Chapter 9: Coevolving in the Research and Quality Ecosystem
Over 20 years ago, Bégin et al criticized Canada’s fragmented healthcare system, [1] and described it as “a country of pilot projects.”. Proven innovations were rarely implemented, funded, or sustained, resulting in wasted investment, time, and effort. Unfortunately, the same can be said about Canada’s health research infrastructure, as revealed during the COVID-19 pandemic. At the time, many Canadian researchers looked on enviously as the UK’s National Institute for Health and Care Research (NIHR), among others, rapidly pivoted to launch pragmatic trials among Britain’s hospitalized COVID-19 patients. [2]
Within four months of the World Health Organization declaring a pandemic, the NIHR had completed and was reporting preliminary results from the RECOVERY Trial. [3] It determined that dexamethasone reduced 28-day mortality in patients with severe COVID-19. [4] Enabling and funding multicentre trials of the highest calibre rapidly changed practice and recommendations, with an immediate effect on clinical practice in Canada.
RECOVERY’s success was due to a pre-existing research network, the NIHR. In 2006, the UK government created the institute with a mission to support the National Health Service by enabling researchers to conduct cutting-edge research that focused on patient and population needs. [2] The NIHR can pivot its network quickly to focus on a single research question once it passes peer review. When COVID-19 was declared a pandemic, the NIHR simultaneously and rapidly provided funding, data sharing, privacy agreements, national harmonized ethics approval, clinical care and consent for its 176 members to begin the mammoth task of mounting this large-scale trial. [5]
More research networks are being established internationally. For example, the International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC) facilitates clinical trial operations, such as adaptive platform trials, and creates generic protocols like the WHO Clinical Characterisation Protocol. ISARIC’s goal is to create an international infrastructure that can efficiently keep up with the volume of knowledge required during a pandemic of a novel pathogen. This consortium produced the SOLIDARITY trial that globally evaluated interventions to treat COVID-19. [6]
These large multi-national networks likely saved hundreds of thousands of lives during the pandemic. By comparison, Canada lacked sustained research relationships, funding, infrastructure; [7] an efficient nationally harmonized ethics review process; uniform institutional privacy; and legal reviews. There were no flexible, pre-existing data-sharing agreements between the provinces or across the country. If this infrastructure had been available pre-pandemic, we could have rapidly accessed the real-time provincial data needed to accelerate pandemic research that would have provided comprehensive clinical or vaccine coverage information. [8] Further exacerbating our challenges was the emergency medicine workforce shortfall; in addition, the low numbers of Canadian researchers disproportionately impacted research.
Canada simply lacked the efficient processes or infrastructure to fund, launch and rapidly conduct multi-centre observational studies or trials. As a result, many researchers were unable to collect data at the speed necessary for timely clinical and policy decisions. Nor could they easily embed randomized control trials into routine clinical care, the way the NIHR could. [5] Consequently, Canada’s COVID-19 research output was frustratingly slow and lacked impact.
The 2021 commentary by Lamontagne et al. in the Canadian Medical Association Journal echoed the same problems as Bégin et al. had outlined two decades earlier: Canadian research infrastructure is still inefficient, culturally separate from clinical medicine, and fragmented. [9]
This needs to change.
As mentioned in other sections of this report, more investment and mentorship are required to increase the physician per capita ratio. This includes researchers. To avoid the fragmentation of a myriad of small, local topic-based research groups with limited capacity and sustainability, we must develop a pan-Canadian EM network with highly connected provincial (or geographic) nodes. Each should have the resources necessary to coordinate researchers across the EM spectrum, and facilitate inter-specialty, interdisciplinary and interprovincial collaborations. A fully-integrated research network would incorporate all stakeholders, including patients, knowledge users and government, so we can become a community of practice and learning health system.
The pandemic gave us pause for reflection. Shojania asked: “What problems in healthcare quality should we target as the world burns around us?” [10] Although the COVID-19 pandemic was the most widely recognized and urgent healthcare crisis, climate change, [11] the toxic drug crisis, [12] inequality, and systemic racism also require urgent attention through high-quality research and quality improvement. However, as Shojania points out, investment and effort continue to be spent on quality improvement projects and practice guidelines that have minimal outcome. [13][14] He consequently calls for change, and asks that efforts and funding be focused on the most urgent and impactful healthcare issues.
Emergency medicine faces many of the same questions: how can quality improvement and emergency medicine research evolve in our changing healthcare system to address the most urgent needs?
There is growing concern that traditional randomized controlled trials use exclusion criteria that are not applicable to the real-life, complex, and heterogeneous populations that are seen in our Emergency Departments. [15] Trials in Canadian emergency medicine have often limited recruitment to academic sites in urban areas, including those where researchers have personal connections. [16] This may have led to short-changing patients who have waited many years for the delayed results to become available, and in the meantime their well-being was impacted, with lives possibly lost.
Canadian emergency medicine research does, however, have a strong track record in conducting multi-centre cohort studies, [17][18][16][19][20] and the recent development of a pan-Canadian research network in Emergency Medicine, the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN), [21] (set up by NCER, the Network of Canadian Emergency Researchers) [22] builds on this. CCEDRRN has the potential to enable rapid and more efficient implementation of studies across the country, including adaptive trials that offer the potential for us to identify the best treatment for a given health problem.
According to Lamontagne et al., improving Canadian research will require small steps, avoiding traps by using thoughtful design, performing baseline evaluations with benchmarking, evaluating the return on investment, and conducting dialogue with political stakeholders. [9] The CIHR-IHPSR (Canadian Institutes of Health Research – Institute of Health Services and Policy Research) is incorporating these changes by introducing the learning health system (LHS) framework with a community of practice. [23] The LHS connects researchers, healthcare providers, patients, and communities to improve the most relevant healthcare issue. By adopting quality improvement methods, it uses Plan-Do-Study-Act (PDSA) cycles, baseline evaluations and benchmarks to foster continual improvement. [24] British Columbia’s emergency medicine community is re-organizing to become Emergency Care BC (ECBC), an LHS with a knowledge translation network that aims to implement new insights from research and quality improvement. [25]
Canada is developing big data platforms, an essential LHS building block [15] linked to digital health records, which includes external sources outside the healthcare system. In 2020, the Health Data Research Network Canada (HDRN) was created with the mission to use Canadian data to drive improvements in health and health equity. [26] HDRN is made up of 20 Canadian members who represent provincial, territorial, and national organizations with health data holdings. These are comprised of patient-orientated research unit data platforms [27] that can be used by researchers, policymakers and decision-makers. The barriers to rapidly and efficiently accessing multi-jurisdictional data are diminishing but will take time to overcome; yet HDRN is a critical piece of the much-needed pan-Canadian research infrastructure.
Researchers have historically worked in silos, but emergency medicine culture is changing rapidly. Canada’s pandemic-driven research networks include CCEDRRN, NCER, the Long COVID Web, and the Emerging and Pandemic Infections Consortium [28] (one of five national hubs awarded through the Canada Biomedical Research Fund by the Government of Canada), [29][30] Aligned with the Quintuple Aim, [31] emergency medicine research is emphasizing patient-orientated outcomes. [32] In addition to patients, these research collaborations extend across multiple disciplines, methods, and stakeholders, knowledge users, and government. Inspired by the achievements in the UK, resources need extending to expedited, nationally-harmonized ethics review, together with simplified privacy and legal approvals of research studies that include trials. This will require long-term government investment, and further development is needed to ensure sustainable funding.
Emergency medicine research is well-poised to contribute to learning health systems.
Recommendations: Coevolving in the Research & Quality Ecosystem
Increase funding, training, infrastructure, and planning to support and expand the emergency medicine research workforce.
Develop a pan-Canadian EM research network with highly connected nodes. Each node should have the resources necessary to coordinate researchers across the EM spectrum and facilitate inter-specialty, interdisciplinary and interprovincial collaborations. This network should incorporate all relevant stakeholders, so we can become an integrated community of practice and learning health system with a focus on achieving the Quintuple Aim.
Facilitate data-sharing across jurisdictions. Develop a simplified and harmonized national approach to funding, data-sharing, privacy and legal agreements, ethics approval and research consent. Eliminate the need for redundant data, ethics, and privacy processes for multicentre and multi-jurisdictional research.
Link clinical care, quality improvement, knowledge transfer and knowledge translation using models to move research rapidly to the bedside.
Emergency medicine research efforts and funding should focus on the most urgent and impactful patient and population healthcare needs.
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