Series: The research agenda for general practice/family medicine and primary health care in Europe. Part 6: Reaction on commentaries – how to continue with the Research Agenda?

Abstract

The Research Agenda should be used as a key reference point to which new research should relate its usefulness and added value. Primary care evolves towards more interdisciplinary care, and research should focus more on the core competency of person-centred team care. There is an urgent need to develop clear definitions and appropriate research instruments for this domain. It will be a particular challenge to study comprehensive approaches in primary-care patients with multi-morbidity. The Research Agenda and the commentaries on it show future directions for primary care research. There are challenges related to a changing society, the shared responsibility and guidance of research by professionals and citizens (patients), and the need to fully integrate research as part of primary healthcare provision. There will be a need for a prioritization of spearheads to guide primary care research for the next decade: translational research, research on equity and health differences, on chronic disease and health systems research. This can not be realized without the development and maintenance of a solid research infrastructure: easily maintained and accessed observational databases, helpful information technology, strategies and techniques for patient involvement, advanced research training possibilities, and the development and validation of appropriate research instruments and outcome measures to capture the different challenges. Worldwide, primary care not only is a priority for health care policy, but it needs to become a research priority as well.

Key words::

• general practice/family medicine
• research agenda
• policy
• challenges
• indicators

Background

The ‘Research Agenda for General Practice/Family Medicine and Primary Healthcare in Europe’ (in short ‘Research Agenda’) was published in September 2009 by the European General Practice Research Network (EGPRN) (1). It summarizes the evidence relating to the core competencies and characteristics of the Wonca Europe definition of General Practice/Family Medicine (GP/FM)(2), and specifies evidence gaps and research needs. The European Journal of General Practice published this document as a series of articles. Background, objectives and methodology were presented in part 1 (3). Results on all core competencies were presented and discussed in parts 2 to 4 (4–6). A summary of the Research Agenda and its implications for general practitioners/family doctors, researchers, research organisations, patients and policy makers, was dealt with in part 5 (7). For all core competencies, international experts gave their views and reflections (8–10). This article presents reactions on these commentaries. It also reflects on possible indicators for a successful dissemination (process) and implementation (outcome) of this European Research Agenda for GP/FM and primary health care.

Methodology and research domains of the Research Agenda

The Research Agenda formulates specific research themes, based on the six core competencies as defined by Wonca Europe. However, other sets of principles have been suggested: direct accessibility, generalism, continuity of care, and a family and community orientation (11). The Research Agenda mostly covered these principles, whereas the eleven essential characteristics of the discipline were also considered equally during the literature searches (2).

By choosing a search strategy using the MeSH terms ‘primary health care’, ‘family practice’ or ‘general practice’, we had to face problems with inappropriate or incomplete labelling or indexing. Therefore, we may have missed some population-based community oriented trials. Furthermore, our reviews were sometimes limited to meta-analyses, systematic reviews and RCTs, excluding opinion papers or non-systematic reviews (11). Moreover, the Research Agenda is mainly based on a comprehensive literature search and review, and therefore, some new directions or research options may have been missed, making this Research Agenda less a ‘preview’ than a ‘review’ document, as was suggested by André Knottnerus (11). The Research Agenda aimed to provide guidance for future research and policy. There was no intention to exclude or discourage research outside the Agenda, because research should stimulate new directions and insights. However, the Research Agenda should be used as a key reference point, to ‘preview’ new research fields, and to which suggested new research should relate its usefulness and added value.

The Research Agenda could also be regarded too much doctor-centred, rather than person-centred or including other disciplines (11). Certainly, primary care evolves towards more interdisciplinary care, and research should focus more on the core competencies of person-centred team care (12). Person-centred care, comprehensive and holistic approaches are all broad concepts, which are not easily translated into well defined research topics. Nicky Britten suggested that ideological elements might have distracted researchers from making clear definitions and developing appropriate research instruments (9). However, both elements are repeatedly mentioned in the Research Agenda, which points out the urgent need for further research in these domains.

Research on primary-care patients with multi-morbidity has been primarily considered within the research domain of specific problem solving skills. However, it will be a particular challenge to study comprehensive approaches in this specific patient group.

In the commentaries, some suggestions were made about the improvement of the Wonca Europe definitions: ‘relationship-centred medicine’ was suggested as an extra dimension of person-centred care, and ‘complementary medicine’ was suggested as an alternative term for holistic approach. The last suggestion had been already pointed out in the Research Agenda. Describing the different domains of the Wonca-definition more clearly and defining good outcome parameters for research in primary care are likely to remain challenges. It might be useful to go into the more specific characteristics of each domain, but also to study the general or ideological issues behind them, and to look at their ‘interfaces’, which may result in either overlap or conflicting demands.

Indicators and outcome measures for implementation of the Research Agenda

It is necessary to develop good indicators and outcome measures to evaluate the dissemination of the Research Agenda (process) (Table I) and the implementation of its recommendations (outcomes) (Table II). However, for some of these outcome indicators it will be difficult to determine exact numbers, for instance the number of proposals and project applications that are based on or mention topics advocated by the Agenda.

Table I. Process indicators to evaluate the dissemination of the Research Agenda.

• How many papers are citing the Research Agenda articles (‘citation index’)?

• How many new project applications or research proposals are referring to the Research Agenda?

• How many presentations on the Research Agenda are given at national conferences?

• In how many training programmes (undergraduate, postgraduate, and research courses) is the Research Agenda used or integrated?

• Is the Research Agenda used or referred to by journals, and on websites?

• How many young researchers and research units are using the Research Agenda to define their project or prioritize their research lines and aims, respectively?

• When and how is Europe informed by the Research Agenda about priorities to influence EU policy on research (for instance Anniversary Fund)?

• Survey to evaluate the knowledge about the Research Agenda and the importance researchers and stakeholders (research units, funding institutions) give to the Research Agenda

• What is the Impact Factor of the Research Agenda articles?

Table II. Outcome indicators to evaluate the implementation of the Research Agenda.

• Is the Research Agenda used as a criterion for the theme of EGPRN conferences and the critical appraisal and appropriate selection of papers and project proposals for funding respectively?

• How many abstracts at EGPRN conferences are related to the Research Agenda?

• How many proposals and project applications mention the topics as proposed by the Research Agenda?

• How many project evaluations (evaluators) are referring to the Research Agenda?

• How many recent and future publications (e.g. as retrieved from MedLine) in the different domains of the Research Agenda are following the recommendations?

• How many papers show new directions?

These indicators would also call for timely updates of the Research Agenda and additional reviews with improved search strategies, and possible links to related documents in and outside Europe. The author group of the Research Agenda might perform update searches in the different domains in the following years, so that there is a common schedule for updating and evaluating the Agenda.

The indicators should be followed on different levels:

• The international and European level: international research agencies either affiliated to Wonca, such as the Wonca workgroup for research and the International Federation of Primary Care Research Networks (IFPCRN), or to other international organisations, and Wonca Europe related core networks such as EGPRN and Wonca Europe Special Interest Groups;

• The national level: national colleges or associations of GP/FM, national governments or governmental committees, other (public and private) funding organisations;

• The local level: local research teams, practice-based networks and universities.

Three challenges for primary care (research)

European primary care, including GP/FM research, has to face important challenges.

First there are the societal challenges, with common transnational issues such as ageing, chronic illness, multi-morbidity, migration and cultural diversity, environmental and lifestyle hazards. Health care policy should focus on providing effective healthcare with limited resources, and with special attention to equity and to patients of low socio-economic status who have to cope with multi-morbidity. There is a need for more interaction between research and health care policy to conceive, design, implement and iteratively evaluate health care systems that are effective in providing sufficient care to those who need it most and that are cost-effective (11).

There is a second and urgent challenge to involve citizens and patients fully in research, not only as subjects or consumers, but also as full partners in participatory research that leads to action. As suggested by Green (8), in some countries community-based participatory research is a well-developed approach to research, enabling full participation by community members in action research, if possible in cooperation with practice-based research networks (13). This would fit well with the competence of person-centeredness and it would be a logical extension of well accepted care concepts like informed consent and shared decision-making. Qualitative methodologies and action research have the potential to clarify difficult problems in health care such as obstacles to adherence (14). There are a lot of questions and barriers to overcome in this field, such as lack of time and resources. Nevertheless, full partnership has the potential to guide the research process, to facilitate recruitment and to allow quick bidirectional translation of research questions and results, to put forward priorities in research and in health care such as human dignity, equity, solidarity, efficiency, transparency and self determination (13).

The third challenge is the integration of research as a part of primary healthcare provision. This demands for a culture of observing what is going on (i.e. data representing everyday practice) and feedback from practitioners to researchers on what is needed in daily practice (i.e. relevant research questions). Feedback of results from observational and interventional research to practice creates shared ownership of the research process and its outcomes. To facilitate this, decision support systems, including links to evidence databases and cross-sectional and longitudinal meta-views of own patient data, will continue to develop and become more integrated in electronic patient record systems. An advanced computational infrastructure could improve integration of research questions and data retrieval for clinical research. One example of this concept is the European TRANSFoRM project (15). Furthermore, GPs may have to realize that participating in RCTs might be in their patients’ best interest, instead of perceiving a conflict between research and good patient care (16). Finally, there is a need for more infrastructure and funding possibilities for comparative assessment (17).

Development and spearheads in different contexts

This Research Agenda and commentaries show future directions for primary care research: the challenges related to a changing society, to the shared responsibility and guidance of research by professionals and citizens, and to the need to integrate fully observational and clinical research as part of primary healthcare provision. There will be a need for a prioritization of spearheads to guide primary care research for the next decade: translational research, research on equity and health differences, on chronic disease and health systems research (18); but there also is a need for visions and development. All this can not be realized without the development and maintenance of a solid research infrastructure: easily maintained and accessed observational databases, helpful information technology, strategies and techniques for involvement and democratisation, advanced research training possibilities, and the development and validation of appropriate research instruments and outcome measures to capture the different challenges.

European diversity, with its richness in different healthcare systems, networks and special interest groups, is an ideal ‘population laboratory’ for comparative studies. As for other continents, this Research Agenda might be useful as well, although some differences in practice and important contextual differences will urge for some adaptation. Therefore, other continents’ organizations, such as NAPCRG for North America, should develop their version of a research agenda for their context. Worldwide, primary care not only is a priority for health care policy, but it needs to become a research priority as well.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.