Minding the research-practice gap

Doctors of chiropractic serve approximately 10 per cent of the Canadian population annually, with the aim to improve the health and well-being of Canadians, primarily with musculoskeletal disorders. Despite available evidence for optimal management of these disorders, poor adherence to guidelines and wide variations in service delivery by clinicians have been noted across health-care disciplines, including chiropractic.

Challenges to the adoption of evidence-informed practice among chiropractors have been previously highlighted. These include: 1) limited research capacity in chiropractic with less than one per cent of the chiropractic profession conducting research; 2) the fragmented integration of chiropractic into the health care system; and 3) more than half of chiropractors working in solo practice with solo providers having greater variation in accepted clinical practices.

One strategy to address these challenges is the creation of practice-based research networks (PBRNs). Primary care PBRNs bring together researchers and groups of clinicians and practices with the goal of improving health services delivery and closing the gap between research and practice.

PBRNs have been successfully created in the U.S., Denmark and in Canada for more than 15 years. The general goal is to stimulate the development of appropriate research that reflects the priorities of patients and clinicians in a real-world primary care setting. Clinics become living laboratories, where clinicians and researchers work in partnership to measure outcomes that more accurately reflect current health-care practice.

PBRNs are well established in other primary health-care professions in Canada as well, and can provide a unique opportunity to engage clinicians in quality improvement activities, foster an evidenced-based practice culture, and improve patient care. They have the potential to increase the uptake of best practice because they “aim to share information and create new knowledge, strengthen research and communication capacity among members, and identify and implement strategies to engage decision makers more directly,” according to a paper written by Heather Creech titled, Strategic Intentions: Principles for Sustainable Development Knowledge Networks, for the International Institute for Sustainable Development in Manitoba.

Establishing a PBRN can provide the structure to recruit clinicians, profile chiropractic practice, identify knowledge-practice gaps, monitor practice change, and evaluate the impact of knowledge translation (KT) strategies to increase uptake of evidence-informed practice. Collectively, clinical practice guidelines (CPG) and PBRNs can provide the structure and processes to improve care delivery and patient outcomes.

PBRN in Canada
The need to establish a formal network of Canadian chiropractors to facilitate the translation of research into practice has been recognized. In December 2014, the Canadian Chiropractic Guideline Initiative (CCGI) welcomed 32 researchers, practitioners, knowledge users and patient representatives to the first planning meeting of the CCGI Practice-Based Research Network held at Canadian Memorial Chiropractic College in Toronto.

The National Chiropractic PBRN was launched soon after, with the establishment of the advisory committee and the approval of a charter outlining the aim of the PBRN, which is to improve the quality and safety of patient care, primarily in the management of musculoskeletal conditions.

The National Chiropractic PBRN is supported financially and administratively by the CCGI. Membership is open to patients (citizen engagement), clinicians (knowledge-users), leaders and decision-makers (provincial and national leaders in the chiropractic profession and decision-makers from insurance and government), and researchers including CPG developers and KT experts. A webpage with information on members, publications and presentations about the Research Network has been set up on the CCGI website (www.chiroguidelines.org).

Current PBRN activities
Already, more than 150 practices have now been recruited to the PBRN program across Canada. To date, there are seven PBRNs in progress and in various stages of development.

1. The British Columbia Spine Flex Practice-Based Research Network led by Dr. Jeffrey Quon and Dr. Brian Arthur was established in the context of interdisciplinary engagement between community-based chiropractors and local medical and chiropractic researchers affiliated with a hospital-based spine care program. The project concerns the implementation and evaluation of a simple spine-care pathway to increase specialists’ utilization of community chiropractors in the management of patients with acute and chronic non-specific low back pain (LBP).

2. In Nova Scotia, a team led by Dr. Jill Hayden and Dr. Peter Stilwell is launching a PBRN looking at implementing biopsychosocial assessment for LBP context. CPGs recommend screening for psychosocial factors and appropriately managing patients with LBP. The aims of this PBRN are: to carry out a qualitative study using the Theoretical Domains Framework to assess Nova Scotian chiropractors’ awareness of CPG recommendations about psychosocial factors in LBP patients; identify barriers and facilitators to the screening and management of psychosocial factors; develop a targeted intervention to address barriers and facilitators; implement and assess intervention outcomes and expand the PBRN for education and research.

3. In Kingston, Ont., a team led by Dr. Simon French and Dr. Peter Beliveau has launched the Queen’s University PBRN. This team looks at observational studies on chiropractic, randomized controlled trials (RCTs) and knowledge translation in the Kingston area. The aims of this study are: to further develop a network of chiropractors interested in collaborating in practice-based research; facilitate a culture of inquiry and critical awareness in chiropractic practice; provide an avenue for knowledge translation activities between academic chiropractors and practicing chiropractors; conduct practice-based research in local chiropractic practices in order to better understand the nature of chiropractic practice in eastern Ontario; and conduct and participate in clinical and health care delivery research in the chiropractic care setting.

4. In Quebec, a team led by Dr. Mathieu Piché and Dr. André Bussières recently launched the Quebec Practice-Based Research Network for clinical and KT research, looking at the delivery of evidence informed care in private practice and at the chiropractic clinic of the Université du Québec à Trois-Rivières. This study aims to establish an infrastructure to conduct knowledge transfer (KT) research in Québec. The team of researchers is conducting a pilot RCT in collaboration with clinicians and patients assessing the feasibility of evaluating whether a KT strategy can increase the use of multimodal care to improve the management of patients with neck pain. They are also interested in looking at factors that increase or decrease the effectiveness of chiropractic care in private practice, and assessing the role of expectations and other psychological factors on the evolution of acute and chronic musculoskeletal pain in patients receiving chiropractic care.

5. In Guelph, Ont., a team led by Dr. John Srbely and Dr. John Riva is preparing to launch a PBRN looking at perceived barriers and facilitators for clinicians to the implementation of evidence-informed practice in whiplash-associated disorders. This PBRN aims to support a two-way KT collaboration between basic scientists and practicing clinicians.

6. In Manitoba, a team led by Dr. Steven Passmore is proposing a study of practice-based chiropractic utilization and outcomes, following referral from a hospital-based spine-care pathway. This proposed PBRN will aim to capture outcomes associated with conservative care for patients referred from a surgical
triage clinic.

7. A Canada-wide study based in Alberta, led by Dr. Kent Stuber, is collecting data from 15 clinics across Canada to assess for patient-centered care in patients with chronic health conditions. This PBRN aims to determine the extent to which patients perceive chiropractic care as patient-centred, and develop strategies to make practices more patient-centred. It also aims to develop clinical tools to favour patient-centered care and to ease implementation research.

A PBRN can create a vital link between researchers, clinicians, patients and professional leaders. The main goal of PBRNs is to optimize the process of care delivery and patient outcomes by ensuring clinical decisions are informed by evidence, patients’ values and preferences, and engaged clinicians. It can serve as a research and a KT network.

Specifically, the PBRN can be a mechanism to link the chiropractic community around research and best practices, and identify practice-based problems requiring research (from patient and provider perspective). The PBRN can mobilize researchers and facilitate conducting clinical research on these issues. When evidence exists, the PBRN can focus on developing and promoting uptake of best practices and guidelines. Such strategies should address issues relevant to chiropractors and their patients, link chiropractors via databases to facilitate research and outcome measurement, and build capacity of the chiropractic profession to participate in, conduct and use research.

The establishment of chiropractic PBRNs is a unique opportunity to establish a network of clinicians, researchers, knowledge users and patient representatives across Canada.

During the CCGI workshop on PBRNs at the CCA National Convention and Tradeshow in September 2015, ongoing research questions and strategies for encouraging clinician participation in PBRNs in Canada were discussed. We hope in 2016 to broaden the base of support for research and recruit more clinicians to join local PBRNs. We look forward to seeing how this exciting and important new initiative of the CCGI will evolve over the coming months, and to observing its impact on the dissemination of clinical practice guidelines and best practice.

If you are interested in keeping up to date with the activities of the National Chiropractic PBRN and would like to view the list of members, visit the Research Network page on the CCGI website: www.chiroguidelines.org.

For more information about PBRNs, please contact Dr. André Bussières at andre.bussieres@mcgill.ca.

Dr. André BussièreS, DC, is project lead for the Canadian Chiropractic Guideline Initiative. He is an assistant professor at the School of Physiotherapy and Occupational Therapy at McGill University and a professor at Université de Québec à Trois Rivières. He holds a Canadian Chiropractic Research Foundation Professorship in Rehabilitation Epidemiology at McGill University.