Research Profile
I 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.
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Projects
QUALITY OF SURGICAL ONCOLOGY CARE
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.
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.
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
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.
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
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.
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
A Human Factors Approach to Improving Quality of Care and Outcomes in the Surgical Domain
Socioeconomic Factors Influencing Breast Reconstruction in the National Comprehensive Cancer Network
The Relationship Between Surgical Volume and Outcome: Is Surgical Volume a Reasonable Proxy for Quality of Care?
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Funding
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Source: NIH Loan Repayment Program
Title (PI): Variation in the Utilization of Surgical Procedures in Early Stage Breast Cancer: What Are the Underlying Etiologies? (C.C. Greenberg)
Dates of Approved/Proposed Project: 2006-2008
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Source: BWH Center for Surgery and Public Health
Title (PI): Explaining Institutional Variations in the Quality of Surgical Oncology Care (C.C. Greenberg)
Dates of Approved/Proposed Project: 2006-2007
Source: BWH Center for Surgery and Public Health
Title (PI): Evaluation of Teaching in the Operating Room (E.M. Breen, J.E. Hafler)
Dates of Approved/Proposed Project: 2005-2006
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Source: Patient Safety Technologies
Title (PI): The Bar Coded Sponge Study (A.A. Gawande)
Dates of Approved/Proposed Project: 2004-2006
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Source: CRICO/RMF
Title (PI): A Human Factors Approach to Improving Quality of Care and Outcomes in the Surgical Domain (M.L. Gustafson)
Dates of Approved/Proposed Project: 2002-2004
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Select Publications
For the latest articles by Dr. Greenberg, please visit 
Original Articles Reviews, Chapters, Editorials Abstracts
Original Articles
Tole S, Christian C, Grove EA. Early specification and autonomous development of cortical fields in the mouse hippocampus. Development. 1997 Dec;124(24):4959-70.
Christian CK, Gustafson ML, Betensky RA, Daley J, Zinner MJ. The Leapfrog volume criteria may fall short in identifying high-quality surgical centers. Ann Surg. 2003 Oct;238(4):447-55; discussion 455-7.
Roth E, Christian CK, Sheridan T, Ghandi T, Zinner MJ, Gustafson M, Dierks M. Using field observations as a tool for discovery: Analyzing cognitive and collaborative demands in the operating room. Cognition, Technology, and Work. 2004 (6); 148-57.
Dierks MM, Christian CK, Roth EM, Sheridan TB, Dwyer K, Gandhi TK, Gustafson ML, Zinner MJ. Healthcare safety: the impact of disabling ‘safety’ protocols. IEEE SMC Transactions-Part A: Systems and Humans. 2004; 34(6): 693-8.
Christian CK, Kwaan MR, Betensky RA, Breen EM, Zinner MJ, Bleday R. Risk factors for perineal wound complications following abdominoperineal resection. Dis Colon Rectum. 2005 Jan;48(1):43-8.
Christian CK, Gustafson ML, Betensky RA, Daley J, Zinner MJ. The volume-outcome relationship: don't believe everything you see. World J Surg. 2005 Oct;29(10):1241-4. Review.
Christian CK, Niland J, Edge SB, Ottesen RA, Hughes ME, Theriault R, Wilson J, Hergrueter CA, Weeks JC. A multi-institutional analysis of the socioeconomic determinants of breast reconstruction: a study of the National Comprehensive Cancer Network. Ann Surg. 2006 Feb;243(2):241-9.
Christian CK, Gustafson ML, Roth EM, Sheridan TB, Gandhi TK, Dwyer K, Zinner MJ, Dierks MM. A prospective study of patient safety in the operating room. Surgery. 2006 Feb;139(2):159-73.
Betensky RA, Christian CK, Gustafson ML, Daley J, Zinner MJ. Hospital volume versus outcome: an unusual example of bivariate association. Biometrics. 2006 Jun;62(2):598-604.
Greenberg CC, Roth EM, Sheridan TB, Gandhi TK, Gustafson ML, Zinner MJ, Dierks MM. Making the operating room of the future safer. Am Surg. 2006 Nov;72(11):1102-8; discussion 1126-48.
Reviews, Chapters, Editorials
Christian CK and Hergrueter C. Soft tissue infiltration injuries. In: Hansen A, Puder M, editors. Manual of the intensive care of the surgical newborn. Ontario (2003): BC Decker.
Abstracts (Manuscripts pending)
Kwaan M, Christian C, Shellito P, Breen E, Zinner M, Bleday R. “Outcome of the Perineal Wound after Abdominal Perineal Resection for Anal Cancer”. American Society of Colon and Rectal Surgeons Annual Meeting, Philadelphia, PA, May 2005.
Greenberg JA, Greenberg CC, Lipsitz S, Bleday R. “Local Excision of Rectal Cancer: A Meta-analysis”. 87th Annual Meeting of the New England Surgical Society, Mystic CT, September 2006.
Greenberg CC, Regenbogen SE, Rogers SO, Studdert DM, Zinner MJ, Gawande AA. “Patterns of Communication Breakdowns Resulting in Injury to Surgical Patients: An Analysis of Malpractice Claims”. American College of Surgeons 92nd Annual Clinical Congress Papers Session, Chicago, IL, October 2006.
Greenberg JA, Irani JL, Greenberg CC, Blanco MA, Lipsitz SR, Ashley SW, Breen EM, Hafler JP. The ACGME competencies in the Operating Room. Society of University Surgeons Annual Meeting, Phoenix AZ, February 2007.
Greenberg CC, Schneider EC, Ko CY, Lipsitz SR, Malin JL, Epstein AM, Weeks JC, Kahn KL. The influence of socioeconomics on post-mastectomy reconstruction: A study of the national initiative on cancer care quality. Association of Academic Surgeons Annual Meeting, Phoenix AZ, February 2007.
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