6- FOXcast PT: Andrew Guccione at CSM 2018

Welcome to FOXcast PT, a podcast for clinician’s made by clinician’s. It’s brought to you by FOX Rehabilitation. Find out more at foxrehab.org.

Jimmy: And we’re doing the FOXcast Live thing still here at CSM 2018 in New Orleans. Want to stop by the booth you can hear him say hi to us on our socials, @foxrehab, or on any platforms.

Coming up next a man who needs no introduction, but I will give him one anyway: Editor of a well-known text in geriatrics, former APTA Speaker of the House, Boston University graduate and PT for 40 years Andrew Guccione, professor and founding chair of the Department of Rehabilitation Science at George Mason University.

Andrew, welcome to the show.

Andrew: Thank you, Jimmy.

Jimmy: Glad you’re glad here. You always say you have something to say, and I think it’s 45 minutes later and we’re just getting the question number two.

Andrew: I told you: I’m a boring guy.

Jimmy: Also joining us is a colleague of FOX Rehabilitation Dr. Will. Will welcome back to the show.

Will: Thanks, Jimmy.

Jimmy: You’re getting comfortable in that chair.

Will: This is my spot.

Jimmy: Bringing you guys on together here at CSM because you guys worked on a project together, and I wanted to talk with both of you guys about that because you two were doing it together and all you want to do is talk about great successes of this project. So, where do we want to start? Tell us what the project is and it is.

Andrew: A while back, Tim Fox of FOX Rehabilitation and I were chatting about how to get research going at FOX. And, you guys have this enormous electronic health record.

Jimmy: Big data set.

Andrew: Big, big data set.

Andrew: And Will can talk to you about that for days. That’s his thing.

Will: That gets me going.

Andrew: Yeah, that gets them up in the morning. So we worked quite some time on cleaning up the data set, electronic health records have very rich data but they don’t always have very clean data.

Jimmy: So by clean, you got to set up a certain way so you could do something with it?

Andrew: I’ll let Will explain that.

Will: Yeah, It’s something I don’t quite understand at a very deep level coming into this process which was a learning process for me all the way through.

So back in 2013 we set up our EHR system to capture a lot of structured data – probably earlier than most that did this. Got a lot of data, tons of it. And I think we didn’t know what we had and we also didn’t know or what we didn’t have or didn’t know some of the nuances of the data that Dr. Guccione helped us with.

So things as simple as you know certain programming the system maybe set up where you know there were pieces of data that were not completely right or it allowed for the ability to have a slip of a finger or add some extra digits. And you know you start throwing those into a data set and it throws it off a little bit.

So we were identifying a lot of those things, going back and fixing that data to make sure that we’ve got data that is accurate and clean, as you would say.

And also different statistical things, you know, ranges. This is a range that makes sense. This is a range that really doesn’t make any sense or there must have been some kind of input error here because at the end of the day you’ve got people in a home putting data into a system so you’ve got do things on the back end to try to make sure that the models that you’re running and the things you’re doing with the data – we know it’s an accurate data set. When we talk about clean data, that’s what we’re talking about. It’s a long process.

Jimmy: So what are you guys looking at? Once you’ve figured you had all this data, what were you going to do with it?

Andrew: Well, that became a separate thing because in order to avoid conflict of interest we basically said thanks for the data. We de-identified it. Put a question through institutional review board for ethical approval at Mason. The FOX administration really has not known what we’ve been working on.

What excited me about the data and why I wanted to do a study, not initially clear on what the study would be about, is: You have information on people living in assisted living communities which is a portion of the adult geriatric population that is under described.

So we have studies of community-based living and we have studies of nursing homes, but we don’t have this assisted living sector. And so from my perspective it was a very exciting opportunity to begin to describe what’s happening in this particular group of individuals.

Will: Yeah, well said. It’s a niche of older adults that really couldn’t access care and traditional models and our model brings that care to them and allows us to look at them see how they react to interventions and describe.

Jimmy: So you guys went into this know what you wanted to do a project but really not knowing what the project was. That’s really cool. You knew you had a big pool to draw from. You just jumped in and said great what are we going to find let’s look at stuff.

Andrew: When you do a big data project. One of the things that’s interesting is the data actually tells you what questions you can ask. It’s a little bit different then when you have an idea, and you guys could do this going forward, say, “We want to find out about X. We’re currently not collecting about X. So let’s go in and prospectively collect.”

When you have big data, and this is really one of the challenges everybody’s hearing big data, big data, big data, you only have what’s in the data set. So a lot of it is: “Will, what do you think is interesting this is what I think I’m interesting.” I brought a colleague of mine in who’s a statistician. And it’s like, “Well, what would be interesting to ask? Can we ask that? And will we have some reasonable certainty about our finding because of the quality of the data.”

“Great question but we have 87 percent missing data on that variable end of asking that question.”

So you have to construct it based upon your interests and what you can reasonably get out of the data set.

Jimmy: So FOX Rehabilitation works with older adults up and down the East Coast United States. What’s your ballpark N value? Give me the sexy numbers you know so.

Andrew: Drumroll please!

Will: About 70,000 cases and growing. That actually is only up until a couple of years ago. We probably have double that now.

Jimmy: Anybody listening or watching on Facebook Live right now knows you have a data set with an N of 70,000, they drool. Because usually you’re dealing with hundreds maybe thousands but never really tens of thousands or 70,000. That’s a big number.

Will: And it’s as Dr. Drew was saying that’s where you can draw some some real nice conclusions. I mean you have a group of people that you don’t have to go crazy and separate them into little groups. You know, if the person has this disease process and are this old and their hair is parted on the right side and on that whole thing. When you’re looking at data like this you’re talking about pretty much anyone that we could see. Which is a big portion of the population and it’s usable.

Jimmy: So, where are we in the process right now with this project?

Will: This project has been a learning process for me definitely. You know coming out as a DPT. I think we learned how to read research interpret it apply it to our practice for the most part. I think doing research I’ve realized is a completely different animal with a whole different skill level and set of skills that the DPT doesn’t necessarily prepare you for. And I think just by will and having decently high aptitude, I’ve learned and been able to do it.

But I think that we’re getting there. We’re at the point where we’re going to be submitting to one of the premier journals and in physical therapy fairly soon with this data.

Some of it’s been easier than I thought a lot of it’s been a little bit more difficult than I thought. But overall it’s been less daunting and definitely enlightening. Something I think you know a lot of clinical practitioners should really start to look into this type of approach and looking at your own data maybe setting a standard of care for yourself even if you’re not doing something like this. But at least understanding what you’re doing internally and elevating that bar if nothing else.

Jimmy: Dr. Guccione: something that happened during the process that you didn’t expect when you started anything that came to mind?

Andrew: Oh a lot of things. Any time you go into a dataset you eventually learn it’s sort of like driving a car. After a while you have a feel for it. The engine works a certain way, the data run a certain way. And that’s really helpful because that’s going to tell you where mistakes are. Will mention ranges that don’t make sense like, “Wait a minute. It says here with one patient had 30,000 visits.”

Jimmy: You know that’s a lot.

Andrew: Right. You know somewhere along the line a couple more zeros were added.

Will is underestimating what he’s managed to do. I would say we’re within about 2 weeks of submission. Some touchups to do and probably one final read before sending it off to a journal to get our heartbroken by the reviewers – and we hate you already, even though we don’t know who you are.

Will: We’re preparing ourselves.

Andrew: The review process is tough. I mean it should be tough but sometimes it’s tougher than it should be. And when you work hard on a project, it’s your baby. And when somebody says, “Yeah it’s your baby and it’s ugly,” and then you have to go back and say, “Oh yeah, they’re right. We missed that.”

That’s something that happened. One of the things that Will’s working on now is, as I was reading through the data there was something I went, “Hmmmmm. Are we actually clear who’s in this study?” And we had a go back and check because we probably had put in data from a group of people that maybe shouldn’t have been there.

And what I realized in reading it through is that would have been a very easy criticism for a reviewer to make. And what you really want to do is anticipate all the ways in which your reviewer is going to look for the easy way to ding your paper. We’re also using some statistical techniques which are not very common and it will be interesting to see how that goes over with the reviewers because it’s not the kind of work that they usually see.

Jimmy: Same question for both of you, but with a twist. You mentioned, Dr. Guccione, in working on this project with Will. So, I’ll ask you and Will: What’s something that you’ve seen change in Will through the process. And I want you to answer the same thing. Something that you’ve seen changed throughout this.

Andrew: I’ve really seen him grow tremendously and your understanding of a research question and how to construct it and how difficult it is to ask a very clear question so that the answer you get actually very tightly matches the question.

Jimmy: It’s difficult for me as a podcast host. I can’t imagine with you and statistics.

Andrew: But what happens is as a communicator you know this is the politicians style and people do this with papers. You ask a question and then you give the answer you always wanted a give and when you’re being reviewed and somebody says, “Excuse me but you have a lovely question but you never answered.” You’re never going to get that paper published. So you really want to make sure that there is a tight match between the question and then the answer. The other hard thing is when you say you have a model of the data or your model fits the data, that means the data that you have, the model is an approximation of truth, or it’s truth based upon the particular data set that you have before you. It is not proven for all time and it is really I think one of the hardest things is a model is only an approximation of what we presume reality to be and the degree of certainty or uncertainty we have as to how well we’ve approximated reality and that is hard when you’re writing about what you found to say well really what we’ve found is a derivative of the data not we have found truth.”

Jimmy: Will, what’s something you’ve noticed that you learn through this process?

Will: I’ve learned a lot about research through this process. Not that Dr. Guccione has changed, but I think just the relationship and our interaction has changed. I think it went very much from a project we’re gonna do and we’re going to get it done to something more of a learning experience and a coaching and a mentorship. It is something I value very highly and I thank you for and I think it’s something that’s going to serve his profession well moving forward and having more people engaging in this type of relationship building and research.

Jimmy: Well good luck as you said a couple of weeks away from submitting so good luck for that last question for both of you. What’s your FOXtale? Why did you decide to work with older adults and you still do it?

Andrew: Because I can, because it’s important.

Why did I start? I think that’s hard because I look at it differently now. I think I started from what I would call a compassionate base. There are these groups of people in need and I have some sense of compassion for them.

I think subsequently as I matured and developed hopefully some skills in the area, you recognize that there is a science and that becomes very, very important and I would say now at least at this point in my life and in part because I’m now of the age of people that I study.

Jimmy: Are you one of the 70,000 in the N?

Andrew: I am not one of them. I’m not in assisted living yet, so no I am not in a FOX database but I’d be eligible to be in one. The science is you recognize that looking at the ageing system under conditions of pathology or health become an expert laboratory to understand the science of the human body and the science of ageing both pathologically and healthy. So if anything, I’ve moved from a sort of compassionate base interest to maybe now real of much more of science-based interest particularly as it might be the recipient of the services from my own research.

Jimmy: A great reason to work hard.

Andrew: It’s all self-serving and really it’s always been about me.

Jimmy: Appreciate you taking the time out of this busy CSM Dr. Will Dieter. Dr. Andrew I thank you guys for coming on the show.

Andrew: Thanks, Jimmy.

Jimmy: Thanks for listening to FOXcast PT a clinically excellent podcast. It’s brought to you by FOX Rehabilitation listen to other episodes or read articles and position papers at foxrehab.org.