- •Foreword
- •Contents
- •Contributor Current and Past Positions: Association for Academic Surgery
- •Contributors
- •Academic Surgeons as Bridge-Tenders
- •Types of Surgical Research
- •Going Forward
- •Selected Readings
- •Introduction
- •Preparation Phase
- •Assistant Professor
- •Job Search
- •The First Three Years
- •Career Development Awards (CDAs)
- •Contemplating a Mid-Career Move?
- •Approaching Promotion
- •Associate Professor and Transition to Full Professor
- •Conclusion
- •Selected Readings
- •Introduction
- •Reviewing the Literature
- •Developing a Hypothesis
- •Study Design
- •Selected Readings
- •Introduction
- •The Dual Loyalties of the Surgeon-Scientist
- •Human Subjects Research
- •Informed Consent
- •Surgical Innovation and Surgical Research
- •Conflict of Interest
- •Publication and Authorship
- •Conclusion
- •References
- •Sources of Error in Medical Research
- •Study Design
- •Inferential Statistics
- •Types of Variables
- •Measures of Central Tendency and Spread
- •Measures of Spread
- •Comparison of Numeric Variables
- •Comparison of Categorical Values
- •Outcomes/Health Services Research
- •Steps in Outcomes Research
- •The Basics of Advanced Statistical Analysis
- •Multivariate Analysis
- •Time-to-Event Analysis
- •Advanced Methods for Controlling for Selection Bias
- •Propensity Score Analysis
- •Instrumental Variable (IV) Analysis
- •Summary
- •Selected Readings
- •Transgenic Models
- •Xenograft Models
- •Noncancer Models
- •Alternative Vertebrate Models
- •Selected Readings
- •Overview
- •Intellectual Disciplines and Research Tools
- •Comparative Effectiveness Research
- •Patient-Centered Outcomes Research
- •Data Synthesis
- •Overview
- •Intellectual Disciplines and Research Tools
- •Disparities
- •Quality Measurement
- •Implementation Science
- •Patient Safety
- •Optimizing the Health Care Delivery System
- •Overview
- •Intellectual Disciplines and Research Tools
- •Policy Evaluation
- •Surgical Workforce
- •Conclusion
- •References
- •Introduction
- •What Is Evidence-Based Medicine?
- •Evidence-Based Educational Research
- •Forums for Surgical Education Research
- •Conducting Surgical Education Research
- •Developing Good Research Questions
- •Beginning the Study Design Process
- •Developing a Research Team
- •Pilot Testing
- •Demonstrating Reliability and Validity
- •Developing a Study Design
- •Data Collection and Analysis
- •Surveys
- •Ethics
- •Funding
- •Conclusions
- •Selected Readings
- •Genomics
- •Gene-Expression Profiling
- •Proteomics
- •Metabolomics
- •Conclusions
- •References
- •Selected Readings
- •Introduction
- •Why Write
- •Getting Started
- •Where and When to Write
- •Choosing the Journal
- •Instructions to Authors
- •Writing
- •Manuscript Writing Order
- •Figures and Tables
- •Methods
- •Results
- •Figure Legends
- •Introduction
- •Discussion
- •Acknowledgments
- •Abstract
- •Title
- •Authorship
- •Revising Before Submission
- •Responding to Reviewer Comments
- •References
- •Selected Readings
- •Introduction
- •Origins of the Term
- •Modern Definition and Primer
- •Transition from Mentee to Colleague
- •Mentoring Risks
- •Conclusion
- •References
- •Selected Readings
- •The Career Development Plan
- •Choosing the Mentor
- •Writing the Career Development Plan
- •The Candidate
- •Research Plan
- •Final Finishing Points About the Research Plan
- •Summary
- •References
- •Introduction
- •Decisions, Decisions!
- •Mission Impossible: Defining a Laboratory Mission or Vision
- •Project Planning
- •Saving Money
- •Seek Help
- •People
- •Who Should I Hire?
- •Advertising
- •References
- •Interviews
- •Conduct a Structured Interview
- •Probation Period
- •Trainees
- •Trainee Funding
- •Time Is on Your Mind
- •Research Techniques
- •Program Leadership
- •Summary
- •Selected Readings
- •Introduction
- •Direct Evidence
- •Indirect Evidence
- •Burnout
- •Prevention of and Recovery from Work–Life Imbalance
- •Action Plan for Finding Balance: Personal Level
- •Action Plan for Finding Balance: Professional Level
- •Conclusion
- •References
- •Introduction
- •Time Management Strategies
- •Planning and Prioritizing
- •Delegating and Saying “No”
- •Action Plans
- •Activity Logs
- •Scheduling Protected Time
- •Eliminating Distractions
- •Buffer Time
- •Goal Setting
- •Completing Large Tasks
- •Maximizing Efficiency
- •Get Organized
- •Multitasking
- •Think Positive
- •Summary
- •References
- •Selected Readings
- •Index
88 A.A. Hayes-Jordan
Alternative Vertebrate Models
Zebrafish have become a popular and excellent model to study development, cancer, and genetics. The zebrafish has become prized because its transparent embryo develops out- side the mother’s body. This transparency allows minute to minute visualization of the cardiovascular, including blood flow,and structural changes that occur in“real time.”Because the zebrafish is a vertebrate animal, it has become a valuable resource for identifying genes involved in human disease.
Thomas Bartman and colleagues use the powerful tools afforded by zebrafish genetics to examine the early steps of heart valve formation. In the process, they provide evidence for a causal relationship between the early function of the heart and its final structure. Using a fluorescent molecular marker highly expressed in the developing heart, the authors found mutations that result in valve defects and identified a fish mutant they named cardiofunk (cfk).Genetic mapping of cfk showed that the abnormality was caused by a mutation in a gene encoding a novel actin molecule that is most closely related to the actins found in muscle cells.Actin is involved in muscle contraction; so these results suggest that muscle con- traction in the embryonic heart is intimately involved in heart development. Valve or septal defects represent 40% of car- diac anomalies in humans. By studying zebrafish, Bartman and colleagues suggest some of these defects may result from congenital defects affecting very early heart function.5
Zebrafish are being used to study cancer by Nancy Hopkins of the Massachusetts Institute of Technology. Her group has created over 500 lines of zebrafish with lesions in key genes involved in development and used them to identify a group of genes that predispose the fish to cancer. Using close observa- tion while cultivating some of these mutant lines, this team noticed that an abnormally large percentage of fish died young, whereas the surviving fish in these lines developed large, highly invasive malignant tumors. This facilitated the discovery of a ribosomal gene (rp) essential for embryonic development. Given the high degree of conservation of genes
Chapter 6. Animal Models for Surgical Research |
89 |
andpathwaysamongvertebrates,it’spossiblethatrpmutations also raise cancer risk in humans. Together, these results dem- onstrate that the tiny freshwater workhorse of developmen- tal biology has a promising future as a model system for human cancer.5
Selected Readings
Hanahan D. Dissecting multistep tumorigenesis in transgenic mice. Annu Rev Gene. 1988;22:479-519.
Wang YX, Mandal D, Wang S, et al. Inhibiting platelet-derived growth factor beta reduces Ewing’s sarcoma growth and metastasis in a novel orthotopic human xenograft model. In Vivo. 2009;23:903-909.
Fidler IJ. Seed and soil revisited: contribution of the organ microenvi- ronment to cancer metastasis. Surg Oncol Clin N Am. 2001;10: 257-269. vii-viiii.
Feretis C, Kalantzopoulos D, Koulouris P, Kolettas C, Chandakas S, Sideris M, Papalois A. Experimental studies of peroral transgastric abdominal surgery. Ann Gastroenterol. 2006;1:60-65.
Bartman T, Walsh EC, Wen KK, et al. Early myocardial function affects endocardial cushion development in zebrafish. PLoS Biol. 2004;2(5):E129.
Chapter 7
Health Services Research
Caprice C. Greenberg and Justin B. Dimick
Keywords Outcomes • Quality • Policy • Disparities
• Implementation
The face of academic surgery is changing. While bench science and traditional translational research remain critical to advancing our field, the last decade has seen a movement toward a more intimate relationship between our scientific inquiry and the “how” of health care delivery. This is reflected not only in the diversification of academic career paths, but also more globally in changes in federal funding priorities and health care policy and reform. Health services research (HSR), defined by the Institute of Medicine as a multidisciplinary field of inquiry, both basic and applied, that examines the use, costs, quality, accessibility, delivery, organization, financing, and outcomes of health care services to increase knowledge and understanding of the structure, processes, and outcomes of health services for individuals and populations, represents a rapidly increasing proportion of surgical scientific inquiry.
C.C. Greenberg ( )
Department of Surgery, University of Wisconsin
Hospitals and Clinics, Highland Avenue,
Madison, WI, USA
H. Chen and L.S. Kao (eds.), Success in Academic Surgery, |
91 |
DOI 10.1007/978-0-85729-313-8_7,
© Springer-Verlag London Limited 2012
92 C.C. Greenberg and J.B. Dimick
In this chapter, we will provide an overview of the field of
HSR in surgery,often also termed “surgical outcomes research.” Although this field is quite broad and could be depicted in several potential ways, we suggest a conceptual model that separates the field into three key components: (1) disease management; (2) the local micro-system in which treatments are provided; and (3) the policy environment (i.e., macro-system) in which health care is delivered. Each of these three key components is intimately related to one another to form the US health care system and can define the major scientific domains of HSR (Fig. 7.1). For each of the three major domains, we will provide a brief overview and discuss the intellectual disciplines (Table 7.1) and research tools (Table 7.2) necessary to conduct high-level studies in this area.
Patient-Level Questions: Evaluating
Disease Management
Overview
This domain of health services research aims to evaluate the management of disease at a population level under “realworld” conditions or from the patient’s point of view. HSR often provides important data that cannot be generated from
FIGURE 7.1 Conceptual model for the discipline of health services research (HSR). Panel A depicts how the key elements of our health care system interact: (1) disease management; (2) the local microsystem in which treatments are provided; and (3) the policy environment (i.e., macro-system) in which health care is delivered. These same three elements form the basic domains of the discipline of HSR, which is dedicated to understanding the system and approach to care provided at the individual patient, local, and health care delivery system levels. Panel B depicts the variety of intellectual disciplines that are considered health services research and how each relates to one of the three elements of the health care system or their intersection
Chapter 7. Health Services Research |
93 |
traditional clinical trials.Traditional randomized clinical trials are “efficacy” trials designed to evaluate a given treatment approach under the best case scenario and thus adhere to strict inclusion and exclusion criteria. “Effectiveness” trials are equally important and evaluate how well a given
|
Health |
|
|
care |
|
|
delivery |
Health |
Payment |
system |
policy |
reform |
|
|
|
Local |
|
|
“Micro- |
|
|
system” |
|
Physicians |
|
Nurses |
Hospital |
Surgical |
Protocols |
technology |
|
|
ward |
|
|
|
|
|
|
Treatment |
|
|
of disease |
|
|
Perioperative |
|
|
care |
|
Disease management
Patient-centered outcomes
Comparative effectiveness
Data synthesis
Patient safety |
Coverage decisions |
|
Technology adoption |
||
|
||
|
Cost-effectiveness |
|
|
Quality |
|
measurement |
Quality improvement
Policy evaluation Payment reform
Implementation Workforce science
Local |
Health care |
“microsystem” |
delivery |
|
system |
94 C.C. Greenberg and J.B. Dimick
TABLE 7.1 The domains and intellectual disciplines that comprise health services research
Domain |
Intellectual discipline |
Areas of focus |
Evaluating disease |
Comparative |
Pragmatic clinical |
management |
effectiveness |
trials |
(patient level) |
research |
Cluster randomized |
|
|
trials |
|
|
Observational |
|
|
studies |
|
Patient-centered |
Quality of life |
|
outcomes |
Patient satisfaction |
|
|
Shared decision- |
|
|
making |
|
Data synthesis |
Meta-analysis |
|
|
Decision analysis |
Understanding local |
Quality |
Public reporting |
provision of care |
measurement |
Benchmarking |
(micro-system) |
|
outcomes |
|
Implementation |
|
|
science |
|
|
Patient safety |
Systems engineering |
|
|
Human factors |
|
|
System redesign |
Healthcare delivery |
Policy evaluation |
Payment reform |
system (macro- |
|
Coverage decisions |
system) |
|
|
|
Work force |
Forecasting future |
|
|
needs |
|
|
Regional variations |
|
|
|
treatment approach works outside of a controlled trial when all patients are considered. This area of HSR is primarily referred to as comparative effectiveness research. Another rapidly expanding area of HSR is patient-centered outcomes research. This area of research includes such important areas as quality of life, patient satisfaction, and shared decision-making. Data synthesis, including such techniques as meta-analyses and decision analyses, aims to answer questions