Review: Integrating Research and Practice 1/2

25. october 2015 at 8:00 | Veronika Valdova, ARETE-ZOE |  Medicine & Pharmacy

Review:Integrating Research and Practice:Health System Leaders Working Toward High-Value Care: Workshop Summary (2015)

The Institute of Medicine Roundtable on Value & Science-Driven Health Care introduced an intriguing vision of
"a continuously learning health system in which science, informatics, incentives, and culture are aligned for continuous improvement and innovation, with best practices seamlessly embedded in the care process, patients and families active participants in all elements, and new knowledge captured as an integral by-product of the care experience" (p xi).

The authors argue that care is often not relevant due to failure to apply the evidence about treatment efficacy as a result of lack of knowledge, accountability, coordination support or insurance, or as the result of misplaced patient expectations (p xi), and that datasets generated through the normal course of health care offer great potential for achieving the "triple aim"-improved care, better health for populations, and reduced health care costs (p 1).

The main topics discussed in the book are: Continuous learning and improvement in healthcare, integration of clinical research and practice, sustainability, regulatory oversight and its challenges, and stakeholder culture which accommodates culture of learning and patient and clinician engagement. Continuous learning of organizations is then seen as the utmost priority.

Efforts to share information across systems are designed to compare data for quality improvement, benchmarking, for public health and drug safety surveillance (e.g. Mini-Sentinel), for the conduct of pragmatic clinical trials, or comparative effectiveness research (CER) through PCORnet (p 3).

In another workshop, Raymond Baxter and Elizabeth McGlynn described the PORTAL network developed by Kaiser Permanente which sees research as a critical part of its strategy (p 21).

"PORTAL's contract with PCORnet focuses its efforts on three specific groups of its 11 million patients: colorectal cancer patients, with an emphasis on treatment and how patients navigate survivorship; 330 adolescents and adults with severe congenital heart disease; and obesity in adults" (p 24).

In workshops relating to the integration of clinical research and practice the speakers introduced among other projects REDUCE MRSA trial (p 46), Improve Care Now Network created to transform care for children with inflammatory bowel disease (p 48), and embedding research into clinical care at Group Health, a nonprofit health system with about 600,000 members in Washington State (p 50).

In a discussion on learning healthcare systems, Brent James recommended Realistic Evaluation, material that that proposes an alternative to the randomized clinical trial that may be useful for evaluating context-specific interventions, and Meta-Analysis by the Confidence Profile Method, that describes methods that could be used to construct more appropriate designs for testing complex interventions (p58).

In section on sustainability, Brent James introduced Intermountain knowledge management system that, according to his experience, saves lives. In addition, the experience suggests that better care is almost always less expensive (p 60).

Concerning business imperatives, Thomas Garthwaite said there are a number of factors that can contribute to sustainability: good quality care is the most effective and efficient care, with reduced variable cost, reduced complications, shorter lengths of stay, and engaged nurses who feel more valued and proud of their efforts. Improved staff retention and morale and reputation enhancement are another benefits that can help grow market share (p 63).

In section Regulatory oversight, Nancy Kass proposed a new way of thinking about ethics and human research, from the current regulatory definition, to a "learning health care system paradigm" in which research and care are integrated (p 72). The most controversial of the obligations, based on feedback Kass received holds that patients have an obligation to participate in the enterprise of learning (p 75).

James Weinstein in his contribution compared RCT and observational trials on spine outcomes. Weinstein and his colleagues found that the RCT was not much better than the observational trial, and that patients had a great deal of decisional regret if they were not involved in the decision-making process. He said that rather than have the process be one of informed consent, it should be one of informed choice, with the patient actively involved in the decision-making process (p 79).


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