Building Strong Research Partnerships Between Public Health and Researchers: A VA Case Study

ABSTRACT

We are in a new era of partner-based implementation research, and we need clear strategies for how to navigate this new era. Drawing on principles from community-based participatory research, the Clinical Public Health group of the Department of Veterans Affairs and the HIV/Hepatitis Quality Enhancement Research Initiative (HHQUERI) forged a longstanding partnership that has improved the care of Veterans with Human Immunodeficiency Virus (HIV) and Hepatitis C Virus. An exemplar HIV testing project epitomizes this partnership and is discussed in terms of the lessons learned as a result of our high level of collaboration around design, analysis, implementation, and dissemination across projects over the past several years. Lessons learned through this partnered testing program involve respecting different time horizons among the partners, identifying relevant research questions for both parties, designing flexible studies, engaging all partners throughout the research, and placing an emphasis on relationship building at all times. These lessons and strategies can benefit others conducting partner-based research both within the Veterans Health Administration (VA) and in other integrated healthcare systems.

“And it is only through normal science that the professional community of scientists succeeds, first, in exploiting the potential scope and precision of the older paradigm and, then, in isolating the difficulty through the study of which a new paradigm may emerge.” – Thomas Kuhn ¹

The field of health services research has undergone a transition during the last two decades. We have gone from what Kuhn refers to as “normal science”—traditional science informed by an older paradigm of clinical research that includes tightly controlled randomized clinical trials—to a science informed by a new paradigm: partner-based, implementation research, which is ideally informed by key partner’s goals. This quote also suggests that health services research, which has benefitted heavily from traditional or clinical research, has limitations that have necessitated a shift toward partner-based, implementation research. Within this paradigm shift, we must determine what constitutes best practices and strategies as we go beyond “normal science.” We believe that the lessons and strategies we have learned as part of the partnership between a research group and a public health group in the Veterans Health Administration (VA) across several years can aid researchers and their partners in the VA and in other integrated healthcare systems.

PARTNERSHIP

The HIV/Hepatitis Quality Enhancement Research Initiative (HHQUERI) is one of ten implementation research centers within the VA’s QUERI program, which originated as a result of a system-wide transformation in 1998 to improve healthcare across high-risk and high-prevalence conditions in the VA. The QUERI program, and HHQUERI, aim to capitalize on communication and integrated efforts across research, operations, clinical services, and policy makers to improve the health of Veterans through systematic and rigorous implementation of clinical research and evidence-based recommendations.²

The public health program with which HHQUERI partners—the VA’s Office of Public Health’s Clinical Public Health group—is a program and policy office. Clinical Public Health is responsible for a broad spectrum of public health programs, including ones aimed to improve the care of patients with Human Immunodeficiency Virus (HIV) and chronic viral hepatitis and prevent new infections. Although the mission of Clinical Public Health is not identical to that of HHQUERI, they are both focused on improving the care of Veterans with HIV and Hepatitis C Virus (HCV).

The partnership between HHQUERI and Clinical Public Health has been heavily influenced by key principles from previous work examining community-based participatory research models,³ including the notion that health research flourishes when there is a partnership with high relational coordination and collaboration, responsive leadership, teamwork, and an organizational culture oriented around a set of goals. In this article, we share lessons learned and strategies that have been adapted from this work and are instrumental to our successful partnership, using an HIV testing project as an exemplar. Although these strategies have been developed within the context of improving care and outcomes for Veterans with HIV and HCV in the VA, they are applicable to anyone who engages in partnered health research (e.g., public health departments, integrated healthcare delivery systems).

HIV TESTING PROJECT

The HIV testing project is a recently completed, multi-year series of programs that examined the effectiveness of a multi-modal intervention to promote HIV testing. The project was carefully based on theoretical and practical considerations⁴ and used an electronic clinical reminder (previously developed by Clinical Public Health) to promote HIV testing. In partnership with Clinical Public Health, HHQUERI demonstrated the effectiveness,⁵ acceptability,⁶ sustainability,⁷ exportability,⁸ and implementation costs⁹ of the intervention in Southwestern sites in the US, which was eventually translated to other regions of the country, where a significant increase in HIV testing rates was observed.^7,10

Throughout the project, Clinical Public Health actively promoted HIV testing (e.g., provider training, social marketing), and after the initial regional research results, promoted the dissemination of the clinical reminder throughout the VA. HHQUERI assisted in demonstrating the cost-effectiveness of HIV testing,¹¹ which supported changes in federal rules governing the performance of HIV testing in the VA. Simultaneously, Clinical Public Health gained an understanding and appreciation for barriers and facilitators of successful HIV testing programs, which resulted in the removal of VA HIV testing barriers (i.e., signature consent, scripted pre-/post-test counseling). Clinical Public Health also led a VA policy change in 2009 that HIV testing be a part of routine medical care (i.e., providers offer HIV testing to all Veterans). Since that time, they have seen a significant increase in HIV testing across the VA. From 2009 to 2011, the number of outpatient Veterans who received an HIV test increased from 9.2 % to 20 %.¹²

LESSONS LEARNED & STRATEGIES

Key strategies identified by HHQUERI and Clinical Public Health as instrumental to the success of the HIV testing project (and many other projects) are: (1) understanding different time horizons for addressing important clinical problems from research and policy perspectives (Time Horizons); (2) identifying research questions that remain relevant to partners over time (Relevant Research), (3) designing studies that are flexible as clinical systems change (Flexible Study Design); (4) engagement of partners throughout the course of research (Engagement) and (5) building relationships of mutual respect, trust, and credibility (Relationship Building).

Time Horizons

Researchers are used to a longer process for studying, analyzing, and reshaping ideas for grants. In contrast, policymakers and those in operations traditionally need to respond to issues that come up in a more rapid fashion (e.g., developing and implementing a new program within weeks). Although each group has different time horizons, this tension may lead to innovative problem solving and allow both researchers and operations to flourish. In the HIV testing project case, Clinical Public Health’s strategic goals were focused on implementation of routine HIV testing (vs. risk-based testing). The optimal research design, however, would have called for an analysis of the impact of the intervention on risk-based testing followed by an assessment of the generalizability of the intervention to routine testing. HHQUERI modified the research plan such that some sites implemented the routine testing component of the program without assessing risk-based testing. In turn, Clinical Public Health compromised by not actively promoting routine testing in sites participating in the risk-based testing phase of the project. The end result of this project—increased HIV testing—was highly relevant to Clinical Public Health, and while there was a desire to effectuate change quickly, Clinical Public Health understood that the effectiveness, costliness, and acceptability of interventions to increase HIV testing and the level of facilitation required to achieve and sustain success needed to be determined.

Relevant Research

HHQUERI and Clinical Public Health work to engage in mutually relevant research through regular discussions and by aligning our projects with each group’s relative priorities through strategic planning. We meet monthly to re-evaluate priorities and discuss project and policy updates, with ad hoc meetings as issues arise. Clinical Public Health leadership is part of HHQUERI’s Executive Committee, which meets annually and advises HHQUERI on its portfolio of projects. In the case of the HIV testing project, the partners identified and discussed their needs with HHQUERI. In turn, a clinical reminder and strategies to facilitate dissemination were developed, and researchers were able to develop an evaluation plan to measure the effectiveness of the reminder and intervention strategies. Clinical Public Health and HHQUERI have built on this success and are currently focusing HIV testing priorities on the accurate identification of new HIV diagnoses. ¹³

HHQUERI and CPH also recently aligned their priorities in mapping a Presidential directive to HHQUERI’s 2014 Strategic Plan. In July 2013, President Obama issued an Executive Order launching the HIV Care Continuum Initiative and established a cross-Departmental Working Group on which the VA serves a prominent role to advise the President on how to improve outcomes across this Care Continuum. HHQUERI and Clinical Public Health have partnered to meet this challenge head on by framing a suite of projects across the Care Continuum to address testing, linkage, engagement, and treatment outcomes over the next three years.

Flexible Study Design

When first developed, HIV testing within the VA required written informed consent. However, partway through the multi-regional project, federal law and VA regulations governing the performance of HIV testing changed to substitute verbal for written consent. Such a midcourse policy change required HHQUERI to redesign the quantitative data analysis evaluation plan of the project. The ability to develop a flexible analytical plan allowed for simplification of HIV testing processes at the study sites and increased the relevance of study findings to the current environment of HIV testing. Failure to have done so would have likely led to dissatisfaction by providers at participating sites (due to being encumbered with more complex HIV consent issues), lower rates of HIV testing (with attendant harm to undiagnosed patients), and less relevance of the study results.

Engagement

Those leading the HIV testing project engaged early and often with key partners and other stakeholders at the national and regional levels, and this engagement has led to continued collaboration with the development and refinement of related projects that are underway and planned (e.g., aforementioned new HIV diagnosis project). It is important to note that at each step of the process, Clinical Public Health and other key stakeholders were apprised of relevant findings and applied early results to their work without compromising the overall integrity of the research endeavor, at times adjusting research questions that may have been impacted by clinical and policy changes since the initiation of the study.

Relationship Building

A high value is placed on maintaining strong relationships of mutual respect, trust, and credibility. We have learned that because there are clear differences in missions, goals, and organizational motivators among researchers and partners, we need to acknowledge the divisions that distinguish our organizations from one another. Simultaneously, we need to focus on the commonalities of our mission—improving Veteran’s health and setting a national standard for healthcare. Recognizing the aligned areas of our missions allow us to maintain a strong relationship, despite having different roles and goals in our projects. In the case of the HIV testing project, HHQUERI and Clinical Public Health were united in the desire to increase identification of Veterans with HIV, and the ramifications such identification would have on improving care. The relationship was also strengthened by the presence of a liaison with policy and research expertise who split time between HHQUERI and Clinical Public Health. This individual provided key cross-organizational communication throughout the HIV testing project and continues to participate in core activities related to each group and facilitate formal and ad hoc communications that allow us to stay closely aligned in our goals.

Final Thoughts

As we reflect on lessons learned in partner-based research, we want to emphasize that the work in implementation research we are conducting has occurred within a larger paradigm shift in science. Although there is a clear place for traditional science and knowledge of best practices has grown significantly as a result, it has become clear that gaps exist in understanding how best to deliver evidence-based clinical care to patients, thus necessitating a shift to implementation science.

Kuhn would argue that this shift occurred because there were issues that were not being resolved by traditional science (i.e., “normal science”), and this new paradigm offers more solutions than previous work, with implementation science and work across strong partnerships facilitating the implementation of evidence-based practices.¹ In the example outlined in this paper, traditional science was important for demonstrating effectiveness of the multi-modal clinical reminder; however, without partner-based implementation research, this evidence-based practice would never have been successfully disseminated. In line with Kuhn’s thinking, we will continue to rely on analytical problem-solving and the systematic application of theory and the scientific method that was instrumental to the success of traditional science. However, we will also maintain a persistent focus on building and cultivating key partnerships so that we can optimize our impact on the quality of care Veterans receive. We believe these same lessons will benefit those in other integrated healthcare systems, and suggest that others consider the systematic study of these principles by operationalizing them and applying them to partner-based research.