So here today with Dr. Soo Chan Carusone. And she received her PhD from McMaster in 2006. And we're here to talk a bit about her PhD research. Soo, you, you did your research on cluster randomized trials in a nursing home study. Could you give us some background context of that? >> Sure. So the "randomized" part means that some of the participants were randomized to receive an intervention. And the "cluster" part means that it was the nursing homes that were randomized, to either continuing as usual, or to receive this intervention. So instead of it being the actual residents that were randomized to receive the intervention, it was the whole entire home that was going to be receiving the intervention. So we had 22 nursing homes, in the kind of, greater Hamilton area. >> Right. >> And half of them were randomized to receive the intervention, and half of them kind of continued as usual, and we collected data from them. >> Okay. And so, there's those that didn't, and did receive the intervention. What was that intervention? >> So the intervention was what's called a "clinical pathway". So basically, it's a set protocol. That, the staff were required to follow, should a resident develop something that they suspected was pneumonia. So it involved identifying the symptoms. And then the process that they would go through to diagnose and then to treat, and at what point in time they should transfer them to hospital. So the idea being, that this would help them in the decision-making process, and hopefully avoid unnecessary transfers to hospital. >> Okay, so what you're leading to, the unnecessary transfer, what we would call in this course, the outcome variable. So, how do you quantify the, the success from your study? >> So obviously, in health care, a big factor is cost. And hospital bed days are expensive. >> Mm-hm. >> So, but we obviously want this to be the best thing for the health of the resident. So, we looked at their health outcomes, including death, and then the number of days that our residents in these nursing homes had spent in hospital during the time of the study; >> Mm-hm. >> and then also the number of transfers. So the total number of days, and then also the number of times someone went. So someone might go and stay for ten days; >> Right. >> which would count as ten days and one admission, or there might be ten people who go for one day. Which would be ten admissions. >> So it sounds like a fairly complex study. What was the duration of this work and the cost involved? >> A study like this is very expensive. It would take years to setup. And we collected data for four years to get the required number of people. To, to really know and understand the impact of using this process. >> Okay, so a really large cohorts of people involved with this to make these sound statistical conclusions. >> That's right, yeah. There were about 700 residents I would say ... >> Oh, wow. >> ... who had developed pneumonia, or what was suspected to be pneumonia. >> Right. Now, ideally we would like the cost of this to be justifiable in some way. What's the long term use of the study. Has it been implemented to your knowledge? Or what, what was the final result, ongoing from this work? >> So as part of the study, we went back and we talked to the administrators and the nursing homes, and asked what their experience was, whether they were interested in continuing to use it? And all of the homes said that it was very positive that they would continue using it in their own environment. The paper was published in JAMA and has, have received a lot of citations. >> Okay. >> And so hopefully people are using it and implementing it. But we also presented to the Ministry of Health and have gone out into other nursing homes and, and conferences to kind of promote the pathway. And, and understanding also the pieces that made this successful. So even if it isn't implemented exactly as it was studied here, that the ideas could be implemented. >> Great. Now, I mean, that also touches on one of the other important aspects of understanding the results from the experiment. It's one thing to do all the work and get your final outcome variable measured, but really having a deep understanding of the reasons for why it was successful - or not successful - is really a critical part of experimentation. Can you talk a bit about the qualitative side that you did in your work, to really come to that understanding? >> Sure. So there was a lot of quantitative data being collected throughout this time. And then at the end we also did qualitative interviews. So with the nursing home residents, their family members, the nurses on the floor, the directors of nursing, and the medical directors. And we asked them about their comfort, and preferences around being transferred to a hospital, >> Okay. >> and also how the pathway went. So, what, what actually made it work? Did they think it worked? Did they like using it? And that was really critical for us to understand, what it was about it. So that is necessary for us to try and replicate it. If we, on our own, just thought that we could give someone this pathway and it would be successful; but now we understand that maybe that's not the case, and what pieces need to be in place to increase the chance of success. >> Nice. So I guess stepping back from all of this, I start to appreciate how easy it is to do engineering experiments. >> [LAUGH]. >> because we can just go ahead and do them, but, when the moment we've got people involved, there's all sorts of complexities. Like not every patient in your cohort is identical. Right, so we've got all these disturbances and variations in our systems, ... >> Mm-hm. >> and then the whole ethical aspect of dealing with people. >> And in my opinion, any research should have the component of the quantitative piece, the numbers. But also the qualitative so that you can understand that. So that you can understand what's causing the results; and also, it gives you the stories to sell your intervention. >> Right. >> It really brings meaning to the importance of what you're doing, and the importance of your outcomes beyond the numbers of saving $1,000 per a nursing home resident. >> Right. Now to end off, maybe talk a bit about the current work that you do. >> The hospital that I'm working at right now only has 13 inpatient beds. So the numbers are very small. So a lot, and also very complex. So the importance of the qualitative research is even more in that context. That we, we need to really be able to understand the stories and get ideas of what interventions would work, and then it's a smaller scale, trial of the intervention. Probably not going to be published in JAMA, because you don't have the statistical basis for supporting your evidence. >> Right. Great. Thanks very much. >> No problem.