Health services and implementation research

Summary

arc organised a one day research strategy meeting of invited attendees to inform arc policy on supporting research into the impact of health policy and the process whereby research advances should be implemented in order to improve the management of patients with musculoskeletal disorders. 

The invited attendees included:

  • Health service researchers (HSR), both those with an interest in musculoskeletal disorders as well as those with methodological expertise
  • Health care professionals
  • Representatives from patient organisations, particularly Arthritis Care

The major aim of the meeting was for arc to outline a strategy for considering how best to translate the results of the basic and clinical research it funds into changing practice, where appropriate.

Background

  • Clinical trials and other studies of medical, surgical, rehabilitation and other approaches to treat musculoskeletal disorders have been relatively successful in enhancing the evidence base for musculoskeletal disease care
  • This evidence base, derived from patients treated in the NHS in the United Kingdom, will increase substantially over the next decade, in large part as a result of the increased investment by investigator-initiated clinical trials linked to the establishment of the Comprehensive Local Research Networks (CLRN)
  • It is not clear at what point the evidence base should be translated into guidelines for practice and how far existing guidelines are appropriately derived
  • Knowledge of how implementation of changes in patient management as a result of accumulating research is achieved is lacking in many areas, especially in musculoskeletal disorders
  • Implementation is constrained by many factors for example, staff training and availability as well as public and professional attitudes.  Knowledge of the relative contribution of these factors in achieving success is limited
  • Both the National Institute of Health Research (NIHR) and Medical Research Council (MRC) are committed to supporting, and in the case of the former, commissioning, research in these areas generally in medicine, but there has been limited activity in relation to musculoskeletal disorders.  In part this may reflect the deficiency in academic strength and interest
  • The current approach by arc to reviewing and supporting research, being predominantly rooted in the biomedical research funding model, may not be appropriate for HSR and implementation research and there may be a case for strategically targeting areas to encourage activity, whilst retaining the requirement for methodological rigour

Structure of Meeting

In brief the meeting was organised around three themes. 

  • The first aimed to identify the approaches that should be adopted to prioritise targets for implementation
  • The second revolved round identifying the nature of the current constraints for achieving implementation of agreed targets
  • The third theme aimed to identify the strategies and methodological approaches that should be adopted to achieve implementation

The summaries below aim to capture the conclusions emerging from each theme based on the general discussions and the outputs from the breakout groups.

1. Identifying Priority Targets for Implementation

Role for systematic reviews

There has to be an evidence base to initiate the path to implementation which should come from a systematic review of the best available evidence. There is a substantial variation in the quality of the published reviews and the existence of a review per se provides no guarantee as to the validity of its conclusions.  There could usefully be a priority setting exercise for stakeholders in arc funded research to determine what reviews should be undertaken.  Interpretation of evidence also varies both between and within ‘class’ of users.

Who should inform priorities?

Buy in from users, including health care providers at the outset is fundamental.  It is important to consider current trends and opinions from both public and health care professionals as implementation cannot take place in a vacuum irrespective of the prevailing climate.

'Doability’

Although in theory the priority setting leading to research should then direct the need to change practice, there is little point in initiating a programme if the implementation is unlikely to be affordable, acceptable or appropriate by the target audience.  Radical changes will always be more difficult to implement than more modest changes.

2. Barriers to Implementation

Technological

Many strategies require the existence of appropriately structured data systems to identify relevant individuals and introduce new interventions.  Access to appropriate technology will vary between groups.  It is also necessary to have the IT systems and knowledge to understand current practice and monitor change.

Public Acceptability

Patients and public may not trust the evidence (e.g. the recent MMR scare).  The nature of the interventions may be too complex to comprehend or does not fit with other policies and approaches. For instance certain exercises may be simultaneously beneficial and harmful to different musculoskeletal end organs. There will be a need for education which requires constant reinforcement at both individual and societal level.  Population-level interventions (e.g. by advertising) may not be less expensive than individual-based activities.

Health Care Professionals

Development of guidelines as a tool to achieve change often fails as they are:

    • Seen as threat to clinical judgement
    • Can lead to guideline overload
    • Often conflict with clinical reality

There is also a lack of organisational will within many health care professionals that guidelines should inform practice.  One problem is that not all research should be implemented and early adopters (e.g. change from standard NSAID’s to coxibs - considered now to have been inappropriate) should not necessarily be seen as role models.  The process as to how research is incorporated into guidelines is unclear and there needs to be a research agenda into the process of developing guidelines, which should include obtaining ‘buy-in’ from health care professionals.  Financial and management issues will dominate professional thinking and need to be factored in.

Institutions

Need to tackle lack of joined up thinking that those who gain from may not be the ones who do the implementation (for example measures to reduce work loss will benefit employers and not the health service).  Institutions tend to look for short term and measurable benefits which can be difficult in areas of chronic disease and secondary prevention. Institutions legitimise current practice and individuals are unable to change without approval.  

 

3. Approaches to Research

Path to implementation

The conventional path is that implementation should be an end stage activity i.e. following successful developmental research (e.g. following a clinical trial).  Considering  implementation however, needs to be built into the development process to ensure a greater understanding of the potential problems.  This suggests a greater need for pragmatic over explanatory studies with the need for trials to consider how the results could be implemented in the trial design.

Tractability

The lack of implementation research in a specific area could reflect intractability and the inability to frame a research question around the specific issue.

What works?

Evidence that both economic and coercion have their places through incentives or sanctions. Clinical conservatism is a major issue and there are a number of ‘inertia’ forces such as ethical and governance constraints to undertaking research.  It is important to identify interventions that are worthy of testing, possibly by surveying health care professionals and, or patients. It will be useful to follow areas of successful implementation elsewhere both within NHS and outside.  Need to develop a toolkit of effective ways of research to implement findings which should specifically follow successful arc funded research developments (e.g. clinical trials)

Capacity building

There is a need for capacity building in several areas including (but not exhaustively): psychology, economics and management applied to musculoskeletal clinical problems

Technology

Needs to engage with patient reported outcomes initiative based on electronic patient record and consider how to use ‘Connecting for Health’ and related initiatives.