March 08, 2017
By Brian Whepley
|Brian Pate, M.D., is the inaugural implementation scientist for the American Academy of Pediatrics|
A major challenge with new clinical guidelines is getting doctors and other providers to promptly adopt the recommendations that define the best practices in patient care.
Although the guidelines are put together largely by experts in a particular condition, sometimes there's a disconnect between science and practice.
"The problem is that it all works pretty well in the ivory tower, but sometimes has no practical relevance or connection to the practicing pediatrician," said Dr. Stephen Kairys, a New Jersey pediatrician and medical director for the Quality Improvement Innovation Networks for the American Academy of Pediatrics.
That's why, for the first time, an AAP clinical guidelines committee will include an "implementation scientist," and Dr. Brian Pate, chair of the Pediatrics Department at KU School of Medicine-Wichita, has been chosen to play that inaugural role on one addressing infantile hemangiomas, the purplish, vascular abnormality that looks like a birthmark.
Pate, a pediatric hospitalist, has extensive experience in quality improvement, having helped found the Value in Inpatient Pediatrics Network, which consists of 160 hospitals and is part of a broader AAP effort to use measures and quality improvement processes to implement guidelines and improve care.
"Quality improvement is a team sport, and he has shown himself to work collaboratively in groups," said Dr. Mark Garber, VIP's medical director and a professor of pediatrics at the University of Florida College of Medicine. "He's a very interactive and dynamic leader. He works really well to make sure everyone's voice is heard."
"The goal is to have somebody like Brian, who understands quality improvement but who is also a practicing pediatrician, to be involved in these guidelines from the beginning," Kairsys said.
Pate says he's honored to be the first such scientist and will work on a committee consisting of infantile hemangioma specialists, general pediatricians, communications and electronic health record experts and others. His goal is to use quality improvement tools to help fellow pediatricians and close the "long gap between publishing and a change in practice."
The role is in its infancy, of course, but Pate has ideas about what it will entail.
"An implementation scientist will focus, as the guideline is being developed, on how people will use that guideline," he said, asking: "Are the recommendations clear? Are they relevant? Can we redefine that recommendation into a metric that anybody can use in their clinical practice?"
"An implementation scientist will influence the creation of the clinical practice guideline and tack onto the end specific tools to allow them to adopt it," he said.
"Metrics will be one tool, establishing a baseline measure of past performance and targets for improvement. That will give practicing physicians a target to aim for with new, recommended treatments."
Both Pate and Garber mention creating toolkits to accompany guidelines as being part of the role. "The toolkit might be educational materials. It might be a scientific lecture, if you need to convince doctors or nurses or other health care workers that the key action statements are evidence-based and should be implemented," Garber said. "It might be order sets, for people like hospitalists. It might be a diagram with arrows and decision points. It might even be a smartphone app."
"By publishing a guideline with some of the tools needed to implement it, I hope that it will have a more bottom-up feel to doctors, more of a 'these are for you to do your work' instead of 'these are instructions coming down from on high,'" Pate said. "You don't help a physician see patients better by telling them what to do. You help them by capturing valid data about their outcomes, and then inspiring the desire to change."
Kairys said that infantile hemangioma is a good test project for the new role, because the guidelines need updating and because they are not likely to be controversial like some topics.
"This is not a real common diagnosis, but it's one where we think it's really important that we're getting things right, and there's a lack of clarity as to what that looks like," Pate said.
Hemangiomas carry the risk of ulceration and bleeding, and some grow large enough to disrupt the normal anatomy of the face, which "can be very cosmetically difficult for kids as they get older," Pate said. Treatments can include oral and topical medications as well as surgery and lasers. "It's important to identify infantile hemangioma that could go through rapid growth in a way that increases the risk of a poor outcome for the patient."
Pate acknowledges he's no expert in the condition but has come to believe that's a good thing, as it allows him to focus on the implementation role and to better serve, in a sense, as a consumer advocate for pediatricians who may see the condition only occasionally.
"He will probably serve as a very smart, qualified physician listening to the conversation. He understands statistics and data, and will probably also serve as a qualified provider," Garber said.
To the role, Pate brings both experience and personal skills.
"He's well grounded in AAP background and methodology," Kairsy said. "He's a great first choice for this. He's a consensus builder. He knows how to get to the goal line."KU School of Medicine-Wichita