Avoiding “voltage drop” when treatments move from research to practice

With crises looming in the U.S. health care system and economy, nobody wants research money wasted. But critics have long complained that it takes too long for health scientists to produce results—and when they do, their findings are not practical. According to Dr. Tom Insel, director of the National Institute of Mental Health (NIMH), “There is a well-described ‘voltage drop,’ or decrease in efficacy, when we move treatments from the research setting to real world practice.”

Many believe the problem stems from doing studies in experimental environments with carefully selected participants—situations designed to produce the scientists’ desired outcomes. But when clinicians try to reproduce the results in real-world conditions, unanticipated complications arise and the well-studied approaches no longer work.

In his blog, Dr. Insel points to a different kind of research. It involves Group Health and promises to answer scientific questions “faster, cheaper, and potentially better” than conventional research approaches. It’s the new Mental Health Research Network (MHRN), led by Group Health’s Dr. Greg Simon, and a similar, broader effort called the Health Care Systems (HCS) Research Collaboratory.

Launched in September by the National Institutes of Health (NIH) to engage health systems in large-scale clinical studies, the Collaboratory’s goal is to help the nation achieve health care’s “triple aim”: better care experiences, better population health, and lower cost. (NIH leaders originally considered including only HMOs in the Collaboratory, but later decided a more diverse range of systems would maximize learning.) Along with Dr. Robert Califf at Duke Clinical Research Institute and Dr. Richard Platt at Harvard Pilgrim Health Care Institute, I’ll be serving as a co-principal investigator.

As Insel explains, MHRN (and the Collaboratory) “will use scientific methods like randomization and statistical comparisons to create learning health care systems.” Leveraging the systems’ health information databases, the networks are creating efficient processes for assessing outcomes—turning clinical practices nationwide into laboratories for research.

This may sound like business as usual for Group Health, which has been operating as a learning health care system for some time, but conducting research within large health plans is new to much of the nation’s research enterprise. Through the Collaboratory, NIH is investing $11.3 million over five years on seven “pragmatic clinic trials” that will develop and spread methods and best practices. Three of these demonstration projects involve GHRI investigators: Drs. Simon, Bev Green, and Dan Cherkin.

Dan’s study is a great example of just how practical a “pragmatic trial” can be. Led by UW’s Dr. Jeffrey Jarvik, it’s based on prior research showing that physiological characteristics—features such as bone spurs—appear on radiology images both from people with and without back pain. In a pilot study, Jarvik found that giving this information as context on back pain patients’ radiology reports can influence physicians’ approach to subsequent treatment. Now Drs. Jarvik, Cherkin, and team will conduct a larger study among Group Health providers to see how the same strategy affects the prevalence of additional testing, opioid prescriptions, invasive therapies, and so on. Can we avoid “overtreatment” simply by giving physicians more information about the appearance of a normal, pain-free back? Dr. Jarvik’s team hopes to find out.

Bev’s and Greg’s studies are similarly down-to-earth. Bev will join collaborators at Oregon Health & Science University to develop and test a culturally tailored program to improve colorectal cancer screening rates at federally funded community health centers, where screening rates are typically low. Greg will lead his MHRN colleagues in a study comparing strategies for preventing suicide attempts: one focuses on risk assessment and care management, the other on helping patients develop emotion regulation skills.

These studies’ practical appeal is similar to those supported by Group Health’s Partnership for Innovation. Funded by Group Health Foundation donors, the Partnership encourages clinicians and others to work with GHRI researchers to develop and test ideas that have potential to meet the triple aim. Successful pilot projects may be implemented within Group Health and/or studied full scale with funding from agencies such as NIH.

It’s all part of our effort to build closer relationships among Group Health clinicians and researchers so we can more efficiently develop and test innovations that really work. As Greg recently told NIMH leaders, we need to stop thinking about moving research to practice, and start thinking of moving practice to research. Doing so will ensure that we’re asking the right questions, collecting data from real (versus experimental) health care situations, and producing findings that can rapidly benefit today’s patients here and nationwide.

—Eric