Questioning Assumptions (pdf)

In 1999, when Donald Likosky interviewed with Gerald O'Connor, PhD, DSc, director of the Center for Evaluative Clinical Sciences (CECS) education programs and associate dean of DMS, about a topic for his PhD dissertation, the recommendation he got seemed like an especially good fit. "When Gerry suggested neurological injury, I immediately thought of my father and oldest brother who are both neurologists," remembers Likosky.

Donny Likosky

At the time, the Northern New England Cardiovascular Disease Study Group (NNECDSG)-a voluntary consortium formed by O'Connor and his colleagues now involving eight surgery centers to improve patient outcomes-had just begun looking at ways to calculate a patient's probability of stroke after coronary artery bypass graft (CABG) surgery. "Donny worked with our data and developed a risk prediction model for stroke that is now used by the American College of Cardiology and the American Heart Association," says O'Connor, also a professor of medicine and community & family medicine at DMS.

But, the more closely Likosky studied the factors associated with stroke the more he began to question long-held assumptions about the condition. "Historically, we have had a very limited definition of stroke," explains O'Connor. "When a patient wakes up after surgery and can't move their arm or can't speak, we say they've suffered a stroke. When another wakes up and exhibits more subtle symptoms-only noticed by family members-we assume they haven't, even though it's exactly the same injury. Donny wanted to look at the problem more deeply."

TAKING A CLOSER LOOK

Working with his colleagues at NNECDSG, Likosky set up noninvasive monitoring devices at Maine Medical Center to capture embolization (clots), low blood pressure, and reduced oxygen levels in the brain during surgeries-key risk factors associated with both overt and subtle injuries. "We are able to link in real time monitoring of these measurements with videos of the procedures," explains Likosky, now an assistant professor in the departments of surgery and community & family medicine.

Since 2002, about 90 patients have been followed in the project. "We produce video clips that we review monthly with our core multidisciplinary group, and we share our findings with other medical centers throughout the region three times a year," he says. "It's giving us a better understanding of variation in clinical practice, and its association with neurological injury. Our goal is to identify key things that can be changed in the process of care to improve outcomes. For example, the team has recently been focused on redesigning care surrounding the management of a diseased aorta. It would not be possible to see these associations if we relied solely on stroke."

"But, we don't restrict ourselves to the knowledge gained from Maine Medical Center," adds Likosky. "We're building on a collaborative approach that Gerry and others started nearly 20 years ago, and that affords us an opportunity to all learn from each other. We want to add additional sites to better understand the benefit of processes of care conducted regionally as they relate to these mechanisms of injury."

"The beauty of the work that Donny is leading is that it is truly groundbreaking," says O'Connor. "In quality of care, sometimes you have to go deeper to generate new knowledge to identify the next things that need to be changed."