strength in numbers corc program annual opta …...• brandon c, jamadar d, girish g, dong q, morag...

3/13/2017

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Strength in Numbers: Fusing Clinician and Researcher Expertise for

High-Quality Science and Practice

Stephanie Di Stasi, PT, PhD, OCS

Kristy Pottkotter, PT, SCS, Cert. MDT

Lucas VanEtten, PT, DPT

Kathy Wayman, PT, DPT, SCS

Disclosures

• No financial disclosures related to the content of today’s presentation or discussion

Today’s Speakers

Kristy Pottkotter Lucas VanettenKathy Wayman Stephanie Di Stasi

Acknowledgements

• Jameson Crane Sports Medicine Institute‒ Sports Medicine Physical Therapy‒ Sports Medicine Research Institute

• The Newhart Family

• OSU Residency and Fellowship programs

Kate Glaws Caroline Lewis Kristy PottkotterKelsey Shonk Lucas Vanetten Kathy WaymanMatt Briggs

References

• Bammer G. Enhancing research collaborations: Three key management challenges. Research Policy. 2008;37(5):875-887.

• Brandon C, Jamadar D, Girish G, Dong Q, Morag Y, Mullan P. Peer support of a faculty "writers' circle" increases confidence and productivity in generating scholarship. Acad Radiol. 2015 Apr;22(4):534-8.

• Embi PJ, Tsevat J. Commentary: the relative research unit: providing incentives for clinician participation in research activities. Acad Med. 2012 Jan;87(1):11-4.

• Goodson P. Becoming an academic writer: 50 exercises for paced, productive, and powerful writing. 2013. Los Angeles: Sage Publications Inc.

• Grimmer-Somers K. Incorporating research evidence into clinical practice decisions. Physiother Res Int. 2007 Jun;12(2):55-8.

• Horn SD, Gassaway J.Practice-based evidence study design for comparative effectiveness research. Med Care. 2007 Oct;45(10 Supl 2):S50-7.

• Nocera R, Ramoska EA, Hamilton RJ. Building a resident research program in emergency medicine. Intern Emerg Med. 2016 Mar;11(2):245-8.

• Wright TM, Buckwalker JA, Hayes WC. Writing for the journal of Orthopaedic Research. J Orthop Res. 1999 (17):459-466.

• Young BK, Cai F, Tandon VJ, George P, Greenberg PB. Promoting medical student research productivity: the student perspective. R I Med J (2013). 2014 Jun 2;97(6):50-2.

Session Outline

• Goals of and infrastructure to support the Ohio State’s Clinical Outcomes Research Coordinator (CORC) program (Di Stasi)

• Impact of CORC program on individual growth, ability to interpret the literature, and provide education of colleagues, peers, and students (Pottkotter)

• Keys to bridging the communication gap between the lab and the clinic (Wayman)

• Lessons learned from the trenches: developing and planning a clinical trial (Vanetten)

• Successes and challenges of the CORC program (Di Stasi)

• Audience Q&A with interactive panel discussion

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Session Objectives

• Understand the common barriers to research participation in multiple clinical settings.

• Develop 1-2 strategies for promoting research participation among colleagues and students.

• Compare and contrast strategies to improve: ‒ scientific literature appraisal, ‒ increase writing productivity, and ‒ facilitate clinical trial implementation

Goals of and infrastructure to support the Ohio State’s Clinical Outcomes Research

Coordinator (CORC) program


[email protected]

In 2012, opportunity knocked…• Born from a 50% FTE vacancy from clinical outcomes

research position• Excellent support from leadership• System of mutual benefit:

• Laboratory science needed clinician insights

• Clinicians wanted ‘in’ on research collaborations

Genesis of the CORC program

Mission, framework, implementation, metrics of success, people:…all up to us to decide!

CORC Program Mission

• Leverage the skill sets of clinicians and researchers to develop a productive, collaborative, and nationally-recognized research program

• Disseminate information gleaned from this interdisciplinary work on local, national, and international platforms

• Apply evidence-based medicine (EBM) to our clinical population and refine treatment based on data collected

CORC Program Mission: Impossible? The big picture on our infrastructure

OSU & OSUWMC

Sports Medicine

Sports Medicine Research Institute

CORC program

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OSU & OSUWMC’s Infrastructure

• Land-grant institution and academic medical center‒ Morrill Acts of mid-late 1800s funded colleges and state

universities with a focus on practical sciences and trades‒ 66,000 students; 22,000 staff

• Colleges, Schools, Departments, Divisions‒ 15 colleges, 200+ undergrad majors, 100+ doctoral

degree programs

• 1,000+ Division I athletes

• Institutional Review Board

• Medical library resources, access to literature

• Biomedical Informatics

Sports Medicine’s Infrastructure

Endurance Medicine

Performing Arts Medicine Sports

Performance

Physicians

Physical Therapists

Nutritionists

Physician Assistants

Sports Psychologists

Athletic Trainers

OR Suites

Research Core

Biomechanics Lab

Administrative Staff

Sports Medicine Research Institute’s Infrastructure CORC Program Infrastructure

CORC program

Sports Medicine Therapy

Sports Medicine

Physicians

EBP Coordinators

and P2P Program

PT Residency and

Fellowship Program

External Collaborators

OSU School of Health and Rehabilitation

Sciences

CORC Program Infrastructure

• Key features‒ Capable, invested clinicians (Our CORCs)‒ Available, committed research mentors‒ Financial (read: protected time) and support from the

clinic/institution‒ Current, smoothly running research projects

Common characteristics of a great CORC

• Self-identified research interests or previous experience

• A few main areas of interest

• The ‘but why?’ clinician

• Good scientific writing skills

• Process-focused

• Ability to contribute extra time outside the paid FTE

• Willingness to follow the data and implement EBP

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How it works

• Weekly hours spent in lab

• Monthly/bimonthly 1-on-1 mentorship meetings

• Quarterly CORC team meetings

Why do we require weekly hours in the lab?

• Focused research time, uninterrupted by patient care

• Adjacency to lab personnel – students, lab manager

• ‘Coverage’ of clinical aspects of lab testing

• Exposure to/discussions with PhD students

• Mentorship for/support from undergraduate students

Monthly/bimonthly 1-on-1 meetings

• Research topic alignment with mentor

• Project collaboration

• Development/implementation of clinician questions and hypotheses

• Abstract development

• Scientific writing mentorship

• Career development

Purpose of the quarterly CORC team meetings

• Pairing members for project collaboration

• Peer review of writing

• Research updates

• Solving problems and developing alternative strategies to current research challenges

• Research ‘classes’‒ Critical appraisal of scientific literature‒ How to submit a new IRB and renewal documents‒ Basic statistics for the clinician‒ Fundamentals of good scientific writing‒ How to submit a manuscript‒ Maintaining research records

Impact of CORC program on:Individual growth

Literature InterpretationPeer Education

Kristy Pottkotter, PT, SCS, Cert. MDT

[email protected]

Lanikai Hike, Oahu

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Koko Head Hike, Oahu Becoming a Buckeye and CORC

Interpreting the Literature Common criteria in clinical appraisal tools Katrak 2004

• Study aims and justification

• Methodology or Scientific Approach‒ Sample selection‒ Randomization‒ Attrition‒ Blinding‒ Characteristics of outcome measure(s)‒ Intervention‒ Reliability/Validity of Testing Procedures

• Data Analyses

• Potential sources of bias

• Issues of external validity – application of evidence; relationships between benefits, cost, and harm

Katrak P, Bialocerkowski AE, Massy-Westropp N, Kumar S, Grimmer KA. A systematic review of the content of critical appraisal tools. BMC Med Res Methodol. 2004 Sep 16;4:22. Review. PubMed PMID: 15369598; PubMed Central PMCID: PMC521688.

(Slide credit: S. Di Stasi)28

Evaluating the scientific approach

• Study aims, methods, sample selection, intervention

‒ Is the research question interesting and important?

‒ Is the writing clear, explicit, and well-written?

‒ Is the sample representative of the population of interest?

‒ Are the steps of the study explained in adequate detail? (ie. Is it repeatable? Comparable to others?)

‒ Does the approach actually test the hypothesis?

(Slide credit: S. Di Stasi)29

Is it Clinically Applicable?

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Are the findings meaningful and translatable?

• External validity – application of evidence; relationships between benefits, cost, and harm

‒ Should you change your practice?• How does this fit your patient population?• Are there barriers to implementation?• Cost-sparing or cost-prohibitive?• Other things to consider?

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(Slide credit: S. Distasi )

Peer Education

Peer Education

• Evidence based medicine (EBM) is the conscientious, explicit, judicious and reasonable use of modern, best evidence in making decisions about the care of individual patients. EBM integrates clinical experience and patient values with the best available research information (Masic et al 2008)

• Seek advice from experts

• Always go back to the literature

Patient Education

The Emotions of Writing a Manuscript

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Successes and Challenges of being a CORC

Successes Challenges

Adapting practice Adapting practice

Appreciating work of research Justifying research time

Dissemination of new research Encouraging others to adapt

Literature Interpretation STATS/Writing

Greatest Success: *Mentorship*

In Summary…

• If you’re stuck, look it up! Don’t make it up!

• Always strive to improve your outcomes

• Critically appraise the literature (not just the abstract)

• Adapt your practice to new research

• Be an Evidence-based Medicine Champion!

Bridgingthecommunicationgapbetweenlabandclinic

KathyWayman,PT,DPT,SCS

OPTAConference3/24/17

Objectives

• Introduce:oPractice‐BasedEvidenceoClinicalPracticeImprovement

• ReviewCORCpersonnelresponsibilities• ClinicalExample• Discussimportanceofbarrieridentification• PersonalReflection:Successes&Challenges

OSU Sports Medicine

Background

• Practice‐basedevidenceforclinicalpracticeimprovement(PBECPI)canbestudiedtodetermineeffectivetreatmentforlargeheterogeneouspatientpopulations

(HornandGassaway,2007)

OSU Sports Medicine

Background

PBECPI:

o Usuallymorecost‐effective thanRandomizedControlTrials(RCTs)

o Utilizessameclinicallimitationsthatexistinpractice

o co‐morbiditiesnotexcluded

OSU Sports Medicine

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CORCResponsibilities1. Leveragetheuniqueskillsetsofbothclinicians

andresearchers todevelopaproductive,collaborative,andnationally‐recognizedclinicaloutcomesresearchprogram.

OSU Sports Medicine

CORCResponsibilities2. Disseminateinformationgleanedfromthis

interdisciplinaryworkonlocal,national,andinternationalplatforms.

OSU Sports Medicine

CORCResponsibilities

3. Applyevidence‐basedmedicine(EBM)toourclinicalpopulationandrefinetreatmentbasedondatacollected.

OSU Sports Medicine

CORCExample• Purpose:Establishreliabilityof2DVideoRunningGaitAnalysis(VRGA)

• Goal:ClinicalPracticeImprovement

OSU Sports Medicine

OurLabResultsOverallICCReliabilityaveragesbytherapists:

1=Excellentreliability4=Goodreliability6=Fairreliability0=Poorreliability

OSU Sports Medicine

RevisitingHypotheses

1. Therapistswithmoreexperience(≥12months)wouldhavegreaterintra‐raterreliability Refuted

ICCValue Rating

>0.75 Excellent

0.60‐0.74 Good

0.40‐0.59 Fair

<0.40 Poor

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RevisitingHypotheses2. Sagittalplanemeasurementswoulddemonstrategreater

inter‐raterreliability Accepted

• exception=hipextension

OSU Sports Medicine

JointAngle ICCValue(95%CI) Reliability

Ankledorsiflexion 0.54(0.32,0.81) Fair

Kneeflexion atIC 0.72(0.53,0.90) Good

Knee flexionatMS 0.57(0.36,0.83) Fair

HipExtension 0.36(0.17,0.68) Poor

DisseminationtoClinicians CPI

• Zoomwithvideo needstobestandardized• Hipextensiononlyon1sideduetospaceaddressedtreadmillorientationasbestaspossible

• Handlebarontreadmilllimitshipvisibility newtreadmillpurchased

• 30framespersecondoniPad updatedtechnologyto120frames/sec(Pipkin etal,2015)

• Standardizecamerasetup upcoming…willpurchasetripod(Pipkin etal,2015)

OSU Sports Medicine

KnowledgeTranslation(KT)

• Physicaltherapist‐drivenEducationforActionableKnowledgetranslation(PEAK)program goalofmeasuringKTamongtherapists(Tilson etal,2016)

• Programconsistsofevaluationofclinicians’:• Attitudes• Knowledge• Skills• Self‐reportedbehaviors

OSU Sports Medicine

BarrierIdentificationClinician(non‐CORC)Barriers:

• Behavioralassessments

• EBPinterest

• Timemanagement

OSU Sports Medicine

BarrierIdentification

OSU Sports Medicine

Equipment/DepartmentBarriers:• Costsforresearchtimeoutofclinic

• Affordableupdatessuggested• ResourcesforCORC

• Conductresearch IRB

• Statisticalmeasures• Researchguidance

PersonalReflection

OSU Sports Medicine

Challenges:• Divingintotheresearchprocess

• IRBcreationandmaintenance

• Patiencewithself• Timecommitment• Revisionsuponrevisions• Statisticalanalysis

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PersonalReflectionSuccesses:

• Divingintotheresearchprocess…withsupport

• Learningaboutstatisticalanalysis

• Fine‐tuningmanuscriptcreation

• Cooperationofclinicalteam

• Presentationopportunitieso 2educationsessionso 5posterso 1platformpresentationo 1textbookchapter

OSU Sports Medicine

Questions?

Thankyou!

OSU Sports Medicine

References1. Deutscher D,HornSD,DicksteinR,HartDL,Smout R,Gutvirtz M,ArielI.

Associationsbetweentreatmentprocesses,patientcharacteristics,andoutcomesinoutpatientphysicaltherapypractice.ArchPhysMedRehabil2009;90:1349‐1363

2. Grimmer‐SomersK.Incorporatingresearchevidenceintoclinicalpracticedecisions.Physiother ResInt 2007;12(2):55‐8

3. HornSD,GassawayJ.Practice‐basedevidencestudydesignforcomparativeeffectivenessresearch.MedCare2007;45(10Supl 2):S50‐7

4. Tilson JK,Mickan S,HowardR,SumJC,Zibell M,ClearyL,Mody B,MichenerLA.Promotingphysicaltherapists'useofresearchevidencetoinformclinicalpractice:part3‐‐longtermfeasibilityassessmentofthePEAKprogram.BMCMedEduc.2016;16:144

OSU Sports Medicine

www.sportsmedicine.osu.edu

Lucas VanEtten, PT, DPTBoard Certified Specialist in Orthopaedic

Physical TherapyOSU Sports Medicine

Lessons Learned from the Trenches: Developing and Planning a Clinical Trial

Objectives

• Discuss misperceptions going into designing a study

• Describe process from conceptualization of the study through performing the study‒ Study Design‒ Statistics‒ Funding‒ Establishing buy-in‒ Coordinating clinics and research labs

• Reflect on lessons learned and areas for growth in the future

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Myth: Researchers Do NOT Listen to Clinicians!

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Myth: Researching Outcomes on Clinical Treatment is Simple!

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A Clinical Trial is Born…

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Refining the Idea

• Identifying the Population

• Initial thought: we do lots of dry needling, why don’t we look at those outcomes? BUT…o Inconsistent outcome measurement o Not enough people in any particular diagnosis to

learn anythingo Couldn’t easily access data…

• BACK TO THE DRAWING BOARD!!!

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An Idea, 2.0

• Needed a diagnosis that is fairly commonly treated with known outcomes and treatment patternso Patellofemoral Pain!

• Do we have the population to support this study?o Over 2500 diagnosed cases in FY 2014o 700 came to PT!

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Myth #4: Sample size is like 20-40 in PT research…

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Myth 5: Research doesn’t cost a thing!!!

• Let me just go over to the grant tree and…

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Now we have funding… What’s Next?

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Inclusion/Exclusion

• Inclusion:o 18-40 yrso Pain around knee cap with:

• Stairs• Squats• Running

• Exclusion:o Pregnanto Bilateral paino Bleeding disorderso Phobia of needleso Presence of imaging with internal derangemento History of knee surgeryo Received dry needling in past

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Current Protocol

Dry Needling RCT (n = 120)

Gluteal Needling (n = 24)

Baseline Testing3 wk follow up

Quad Needling(n = 24)


Sham Quad(n = 24)


Sham Glute(n = 24)


Control Group(n = 24)


Outcomes

Pain and FunctionWorst, Average, with Activity

Neuromuscular controlLateral heel tap

StrengthIsometric knee extension, flexionIsometric Hip ABD, extension

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Successes & Challenges of the CORC Program

• Research requires discipline

• Communication is key!

• Recognize when help is needed

• Don’t give up. Don’t ever give up!

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Successes and challenges of the CORC program


[email protected]

Successes of the first 5 years….

• CSM 2013 –‒ Attended, no abstracts submitted

• CSM 2014 –‒ 10 podium presentations

• CSM 2015 –‒ 3 educational sessions, 5 poster presentations,

4 podium presentations





Successes of the first 5 years….

• 10+ Ohio PT Association Scientific Symposium and

Annual Conference podiums & platforms

• 12 publications; 4 publications in review

• AWARDS/HONORS/FUNDING:‒ Legacy Fund grants from the Sports Section of the APTA ‒ OSU Service Board Grant ‒ Ohio Physical Therapy Association Grant ‒ Ohio Athletic Trainers Association Grant‒ 2013 Excellence in Clinical Inquiry Award, Journal of

Orthopaedic & Sports Physical Therapy‒ 2015 Outstanding Physical Therapist Award

Other positives

• Individual Level

‒ Developing a growth mindset

‒ Interest in and pursuit of formal research training

‒ National exposure for clinical expertise in their research area (ie. CSM, invited regional talks)

• Social Level

‒ Growing body of ‘change agents’ and EBP champions

‒ Camaraderie and pride in research efforts

Oh, the challenges…

• Difficulty shielding clinician research time early on

• 1 clinician mentor, 5 CORC members

• Lack of formal mission and vision statement

• Lack of transparency and coordination with interviewing process

• Perception of ‘getting out of patient care time’

• 10% FTE is only 10% FTE

• Competition with the Clinical Ladder metrics

• Dissemination of information

• Demonstrating value for front-line clinicians

Keys to a great CORC project

Focused and Feasible

• Identify opportunities within current projects

• Establish reasonable goals and timelines – remember your FTE

• Regular meetings‒ Group collaborate on overlapping ideas, share research

talks, improve accountability‒ One-on-one mentorship developing testable hypotheses,

writing feedback

• Patience‒ Research momentum takes time and persistence

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Getting to the publication finish line

• Identify and discuss writing barriers‒ Time‒ Confidence‒ Motivation‒ Perfectionism

• Know your audience‒ JOSPT? PTJ? Go to their manuscript submission page and write to

their ‘template’ from the beginning

• Writing plan‒ Create an outline for each section – plan your attack!‒ What can I do in 5 minutes?.....30 minutes…. 2 hours?‒ Ask for feedback, early and often

Lessons learned

• The program can’t survive without the clinicians and researchers working TOGETHER

• Cultural support (ie. Leadership/management) is crucial

• Clearly define mission and vision of the program

• Clearly define expectations‒ Develop your ‘meets’ and ‘exceeds’ metrics early and

refine often‒ Confer with clinic managers and clinicians

• Make an open ‘casting call’

• Lean on standard didactics to complement hands-on, real-world learning

• Celebrate and advertise your successes

Tips for making it work in other environments

• Thoughts from my colleagues at CSM 2017

Small, academic institution Private practice

Initiate strong community connections (ie. Local symposia, seminars)

Develop a work group (in-house or community-based)

Reach out to other care providers (ie. Orthopaedists, ATs, PT clinics)

Connect with investigators from a local (or distant!) college or university

Collaborate with your service-learning, free student clinics

Interface with SIG groups in APTA

Connect with your clinical sites

Develop long-standing capstone projects

Identify and engage interested students

Special thanks to Ann Harrington, Leann Kerr, Sara Voorhees, Kellie Stickler, Airelle Hunter, Audrey Elias

Audience Q&A; Panel Discussion

strength in numbers corc program annual opta …...• brandon c, jamadar d, girish g, dong q, morag...

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