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FORUM - Translating research into quality health care for Veterans

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Accelerating Innovation and Translation through Strategic Partnerships: Collaborative Research to Enhance and Advance Transformation and Excellence (CREATE) and Centers of Innovation (COIN)

The Veterans Health Administration (VHA), Health Services Research and Development Service (HSR&D) launched two transformational initiatives in the past year, both designed to accelerate the translation of VA research findings in clinical practice and community settings. The Collaborative Research to Enhance and Advance Transformation and Excellence (CREATE) program aims to identify and bridge significant gaps in health care delivery through three to five independent, yet coordinated, research projects that are closely aligned with health care system problems of importance to VHA. The new Centers of Innovation (COIN) build from the successful HSR&D Centers of Excellence. COIN seeks the rapid advancement of the translation of research findings by supporting independent investigators conducting novel research as well as groups of investigators collaborating to address significant clinical, policy, and methodological questions whose answers will lead to improvements in Veterans health care and health outcomes.

Why is a transformational approach needed? While health services research has made rich contributions to the organization of health care, its relevance and usefulness to key decision makers in health care systems is sometimes unclear; moreover, the translation of evidence from health services research is often slow and inconsistent. Few mechanisms are in place to align health care research with the needs of health care policymakers and administrators. 1 In this respect, CREATE and COIN are transformational; they support not only collaborative researchers but also the VHA managers, or stakeholders, likely to use the results of the research. Researchers and stakeholders work together throughout the course of a study--from the formulation of research questions to the analysis and interpretation of the results. When the research is complete, VHA managers will be poised to use the results to improve practice.

Partnered research is not new and has played an important role in several approaches to research, including comparative effectiveness research, community-based participatory research, and action research. 2, 3 In fact, the Patient Protection and Affordable Care Act of 2010 and the creation of the Patient-Centered Outcomes Research Institute (PCORI) both recognize the importance of engaging community members, patients, caregivers, clinicians, and administrators in research. PCORI's directive calls for it to engage a range of stakeholders as it develops its mission, foci, and initiatives, and the researchers funded through PCORI are required to engage their stakeholders throughout the research process.

What is new about CREATE and COIN is their emphasis on high-level health care system partners, such as VHA's national and regional managers and health care executives. Researchers are required to link their studies with those who make decisions about how health care is organized and resourced. Among the partners of the newly funded CREATEs and COINs are VHA's national offices of Public Health, Mental Health, Primary Care, Specialty Care, Informatics and Analytics, and Women's Health. Given that CREATE and COIN partners are deeply connected with the research, they will likely have a greater stake in using the resultant evidence for policy development, health care system redesign, and implementation of clinical initiatives.

Even though the emphasis on key decision makers as partners is highly innovative, the focus on managers and administrators may suggest limited representation of patient and clinician perspectives. To avoid a top-down approach, CREATEs and COINs advocate for diversity in stakeholder engagement. However, the simultaneous engagement of patients, clinicians, and other stakeholders in research is potentially complex and costly. To address such challenges, Hoffman and colleagues proposed several principles for multiple-stakeholder participation, including: (1) balancing representation among all stakeholder groups; (2) ensuring the understanding and acceptance of roles across stakeholders; (3) providing expert facilitation of discussions; (4) building from connections among stakeholders; and (5) investing in sustained stakeholder engagement. The development of these and other principles of stakeholder engagement and of new conceptual frameworks for partnered research are essential as diverse stakeholders participate in research processes.

Both CREATE and COIN aim to influence change in the VHA health care system and to build evidence that influences health care delivery in VHA and beyond. Expanding the partnered research vision to include a wide variety of stakeholders will trigger considerations such as tailoring the complexity of information presented to various stakeholder types (e.g., Veterans, clinicians, VHA executives) in order to facilitate their informed contributions. However, the involvement of a diversity of partners in research will likely permit the alignment of research aims with the potentially competing needs of patients, clinicians, and managers.

  1. Kupersmith J. and S. Eisen. "A New Approach to Health Services Research," Archives of Internal Medicine 2012; 172(13):1033-4.
  2. Hoffman, A. et al. "How Best to Engage Patients, Doctors, and Other Stakeholders in Designing Comparative Effectiveness Studies," Health Affairs 2010; 29(10):1834-41.
  3. Kitson, A. et al. "Knowledge Translation within a Population Health Study: How Do You Do It?"Implementation Science 2013; 8:54.

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