Thursday, 5 January 2012

New Research Area: Scientific Research vs Healthcare Delivery Research

Conventional Scientific Research Vs. Health Care Delivery Improvement Research: Both are important

I write with the confidence that many of you would already know about this..........

Research is about finding out if a proposed intervention works better than the current one. Is a new drug, operation, investigation, procedure, etc effective compared to an existing one? To find that out by definition research is a must and RCTs are essential (as RCTs are considered to be the highest form of conventional scientific research). Since the question is about the proposed intervention (and not about anything else) the confounding variables are reduced to minimum (inclusion and exclusion criteria etc). That will be conventional scientific research.

We all know real life clinical practice is not delivered under controlled research conditions.

Healthcare Delivery research (operational research) therefore becomes important. The question here is, what worked elsewhere and how to make it work for us in real practice where there will be all sorts of variables. This kind of research is important for two reasons: a) to put into practice the good things discovered by research (introduction and roll out of research findings - could probably be called innovation) and b) to discover what actually works (or does not work) in our location and to see if we can do better (clinical improvement)

I believe an example is the critical care outreach teams; apparently RCTs have not conclusively shown that they work. But in some hospitals they work very well. Now, we have such outreach teams in all hospitals; however it works in some hospitals and does not in others (again so much like RCTs finding different things when variables are changed) obviously the operational variables are different in each hospital. The point though is not if critical care outreach teams have been proven by RCTs but why it works in some places and do we want to make it work in our place?

So in practice, the question for healthcare delivery research is not whether something works (as that is an RCT question); the real question would be 'it works in St Elsewhere (even though it may or may not have been proven in RCTs); how do we make it work for us?' Where we know what works it is also about how to deliver that to every patient in our care.

As a surgeon I can say that the common operation of laparoscopic cholecystectomy surged to popularity even before any strong RCTs were done.

Let me state very clearly, that I am not for a moment supporting/encouraging dubious practices. I am talking about the existence of a different branch of research in which doctors have not been engaged actively in the past. I am suggesting that for most of us practising in normal day to day circumstances clinical operational research and/or management to benefit healthcare delivery could be equally relevant in providing good care (as RCTs). Most often the ideas for operational research comes from proven conventional research findings.

I would fully understand if trainees do not engage in this due to the expectation that they do conventional research. Doctors who are not in training ie consultants, SAS and specialty doctors could consider getting involved in this kind of work (clinical operational improvement work). This is not operational research from a management or administrative perspective. This is clinical care delivery operational research. If you thought this is managerial or admin work, sorry, you are mistaken. This is as directly clinical as it gets.

Clinicians have been taught what is best. This new area of activity and research shows us how to deliver that best to every patient at all times.

You could make a start by learning more about this. Check out IHI various courses including the on-line ones, NHS Institute's courses and of course the CQI course at NLG NHS are basic starting points to kindle interest in the area. Warwick's CSI course is reputed to get you thinking in this direction.

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