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 2009-2010 E.J. Wylie Traveling Fellowship Report

Todd R. Vogel, MD, MPH
UMDNJ-Robert Wood Johnson Medical School
New Brunswick, New Jersey

Background

It is with great appreciation that I have the privilege to report to the Lifeline Programs of the American Vascular Association for the tremendous educational opportunity of receiving the E.J. Wylie Traveling Fellowship.

As the landscape of vascular surgery changes dramatically with the advent of new technology, this also demands the evaluation of these technologies from a global outcomes perspective which will be germane for the future of vascular surgery.  The objectives of my proposal were to visit centers of excellence not only in novel endovascular techniques, but institutions with acclaimed outcomes research centers. 

I utilized the opportunity of the Lifeline Programs of the American Vascular Association to expand my knowledge in both of these realms of vascular surgery.  With the opportunity I wished to expand my current outcomes knowledge and further my understanding of quality initiatives within our field and learn of new techniques and methodologies for outcomes research.  In conjunction with this, I wished to gain an insight into the latest technology for the treatment of abdominal aortic aneurysms with the implementation of fenestrated and branched graft technology.

The Cleveland Clinic, Ohio.

To begin my experience I wished to visit an institution renowned for the implementation and development of new aortic graft technology.  For this experience, I was able to plan an observership of Dr. Roy Greenberg performing fenestrated stent grafts. 

Through the hospitality and generosity of the Cleveland clinic I was able to observe many cases and spend time with Dr. Greenberg which afforded me an understanding of the principals of fenestrated technology.  As well, I had the opportunity to observe Dr. Matt Eagleton and other faculty in the clinic, on rounds, and in the OR.  Furthermore, I was able to gain an understanding into the planning of these grafts.

Beyond the clinical scope, I met with several investigators at the Outcomes Research Consortium at the Cleveland Clinic.  There I was able to spend time with several researchers where there they are using complex Hospital Data Evaluation and Computer Interface as well as performing studies utilizing the NSQIP Evaluation (National Surgical Quality Improvement Program).

The University of California, San Francisco (UCSF).

It was with great pleasure that I was able to meet with the faculty at UCSF regarding advanced endovascular techniques and the use of branched devices for the management of aortic aneurysms.  Through the generosity of Dr. Tim Chutter, I was able to observe the implantation of branched devices and have a deeper understanding of the use of branched technology as compared to fenestrated technology.  As well, I spent time with Drs. Michael Conte and Linda Reilly which provided insight regarding trial creation for claudication and patient planning of branched devices.

With regard to the outcomes, I had the opportunity to meet with Dr. Andrew Auerbach and further understand the AHRQ-funded Multicenter Hospitalist Study.  Dr. Auerbach is currently the principal investigator for studies examining associations between surgical volume, care quality, and patient outcomes.  From this experience I was able to further gain insight into the Quality Measure and Outcome Analysis, Regional Quality Marker Identification, Patient Safety Indicators, and Medical Effectiveness Research for diverse populations.

The University of Washington, Seattle.

For this portion of my travel I had the phenomenal opportunity to spend quality time with Dr. Benjamin Starnes.  During my visit, Dr. Starnes performed several complex aortic Endografts.  Dr. Starnes also spent a large portion of his time teaching me the planning of complex fenestrations.  His generosity and hospitality were incredible. 

While at UW I had the opportunity to meet with Dr. David Flum.  This time was to further evaluate the creation of a multidisciplinary research center established by the Department of Surgery.  As well, I was able to learn more regarding SCOAP (the Surgical Clinical Outcomes Assessment Program).  SCOAP's goal is to improve quality by reducing variation in process of care and outcomes at every hospital in the region.  At more than 50 hospitals in Washington State, SCOAP is a community of clinicians working to build a safer, higher quality, and more cost effective surgical healthcare system.  As well, SCOAP is utilizing complex informatics for the assistance of improving outcomes via data interface and collection.

Australia

This portion of the Wylie fellowship was focused at understanding the healthcare delivery in another country, to understand different methodologies for collection of data, and to further my understanding of population linked data sets.

To achieve this goal I had the opportunity to spend time with several outcomes researchers at the School of Population Health at The University of Western Australia.  While there I met with Dr. Tom Briffa from the School of Population Health who is currently utilizing longitudinal person-based linked hospital and mortality data sets which are in Western Australia.  This study determined population trends in the prevalence of coronary heart disease (CHD) and the proportion of major CHD events that occur in this population.  Dr. Briffa has performed population based studies utilizing longitudinal person-based event-linked files of CHD extracted from State Hospital Morbidity Data and Death Registry.  Further discussions were held with faculty regarding cost-effectiveness of procedures and management, cost effectiveness of resource allocation, quality-adjusted life year analysis, knowledge translation, and further insight into data linkage systems. 

I also had the opportunity in Perth for an observership with Drs. Brendan Stanley and Peter Bray.  Most fascinating was the time I spent in Perth at the planning center for their fenestrated grafts working with the Cook planning team regarding the sizing and planning of fenestrated and branched grafts. 

Further travel within Australia allowed for further exposure to fenestrated technology and allowed me the opportunity to visit Brisbane and the Cook Medical regional office to tour the manufacturing facility and see where they make the branched and fenestrated devices.  I also spent time with the engineers responsible for these and future products.  Following this I visited Melbourne for an observership at St. Vincent’s Hospital with Dr. Michael Denton.  I would also like to thank Phil Nowell from Cook for making the trip feasible from a technical standpoint.

Dartmouth-Hitchcock Medical Center, New Hampshire.

I utilized this portion of the Fellowship to gain insight into the utilization and expansion of registry data.  Through this experience I had the opportunity to spend time with the faculty including Drs. Jack Cronenwett, Philip Goodney, and Brian Nolan.  Through this experience not only did I gain insight, but have developed an understanding of the Vascular Quality Initiative (VQI). The VQI includes an outcomes registry for all major vascular procedures, plus regional study groups to analyze the registry data and initiate quality improvement activities. VQI will provide an opportunity for the long-term data collection that is critical to meaningful outcomes assessment of treatment options for vascular disease.  These regional networks build on the highly successful Vascular Study Group of New England model.

Furthermore, I had the opportunity to attend the White River Junction Outcomes Group’s weekly meeting.  Beyond research, I also had the opportunity to observe cases of Drs. Richard Powell and Mark Fillinger.  I also was afforded the opportunity to spend time discussing the considerations for advanced endografting.

University of Michigan

The final destination of the fellowship was at the University of Michigan and was hosted through the extreme generosity of Dr. Gilbert Upchurch.  This portion of the experience was spent evaluating the latest in outcomes ideology and included time spent with the surgeon s of M-Score.  M-SCORE is a consortium of surgeons and other clinical scientists sharing common interests in health services research.  As well, I had the opportunity to visit the Population Studies Center, Institute for Social Research to learn more about the
University of Michigan Health and Retirement Study (HRS). 

While visiting with many of the faculty, I had the opportunity to learn more about topics including instrumental variables, reliability analysis, and econometric evaluation.  As well I had the opportunity to meet with Dr. Nicholas Osborne who is currently interested in utilizing a modified Delphi approach to consensus development with hopes to develop a Blueprint for Quality Improvement in vascular surgery.  Finally, I would also like to thank Drs. Justin Dimick and John Birkmeyer for their time during my visit.

Conclusions

This phenomenal experience allowed me the opportunity to gain significant research exposure, clinical insight, and foster many relationships for future collaboration throughout my academic career in vascular surgery. 

The opportunity to create relationships with national and international leaders is the motivation for this proposal and follows in the spirit of Dr. Wylie.  Through interactions with leaders in vascular surgery and outcomes research, I hope to further develop my own department’s outcomes research and improve the quality of outcomes research within vascular surgery as a specialty.

Current tangible outcomes from this experience and networking include:  Implementing the utilization of new data techniques including instrumental variables; gaining a detailed understanding of the collaborative effort of VSGNE, and attending quality improvement meetings.   I have begun to lay the ground work implementing a quality improvement in our current state which is the Vascular Quality Initiative (VQI).  I have implemented advanced endografts techniques at my current institution with knowledge gained in managing these complex problems.   I participated in a Blueprint for Quality Improvement in vascular surgery and the round table discussion and I currently hope to participate with Centers for Medicare & Medicaid Services (CMS) in developing a hospital-level all-cause readmission measure that reflects the quality of care for patients undergoing vascular procedures.

After recently meeting Dr. Yao and learning of the history of the E. J. Wylie Traveling Fellowship, I believe my indebted thanks is also in order for Drs John Bergan and James Yao who originated the idea of a traveling fellowship in 1984.  Their vision has influenced many vascular surgeons to broaden their horizons in surgery and also to provide them with personal contacts with leaders and researchers in vascular surgery at home or abroad.

I am very grateful to my current institution, colleagues, and mentor Dr. Alan Graham, a previous Wylie Traveling Fellow, for making the commitment to allow me to travel and gain from this unbelievable opportunity.  I hope to utilize the skill set which I have gained to further the field of vascular surgery, improve outcomes for vascular patients, and progress to be a leader in the field of vascular surgery, like many of the physicians I met in during my travels.   Thank you again to the American Vascular Association for this tremendous educational experience.

Posted February 2011 
 

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