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TABLE OF CONTENTSPreamble ……………………………….280 Introduction ………………………281 1.1. Methodology and Evidence Review … . .2811.2. Organization of the Writing Committee …2831.3. Document Review and Approval …… .2831.4. Scope of the Guideline ……………283 1.4.1. Critical Issues …………… . .2831.5. Glossary of Terms and

Alice K. Jacobs, MD, FACC, FAHA, Chair 2009–2011; Sidney C. Smith, Jr, MD, FACC, FAHA, Immediate Past Chair 2006–2008[†††][1]; Jeffery L. Anderson, MD, FACC, FAHA, Chair-Elect; Cynthia D. Adams, MSN, PhD, FAHA[†††][1]; Christopher E. Buller, MD, FACC; Mark A. Creager, MD, FACC, FAHA

It is essential that the medical profession play a central role in critically evaluating the evidence related to drugs, devices, and procedures for the detection, management, or prevention of disease. Properly applied, rigorous, expert analysis of the available data documenting absolute and relative

In an environment of increased fiscal responsibility and cost constraints, the medical staff must take an active role in deciding how an institution's operating budget is spent. A major expense of a military treatment facility (MTF) is maintaining an adequate and cost-effective formulary. The large number of pharmaceuticals available on the market forces a decision regarding which products to stock. Decision analysis is a technique that helps a medical staff to manage its formulary by listing all of the objective and subjective considerations. The Department of Defense Pharmacoeconomic Center has developed a tri-service formulary to standardize a basic drug list that would be available in each military treatment facility. However, this list cannot be expected to answer all of the factors a medical staff must weigh in developing an MTF-specific formulary. Many considerations must be addressed in these decisions, including the beneficiary population, the potential diagnoses as defined by a database such as the Retrospective Case Mix Analysis System or the Military Health Services System, the institution's mission and defined scope of care, physician interests and specialization, and facility limitations. Military treatment facilities can maintain an appropriate stock of medications that is specific for the scope and practice of a medical staff and work within a budget through careful planning and employment of a decision matrix. This balance of appropriateness and fiscal responsibility allows the maximum range of services within a facility.

In today's complex medical world, physicians often face difficult decisions about whom they serve first--patients, corporations, insurance companies, the government, etc.

A medical facility is responsible for the standards of practice of its medical staff and can be found liable if it was negligent in appointing or reappointing a member of the staff who is incompetent. Joint Commission standards require that recommendations for consideration of initial, renewal, or revision of clinical privileges be made based upon peer evaluations of professional performance, judgment, and clinical and technical skills. Valid recommendations involve two discrete steps: collecting data and evaluating that data. The most pertinent data are those of current competence. The responsibility of interpreting the data rests with the Department or Service Chief. It is his clinical experience that enables him to evaluate a providers' care, in light of accepted standards of practice, for a specialty and for a specific region. Subsequently, in order for the Credentials Committee to make a meaningful performance-based privileging recommendation to the military treatment facility Commander, a summary must be written by the Department/Service Chief, incorporating all of the relevant data and the evaluation of those data. Based on the objective data with the accompanying evaluation, the summary must conclude that the provider is physically and mentally capable of performing the procedures requested, including having the social skills necessary to relate with others in the total care of the patient, and that his training, experience, and recent past performance is consistent with the prudent delivery of care. Continuous performance improvement strategies must support this process by organizing hospital committee structures, ancillary staffing, and information management processes to support a decision-making process based on facts.

Echocardiograms were recorded using a left posterior thoracic approach in 17 patients with left pleural effusion. Comparison of these records with those obtained using the conventional technique in the same patients revealed that the left posterior thoracic approach yielded records of adequate quality in all patients. The mitral valve, the left ventricle, and the posterior pericardium were well defined. In 10 patients in whom pericardial effusion was also p;esent, the posterior approach facilitated clear separation of the pleural and pericardial effusions. A major limitation of the posterior technique appears to be inability to record the aortic root, the aortic valve, and the left atrium.