How Clinical Faculty Can Develop Scholarship Out of Clinical Work

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

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

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

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

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

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”

Differences between Traditional Research and Quality Improvement

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

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

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

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

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

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

Differences between Abstracted Clinical Data and Administrative Data Bases for ClinicalPerformance • 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

Payers (e.g. CMS, BCBS) State UHC Clinical Data Base (CDB) 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.

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

Died Survived Clinical Data must be risk adjusted Risk Model Low Risk High 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)

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

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

How Clinical Faculty Can Develop Scholarship Out of Clinical Work