Dissemination of research results to clinicians an art in itself
Ann Silversides
CMAJ 1997;156:1746-7
[ en bref ]
Ann Silversides is a freelance writer living in Toronto.
© 1997 Ann Silversides
In brief
Communicating the results of health care research to change the way clinicians practise has become an art in itself. During a recent workshop on "research transfer," participants discussed the importance of explaining evidence to clinicians, the public and government.
En bref
Communiquer les résultats de recherches sur les soins de santé aux cliniciens afin de leur faire adopter de nouvelles pratiques est devenu un art en soi. Au cours d'un récent atelier sur le «transfert des résultats de recherches», les participants ont discuté de l'importance d'expliquer les données probantes aux cliniciens, à la population et au gouvernement.
Until recently academics interested in health care toiled at their own "curiosity-driven" research. Their findings, however interesting, were barely communicated and usually had minimal impact on health policy.
Some things have changed, a recent national workshop for representatives from Canada's health research and policy units was told. Today, more researchers are employed outside universities, public granting agencies are demanding "partnered" research and the growing number of private companies funding research are insisting on results. Meanwhile, governments, health care providers and institutions have developed an appetite for research -- especially protocols and clinical practice guidelines (CPGs) that can be applied immediately.
These trends mean that the "research-transfer function," which is broadly defined as communicating research results and promoting their application, has been thrown into the spotlight. "This workshop was really born out of frustration," said Cathy Fooks, director of research transfer at the Institute for Clinical Evaluative Sciences (ICES) in Ontario.
"We all go to academic conferences, but there is almost no talk about research transfer," she told the 45 participants, adding that only about 3% to 5% of research funding is spent communicating findings. The workshop was cosponsored by ICES, the Toronto-based Institute for Work and Health and the Centre for Health Economics and Policy Analysis at McMaster University.
Morons or geniuses?
Successful research transfer depends on market demand and timing, said Steven Lewis, chief executive officer with Saskatchewan's Health Services Utilization and Research Commission (HSURC). The benefits of making changes because of research findings should be obvious, he said, and incentives should be positive and somebody influential should be promoting change. If the Saskatchewan commission had to "rely on goodwill and the propensity of clinicians to cut their own incomes, little would change."
Lewis said physicians often argue that products of research such as CPGs dictate rather than guide a course of action, but organizations like his want to "create a culture of evidence-based medicine" and give clinicians practice tools. The more doctors demonstrate that they are thinking about and are sensitive to evidence, the less likely it will be that governments and other insurers will create arbitrary categories for practice, he said.
Meanwhile, those who suggest that CPGs and protocols are "just a way to save the government money" are ignoring reality, Lewis argued. "Governments set their health care budget once a year and we can safely assume the money spent in 1 year will be [similar to] what was spent the previous year. Clinicians can practise either brilliant evidence-based medicine or anecdote-based wasteful medicine [but] the budget will be the same.
"In other words, we can practise like geniuses or like morons, and it won't make much difference to overall spending. However, practising more like geniuses means the public gets more units of good health for the money spent."
Unfortunately, Lewis said, good practice is not actively promoted and there are no adverse consequences for those who practise poorly. "The system looks with equanimity on good and bad practice, and there seems to be remarkably little public anxiety about things like wide practice variations."
Although the health care system may not be sufficiently receptive to research results, communication specialists face problems within their own organizations. A stumbling block for those in university-affiliated centres is the reality that researchers win favour for publishing in academic journals but receive no reward for communicating research results more widely.
Dr. John Frank, director of research at the Institute for Work and Health, noted that even when a research organization has staff with expertise in research transfer they "aren't always made welcome" by the research team. "There is a cultural clash that is slowly being worked out."
Alberta's efforts
Attempts to communicate research findings, such as the Alberta Clinical Practice Guidelines Program, are sometimes hard pressed to explain their impact. "We were just slaughtered on our prostate guidelines," said Nancy Rowan, project manager for the program, which was funded jointly by Alberta Health and the Alberta Medical Association (AMA).
"We were in shock. . . . I think we emphasized too much what doctors should not do instead of what they should do," she speculated. However, a subsequent initiative involving cardiovascular guidelines was an overwhelming success, and an AMA survey of physicians found that the CPG program ranked second only to insurance programs in terms of popularity.
Saskatchewan's HSURC scored some early victories in promoting changes that improved practice and saved money, Lewis said. However, it has also had some failures -- its work on high rates of cataract surgery and unnecessary use of ultrasound had little impact on practice patterns.
Some organizations lack tools to measure their success at communicating research results. For example, no one really knows the impact of CPGs on practice in Alberta because the province's health care records are not detailed enough to provide an assessment, Rowan noted.
Meanwhile, Catherine Cornell, vice-president of Ontario's Scarborough General Hospital, gave a sobering account of the leading causes of changes in clinical practice in community hospitals. She said the top 5 causes are:
- doctors attending US specialist conferences;
- changes in ministry funding;
- doctors moving into management roles and dealing with financial accountability;
- the influence of drug and equipment company representatives; and
- peer comparison, as revealed, for example, in the ICES Practice Atlas: Patterns of Health Care in Ontario.
If ICES hadn't "embarrassed us in front of the whole province," said Cornell, the hospital would not have taken steps to reduce its relatively high rates of transurethral resection of the prostate.
In addressing "the real world in hospitals," Cornell noted that doctors are not hospital employees so "we can't tell them what to do. As a result, we focus on patients." To help reduce the hospital's high rate for cesarean section, staff educate mothers who have undergone the procedure about attempting a vaginal delivery the next time. "If you are developing guidelines I urge you to develop a patient version first," she said.
She also noted that hospitals often respond to financial incentives rather than perceived need or research-based evidence. Her hospital opened a lipid clinic because the costs were covered by a drug company; it opened a sleep laboratory because Ontario Hospital Insurance Plan rates were high.
Today, budget cuts and restructuring mean that "new questions are being asked, like 'Why do this at all?' "
Richard Barnhorst, director of the health policy branch at Ontario's Ministry of Health, agreed that the pace of decision-making is quickening. He stressed that governments "make decisions and they will do so with or without evidence. . . . I sit on the Senior Management Committee of the ministry and I have rarely seen research explicitly [discussed]."
Even though there is a general sense in government that research is too often "wilfully irrelevant," he acknowledged that policy priorities themselves are not very clear. His ministry has published a business plan, and he suggested that researchers "find out what is needed and then be willing to do research to address the needs of the Ministry of Health quickly and flexibly."
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