Spinning Flax into Gold:Spinning Flax into Gold:Turning Your QI projects into Turning Your QI projects into

Scholarly WorkScholarly Work

Saul N. Weingart, MD

Dana-Farber Cancer Institute

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ObjectivesObjectives

• Identify QI projects that make good scholarly products

• Design QI projects that optimize opportunities for scholarly work

• Identify appropriate professional meetings and journals 

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DisclosuresDisclosures

None.

Alas.

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What do we mean by What do we mean by “quality improvement”?“quality improvement”?

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Quality is the degree to which health Quality is the degree to which health services for individuals and populations services for individuals and populations increase the likelihood of desired health increase the likelihood of desired health outcomes and are consistent with current outcomes and are consistent with current professional knowledge. professional knowledge.

IOM IOM

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AgendaAgenda

• QI vs. research

• Why bother?

• Thinking forward

• Thinking backward

• Hurdles

• Outlets

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QI vs. ResearchQI vs. Research

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Why bother?Why bother?

 

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Thinking forwardThinking forward

• You’d like to do an improvement project, but haven’t fully formed the idea. What do you need to do to make it publishable?

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Types of projectsTypes of projects

• Lit review

• Chart review

• Survey

• Education

• Intervention Retrospective Prospective

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Medication ReconciliationMedication Reconciliation

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Baseline dataBaseline data

No. of patients 338

No. of drugs 2146

Corrected 102 5%

D/C’d drugs 510 24%

Missing drugs 585 27%

Total changes 1197 56%

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Patient-Identified Patient-Identified Medication UpdatesMedication Updates

• Corrected Oxycontin Mycophenolate

mofetil Gabapentin Keppra Warfarin

• D/C’d Antibiotics (various) Antiemetics

• Missing Heparin Warfarin Imatinib Oxcarbazepine Erlotinib Testosterone Dexamethasone Thalidomide Celecoxib

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Medication Reconciliation Medication Reconciliation ProtocolProtocol

CAsPrep

Charts

Providers or Pharmacists Update EMR

Collect & Evaluate

CAsProvide

Med Lists

Patients Update

Med Lists

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Medication Reconciliation Monthly TotalsNovember 2005 - March 2008

0

500

1000

1500

2000

2500

Nov '05

Jan

'06 Mar

May

Jul '0

6Sep

tNov

Jan

'07 Mar

May

July

'07Sep

tNov

Jan

'08

Mar

chMed

icat

ion

sh

eets

rec

on

cile

d

Sheets reconciled 95% CI

Develop

ImplementSustain

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Usual care groupN=54

ReconciliationGroupN=50

Patient receives & updates own

Med list

Evaluation staff review Med list 2 weeks after visit

Med list NOT given

to MD

Med list given to MD

MD reviews list, enters/approves

updates, or does nothing

“Usual care”

Eva

luat

ion

Des

ign

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Reconciled Medication ListsReconciled Medication ListsMed List Updates

Reconciliation

N=42

Usual Care

N=47 P-value

Any 38 (90%) 1 (2%) <0.001

Mean no. of updates (s.d.)

4.3 (4.1) 0.1 (0.4) <0.001

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Thinking backwardThinking backward

• You’ve done your project. It worked good. Can you write it up?

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Teamwork Training for PatientsTeamwork Training for Patients

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Revised approachRevised approach

• Campaign • Hazards > skills• Bringing messages

to the patient • Empowerment

without obligation “You CAN… check,

ask, notify”

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Anticoagulation Management Anticoagulation Management ServiceService

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What would you recommend?What would you recommend?

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Baseline (N=46) Usual Care(N=46)

Anticoag-ulation

Management Service (AMS)

(N=33)

Base-line vs. Usual

P-value

Base-line vs. AMS

P-value

Usual vs.

AMSP-value

No. of laboratory tests (hemoglobin, platelets count, serum creatinine) performed per patient, mean ±SD (range)

15.1±9.4(0-42)

18.2±9.7(0-41)

9.9±8.7(0-35)

p=0.13 p=0.015 p<0.001

No. of INR tests performed per patient on warfarin, mean ±SD (range)

Percent of INR tests in range, mean ±SD (range)

3.7±4.0(0-16)[n=20]

35.9%±31.7(0-75%)

4.3±4.2(0-10)[n=8]

54.0%±30.9

(30.0-88.9%)

9.2±4.7(1-22)[n=33]

50.0%±23.8(0-100%)

p=0.75

p=0.43

p<0.01

p=0.19

p=0.01

p=0.79

Percent of days within range (Rosendaal method), mean ±SD (range)

49.0%±37.5(0-94.6%)

[N=11]

46.1%±49.2(0-97.7%)

[N=4]

56.5%±28.0(0-100%)[N=21]

p=0.90 p=0.53 p=0.55

Any complication (venous clot, minor bleed, major bleed)

5 (10.9%)Venous clot, 1Minor bleed, 4

10 (21.7%)Venous clot, 4Minor bleed, 5Major bleed, 1

8 (24.2%)Venous clot, 1Minor bleed, 6Major bleed, 1

p=0.16 p=0.11 p=0.79

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HurdlesHurdles

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HurdlesHurdles

• Time and money

• IRB (expedited vs. exempt vs. full)

• Authorship

• Lit review

• Writer’s block

• Biostatistics support

• Null results

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Need IRB approval?Need IRB approval?• Expedited

“Minimal risk”

• Exempt

“Research involving the collection or study of existing data, documents, records, pathological specimens, or diagnostic specimens, if these sources are publicly available or if the information is recorded by the investigator in such a manner that subjects cannot be identified, directly or through identifiers linked to the subjects.”

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Outlets for your writingOutlets for your writing

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Types of papersTypes of papers

• Original research• Literature review• Methodology• Quality in practice• Perspective• Editorial

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Anatomy of a paperAnatomy of a paper

• Introduction• Methods

Setting/subjects Design Intervention Implementation Evaluation Analysis

• Results Outcomes Sustained

• Discussion Summary Context Limitations Implications

See SQUIRE Guidelines

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TipsTips

• Background Clarify the question, importance, and

hypothesis

• Results Follow the analysis plan, report most #s in

tables and figures

• Discussion Know and cite the literature, <3,000 words

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JournalsJournals

• General medicine JAMA Archives JGIM AJM (Green) Academic medicine J Hosp Med

• Quality/Safety Joint Commission

Journal BMJ Quality & Safety IJQHC (ISQua) J Patient Safety AJHSP (pharmacy) Nursing quality

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MeetingsMeetings

• Abstracts Posters Abstract

presentations

• Workshops

• General medicine SGIM SHM

• Quality/Safety IHI (US, European) NPSF ISQua AMIA Academy Health

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Thank youThank you