Research SummaryI am a health services researcher with a specific interest in quality of care and patient safety. Through my work at the Center for Outcomes and Policy Research at Dana-Farber Cancer Institute, I study the quality of surgical oncology care, particularly as it relates to breast cancer. Our approach to improving quality of care is to understand the factors that underlie variations in care across institutions or specific populations of patients. Such a study of variations in care can help decrease disparities in care as well as identify specific structural or process characteristics that can help to measure quality. Through my collaborations in the Department of Health Policy and Management at Harvard School of Public Health, I work to understand the components of surgical safety and identify ways to improve it. QUALITY OF SURGICAL ONCOLOGY CARE 1. The Influence of Socioeconomics on Post-Mastectomy Breast Reconstruction Variations can occur in the utilization of certain procedures across institutions or according to socioeconomics or race. My first set of projects focuses on understanding variations in the surgical treatment of early stage breast cancer. Using data from the National Comprehensive Cancer Center, we demonstrated that patients of lower socioeconomic status are less likely to receive breast reconstruction than those of higher SES, even when care is provided at an NCCN center. This suggests that access to care cannot explain SES disparities in reconstruction and patient preference or provider bias in offering reconstruction are likely to play a role. In follow up to this study, we are currently analyzing data collected as part of the National Initiative on Cancer Care Quality, a joint initiative of the Rand Corporation and Harvard School of Public Health, to understand whether variations in provider discussion of reconstructive options may explain these disparities. 2. Variation in the Utilization of Surgical Procedures in Early Stage Breast Cancer As part of the original NCCN study, we also noticed that there appears to be an inverse relationship between institutional rates of breast conserving surgery and reconstruction following mastectomy. We are currently using data from the NCCN to further investigate this observation. We hypothesize that institution is the strongest predictor of type of surgery for early stage breast cancer. Furthermore, structural characteristics can be identified that correlate with these rates and may be useful in defining future quality measures. 3. Explaining Institutional Variations in the Quality of Surgical Oncology Care The other project that I am working on in this area strives to investigate variations in institutional performance for proposed quality measures in surgical oncology. We are using the SEER-Medicare database to document institutional variation in an attempt to define benchmarks for quality. We will link SEER-Medicare to several other large national databases to investigate the factors that explain institutional performance for proposed quality measures in surgical oncology. PATIENT SAFETY IN SURGICAL CARE 1. Patterns of Communication Breakdowns Resulting in Injury to Surgical Patients Several years ago, in collaboration with human factors engineers, we performed an observational field study to identify factors that influence patient safety in the operating room. In this study, we identified communication breakdowns and high workload as the most common threats to surgical safety. To further characterize communication breakdowns in the peri-operative period, we are using malpractice claims data from the Malpractice Insurers Error Prevention Study (MIMEPS) to identify recurring patterns and devise interventions to decrease these breakdowns. 2. The Bar Coded Sponge Study In the human factors study, the counting protocol was found to be a significant contributor to high workload and competing tasks. We performed an observational study to further characterize the limitations of the current counting protocol. Simultaneously, a randomized, controlled trial was performed to investigate whether bar-coding sponges in the operating room could improve the accuracy of the current counting protocol. OTHER COLLABORATIVE RESEARCH ACTIVITIES 1. Evaluation of Teaching in the Operating Room Collaborating with professional educators, we use observational techniques to assess the teaching of medical students during their core clerkship and determine the feasibility of teaching and evaluating the ACGME competencies for surgical residents in the operating room. 2. Analysis of Strategies to Reduce Technical Errors in Surgery Technical errors are a leading cause of adverse events in surgery. Similar to the communication project described above, we are using data from the MIMEPS study to identify patterns of technical errors in surgical care to develop and prioritize interventions to reduce such errors. COMPLETED RESEARCH ACTIVITIES 1. A Human Factors Approach to Improving Quality of Care and Outcomes in the Surgical Domain 2. Socioeconomic Factors Influencing Breast Reconstruction in the National Comprehensive Cancer Network 3. The Relationship Between Surgical Volume and Outcome: Is Surgical Volume a Reasonable Proxy for Quality of Care? Back to the top | 
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