Commentary :Opportunities for clinical research in primary care practice
R.J. Mellanby BSc BVMS PhD DSAM DipECVIM-CA FRCVS
Royal (Dick) School of Veterinary Studies and The Roslin Institute,
Division of Veterinary Clinical Studies,
The University of Edinburgh,
Hospital for Small Animals,
Easter Bush Veterinary Centre,
Roslin, Midlothian,
EH25 9RG.
A high proportion of published veterinary clinical research involves patients evaluated at specialist, multi-discipline university hospitals, in part because veterinarians in academia often have the time, expertise and support to engage in research involving their patients. In contrast, the commercial reality of private primary care practice canlimit opportunities for many practitioners to undertake clinical research. Whilst specialist led, university hospital based clinical research has advanced understanding of many diseases, this approach is not without its limitations. Clinicians in universities engaged in specialist practice often have a low daily caseload compared to colleagues in primary care practice which limits their ability to generate large cohort studies. In addition, cases referred to multi-discipline referral hospitals often have several concurrent disorders which complicates the investigation of specific diseases. Furthermore, common diseases, which arguably have the greatest impact on animal welfare, are often diagnosed and managed exclusively in the primary care setting. Therefore, it remains challenging for many university based specialist clinicians to address important research questionson diseases which cause significant morbidity to veterinary patients.
Why clinical research in primary care practice is important
Research in primary care practice has the potential to be some of the most impactful research undertaken by veterinarians(Mellanby 2015). Primary care practitioners typically examine large numbers of patients each day suffering from common disorders that presently cannot be adequately treated. An improved understanding of these common diseases, which can often be readily diagnosed in primary care settings, has tremendous potential to enhance animal welfare. The large number of cases observed by groups of clinicians working in multi-site primary care practices offers the opportunity to undertake ‘big data’ research, an emerging discipline which harnesses recent technological advancements in healthcare informatics, large dataset management and computational power. Clinicians engaged in primary care practice are also ideally placed to undertake critically important surveillance studies which allow the emergence of novel infectious and non-infectious diseases to be rapidly identified. An often overlooked benefit of clinical research in the primary care setting is the enhancement in job satisfaction that comes from answering an important healthcare question as well as the likely improvement inthe retention of skilled staff within a primary care veterinary setting which will occur when clinicians are research active.
Lessons learnt from research undertaken in humangeneral practice
The value of primary care research has long been acknowledged in human medicine, notably through the establishment of a several of databases which contain the clinical records of large number of patients(Vezyridis and Timmons 2016). For example, the Clinical Practice Research Database is a not-for-profit research service funded by the NHS National Institute for Health Research and the Medicines and Healthcare Products Regulatory Agency. It is owned by the UK Department of Health and contains the health records of 11 million patients from 674 general practices. The Health Improvement Network database contains health records of 12 million patients from around 600 practices. Qresearch is another database that contains health records of 18 million patients from 1000 general practices. These huge databases have allowed large scale observational studies to be undertaken on a wide range of treatments and medications. An example is the demonstration that measles-mumps-rubella vaccination was not associated with autism in children(Smeeth and others 2004). A recent review found that between 1995 and 2015, 1891 papers had been published from these three databases, many of which were highly cited and published in journals with a high impact factor(Vezyridis and Timmons 2016). The prioritisation of general practice research was recently demonstrated by the Wellcome Trust through theaward ofone of only seven new PhD training programmes awards to Keele, Cambridge, Oxford and Southampton Universities to develop a postgraduate clinical research training programme focussed on primary care research over the next five years.
Recent developments in primary care veterinary research
The importance of primary care practice based veterinary research is reflected in the recent emergence ofimportant practice-academia collaborative initiatives. Examples include the VetCompass companion animal surveillance programme which collates de-identified electronic patient record data from primary-care veterinary practices in the UK for epidemiological research(O'Neill and others 2016). The Small Animal Veterinary Surveillance Network (SAVSNET), a joint venture between BSAVA and the University of Liverpool, is another important initiative which also undertakes practice-based surveillance(Sanchez-Vizcaino and others 2016). Such approaches are augmented by academia-client collaborative research programmes such as University of Edinburgh’s Dogslife project and the University of Cambridge’s Genetics of Obesity in dogs (GODogs) study(Pugh and others 2015; Raffan and others 2016). Collectively these examples of‘big data’ clinical research programmes will enable the emergence of novel diseases to be readily detected and allow the pathogenesis of important, common disorders to be probed. They have already yielded important insights into the genetic basis of common disorders and established the prevalence of important infectious and non-infectious diseases. The growth in corporate veterinary practices, which utilise a common patient record system and provide a framework for standardised diagnostic, therapeutic and data collection approaches, offers further growth opportunities for primary care based clinical research(Gyles 2014; Kass and others 2016).
Recent initiatives to lower barriers to research in general practice
A number of initiatives have emerged in recent months which aim to lower the barriers faced by veterinarians working in primary care practice who want to undertake clinical research. Two recent ones involve the provision of mentorship to veterinarians keen to engage in clinical research. The launch of an MSc in Clinical Research by BSAVA is an important initiative which enables practitioners to secure an advanced qualification whilst undertaking clinical research. Secondly, the Clinical Research Assessment Guidance (CRAG) panel was recently initiated by JSAP which aims to provide support and guidance to veterinarians undertaking prospective clinical research(Jeffery 2015). Veterinarians are invited to submit study outlines and if approved by the CRAG panel, the authors are assured of rapid publication of their results.
Another important initiative has been the development of an Ethics Review Panel (ERP) by the RCVS. All clinical research should undergo ethics review to ensure that the welfare of participating animals are optimised, and the veterinarian’s responsibilities to the owners recognised and addressed. However, formal ethics approval has historically proved challenging for practice-based researchers to secure since they often do not have access to ethics review committees which are common place in universities and inindustry research centres. The one year trial RCVS ERP initiative arose following the findings of a joint working party established by the RCVS and BVA, which reported on the challenges facing practice-based research in the UK. One of the key recommendations of the report, therefore, was that the RCVS should consider establishing a committee for ethics review of practice-based research thereby providing a transparent and rapid process which will enable practitioners to apply for ethics approval.
It is hoped that the increasing awareness of the value of primary care based research, both in terms of the importance of the clinical diseases investigated and the ability to have access to sufficient cases to answer the research question robustly, and the recent initiatives surrounding mentorship and access to ethics review panels will enable more practitioners to engage in clinical research within the primary care setting. This will, hopefully, be highly rewarding for the veterinarians involved and have the potential to improve understanding of disease biology and ultimately, enhance patient outcomes.
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