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

Squire Guidelines

QI vs. Clinical ResearchHow to develop a project

Where to get the data

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”

Traditional Research Innovative Local QI Routine Local QI

Measure Epidemiologic studies of quality problems

Multi-dimensional ‘quality report card’

Performance data mandated by payors

Intervene Description 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

Example Rigorous 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

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

Characteristics of “good” data

Sources/categories of data

Administrative databases – pros &cons

Data Sources

Clinical Data

Administrative Data Bases

Registries Clinical Trials

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

• 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

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)

StateUHC Clinical

Data Base (CDB)

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

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)

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

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

Squire Guidelines

QI vs. Clinical ResearchHow to develop a project? What are you interested in?

Where to get the data – Registries, Clinical Data Base, O2