1. How Clinical Faculty Can Develop Scholarship Out of Clinical Work Susan K. Pingleton, MD

2. Scholarship Out of Clinical Work Why? What is Scholarship?? Resources – Mentor Squire Guidelines QI vs. Clinical Research How to develop a project Where to get the data

3. WHY ?? You are faculty in an academic medical center Scholarship is needed for promotion It is the right thing to do for your students and trainees

4. Resources Mentor –Now School of Medicine Requirement for all Departments – clinical and basic science Pediatrics Dept of Medicine Mentoring Toward PromotionMentoring Toward Promotion –Understanding Ranks and Tracks –Understanding Criteria for Promotion

5. Scholarship Discovery Traditional research –Basic and Clinical Quality Improvement Educational curriculums Health Policy Dissemination Presentations Publications Other Academic Medical Centers, Hospitals

6. Survey IM Chairs 65 responses (55%) 80% have one or more faculty members spending 20% effort on QI 78% think faculty should be promoted based on QI 26% think evidence of scholarship or academic progress should be required; few consider it “service”

7. Traditional ResearchInnovative Local QIRoutine Local QI MeasureEpidemiologic studies of quality problems Multi-dimensional ‘quality report card’ Performance data mandated by payors InterveneDescription of multiple root cause analyses, outlining common problems identified and changes made Modifying incident reporting system to better inform improvement efforts Membership on hospital critical incident review committee ExampleRigorous evaluation of novel QI intervention Leading a complex QI undertaking (eg. implementing CPOE) Modifying a national practice guideline for local uptake Differences between Traditional Research and Quality Improvement

8. Routine Quality-Related Activities General internist who led the local adoption of national guidelines for peri- operative care Chairs hospital P&T committee Also sits on critical incident review committee Counts as ‘Hospital Service’, expected of all faculty, but little to intrinsic academic merit

9. Clinician Engaged in Innovative QI Hospitalist who during his non-clinical time led development of an innovative program to improve the discharge process Successfully led hospital-wide implementation of medication reconciliation Based on above successes, hospital now supports part of his salary to lead new QI projects Discovery and dissemination characteristics worthy of academic promotion

10. How to Develop a Project ? Assignment of a project by a mentor Interesting clinical/educational/health policy question that you have and cannot find an answer “Does routine phone call after discharge improved discharge planning”? “Does a serum lactate predict mortality in acute bowel obstruction?” “What interventions in the EMR can improve core measure compliance?” “What are the benefits of a Hospitalist Administrator on Duty?” Requires literature search

11. DATA Role of data in quality improvement Characteristics of “good” data Sources/categories of data Administrative databases – pros &cons

12. Data Sources Clinical Data Administrative Data Bases RegistriesClinical Trials Proprietary UHC, Premier, HMO’s Government VAH, CMS Specialty organizations Industry registries CDC, States NIH funded Industry/FDA

13. Multiple types of Clinical registries: All afford data for clinical research Specialty registries, e.g. CTS Anesthesia Quality Institute (AQI) Data Registry American College of Chest Physicians Bronchoscopy Registry Disease registries, e.g. Cancer Pulmonary Hypertension Government/Organization registries, e.g. CDC Veterans Administration CDB State of Kansas Diabetes Registry

14. Clinical data (National Surgical Quality Improvement Program) –Prospective data collection, chart abstraction –Expensive, labor-intensive, but face validity among physicians Administrative data base (UHC’s CDB, Premier, Thomson-Reuters) –Always retrospective, Claims data (medical record coding) –Very efficient way to collect data Hybrid (CDB/Resource Manager) –Administrative clinical data supplemented with resource utilization Differences between Abstracted Clinical Data and Administrative Data Bases for Clinical Performance

15. Where do the data elements come from ? Physician: Documentation of patient care Coders: Assignment of codes to diagnoses and procedures Creation of a ‘CLAIM’ with patient demographics; DRG; diagnoses and procedures; LOS; charges; admission/discharge dates, status; physician; etc. Payers (e.g. CMS, BCBS) State UHC Clinical Data Base (CDB)

16. Good Correlation between administrative clinical data and abstracted clinical data: 30 mortality AMI “ indicating strong agreement of the hospital risk- standardized mortality estimates between the 2 data sources.” Circulation. 2006;113:1683-1692

17. Risk Model High RiskLow Risk A robust model should assign higher probability of death to patients who died than to those who survived, at least 70% of the time (i.e. c-index >= 0.70) Survived Died Clinical Data must be risk adjusted

18. SQUIRE: Standards for Quality Improvement Reporting Excellence http://www.squire-statement.org/

19. Scholarship Out of Clinical Work Scholarship is discovery and dissemination All departments will have mentoring program and web site Squire Guidelines QI vs. Clinical Research How to develop a project? What are you interested in? Where to get the data – Registries, Clinical Data Base, O2