Bridging the gap between basic science and clinical practice: a role for community clinicians

Kahn Katherine, Ryan Gery, Beckett Megan, Taylor Stephanie, Berrebi Claude, Cho Michelle, Quiter Elaine, Fremont Allen, Pincus, Pincus Harold

Description

Translating the extraordinary scientific and technological advances occurring in medical research laboratories into care for patients in communities throughout the country has been a major challenge. One contributing factor has been the relative absence of community practitioners from the US biomedical research enterprise. Identifying and addressing the barriers that prevent their participation in research should help bridge the gap between basic research and practice to improve quality of care for all Americans. Methods We interviewed over 200 clinicians and other healthcare stakeholders from 2004 through 2005 to develop a conceptual framework and set of strategies for engaging a stable cadre of community clinicians in a clinical research program. Results Lack of engagement of community practitioners, lack of necessary infrastructure, and the current misalignment of financial incentives and research participation emerged as the three primary barriers to community clinician research participation. Although every effort was made to learn key motivators for engagement in clinical research from interviewees, we did not observe their behavior and self-report by clinicians does not always track with their behavior. Conclusions A paradigm shift involving acknowledgement of the value of clinicians in the context of community research, establishment of a stable infrastructure to support a cohort of clinicians across time and research studies, and realignment of incentives to encourage participation in clinical research is required.

Informations

• Publié par: biomed
• Publié le: 01 janvier 2011
• Nombre de lectures: 1
• Langue: English

Extrait

Kahn
etal
.
ImplementationScience
2011,
6
:34
http://www.implementationscience.com/content/6/1/34

RESEARCH

ImpleSmcieenntacteoinOpenAccess

Bridgingthegapbetweenbasicscienceand
clinicalpractice:aroleforcommunityclinicians
KatherineKahn
1,2*
,GeryRyan
1
,MeganBeckett
1
,StephanieTaylor
1
,ClaudeBerrebi
1
,MichelleCho
6
,ElaineQuiter
7
,
AllenFremont
1
andHaroldPincus
3,4,5

Abstract
Background:
Translatingtheextraordinaryscientificandtechnologicaladvancesoccurringinmedicalresearch
laboratoriesintocareforpatientsincommunitiesthroughoutthecountryhasbeenamajorchallenge.One
contributingfactorhasbeentherelativeabsenceofcommunitypractitionersfromtheUSbiomedicalresearch
enterprise.Identifyingandaddressingthebarriersthatpreventtheirparticipationinresearchshouldhelpbridge
thegapbetweenbasicresearchandpracticetoimprovequalityofcareforallAmericans.
Methods:
Weinterviewedover200cliniciansandotherhealthcarestakeholdersfrom2004through2005to
developaconceptualframeworkandsetofstrategiesforengagingastablecadreofcommunitycliniciansina
clinicalresearchprogram.
Results:
Lackofengagementofcommunitypractitioners,lackofnecessaryinfrastructure,andthecurrent
misalignmentoffinancialincentivesandresearchparticipationemergedasthethreeprimarybarriersto
communityclinicianresearchparticipation.Althougheveryeffortwasmadetolearnkeymotivatorsfor
engagementinclinicalresearchfrominterviewees,wedidnotobservetheirbehaviorandself-reportbyclinicians
doesnotalwaystrackwiththeirbehavior.
Conclusions:
Aparadigmshiftinvolvingacknowledgementofthevalueofcliniciansinthecontextofcommunity
research,establishmentofastableinfrastructuretosupportacohortofcliniciansacrosstimeandresearchstudies,
andrealignmentofincentivestoencourageparticipationinclinicalresearchisrequired.

Background
bringcommunitiesandcommunitycliniciansintothe
Translatingtheextraordinaryscientificandtechnologi-mainstreamofthenationalclinicalresearchenterprise,
caladvancesfromthebiomedicalresearchlaboratory[2,3,6-8],whichhastraditionallybeendominatedby
intoactualpatientcarepracticesandotherprocessescliniciansandscientistsatacademicmedicalcenters,
aimedatpromotinghealthhasbeenamajorchallenge,federalandotherresearchcenters,andpharmaceutical
particularlyforpatientsseenincommunitysettings.Incompanies.
2003,inanefforttoaddressthischallenge,theNationalIncreasingparticipationofcommunitycliniciansin
InstitutesofHealth(NIH)developedtheRoadmapforclinicalresearchwouldhaveanumberofbenefits.First,
MedicalResearch,aframeworkoftheprioritiestheapplicabilityandrelevanceofclinicalresearchtothe
endorsedbytheNIHtooptimizeitsentireresearchcommunitypractitionerswhodelivermostAmerican
portfolio[1].Recommendationsforaddressingthechal-healthcareservicesandtotheirpatientswouldbe
lengeshaveincludedimprovingthepublicandpoliticalimprovedbyderivingdatafromcommunitypopulations
dialogaboutscience[2],recruiting,training,andretain-similartothosetowhomevidence-basedprinciplesof
ingadditionalclinicalresearchscientists[3,4];andcarewillbeapplied.Improvingtheapplicabilityofclini-
finally,reconfiguringthescientificworkforce[1,5]tocalfindingswouldmotivateclinicianstoincreaseadher-
encetoevidence-basedpractices,improvingsurvivaland
health-relatedqualityoflife[9-11].
*Correspondence:[e-mail]
1
RANDHealth,SantaMonica,California,USA
Second,asexpertsinthedeliveryofclinicalcarein
Fulllistofauthorinformationisavailableattheendofthearticle
communitysettings,communityclinicianshavemuchto
A©tt2ri0b1u1tiKoanhLniceetnasl;eli(chettnps:e//ecrBeiaotiMveedcoCmenmtroanlsL.todr.g/Tlihcisenisseasn/bOy/p2e.n0),Acwcheiscshaprteirclmeitdsisutrnirbeustteridctuendduesret,hdeistterirbmustioofn,thaendCrreeaptrivoeduCcotimonmionns
anymedium,providedtheoriginalworkisproperlycited.

Kahn
etal
.
ImplementationScience
2011,
6
:34
http://www.implementationscience.com/content/6/1/34

Page2of11

contribute.Theyprovidecareforpatientsacrossthesystemstoimprovedata-gatheringassociatedwith
spectrumofdisease,areamongthefirsttorecognizeresearch.Yet,ifmeaningfulexpansionofpractice-based
changesinpatients
’
needsassociatedwithshiftingresearchincommunitysettingsistooccur,itisessential
demographicsandburdenofillness,andseepatientsintounderstandthereasonswhyonly3%ofallclinicians
proportiontotheprevalenceofconditionsinourcom-participatedinresearchasof2004[12],andtodevelop
munities.Cliniciansareattheforefrontofpatientcarestrategiestofacilitateresearchincommunitysettings.
associatedwithunexpectedeventssuchastrauma,nat-Noaccuratesourceforthetotalnumberofcommunity
uraldisasters,andpandemicinfections.Theyarealsoinvestigatorscouldbeidentifiedintheliterature,buta
directlyaffectedbypolicy-relatedmatters(
e.g.
,healthcountofcliniciansincludedintheFederationofPrac-
consequencesassociatedwithchangesinpharmacyben-tice-BasedResearchNetworks
’
November2006Inven-
efitsortheclinicalconsequencesofwar,suchasthetoryofNetworksrevealedapproximately9,750
rapidriseinthenumberofindividualswithprostheticphysicians(1to2%ofUSphysicians)asmembers[13].
limbsandposttraumaticstresssyndrome).Further,Since2006,NIHhasfundedClinicalandTranslational
giventheirbroadsetofskills,theinvolvementofcom-ScienceAwards(CTSA)at55academicinstitutionsin
munityclinicianswithresearchcouldfacilitatetheiden-28stateswithagoalof60institutionsby2012when
tification,design,andimplementationofresearchinthetheprojectwillbefullyimplementedandlinked[14,15].
communityonascalethatcouldmakeadifferencetoAmajorgoaloftheCTSAprogramisthedevelopment
theAmericanpopulation.ofteamsofinvestigatorsfromavarietyofresearchdisci-
Finally,participationinclinicalresearchwouldbenefitplineswhocantakescientificdiscoveriesfromthe
communitycliniciansinavarietyofways.Table1out-laboratoryandturnthemintotreatmentsandstrategies
linesthesebenefits,suchas:contributingtothemissionforpatientsinofficesandcommunities.However,even
ofmedicineandimprovingthescientificbasisforthewiththeirintroductiononlyasmallproportionofcom-
practiceofmedicine;allowingclinicianstoremaincur-munityprovidersactuallyparticipateinclinicalresearch.
rentwithnewinnovations;anddevelopinginformationThegoalofthisresearchistoidentifythebarriersand

Table1Benefitstocommunitycliniciansassociatedwiththeirparticipationinclinicalresearch
TypeofBenefitHowCliniciansBenefit
Benefitstotheprofessionofclinicalmedicineand
•
Contributestothemissionofmedicineandimprovesthescientificbasisforthepracticeof
associatedspecialtyorganizationsmedicine.
•
Facilitatesclinicians
’
gainingsupportfromprofessionalorganizationsandNIH.
•
Allowsclinicianstocontributetothedevelopmentofnewknowledge;research
participationprovidesamechanismforthistotakeplace.
•
Supportclinicianstolearnandimplementwhat
’
sbestfortheirpatients.
Benefitstocliniciansintheirroleasclinicians
•
Allowsclinicianstoremaincurrentwithnewinnovations.
•
Affordsintellectualstimulation,anoften-welcomedchangefromdemandsofclinical
practice.
•
Promotesaffiliationwithdesirablecolleaguesandbelongingtoacommunitywithother
professionals.
•
Providesasecondincomestream,whichdiversifiesfinancialrisk.
•
Generatesprestigeofbeingengagedinresearchandprofessionalrecognition(
e.g.
,
authorship,wallcertificates,orCMEcredits).
•
Offersfreemedicationsand/ordiagnosticandtherapeuticinterventionstoparticipantsof
somestudies.
Benefitstocliniciansintheirroleasmanagersoftheir
•
Withpatientswantingmoreandpayorsgivingless,clinicianshavemuchtogainfrom
practicesettingsevidence-basedstudiesthatdelineatecareknowntoimproveoutcomes.
•
Manypatientsseekoutclinicianswhoareatthecuttingedgeofresearchandthusprovide
accesstothebestdiagnosticandtreatmentoptions,someofwhichmayotherwisebe
unavailable.
•
Participationinclinicalresearchservesasamarketingtoolforclinicianstosignaltheir
clinicsasoutstanding.
Benefitstocliniciansintheirinteractionswith
•
Clinicianparticipationinresearchbuildsinfrastructurethatcanfacilitateengagementwith
managedcaremanagedcare.
•
Informationsystemsimprovewiththedatagatheringandtransferassociatedwithresearch.
Benefitstocliniciansintheireffortstoimprovethe
•
Participationbyadiversesetofcliniciansandtheirpatientsismostlikelytoilluminate
healthofcommunitypopulationsrelationshipsbetweencareandoutcomesthatapplytomostpatientsseenincommunity
practice.

Kahn
etal
.
ImplementationScience
2011,
6
:34
http://www.implementationscience.com/content/6/1/34

proposesolutionstochallengesassociatedwithengage-
mentofcommunityclinicianstofacilitatecurrentand
futureCTSAandothercommunityresearcherparticipa-
tioninmedicalresearch.InadditiontotheNIHendor-
sement,valueassociatedwithcommunityprovider
participationisbecomingmoreapparent[16,17].Asa
componentoftheNIHroadmap,considerationwas
giventothedevelopmentofasustainedcadreoflarge
numbersofpracticingclinicianswhocouldparticipate
inclinicalresearchinthecontextoftheircommunity
practice[1,2].WewerefundedbyNIHtodevelopa
conceptualframeworkasamodelforasystemthat
wouldallowalargenumberofclinicianstoparticipate
inclinicalresearchwhiletheycareforpatientsintheir
officesettings.ToassistNIHinthedevelopmentofa
conceptualframeworkasamodelforthisnewtypeof
infrastructurefortranslatingre