accreditation standards, and stay competitive in the ever-evolving health care landscape.

Corresponding author: Ebrahim Barkoudah, MD, MPH; Ebrahim.Barkoudah@baystatehealth.org

As the movement to improve quality in health care has evolved over the past several decades, organizations whose missions focus on supporting and promoting quality in health care have defined essential concepts, standards, and measures that comprise quality and that can be used to guide quality improvement (QI) work. The World Health Organization (WHO) defines quality in clinical care as safe, effective, and people-centered service.¹ These 3 pillars of quality form the foundation of a quality system aiming to deliver health care in a timely, equitable, efficient, and integrated manner. The WHO estimates that 5.7 to 8.4 million deaths occur yearly in low- and middle-income countries due to poor quality care. Regarding safety, patient harm from unsafe care is estimated to be among the top 10 causes of death and disability worldwide.² A health care QI plan involves identifying areas for improvement, setting measurable goals, implementing evidence-based strategies and interventions, monitoring progress toward achieving those goals, and continuously evaluating and adjusting the plan as needed to ensure sustained improvement over time. Such a plan can be implemented at various levels of health care organizations, from individual clinical units to entire hospitals or even regional health care systems.

The Institute of Medicine (IOM) identifies 5 domains of quality in health care: effectiveness, efficiency, equity, patient-centeredness, and safety.³ Effectiveness relies on providing care processes supported by scientific evidence and achieving desired outcomes in the IOM recommendations. The primary efficiency aim maximizes the quality of health care delivered or the benefits achieved for a given resource unit. Equity relates to providing health care of equal quality to all individuals, regardless of personal characteristics. Moreover, patient-centeredness relates to meeting patients’ needs and preferences and providing education and support. Safety relates to avoiding actual or potential harm. Timeliness relates to obtaining needed care while minimizing delays. Finally, the IOM defines health care quality as the systematic evaluation and provision of evidence-based and safe care characterized by a culture of continuous improvement, resulting in optimal health outcomes. Taking all these concepts into consideration, 4 key attributes have been identified as essential to the global definition of health care quality: effectiveness, safety, culture of continuous improvement, and desired outcomes. This conceptualization of health care quality encompasses the fundamental components and has the potential to enhance the delivery of care. This definition’s theoretical and practical implications provide a comprehensive and consistent understanding of the elements required to improve health care and maintain public trust.

Health care quality is a dynamic, ever-evolving construct that requires continuous assessment and evaluation to ensure the delivery of care meets the changing needs of society. The National Quality Forum’s National Voluntary Consensus Standards for health care provide measures, guidance, and recommendations on achieving effective outcomes through evidence-based practices.⁴ These standards establish criteria by which health care systems and providers can assess and improve their quality performance.

In the United States, in order to implement and disseminate best practices, the Centers for Medicare & Medicaid Services (CMS) developed Quality Payment Programs that offer incentives to health care providers to improve the quality of care delivery. This CMS program evaluates providers based on their performance in the Merit-Based Incentive Payment System performance categories.⁵ These include measures related to patient experience, cost, clinical quality, improvement activities, and the use of certified electronic health record technology. The scores that providers receive are used to determine their performance-based reimbursements under Medicare’s fee-for-service program.

The concept of health care quality is also applicable in other countries. In the United Kingdom, QI initiatives are led by the Department of Health and Social Care. The National Institute for Health and Care Excellence (NICE) produces guidelines on best practices to ensure that care delivery meets established safety and quality standards, reaching cost-effectiveness excellence.⁶ In Australia, the Australian Commission on Quality and Safety in Health Care is responsible for setting benchmarks for performance in health care systems through a clear, structured agenda.⁷ Ultimately, health care quality is a complex and multifaceted issue that requires a comprehensive approach to ensure the best outcomes for patients. With the implementation of measures such as the CMS Quality Payment Programs and NICE guidelines, health care organizations can take steps to ensure their systems of care delivery reflect evidence-based practices and demonstrate a commitment to providing high-quality care.

Implementing a health care QI plan that encompasses the 4 key attributes of health care quality—effectiveness, safety, culture of continuous improvement, and desired outcomes—requires collaboration among different departments and stakeholders and a data-driven approach to decision-making. Effective communication with patients and their families is critical to ensuring that their needs are being met and that they are active partners in their health care journey. While a health care QI plan is essential for delivering high-quality, safe patient care, it also helps health care organizations comply with regulatory requirements, meet accreditation standards, and stay competitive in the ever-evolving health care landscape.

Corresponding author: Ebrahim Barkoudah, MD, MPH; Ebrahim.Barkoudah@baystatehealth.org

This issue of the Journal of Clinical Outcomes (JCOM) debuts a new cover design that brings forward the articles and features in each issue. Although the Journal’s cover has a new look, JCOM’s goals remain the same—improving care by disseminating evidence of quality improvement in health care and sharing access to the medical literature with our readers. We continue our mission to promote the best medical practice by providing clinicians with updates and communicating advances that lead to measurable improvement in health care delivery, quality, and outcomes.

As we continue the work of improving health care quality, knowledge gaps and unmet needs in the literature remain. These unmet needs are evident throughout all phases of health care delivery. Moreover, the Institutes of Medicine report that centered on efforts to build a safer health care environment by redesigning health care processes remains salient.¹ The journey to continuous improvement in health care, where we achieve threshold change in the quality of each process and across the entire health care system, requires collective effort. Such efforts include establishing clear metrics and measurements for improvement goals throughout the patient’s journey through diagnosis, treatment, transitions of care, and disease management.^2,3 To address evidence and knowledge gaps in the literature, JCOM publishes reports of original studies and quality improvement projects as well as reviews, providing its 30,000 readers with new evidence to implement in daily practice. We welcome submissions of original research reports, reports of quality improvement projects that follow the SQUIRE 2.0 standards,⁴ and perspectives on developments and innovations in health care delivery.

The next chapter in health care delivery improvement will encompass value-based care.⁵ This new era of clinical outcomes management will dictate the metrics and outcomes reporting⁶ and how to plan future investments. The value-based phase will increase innovation and shape policies that advance population health, transforming every step in the care delivery journey.⁷ The next phase in health care delivery will also create a viable financial structure while implementing effective performance measures for optimal outcomes through patient-centered care and optimization of cost and care strategies. In light of health care’s evolution toward a value-based model, JCOM welcomes submissions of manuscripts that explore themes central to this model, including patient-centered care, implementation of best practices, system design, safety, cost-effectiveness, and the balance between cost optimization and quality. For JCOM’s authors and readers, our editorial team remains commited to the highest standards in timely publishing to support our community through our collective expertise and dedication to quality improvement.

Corresponding author: Ebrahim Barkoudah, MD, MPH, Department of Medicine, Brigham and Women’s Hospital, Boston, MA; ebarkoudah@bwh.harvard.edu

This issue of the Journal of Clinical Outcomes (JCOM) debuts a new cover design that brings forward the articles and features in each issue. Although the Journal’s cover has a new look, JCOM’s goals remain the same—improving care by disseminating evidence of quality improvement in health care and sharing access to the medical literature with our readers. We continue our mission to promote the best medical practice by providing clinicians with updates and communicating advances that lead to measurable improvement in health care delivery, quality, and outcomes.

As we continue the work of improving health care quality, knowledge gaps and unmet needs in the literature remain. These unmet needs are evident throughout all phases of health care delivery. Moreover, the Institutes of Medicine report that centered on efforts to build a safer health care environment by redesigning health care processes remains salient.¹ The journey to continuous improvement in health care, where we achieve threshold change in the quality of each process and across the entire health care system, requires collective effort. Such efforts include establishing clear metrics and measurements for improvement goals throughout the patient’s journey through diagnosis, treatment, transitions of care, and disease management.^2,3 To address evidence and knowledge gaps in the literature, JCOM publishes reports of original studies and quality improvement projects as well as reviews, providing its 30,000 readers with new evidence to implement in daily practice. We welcome submissions of original research reports, reports of quality improvement projects that follow the SQUIRE 2.0 standards,⁴ and perspectives on developments and innovations in health care delivery.

The next chapter in health care delivery improvement will encompass value-based care.⁵ This new era of clinical outcomes management will dictate the metrics and outcomes reporting⁶ and how to plan future investments. The value-based phase will increase innovation and shape policies that advance population health, transforming every step in the care delivery journey.⁷ The next phase in health care delivery will also create a viable financial structure while implementing effective performance measures for optimal outcomes through patient-centered care and optimization of cost and care strategies. In light of health care’s evolution toward a value-based model, JCOM welcomes submissions of manuscripts that explore themes central to this model, including patient-centered care, implementation of best practices, system design, safety, cost-effectiveness, and the balance between cost optimization and quality. For JCOM’s authors and readers, our editorial team remains commited to the highest standards in timely publishing to support our community through our collective expertise and dedication to quality improvement.

Corresponding author: Ebrahim Barkoudah, MD, MPH, Department of Medicine, Brigham and Women’s Hospital, Boston, MA; ebarkoudah@bwh.harvard.edu

This issue of the Journal of Clinical Outcomes (JCOM) debuts a new cover design that brings forward the articles and features in each issue. Although the Journal’s cover has a new look, JCOM’s goals remain the same—improving care by disseminating evidence of quality improvement in health care and sharing access to the medical literature with our readers. We continue our mission to promote the best medical practice by providing clinicians with updates and communicating advances that lead to measurable improvement in health care delivery, quality, and outcomes.

As we continue the work of improving health care quality, knowledge gaps and unmet needs in the literature remain. These unmet needs are evident throughout all phases of health care delivery. Moreover, the Institutes of Medicine report that centered on efforts to build a safer health care environment by redesigning health care processes remains salient.¹ The journey to continuous improvement in health care, where we achieve threshold change in the quality of each process and across the entire health care system, requires collective effort. Such efforts include establishing clear metrics and measurements for improvement goals throughout the patient’s journey through diagnosis, treatment, transitions of care, and disease management.^2,3 To address evidence and knowledge gaps in the literature, JCOM publishes reports of original studies and quality improvement projects as well as reviews, providing its 30,000 readers with new evidence to implement in daily practice. We welcome submissions of original research reports, reports of quality improvement projects that follow the SQUIRE 2.0 standards,⁴ and perspectives on developments and innovations in health care delivery.

The next chapter in health care delivery improvement will encompass value-based care.⁵ This new era of clinical outcomes management will dictate the metrics and outcomes reporting⁶ and how to plan future investments. The value-based phase will increase innovation and shape policies that advance population health, transforming every step in the care delivery journey.⁷ The next phase in health care delivery will also create a viable financial structure while implementing effective performance measures for optimal outcomes through patient-centered care and optimization of cost and care strategies. In light of health care’s evolution toward a value-based model, JCOM welcomes submissions of manuscripts that explore themes central to this model, including patient-centered care, implementation of best practices, system design, safety, cost-effectiveness, and the balance between cost optimization and quality. For JCOM’s authors and readers, our editorial team remains commited to the highest standards in timely publishing to support our community through our collective expertise and dedication to quality improvement.

Corresponding author: Ebrahim Barkoudah, MD, MPH, Department of Medicine, Brigham and Women’s Hospital, Boston, MA; ebarkoudah@bwh.harvard.edu

The Institute of Medicine brought much-needed attention to the need for process improvement in medicine with its seminal report To Err Is Human: Building a Safer Health System, which was issued in 1999, leading to the quality movement’s call to close health care performance gaps in Crossing the Quality Chasm: A New Health System for the 21st Century.^1,2 Quality improvement science in medicine has evolved over the past 2 decades to include a broad spectrum of approaches, from agile improvement to continuous learning and improvement. Current efforts focus on Lean-based process improvement along with a reduction in variation in clinical practice to align practice with the principles of evidence-based medicine in a patient-centered approach.³ Further, the definition of quality improvement under the Affordable Care Act was framed as an equitable, timely, value-based, patient-centered approach to achieving population-level health goals.⁴ Thus, the science of quality improvement drives the core principles of care delivery improvement, and the rigorous evidence needed to expand innovation is embedded within the same framework.^5,6 In clinical practice, quality improvement projects aim to define gaps and then specific steps are undertaken to improve the evidence-based practice of a specific process. The overarching goal is to enhance the efficacy of the practice by reducing waste within a particular domain. Thus, quality improvement and implementation research eventually unify how clinical practice is advanced concurrently to bridge identified gaps.⁷

System redesign through a patient-centered framework forms the core of an overarching strategy to support system-level processes. Both require a deep understanding of the fields of quality improvement science and implementation science.⁸ Furthermore, aligning clinical research needs, system aims, patients’ values, and clinical care give the new design a clear path forward. Patient-centered improvement includes the essential elements of system redesign around human factors, including communication, physical resources, and updated information during episodes of care. The patient-centered improvement design is juxtaposed with care planning and establishing continuum of care processes.⁹ It is essential to note that safety is rooted within the quality domain as a top priority in medicine.¹⁰ The best implementation methods and approaches are discussed and debated, and the improvement progress continues on multiple fronts.¹¹ Patient safety systems are implemented simultaneously during the redesign phase. Moreover, identifying and testing the health care delivery methods in the era of competing strategic priorities to achieve the desirable clinical outcomes highlights the importance of implementation, while contemplating the methods of dissemination, scalability, and sustainability of the best evidence-based clinical practice.

The cycle of quality improvement research completes the system implementation efforts. The conceptual framework of quality improvement includes multiple areas of care and transition, along with applying the best clinical practices in a culture that emphasizes continuous improvement and learning. At the same time, the operating principles should include continuous improvement in a simple and continuous system of learning as a core concept. Our proposed implementation approach involves taking simple and practical steps while separating the process from the outcomes measures, extracting effectiveness throughout the process. It is essential to keep in mind that building a proactive and systematic improvement environment requires a framework for safety, reliability, and effective care, as well as the alignment of the physical system, communication, and professional environment and culture (Figure).

In summary, system design for quality improvement research should incorporate the principles and conceptual framework that embody effective implementation strategies, with a focus on operational and practical steps. Continuous improvement will be reached through the multidimensional development of current health care system metrics and the incorporation of implementation science methods.

Corresponding author: Ebrahim Barkoudah, MD, MPH, Department of Medicine, Brigham and Women’s Hospital, Boston, MA; ebarkoudah@bwh.harvard.edu

Disclosures: None reported.

The Institute of Medicine brought much-needed attention to the need for process improvement in medicine with its seminal report To Err Is Human: Building a Safer Health System, which was issued in 1999, leading to the quality movement’s call to close health care performance gaps in Crossing the Quality Chasm: A New Health System for the 21st Century.^1,2 Quality improvement science in medicine has evolved over the past 2 decades to include a broad spectrum of approaches, from agile improvement to continuous learning and improvement. Current efforts focus on Lean-based process improvement along with a reduction in variation in clinical practice to align practice with the principles of evidence-based medicine in a patient-centered approach.³ Further, the definition of quality improvement under the Affordable Care Act was framed as an equitable, timely, value-based, patient-centered approach to achieving population-level health goals.⁴ Thus, the science of quality improvement drives the core principles of care delivery improvement, and the rigorous evidence needed to expand innovation is embedded within the same framework.^5,6 In clinical practice, quality improvement projects aim to define gaps and then specific steps are undertaken to improve the evidence-based practice of a specific process. The overarching goal is to enhance the efficacy of the practice by reducing waste within a particular domain. Thus, quality improvement and implementation research eventually unify how clinical practice is advanced concurrently to bridge identified gaps.⁷

System redesign through a patient-centered framework forms the core of an overarching strategy to support system-level processes. Both require a deep understanding of the fields of quality improvement science and implementation science.⁸ Furthermore, aligning clinical research needs, system aims, patients’ values, and clinical care give the new design a clear path forward. Patient-centered improvement includes the essential elements of system redesign around human factors, including communication, physical resources, and updated information during episodes of care. The patient-centered improvement design is juxtaposed with care planning and establishing continuum of care processes.⁹ It is essential to note that safety is rooted within the quality domain as a top priority in medicine.¹⁰ The best implementation methods and approaches are discussed and debated, and the improvement progress continues on multiple fronts.¹¹ Patient safety systems are implemented simultaneously during the redesign phase. Moreover, identifying and testing the health care delivery methods in the era of competing strategic priorities to achieve the desirable clinical outcomes highlights the importance of implementation, while contemplating the methods of dissemination, scalability, and sustainability of the best evidence-based clinical practice.

The cycle of quality improvement research completes the system implementation efforts. The conceptual framework of quality improvement includes multiple areas of care and transition, along with applying the best clinical practices in a culture that emphasizes continuous improvement and learning. At the same time, the operating principles should include continuous improvement in a simple and continuous system of learning as a core concept. Our proposed implementation approach involves taking simple and practical steps while separating the process from the outcomes measures, extracting effectiveness throughout the process. It is essential to keep in mind that building a proactive and systematic improvement environment requires a framework for safety, reliability, and effective care, as well as the alignment of the physical system, communication, and professional environment and culture (Figure).

In summary, system design for quality improvement research should incorporate the principles and conceptual framework that embody effective implementation strategies, with a focus on operational and practical steps. Continuous improvement will be reached through the multidimensional development of current health care system metrics and the incorporation of implementation science methods.

Corresponding author: Ebrahim Barkoudah, MD, MPH, Department of Medicine, Brigham and Women’s Hospital, Boston, MA; ebarkoudah@bwh.harvard.edu

Disclosures: None reported.

The Institute of Medicine brought much-needed attention to the need for process improvement in medicine with its seminal report To Err Is Human: Building a Safer Health System, which was issued in 1999, leading to the quality movement’s call to close health care performance gaps in Crossing the Quality Chasm: A New Health System for the 21st Century.^1,2 Quality improvement science in medicine has evolved over the past 2 decades to include a broad spectrum of approaches, from agile improvement to continuous learning and improvement. Current efforts focus on Lean-based process improvement along with a reduction in variation in clinical practice to align practice with the principles of evidence-based medicine in a patient-centered approach.³ Further, the definition of quality improvement under the Affordable Care Act was framed as an equitable, timely, value-based, patient-centered approach to achieving population-level health goals.⁴ Thus, the science of quality improvement drives the core principles of care delivery improvement, and the rigorous evidence needed to expand innovation is embedded within the same framework.^5,6 In clinical practice, quality improvement projects aim to define gaps and then specific steps are undertaken to improve the evidence-based practice of a specific process. The overarching goal is to enhance the efficacy of the practice by reducing waste within a particular domain. Thus, quality improvement and implementation research eventually unify how clinical practice is advanced concurrently to bridge identified gaps.⁷

System redesign through a patient-centered framework forms the core of an overarching strategy to support system-level processes. Both require a deep understanding of the fields of quality improvement science and implementation science.⁸ Furthermore, aligning clinical research needs, system aims, patients’ values, and clinical care give the new design a clear path forward. Patient-centered improvement includes the essential elements of system redesign around human factors, including communication, physical resources, and updated information during episodes of care. The patient-centered improvement design is juxtaposed with care planning and establishing continuum of care processes.⁹ It is essential to note that safety is rooted within the quality domain as a top priority in medicine.¹⁰ The best implementation methods and approaches are discussed and debated, and the improvement progress continues on multiple fronts.¹¹ Patient safety systems are implemented simultaneously during the redesign phase. Moreover, identifying and testing the health care delivery methods in the era of competing strategic priorities to achieve the desirable clinical outcomes highlights the importance of implementation, while contemplating the methods of dissemination, scalability, and sustainability of the best evidence-based clinical practice.

The cycle of quality improvement research completes the system implementation efforts. The conceptual framework of quality improvement includes multiple areas of care and transition, along with applying the best clinical practices in a culture that emphasizes continuous improvement and learning. At the same time, the operating principles should include continuous improvement in a simple and continuous system of learning as a core concept. Our proposed implementation approach involves taking simple and practical steps while separating the process from the outcomes measures, extracting effectiveness throughout the process. It is essential to keep in mind that building a proactive and systematic improvement environment requires a framework for safety, reliability, and effective care, as well as the alignment of the physical system, communication, and professional environment and culture (Figure).

In summary, system design for quality improvement research should incorporate the principles and conceptual framework that embody effective implementation strategies, with a focus on operational and practical steps. Continuous improvement will be reached through the multidimensional development of current health care system metrics and the incorporation of implementation science methods.

Corresponding author: Ebrahim Barkoudah, MD, MPH, Department of Medicine, Brigham and Women’s Hospital, Boston, MA; ebarkoudah@bwh.harvard.edu

Disclosures: None reported.

As we transition out of the Omicron surge, the lessons we’ve learned from the prior surges carry forward and add to our knowledge foundation. Medical journals have published numerous research and perspectives manuscripts on all aspects of COVID-19 over the past 2 years, adding much-needed knowledge to our clinical practice during the pandemic. However, the story does not stop there, as the pandemic has impacted the usual, non-COVID-19 clinical care we provide. The value-based health care delivery model accounts for both COVID-19 clinical care and the usual care we provide our patients every day. Clinicians, administrators, and health care workers will need to know how to balance both worlds in the years to come.

In this issue of JCOM, the work of balancing the demands of COVID-19 care with those of system improvement continues. Two original research articles address the former, with Liesching et al¹ reporting data on improving clinical outcomes of patients with COVID-19 through acute care oxygen therapies, and Ali et al² explaining the impact of COVID-19 on STEMI care delivery models. Liesching et al’s study showed that patients admitted for COVID-19 after the first surge were more likely to receive high-flow nasal cannula and had better outcomes, while Ali et al showed that patients with STEMI yet again experienced worse outcomes during the first wave.

On the system improvement front, Cusick et al³ report on a quality improvement (QI) project that addressed acute disease management of heparin-induced thrombocytopenia (HIT) during hospitalization, Sosa et al⁴ discuss efforts to improve comorbidity capture at their institution, and Uche et al⁵ present the results of a nonpharmacologic initiative to improve management of chronic pain among veterans. Cusick et al’s QI project showed that a HIT testing strategy could be safely implemented through an evidence-based process to nudge resource utilization using specific management pathways. While capturing and measuring the complexity of diseases and comorbidities can be challenging, accurate capture is essential, as patient acuity has implications for reimbursement and quality comparisons for hospitals and physicians; Sosa et al describe a series of initiatives implemented at their institution that improved comorbidity capture. Furthermore, Uche et al report on a 10-week complementary and integrative health program for veterans with noncancer chronic pain that reduced pain intensity and improved quality of life for its participants. These QI reports show that, though the health care landscape has changed over the past 2 years, the aim remains the same: to provide the best care for patients regardless of the diagnosis, location, or time.

Conducting QI projects during the COVID-19 pandemic has been difficult, especially in terms of implementing consistent processes and management pathways while contending with staff and supply shortages. The pandemic, however, has highlighted the importance of continuing QI efforts, specifically around infectious disease prevention and good clinical practices. Moreover, the recent continuous learning and implementation around COVID-19 patient care has been a significant achievement, as clinicians and administrators worked continuously to understand and improve processes, create a supporting culture, and redesign care delivery on the fly. The management of both COVID-19 care and our usual care QI efforts should incorporate the lessons learned from the pandemic and leverage system redesign for future steps. As we’ve seen, survival in COVID-19 improved dramatically since the beginning of the pandemic, as clinical trials became more adaptive and efficient and system upgrades like telemedicine and digital technologies in the public health response led to major advancements. The work to improve the care provided in the clinic and at the bedside will continue through one collective approach in the new normal.

Corresponding author: Ebrahim Barkoudah, MD, MPH, Department of Medicine Brigham and Women’s Hospital, Boston, MA; ebarkoudah@bwh.harvard.edu

As we transition out of the Omicron surge, the lessons we’ve learned from the prior surges carry forward and add to our knowledge foundation. Medical journals have published numerous research and perspectives manuscripts on all aspects of COVID-19 over the past 2 years, adding much-needed knowledge to our clinical practice during the pandemic. However, the story does not stop there, as the pandemic has impacted the usual, non-COVID-19 clinical care we provide. The value-based health care delivery model accounts for both COVID-19 clinical care and the usual care we provide our patients every day. Clinicians, administrators, and health care workers will need to know how to balance both worlds in the years to come.

In this issue of JCOM, the work of balancing the demands of COVID-19 care with those of system improvement continues. Two original research articles address the former, with Liesching et al¹ reporting data on improving clinical outcomes of patients with COVID-19 through acute care oxygen therapies, and Ali et al² explaining the impact of COVID-19 on STEMI care delivery models. Liesching et al’s study showed that patients admitted for COVID-19 after the first surge were more likely to receive high-flow nasal cannula and had better outcomes, while Ali et al showed that patients with STEMI yet again experienced worse outcomes during the first wave.

On the system improvement front, Cusick et al³ report on a quality improvement (QI) project that addressed acute disease management of heparin-induced thrombocytopenia (HIT) during hospitalization, Sosa et al⁴ discuss efforts to improve comorbidity capture at their institution, and Uche et al⁵ present the results of a nonpharmacologic initiative to improve management of chronic pain among veterans. Cusick et al’s QI project showed that a HIT testing strategy could be safely implemented through an evidence-based process to nudge resource utilization using specific management pathways. While capturing and measuring the complexity of diseases and comorbidities can be challenging, accurate capture is essential, as patient acuity has implications for reimbursement and quality comparisons for hospitals and physicians; Sosa et al describe a series of initiatives implemented at their institution that improved comorbidity capture. Furthermore, Uche et al report on a 10-week complementary and integrative health program for veterans with noncancer chronic pain that reduced pain intensity and improved quality of life for its participants. These QI reports show that, though the health care landscape has changed over the past 2 years, the aim remains the same: to provide the best care for patients regardless of the diagnosis, location, or time.

Conducting QI projects during the COVID-19 pandemic has been difficult, especially in terms of implementing consistent processes and management pathways while contending with staff and supply shortages. The pandemic, however, has highlighted the importance of continuing QI efforts, specifically around infectious disease prevention and good clinical practices. Moreover, the recent continuous learning and implementation around COVID-19 patient care has been a significant achievement, as clinicians and administrators worked continuously to understand and improve processes, create a supporting culture, and redesign care delivery on the fly. The management of both COVID-19 care and our usual care QI efforts should incorporate the lessons learned from the pandemic and leverage system redesign for future steps. As we’ve seen, survival in COVID-19 improved dramatically since the beginning of the pandemic, as clinical trials became more adaptive and efficient and system upgrades like telemedicine and digital technologies in the public health response led to major advancements. The work to improve the care provided in the clinic and at the bedside will continue through one collective approach in the new normal.

Corresponding author: Ebrahim Barkoudah, MD, MPH, Department of Medicine Brigham and Women’s Hospital, Boston, MA; ebarkoudah@bwh.harvard.edu

As we transition out of the Omicron surge, the lessons we’ve learned from the prior surges carry forward and add to our knowledge foundation. Medical journals have published numerous research and perspectives manuscripts on all aspects of COVID-19 over the past 2 years, adding much-needed knowledge to our clinical practice during the pandemic. However, the story does not stop there, as the pandemic has impacted the usual, non-COVID-19 clinical care we provide. The value-based health care delivery model accounts for both COVID-19 clinical care and the usual care we provide our patients every day. Clinicians, administrators, and health care workers will need to know how to balance both worlds in the years to come.

In this issue of JCOM, the work of balancing the demands of COVID-19 care with those of system improvement continues. Two original research articles address the former, with Liesching et al¹ reporting data on improving clinical outcomes of patients with COVID-19 through acute care oxygen therapies, and Ali et al² explaining the impact of COVID-19 on STEMI care delivery models. Liesching et al’s study showed that patients admitted for COVID-19 after the first surge were more likely to receive high-flow nasal cannula and had better outcomes, while Ali et al showed that patients with STEMI yet again experienced worse outcomes during the first wave.

On the system improvement front, Cusick et al³ report on a quality improvement (QI) project that addressed acute disease management of heparin-induced thrombocytopenia (HIT) during hospitalization, Sosa et al⁴ discuss efforts to improve comorbidity capture at their institution, and Uche et al⁵ present the results of a nonpharmacologic initiative to improve management of chronic pain among veterans. Cusick et al’s QI project showed that a HIT testing strategy could be safely implemented through an evidence-based process to nudge resource utilization using specific management pathways. While capturing and measuring the complexity of diseases and comorbidities can be challenging, accurate capture is essential, as patient acuity has implications for reimbursement and quality comparisons for hospitals and physicians; Sosa et al describe a series of initiatives implemented at their institution that improved comorbidity capture. Furthermore, Uche et al report on a 10-week complementary and integrative health program for veterans with noncancer chronic pain that reduced pain intensity and improved quality of life for its participants. These QI reports show that, though the health care landscape has changed over the past 2 years, the aim remains the same: to provide the best care for patients regardless of the diagnosis, location, or time.

Conducting QI projects during the COVID-19 pandemic has been difficult, especially in terms of implementing consistent processes and management pathways while contending with staff and supply shortages. The pandemic, however, has highlighted the importance of continuing QI efforts, specifically around infectious disease prevention and good clinical practices. Moreover, the recent continuous learning and implementation around COVID-19 patient care has been a significant achievement, as clinicians and administrators worked continuously to understand and improve processes, create a supporting culture, and redesign care delivery on the fly. The management of both COVID-19 care and our usual care QI efforts should incorporate the lessons learned from the pandemic and leverage system redesign for future steps. As we’ve seen, survival in COVID-19 improved dramatically since the beginning of the pandemic, as clinical trials became more adaptive and efficient and system upgrades like telemedicine and digital technologies in the public health response led to major advancements. The work to improve the care provided in the clinic and at the bedside will continue through one collective approach in the new normal.

Corresponding author: Ebrahim Barkoudah, MD, MPH, Department of Medicine Brigham and Women’s Hospital, Boston, MA; ebarkoudah@bwh.harvard.edu

For years, professional athletes have used simulation-based training (SBT), a combination of virtual and experiential learning that aims to optimize technical skills, teamwork, and communication.¹ In SBT, critical plays and skills are first watched on video or reviewed on a chalkboard, and then run in the presence of a coach who offers immediate feedback to the player. The hope is that the individual will then be able to perfectly execute that play or scenario when it is game time. While SBT is a developing tool in medical education—allowing learners to practice important clinical skills prior to practicing in the higher-stakes clinical environment—an important question remains: what training can go virtual and what needs to stay in person?

In this issue, Carter et al² present a single-site, telesimulation curriculum that addresses consult request and handoff communication using SBT. Due to the COVID-19 pandemic, the authors converted an in-person intern bootcamp into a virtual, Zoom^®-based workshop and compared assessments and evaluations to the previous year’s (2019) in-person bootcamp. Compared to the in-person class, the telesimulation-based cohort were equally or better trained in the consult request portion of the workshop. However, participants were significantly less likely to perform the assessed handoff skills optimally, with only a quarter (26%) appropriately prioritizing patients and less than half (49%) providing an appropriate amount of information in the patient summary. Additionally, postworkshop surveys found that SBT participants were more satisfied with their performance in both the consult request and handoff scenarios and felt more prepared (99% vs 91%) to perform handoffs in clinical practice compared to the previous year’s in-person cohort.

We focus on this work as it explores the role that SBT or virtual training could have in hospital communication and patient safety training. While previous work has highlighted that technical and procedural skills often lend themselves to in-person adaptation (eg, point-of-care ultrasound), this work suggests that nontechnical skills training could be adapted to the virtual environment. Hospitalists and internal medicine trainees perform a myriad of nontechnical activities, such as end-of-life discussions, obtaining informed consent, providing peer-to-peer feedback, and leading multidisciplinary teams. Activities like these, which require no hands-on interactions, may be well-suited for simulation or virtual-based training.³

However, we make this suggestion with some caution. In Carter et al’s study,² while we assumed that telesimulation would work for the handoff portion of the workshop, interestingly, the telesimulation-based cohort performed worse than the interns who participated in the previous year’s in-person training while simultaneously and paradoxically reporting that they felt more prepared. The authors offer several possible explanations, including alterations in the assessment checklist and a shift in the facilitators from peer observers to faculty hospitalists. We suspect that differences in the participants’ experiences prior to the bootcamp may also be at play. Given the onset of the pandemic during their final year in undergraduate training, many in this intern cohort were likely removed from their fourth-year clinical clerkships,⁴ taking from them pivotal opportunities to hone and refine this skill set prior to starting their graduate medical education.

As telesimulation and other virtual care educational opportunities continue to evolve, we must ensure that such training does not sacrifice quality for ease and satisfaction. As the authors’ findings show, simply replicating an in-person curriculum in a virtual environment does not ensure equivalence for all skill sets. We remain cautiously optimistic that as we adjust to a postpandemic world, more SBT and virtual-based educational interventions will allow medical trainees to be ready to perform come game time.

For years, professional athletes have used simulation-based training (SBT), a combination of virtual and experiential learning that aims to optimize technical skills, teamwork, and communication.¹ In SBT, critical plays and skills are first watched on video or reviewed on a chalkboard, and then run in the presence of a coach who offers immediate feedback to the player. The hope is that the individual will then be able to perfectly execute that play or scenario when it is game time. While SBT is a developing tool in medical education—allowing learners to practice important clinical skills prior to practicing in the higher-stakes clinical environment—an important question remains: what training can go virtual and what needs to stay in person?

In this issue, Carter et al² present a single-site, telesimulation curriculum that addresses consult request and handoff communication using SBT. Due to the COVID-19 pandemic, the authors converted an in-person intern bootcamp into a virtual, Zoom^®-based workshop and compared assessments and evaluations to the previous year’s (2019) in-person bootcamp. Compared to the in-person class, the telesimulation-based cohort were equally or better trained in the consult request portion of the workshop. However, participants were significantly less likely to perform the assessed handoff skills optimally, with only a quarter (26%) appropriately prioritizing patients and less than half (49%) providing an appropriate amount of information in the patient summary. Additionally, postworkshop surveys found that SBT participants were more satisfied with their performance in both the consult request and handoff scenarios and felt more prepared (99% vs 91%) to perform handoffs in clinical practice compared to the previous year’s in-person cohort.

We focus on this work as it explores the role that SBT or virtual training could have in hospital communication and patient safety training. While previous work has highlighted that technical and procedural skills often lend themselves to in-person adaptation (eg, point-of-care ultrasound), this work suggests that nontechnical skills training could be adapted to the virtual environment. Hospitalists and internal medicine trainees perform a myriad of nontechnical activities, such as end-of-life discussions, obtaining informed consent, providing peer-to-peer feedback, and leading multidisciplinary teams. Activities like these, which require no hands-on interactions, may be well-suited for simulation or virtual-based training.³

However, we make this suggestion with some caution. In Carter et al’s study,² while we assumed that telesimulation would work for the handoff portion of the workshop, interestingly, the telesimulation-based cohort performed worse than the interns who participated in the previous year’s in-person training while simultaneously and paradoxically reporting that they felt more prepared. The authors offer several possible explanations, including alterations in the assessment checklist and a shift in the facilitators from peer observers to faculty hospitalists. We suspect that differences in the participants’ experiences prior to the bootcamp may also be at play. Given the onset of the pandemic during their final year in undergraduate training, many in this intern cohort were likely removed from their fourth-year clinical clerkships,⁴ taking from them pivotal opportunities to hone and refine this skill set prior to starting their graduate medical education.

As telesimulation and other virtual care educational opportunities continue to evolve, we must ensure that such training does not sacrifice quality for ease and satisfaction. As the authors’ findings show, simply replicating an in-person curriculum in a virtual environment does not ensure equivalence for all skill sets. We remain cautiously optimistic that as we adjust to a postpandemic world, more SBT and virtual-based educational interventions will allow medical trainees to be ready to perform come game time.

For years, professional athletes have used simulation-based training (SBT), a combination of virtual and experiential learning that aims to optimize technical skills, teamwork, and communication.¹ In SBT, critical plays and skills are first watched on video or reviewed on a chalkboard, and then run in the presence of a coach who offers immediate feedback to the player. The hope is that the individual will then be able to perfectly execute that play or scenario when it is game time. While SBT is a developing tool in medical education—allowing learners to practice important clinical skills prior to practicing in the higher-stakes clinical environment—an important question remains: what training can go virtual and what needs to stay in person?

In this issue, Carter et al² present a single-site, telesimulation curriculum that addresses consult request and handoff communication using SBT. Due to the COVID-19 pandemic, the authors converted an in-person intern bootcamp into a virtual, Zoom^®-based workshop and compared assessments and evaluations to the previous year’s (2019) in-person bootcamp. Compared to the in-person class, the telesimulation-based cohort were equally or better trained in the consult request portion of the workshop. However, participants were significantly less likely to perform the assessed handoff skills optimally, with only a quarter (26%) appropriately prioritizing patients and less than half (49%) providing an appropriate amount of information in the patient summary. Additionally, postworkshop surveys found that SBT participants were more satisfied with their performance in both the consult request and handoff scenarios and felt more prepared (99% vs 91%) to perform handoffs in clinical practice compared to the previous year’s in-person cohort.

We focus on this work as it explores the role that SBT or virtual training could have in hospital communication and patient safety training. While previous work has highlighted that technical and procedural skills often lend themselves to in-person adaptation (eg, point-of-care ultrasound), this work suggests that nontechnical skills training could be adapted to the virtual environment. Hospitalists and internal medicine trainees perform a myriad of nontechnical activities, such as end-of-life discussions, obtaining informed consent, providing peer-to-peer feedback, and leading multidisciplinary teams. Activities like these, which require no hands-on interactions, may be well-suited for simulation or virtual-based training.³

However, we make this suggestion with some caution. In Carter et al’s study,² while we assumed that telesimulation would work for the handoff portion of the workshop, interestingly, the telesimulation-based cohort performed worse than the interns who participated in the previous year’s in-person training while simultaneously and paradoxically reporting that they felt more prepared. The authors offer several possible explanations, including alterations in the assessment checklist and a shift in the facilitators from peer observers to faculty hospitalists. We suspect that differences in the participants’ experiences prior to the bootcamp may also be at play. Given the onset of the pandemic during their final year in undergraduate training, many in this intern cohort were likely removed from their fourth-year clinical clerkships,⁴ taking from them pivotal opportunities to hone and refine this skill set prior to starting their graduate medical education.

As telesimulation and other virtual care educational opportunities continue to evolve, we must ensure that such training does not sacrifice quality for ease and satisfaction. As the authors’ findings show, simply replicating an in-person curriculum in a virtual environment does not ensure equivalence for all skill sets. We remain cautiously optimistic that as we adjust to a postpandemic world, more SBT and virtual-based educational interventions will allow medical trainees to be ready to perform come game time.