Elizabeth A. Martinez, MD, MHS Johns Hopkins Medical Institutions September 10, 2008 Organization of Care and Outcomes in Cardiac Surgery AHRQ grant 1K08HS013904-01A1.

Elizabeth A. Martinez, MD, MHSJohns Hopkins Medical Institutions

September 10, 2008

Organization of Care and Outcomes in Cardiac Surgery

AHRQ grant 1K08HS013904-01A1

Building a Health Services Career

Background

• Interest in research as a senior resident and fellow

• Stepping stones♦ Became involved in ongoing projects

♦ Took advantage of “evening” classes in research

Life prior to the K

• Stayed involved in multiple projects

♦ NO theme

♦ NO expertise

♦ NO advancement

♦ NO likelihood of independence

I did have a mentor

Building a Health Services Career

Personal Career Goals:

1. Develop and conduct the proposed research

♦ Define area of interest

♦ Develop the research protocol and grant

♦ Core curriculum required

2. Develop into an independent investigator

♦ What does it take?

3. Become a leader in Health policy

Building a Health Services Career

How to achieve the goals:

• Define area of interest

♦ Define your passion

♦ What links your experiences?

● Clinical

● Research

● Personal

Life prior to the K

• Further focused my clinical and research area of interest♦ Became more involved in performance improvement

and patient safety projects in cardiac surgery

• Identified sub-areas of interest/potential research questions

• Further recognized my limitations especially when it came to measurement, analysis and transforming care.

• Participated in the GCRC grant review committee

Applied for University Support

• Recognition of limitations• Interest in pursuing an advanced degree♦ Precedence in our department

• Encouragement of my chairman and mentor• Johns Hopkins University♦ Sought to gain local support first

• Johns Hopkins Clinician Scientist Award

Life prior to the K• One of the courses included “grant writing”

♦ Helped with focusing thoughts and first iterations of the development of my abstract for the eventual grant.

♦ Broke it down into manageable pieces

• Overwhelming at first

• Made the psychological commitment to complete the grant♦ Johns Hopkins University Clinician Scientist Award first

♦ If it were easy, everybody would be doing it!

Life in K-Limbo

• Resubmitted the grant twice to AHRQ

• Challenging to wait for funding♦ Some delays in funding with a “fundable”

score♦ Proposed project most appropriate for AHRQ

• Some experience with NIH and couldn’t find a home for this type of grant proposal

• Started to (needed to) consider alternative career path

Life during the K• Meet with advisors

♦ High rate of attendance!

♦ Taken seriously with the award—

• Reflects hard work to get there (writing the grant!) and quality of the planned project

– The process of writing the grant (and, of course, resubmitting it!) DOES improve it

• Pursue advanced coursework in Health Services

Building a Health Services Career

How to achieve the goals:

1. Develop and conduct the proposed research

♦ Define area of interest

♦ Write the research protocol and grant

♦ Core curriculum required

2. Develop into an independent investigator

♦ What does it take?

♦ How the K08 facilitates this

3. Be a leader in Health policy

Building a Health Services Career

How to achieve the goals:

♦ Core curriculum required

• Epidemiology and Biostatistics

• Health systems

• Organizational and behavioral change

• Leadership change

Why formal training?

• Health services and outcomes research is very complex♦ Need to be an expert in epi, biostats♦ Need to be able to be address biases♦ Measurement in outcomes research

remains a challenge

• Need sophisticated background to develop independence and a leadership role

Develop into an Independent Investigator

• Formal training additional importance♦ Just like lab researchers♦ Very complex systems that are being evaluated♦ Need to be an expert in many fields♦ Form professional relationships

• Skills in project management• Gain experience outside of the proposed project

and coursework♦ National professional societies♦ Research conferences

• Broaden professional relationships

Life during the K

• Member of national committee for professional society to develop quality measures for anesthesia

• Have been asked to represent the American Society of Anesthesiologists in development of national guidelines

• And, of course, the grant work……

Organization of Care and Outcomes in Cardiac Surgery

• 700,000 cardiac surgical cases in US• Hypothesis:

Differences in the processes of postoperative care contribute to differences in mortality in low-volume and high-volume hospitals.

• Primary goal:♦ Identify the structure and processes of the

perioperative management of patients undergoing cardiac surgery that impact their mortality.

Organization of Care and Outcomes in Cardiac Surgery

• Variation in Care♦ Cardiac ICU physician staffing

♦ Cardiac ICU nurse staffing

♦ Cardiac ICU mid-level provider staffing

♦ Protocols

• Link variation in care to outcomes

Life during the K

• Completed preliminary site visits to explore current practices in cardiac surgery

• Developed pilot survey

♦ Iterative process

♦ Survey development course

• Piloted survey

♦ Lessons learned

Life during the K

The importance of pilot testing• It’s true!• Found significant issues with questions

♦ Despite reviewing while visiting sites♦ Outline a plan to remedy

• Explore contributors

• Revise the survey

• Re-pilot!

Impact of research on Healthcare Delivery

• Significantly advance our knowledge of how cardiac surgical patients are managed postoperatively and how the differences in organizational characteristics are related to their outcomes.

• Identify strategies to reduce mortality in low-volume hospitals and to decrease variation in mortality within all centers.

Become a Leader in Health Policy:

• Professional societies

♦ Inform/develop quality measures for cardiac surgery

• Inform insurers whether cardiac surgery should be included in the volume or intensivist measure

• Prioritization of efforts to improve cardiac surgical care

Thank you.

Elizabeth [email protected]