Why bother with research?
By Dr Victoria L Keevil, Consultant Physician (Dept Medicine for the Elderly, Addenbrooke’s Hospital) and CHARMER co-applicant
Equity in research and clinical practice
At various points in our professional lives, it is reasonable to consider why we do what we do. One chance for such reflection materialised when I was asked to consider joining the CHARMER study team as a co-applicant. I had research training, a PhD in Epidemiology, and I had used this training to conduct large scale, data driven service evaluations as a full time NHS consultant. Despite this, I felt I was not fulfilling my obligations to fully capitalise on the skills learnt through my doctoral experience. This professional guilt was balanced against the ever-increasing clinical demands on Consultant Geriatricians as the complexity of inpatient caseloads increased year on year. Why would anyone want to make professional life more challenging, by adding in the demands of clinical research and academia?
As I pondered this, I considered an editorial in Age & Ageing that picked out a review of rehabilitation interventions after hip fracture. The authors found that over a quarter of all potential participants in trials of rehabilitation interventions after hip fracture were excluded due to equity factors; things like place of residence (i.e., living in a care home), age, occupation, disability, or socioeconomic status. A major criterion excluding potential participants was cognitive impairment, despite one third of patients who are admitted to hospital with a hip fracture having cognitive impairment.
This imbalance between the research and patient populations raises the possibility, as discussed in the editorial, that inequitable research might inadvertently contribute to inequitable healthcare. If certain population groups are not included in research data, and the NHS continues to prioritise evidence-based care as one of its constitutional commitments, it is going to be hard to develop treatments and services to meet the needs of all patients. Thus, older adults along with other vulnerable population groups may not have equal opportunity to reach their full heath potential compared to the general population.
Evidence was also emerging that research active hospitals had lower risk-adjusted mortality for acute admissions than centres that were not research active, which persisted after adjustment for staffing and other structural factors. Embedding research into everyday practice appeared to benefit all patients, whether they were directly involved or not. Consistent with this, being research active was also associated with a happier workforce and a more efficient healthcare system, leading to the Royal College of Physicians and National Institute for Health and Care Research to publish a joint position statement entitled ‘making research everybody’s business’.
So there seemed a lot of positives about engaging with research opportunities as a Consultant Geriatrician. It was important to support development of evidence-based interventions tailored to the needs of older adults and collaboration could also enhance my own professional well-being.
The role of CHARMER – why did I take up this opportunity and has it lived up to expectation?
The CHARMER programme is working with older adult inpatients, a patient group undoubtedly underserved by clinical research, to develop and test a behaviour change intervention for hospital doctors and pharmacists to encourage proactive deprescribing. This means stopping medicines before they cause harm.
Currently half of older people are prescribed a medicine with a potential safety risk. The CHARMER team’s previous research found that these medicines are rarely stopped; less than 1% of hospital admission medication is proactively deprescribed. Yet 99.8% of patients and carers want doctors to initiate deprescribing discussions in hospital.
We can only speculate as to why older adult inpatients are often excluded from research. In order to enable participation, the CHARMER research team adopted a collaborative approach from the study’s inception. Consultants like myself, specialising in Medicine for Older People, as well as public and patient representatives were included as co-applicants and have been embedded in all CHARMER study activities. The work packages offered further opportunities to engage Geriatricians, both consultants and higher specialist trainees, other practitioners working in healthcare for older people and importantly older patients themselves, in research across multiple sites. For example, Work Package 2 involved researchers, patients and healthcare professionals, from both district general hospitals and tertiary centres, co-designing the final behaviour change intervention. So, as well as investigating important research questions around prescribing, I saw CHARMER as an important resource; helping our workforce and patients to engage with and participate in clinical research.
As we now approach the definitive trial stage of CHARMER, it has the potential to be the largest and most significant trial within the Ageing Specialty of the Clinical Research Network’s portfolio across England. The trial aims to recruit approximately 20,000 older inpatients across 20 hospitals. To achieve this, there will be challenges and more boundaries to push. In comparison to professionals from other specialties, it is not routine for consultants and pharmacists working in Medicine for Older People to take on the role of site Principal Investigator. Specialties such as Cardiology and Oncology have had decades of lived experience of participating in multi-centre clinical trials, building strong relationships with hospital Research and Development departments as well as national research networks.
But, if we are to advance healthcare for older adults through research, it is vital that clinical research is part of our ‘business as usual’. Through clinical academic leadership and research activity we can better serve older patients in the future, helping to shape research agendas and identify where there is uncertainty of practice and need for more evidence. This has been an important consideration in my own motivation to re-engage with research, both via collaboration on CHARMER and my own independent research activity, facilitated through award of a Clinical Academic Research Partnership grant from the MRC.
The CHARMER study has delivered on its promise to better involve older adult inpatients and professionals across the specialty in clinical research. I hope we can continue this success as we enter into the final programme of activity, the CHARMER trial. It is important that we can develop evidence-based interventions for this underserved patient group and to do this we need high quality research that focuses on them.