purposes and structures of canadian hospital-based research: results of a national survey

Volume 9, No. 3 FalVAutomne 1996

I I

Purposes and Structures of Canadian Hospital-based Research: Results

of a National Survey by Dan W. Harper, Patricia A. O'Hara and Jeannine Sigouin

Hospita 1 -based research t is axiomatic that Canadian teaching hospitals have three roles: patient care, education and re- I search.' Increasingly, non-teaching hospitals have

also adopted "research as a defining role, including research conducted by non-academic and 1 or non- medical staff.' In spite of this, no information is available concerning the way in which individual Canadian hospitals implement research.

As part of the changing Canadian health care sys- tem, hospitals face many challenges. Research in hospitals will undoubtedly affect and be affected by such challenges as changing roles, closures, amalgamations, increased requirements for proof of efficiency and ef- fectiveness, privatization, and reorganisation of other kinds.

Meanwhile, biomedical and health service research face challenges such as reduced access to funding, public scepticism and disenchantment and, con- versely, increased expectations and demands by the p ~ b l i c . ~ If Canadian Hospital-Based Research (CHBR) is to adapt to these new realities, it would be helpful to have an understanding of its current purpose and structure.

The present survey addresses nine specific questions: 1. Is research an activity valued by Canadian

hospitals?

2. For what purposes is CHBR conducted? 3. How common is CHBR, and what types of re-

4. What disciplines are involved in CHBR? 5. How often does CHBR result in a peer-reviewed

publication? 6. What hospital administrative structures and func-

tions exist to support CHBR? 7. What research support resources are made avail-

able by Canadian hospitals? 8. How are the indirect costs of CHBR funded? 9. For all of the above, are there differences associ-

ated with the following variables: a) university affiliation status b) size of hospital c) type of services offered by hospital (general

d ) geographic location of hospital

search are conducted?

versus specialized)

Method Questionnaire and survey procedure

A 20-item questionnaire was developed to assess various aspects of the purpose and organization of research in individual hospitals. (The questionnaire is available from the authors on request.) It was addressed and sent to the CEO (or equivalent) of all Canadian hospitals with 100 or more beds. The hospitals and CEOs were identified using the most recently

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Fall/Automne 1996 Volume 9, No. 3

RETURN RATE

NO. OF BEDS

Table 1: Representativeness of Sample

Response No Response Response No Response Response No Response Response No Response

227 (58.4%) 162 (41.6%) 69 (79.3%) 18 (20.7%) 46 (55.4%) 37 (44.6%) 112 (51.1%) 107 (48.9%)

330 273 513 391 279 375 238 21 7

NON-TEACHING I (N=219) I OVERALL I TEACHING I TEACHING

(N=389) MEMBERS (N=87) NON-MEMBERS (N=83)

GEOGRAPHIC LOCATION:

1. WEST (BE. & ALBERTA)

~~ ~~~ ~ ~~~


47 (53%) 42 (47%) 12 ( 75%) 4 (25%) 7 (47%) 8 (53%) 28 (48%) 30 (52%)

2. PRAIRIES (SASK & MAN)

3. Ontario

4. Quebec

16 (59%) 11 (41%) 5 (1 00%) 0 ( 0%) 4 (80%) 1 (20%) 7 (41 %) 10 (59%)

93 (68%) 43 (32%) 30 ( 83%) 6 (1 7%) 16 (73%) 6 (27%) 47 (60%) 31 (40%)

49 (52%) 45 (48%) 12 ( 75%) 4 (25%) 14 (42%) 19 (58%) 23 (51%) 22 (49%)

5. Atlantic

TYPE OF SERVICE:

1. General

2. Specialized

available edition of the Guide to Canadian Health Care Facilities, 1994-1995.'

From this source, it was possible to pre-code the questionnaire according to the following variables: type of hospital (general or specialized), number of beds, province, and teaching hospital status. This last variable was further coded to indicate whether or not the prospective responding institution was a member of the Association of Canadian Teaching Hospitals (ACTH).

A total of 393 questionnaires were sent out in May 1995, with a cover letter explaining the nature of the project and a self-addressed prepaid return envelope. The letter also emphasized that return was requested, "even if research and other data gathering activities are not an important activity in your hospital." All materials were in the language indicated as appropriate to each hospital in the Guide to Canadian Health Cave Facilities, 1994-1995.' Between June 6 and June 20 "reminder" letters were sent to institutions that had not responded. The reminder offered to provide another questionnaire, if required, on request. All responses received by July 20,1995 were included in the sample.

employed were consistent with a artial" version of the major depar- Dillman's Total Design M e t h ~ d , ~ ' ~ ~ ~ . 4,

ture being that one follow-up was attempted, rather than the prescribed two.

The survey instrument and the survey technique

'7

~~~~ ~ ~~ ~~ ~ ~

21 (51%) 20 (49%) 10 (71%) 4 (29%) 5 (63%) 3 (38%) 6 (32%) 13 (68%)


159 (57%) 11 9 (43%) 46 (79%) 12 (21%) 26 (51%) 25 (49%) 87 (52%) 82 (49%)

68 (61%) 43 (39%) 23 (79%) 6 (21%) 20 (62%) 12 (38%) 25 (50%) 25 (50%)

Comparisons between rates and between proportions were assessed for statistical significance using Z tests for equality or chi-square analysis as appropriate. Comparisons of continually distributed data were made using "t" tests or ANOVA, as appropriate. "Differences" cited in the text have been shown to be statistically significant at p<.05 (two-tailed), unless otherwise indicated.

Results Sample and representativeness of sample

Table 1 documents the return rates by geographic area (West = British Columbia and Alberta; Prairies =

Saskatchewan and Manitoba; Ontario; Quebec; and the Atlantic = New Brunswick, Nova Scotia, Prince Edward Island and Newfoundland6), type of hospital (general and specialized), size of hospital (number of beds), and type of academic affiliation. For the purposes of this report, results will be identified sepa- rately for three groups, based on academic affiliation:

1. Members of the Association of Canadian Teach- ing Hospitals: Membership requires an active teaching program in affiliation with an accredited university faculty of Medicine (n=87). [See Table 1: Teaching Members]

2. Non-member teaching hospitals: This group consistsof hospitals which are designated as teaching hospitals in the most recent Guide to Canadian Health Care Facilities, 1994-1995,4 but are

6 Healthcare Management FORUM

Volume 9, No. 3 FalUAutomne 1996

not members of ACTH (n=83). These hospitals are most often affiliated with a university faculty other than Medicine. [See Table 1: Teaching Non- members]

3. Non-teaching hospitals: This group consists of all hospitals listed in the Guide to Canadian Health Care Facilities, 1994-1995,' which are not designated as teaching hospitals (n=219). [See Table 1: Non-teaching]

The overall return rate of 58.4% is reasonably good,s and the return rate of ACTH teaching members (79.3%) is very good. Using the correction suggested by Steiber and Krowinski7 for samples which repre- sent large proportions of the population, the overall confidence interval for the survey is approximately f 4.4%. The total potential population of 393 was reduced to 389 because of closures and mergers during the study period.

Variables were compared for the responders and non-responders in order to gauge the representativeness of the sample (Table 1). Overall, the type of service provided (general hospital versus specialized hospital) and the geographic location of the hospitals were not significantly different between the responding and non-responding groups. Responding hospitals, on average, had more beds (330 versus 273) and were more likely to be teaching members (78.2% ver-

Given that teaching hospitals tend to be larger than non-teaching hospitals (average beds in these samples [responders and non-responders] 487 versus 321), the two distinguishing variables are likely related. It seems reasonable, even though the instructions ac- companying the survey stressed the need for a response, "if research and other data gathering activities are not an important activity in your hospital," that institutions involved in research would be more likely to complete such a survey, thus the high return rate of this group.

When the teaching members that responded were compared with those that did not, they were found not to differ significantly in size, type of services provided, geographical area, or language of response. This, and the high response rate (79%) suggest that the sample of medical teaching hospitals (responding teaching members) is representative of that population, and that the conclusions derived from the data presented by this group concerning interest in research, purpose for doing research, research infrastructure and infrastructure funding, are valid for the population.

The lower return rate (48.7%) of the smaller and non-teaching hospitals probably reflects less research interest, opportunity and activity at this type of hospital. Although no statistical differences were found

sus 48.7%).

between responders and non-responders in terms of geographic location, type of services offered or size, generalization from this sample must be qualified and made with more caution because of the lower response rate. The sample of non-teaching smaller hospitals is taken to be: (1) different from the teaching member hospital sample, but (2) representative of a sub-group of smaller, non-medical school affiliated hospitals with relatively more research interest and activity than the overall population of Canadian non- teaching hospitals. Is research a valued activity?

tors of the value accorded research by an institution. These items addressed:

(1) whether or not the vision/mission statement of the hospital mentioned research directly, (2) whether the respondent predicted that research would become more important to their institution in the future, (3) whether, during the last 12 months, some (specified) type of research or research activity had been conducted at the hospital, and (4) whether there was interest in joining a national group designed to promote hospital-based research. Research mentioned in visionlmission statement

One hundred and thirty-one (57.7%) of the responding institutions reported that research was specifically mentioned in the vision/mission statements of their institutions. Significant differences were found depending on university affiliation status, with 91.3% of teaching members reporting that research was mentioned. About two-thirds and one-third respectively of teaching non-members and non-teaching hospitals reported that research was mentioned in their vision/ mission statements.

Specialized hospitals (75%) were significantly more likely than general hospitals (50%) to specify research as part of their official defining documents. Almost every member of the group of largest hospitals (>600 beds) mentioned research (95.7%) in their vision or mission statement. This became less likely as the number of beds decreased: (400-600, 68.3%; 200-400, 58.8%; and <200, 39.7%). There were no significant regional differences in tendency to refer to research in vision/ mission statements. Increasing importance

Approximately three-quarters (74.9%) of respondents reported that they expected research to become more important at their institution in the future. Again, ACTH teaching members (88.4%) were significantly more likely to expect this than teaching non- member hospitals (69.6%) or non-teaching hospitals (68.8%). The largest hospitals almost uniformly expected an increased emphasis on research (95.7%)

Four items from the survey were taken to be indica-



Reason for Engaging in Research

Table 2: Reported Reasons for Engaging in Research

Overall Average Overall %

These Items' Respondents Citing Ranking of Reason

~

Create Centre of Excellence

Vision Statement Requirements

Meet Professional Standards

Discover Best 80.5% I 1.6 Treatment I

60 6% 3 2

58 8% 3 4

62 4% 3 5

Attract Staff

Meet Accreditation Standards

Fulfill University Obligation

Attract Resources

52% 4 3

56 1% 4 5

36 7% 5 1

41 6% 6 1

and less was expected as the number of beds declined (87.8%, 70.6% and 66.7% respectively for the bed number groupings cited above). Expectations were not significantly different for general and specialized hospitals. Responding hospitals from Quebec were somewhat less likely to expect the importance of research to increase than other areas, while those in the Atlantic region were the most likely to have higher expectations (85.7% versus 59.2% respectively). Participation in research

Almost every responding institution reported being involved in some systematic data-based investigation beyond that required to attend to the individual patient (97.4%) during the preceding 12-month period, although the type of activity engaged in varied greatly (see section below). University affiliation status, type of services provided, number of beds and the geographical location of reporting hospitals did not differentiate responses on this variable. Promotional organization

The majority of responding hospitals expressed a desire to join a Canadian hospital-based research promotional organization should one be established (52.0%), while another 6% indicated that they may wish to take part depending on the group's mandate, role and the specifics required of member institutions. ACTH affiliation status again predicted response, with teaching members (75.4%) being most interested, while teaching non-members (56.5%) were less interested. Non-teaching hospitals showed the least interest (35.7%). Hospital size was also related to interest in

Reason for Teaching Engaging in Members Research

joining this group (>600 beds, 82.6%; 400-600, 65.9%;

Specialized hospitals were significantly more likely to be interested in a promotional organization than general hospitals (61.8% versus 47.8%). This is a par- ticularly interesting finding in light of the other predictive factors. While specialized hospitals are significantly more likely to be teaching members (66.7% versus 33%) than general hospitals, they also have significantly fewer beds (272 versus 354). There were no significant regional differences in interest in joining an organization promoting Canadian hospital- based research. Purposes of CHBR

Respondents who previously indicated that their institution engaged in research (n=221) were asked to select and priorize the reasons for conducting research from a list of eight pre-identified options. Table 2 shows the reasons chosen by responding institutions for engaging in research, including the average ranking of reasons.

Table 3 presents the order of ranks of reasons for doing research as a function of affiliation status, as well as the overall order for comparison. The only moderate deviation from the otherwise remarkable

Table 3: Order of Average Ranks

200-400, 52.9%; <200, 34.6%).

Non- Teaching Overall Teaching Non- Members Members

Discover Best Treatment

Create Centre of Excellence

vision Statement Requirements

Attract S t a q 5 I 6 1 4 1 5

Meet Accredi- 1 7 I 5 1 6 tation Stan- dards I 6

Fulfill Univer- sity Obligation --+++-++ Attract Resources

Percentage based on those hospitals which have university affiliation and which have "research" mentioned in their vision statement

consistency in ranking among these groups is the relatively greater importance of "allowing staff to meet professional standards" for the non-teaching hospitals.

~


Volume 9, No. 3 Fall/Automne 1996

Other noteworthy findings include the uniformly highest ranking achieved by "discovery of best treat- ments for our patients" and the nearly unanimous ranking of "opportunity to attract new resources" as the lowest rated reason for doing research. The relatively low ranking by teaching member hospitals of "university affiliation" as a reason for hospital research is perhaps surprising (sixth and seventh for teaching members and teaching non-members, respectively). What types of research are conducted?

define. For the present purposes, hospital-based research is considered to be any systematic data- gathering activity carried out in a hospital, the purpose of which is more general than the care of a specific individual. For convenience, such activities were divided into the following categories: data-based quality assurance / improvement (QA / QI) projects; formal data-based program evaluation; formal chart audits; corporate-initiated drug/ product trials; staff-initiated clinical trials; in irivo / vitro animal-based research; and epidemiology.

taken place at their hospital during the previous 12 months. As noted in the previous section, nearly all respondents (97.4%) indicated activity in at least one of these categories. QAIQI - Chart audits

The two most common research-type activities engaged in by respondents were formal data-based QA/QI projects (overall 93.4%) and formal chart audits (92.5%). No significant differences in the likelihood of engaging in these activities were noted as a function of affiliation status, type of services offered, number of beds or geographical location. Formal program evaluation

Almost 70% (69.2%) of respondents indicated that formal program evaluation involving the collection of data had taken place at their institution during the previous 12 months. A high degree of variability in this activity is evident, although only the difference between the largest and smallest hospitals reaches statistical sipficance, whereas comparisons as to geographic location, type of services offered and university affiliation do not. Corporate-initiated drug trials

reported that corporate-initiated drug trials had been carried out in their institution during the previous 12 months. Variability was great, however, with clear predictors of likely participation. All responding hospitals with more than 600 beds (n=23), and 91.3% of responding teaching members, reported having

"Research is an increasingly difficult activity to

Institutions were asked which of these activities had

Well over half (58.1%) of the hospitals surveyed

participated in corporate drug trials. Less than half (43.8%) of teaching non-members and non-teaching hospitals (43.5%) reported this activity.

The smaller hospital groups did not differ significantly from each other in the likelihood of hosting this type of research, but the now predictable trend was apparent (<200 beds, 35.4%; 200-400, 62.4%; and 400-600, 68.3%). This was a commonly reported activity in all areas of the country (range: 62.4% to 68.8%) with the exception of the West (B.C. and Alberta), where only 38.3% of the respondents reported collabo- rating in corporate-sponsored drug trials. Clinical trials

Hospital staff-initiated clinical trials were reported by 58.6% of respondents. This type of research is ex- tremely common among teaching member hospitals (91.3%), significantly more so than in either teaching non-member hospitals (52.2%) or non-teaching hospitals (41.1%). The largest hospital group (>600 beds) was significantly more likely to conduct clinical trials (91.3%) than all other size groups, and the smallest (<200) was less likely than all other groups (34.2%). Ontario hospitals were significantly more likely than hospitals in the West to report this activity (68.8% versus 42.6%); no other differences due to geographic location of the respondents reached significance. Both general and specialized hospitals reported this activity in 58.5% of cases. Epidemiology

Hospital-based epidemiological research was reported by just over one-third of respondents (33.6%). It was rarely reported by non-teaching hospitals (10.7%). Such research is somewhat more common in teaching non-member hospitals (32.6%) and quite common in ACTH teaching members (71%). The familiar pattern relating likelihood of activity to size of hospital was also evident (<200 beds, 19%; 200-400,

Epidemiological research was a significantly less often reported activity in the West (19.1%) and the Prairies (18.8%) than in Ontario, Quebec or the Atlantic region (38.7%, 38.8%, 42.9% respectively). There was a non-statistically significant trend for specialized hospitals to report this activity more often than general hospitals (42.6% versus 29.6%). Lab-based ( in vivoluitro) research

In vivo / vitro research was the least commonly reported type of research activity (18.5% overall). Only teaching members and the hospital group with the most beds reported this activity in more than half the cases (55% and 65.2%). Less than 1% of non- teaching hospitals and only 6.5% of teaching non- members carry out this kind of research. Less than 10% of the smaller hospitals (<400 beds) reported

29.4%; 400-600, 46.3%; >600, 73.9%).



Table 4: Hospitals Publishing at Least One Article, by Discipline of Author, and by Characteristics of the Hospital

DISCIPLINES

TYPE OF

HOSPITAL

UNIVERSITY AFFILIATION OF HOSPITAL

SIZE (BEDS) GEOGRAPHIC LOCATION OF HOSPITAL OF HOSPITAL

-

N TOTAL

130

111 85.4

72 55.4

87 66.9

22 16.9

in vivo/vitro research. Moderate sized hospitals (400-600 beds), although not nearly as likely as the very large hospitals to do this research, were about three times as likely to do so than the smaller ones (29.3%). Animal-based research was significantly more commonly reported by Quebec (26.5%) than by the Atlantic region (9.5%). What disciplines are involved in Canadian hospital- based research?

Of those institutions reporting the publication of at least one research article appearing in a national or international peer-reviewed journal during the previous year (n=130, 57.3% of respondents), 85.4% report publication by physicians, 55.4% by nursing, and 66.9% by other health care professionals. Published research by administrative staff was reported by 16.9% of respondents. Among the "other health professional" group, psychologists (44.6%) and physio- therapists (27%) were most often identified as having published. Table 4 shows the distribution of publishing discipline by university affiliation, status, type of services offered, size (beds) and geographic location. Publication of peer-reviewed articles

Respondents were asked to estimate the number of papers that were published in 1994 in peer-reviewed national/ international journals based on data gath- ered (at least in part) at their hospital. Just over three- quarters (173 or 76.2%) of respondents answered this question. Of these, 130 (75.1%) reported at least one such publication, and 46 (26.6%) reported at least 20.

Thirty (17.3%) of the respondents answering this question reported over 100 peer-reviewed publications in national / international journals during the year 1994.

University affiliation status and number of beds in responding institutions were the best predictors of publishing and of publishing over 100 articles. All responding hospitals with over 600 beds had published, and 13 (61.9%) had published over 100 articles. Only a little over half the members of the category of smallest hospitals (<200 beds) had published (52.9%), and only four (14.8%) in this category had published more than 100 times. Almost all teaching members (93.8%) had published, and 27 (45%) had published over 100 articles. Non-teaching hospitals and teaching non-member hospitals had published less frequently (57.7% and 80.6% respectively), and were much less likely to have published more than 100 articles (2.2% and 8% respectively).

The type of services (general/ specialized) offered by responding hospitals did not sigruficantly differentiate the tendency to publish (70.8% versus 84.9%) or the likelihood of publishing over 100 articles in 1994 (18.3% and 15.1%). Few differences in publication estimates were found for different parts of the country. Fewer responding institutions in the West had published (57.1%) than other areas, but the relative frequency of very high publication rates (>lo0 articles) was not different from other areas. In the Atlantic regon, publication per se was at the national average (75%), but there was a smaller percentage of respondents reporting the highest publication category (8.3%).


Volume 9, No. 3 Fall/Automne 1996

Research administrative structures and functions Research in Canadian hospitals is carried out under

a variety of administrative structures. Only 17 (7.5%) of responding institutions have a Vice-president of Re- search, and almost all of these are at the largest hospitals (>600 beds, 34.8%). Some hospitals appoint Direc- tors of Research (26.9%) at the institutional level, although again this is most common in large (65.2%) and teaching member (60.9%) hospitals. Where there are such Directors, they report to the Vice-president Medicine in about 10% of the cases (9.7%).

Directors of Research at the department /portfolio levels are common (47.8%) only at the largest hospitals, and somewhat less so at teaching member institutions (36.2%). Overall, however, such positions occur in only 15.4% of responding hospitals. Geographic location of respondents and type of services provided do not significantly differentiate the likelihood of having a Vice-president of Research or Research Directors at the corporate or departmental levels.

Almost half of respondents indicated that a research committee charged with facilitating research (rather than simply reviewing proposed protocols for approval) existed at their hospital. University affiliation is a predictor (teaching members, 81.2%; teaching non-members, 47.8%; non-teaching hospitals, 22.3%) as is hospital size (<200 beds, 20.5%; 200-400,42.4%; 400-600, 78%; >600, 82.6%). Specialized hospitals are more likely to have such committees than are general hospitals (58.8% versus 39.6% respectively). Some regional disparity is also evident, with these committees being more likely on the Prairies, Ontario and Quebec (62.5%, 50.5%, and 49%) than in the West (34%) or the Atlantic region (28.6%).

Offices of research, although not common overall (26%), show differences in patterns of distribution (university affiliation, type of services offered, number of beds and geographical location of the responding hospital) which are virtually identical to the distribution patterns of research committees. The functions performed by research offices almost universally include the distribution of granting information (93.2%), the provision of techrucal (e.g., methodological) research consultation (86.4%) and the facilitation/ coor- dination of the institutional research approval process (94.9%). Research offices administer research grants in three-quarters of cases (74.6%). Predictably, this function is most common in large (93.5%) and teaching member (80%) hospitals. The small number of research offices in some geographic areas prevents statistical comparison of this variable (e.g., Prairies: n=5, the West: n=9). Ethical clearance for hospital-based research

Formal ethical evaluation of proposed corporate- initiated drug trials, clinical trials, in vivo/vitro type research, and epidemiological research, is nearly

universal in Canadian hospitals (95.5%, 96.2%, 97.6%, 90.8% respectively). Quality research, formal chart audits and program evaluation are somewhat less commonly reviewed for ethics (66.5%, 70.5%0, 71.3%). Al- though the requirement of ethical review varies somewhat with the type of research, it is noteworthy that for each type, the factors of affiliation status, hospital service type, beds and geographical location of the hospital do not predict ethical review requirements.

Overall, research ethical review is solely an internal hospital activity in just over half of responding institutions (51.9%). Only in the case of ”in vivo/vitro” research is there much deviation from this level (31%). It is interesting that even where hospitals are affiliated with universities, the hospitals remain the only reviewing body in many cases (overall research categories, 48.8% for teaching members and 59.2% for teaching non-members). In only 9.8% (overall research types) of teaching member cases is a review carried out solely by the affiliated university. In teaching non- members that drops to 4.5%. However, each of the three teaching non-member hospitals conducting in vivo / vitro research have research protocols reviewed by their affiliated university only. Twenty-six percent of teaching members have their in vivo /vitro research reviewed for ethics by the university only.

It is much less common to require ethical approval from both a hospital and a university committee (overall categories, 18.3% for teaching members and 7.8% for teaching non-members). These percentages are higher for those categories traditionally considered university activities (e.g., among teaching members: corporate drug trials, 28.6%; clinical trials, 30.1%; animal research, 26.3%; and epidemiological research 28.6%).

Although the numbers are not large enough for definitive analyses, there appear to be no predictors of differences in patterns of usage of university and hospital committees based on the geographic, type of hospital, or size of hospital variables.

Respondents were asked if ethical reviews carried out at (or for) research at their institutions followed the guidelines published by the Medical Research Council (MRC).8 Overall, 40.1% of institutions engaging in research followed these guidelines. The likelihood of this follows the familiar pattern of increasing with the size of hospital (22.8%, 36.1%, 55.9%, 78.9% for increasing ”bed number” categories), and for teaching members (70.7%).

Not surprisingly, institutions which engage in (and internally review), the traditional activities of corporate and internally initiated clinical trials, in vivo/ vitro research, and epidemiology, are much more likely to use the MRC guidelines than those whose research consists of QM/QI, program evaluation and chart audits only (46.1% versus 13%).

FORUM Gestion des soins de sante‘ 11


Methodological and impact review

which conduct QA/QI, chart audits, and program evaluations, conduct a methodological (science) review as part of approval of projects to proceed (14.6%, 15.2% and 21.7% respectively). Membership in ACTH increases the likelihood of conducting such a review for these activities although the number remains low (non-teaching hospitals, 23.9%; teaching non- members, 24.6%; and teaching members, 32.7%).

The more traditional (academic) activities of corporate-sponsored drug research, clinical trials, in vivo / vitro research and epidemiological research are more likely to receive in-house science review (65.9%, 69.270, 81% and 65.8% respectively). There is no significant variation as a function of affiliation, type of services offered, or size of hospital. However, the number of hospitals engaging in these activities in some regions is too small to support statistical analysis as to geographic differences concerning this variable.

The likelihood of review as to the impact of proposed research activities on hospital resources shows a pattern similar to methodological review in that it is less commonly required for QA/QI (32.1%), chart audits (21.9%) and program evaluation (51.6%), than for corporate-sponsored drug trials (66.7%), clinical trials (72.2%) and animal research (57.1%). In about half the cases (48.7%), such a review is required for hospital- based epidemiological research. It is interesting to note that the predictor variables of affiliation status, type of services offered, size and geographical location of an institution, do not distinguish between those hospitals that internally review for impact on hospital resources, and those that do not.

Just over one-third of hospitals that evaluate internally for both "ethics" and "impact" do so with a single committee (36.1%). Again, little variation is evident as a function of the predictor variables mentioned above. Research support resources

Respondents were asked to indicate if each of sev- eral kinds of research support resources existed within their institution. These included: a large library; centralized computer facilities; dedicated research space and an organized research methods consultation service.

Hospital-based library facilities judged to be large enough and specific enough to support research were reported by 59% of respondents. Such facilities were less likely among non-teaching hospitals (38.4%), small hospitals (<ZOO beds, 35.9%) and in the West

Overall, a small minority of responding institutions

(38.3%). Centralized computer facilities were located on-site

in 31.7% of hospitals. These are most common in teaching member and large hospitals (49.3%, 56.5%)

and at Prairie hospitals (50%), and least commonly available at non-teaching and small hospitals (22.370, 24.3%), and in the Atlantic region (14.3%).

Thirty percent of respondents report that a formal- ized service providing research methodology consultation exists at their hospital. Once again, teaching members and large hospitals are more likely to have such groups (55.1%, 47.8%), while these are relatively rare in non-teaching hospitals (13.4%), and in the smallest hospitals (19.2%). Specialized hospitals are also more likely to provide this service than are general hospitals (47.1% versus 22.6%). Such services appear to be available equally throughout the country.

Dedicated research space exists in just over one- third of responding hospitals (34.4%), and in almost one-quarter (24.7%) of responding hospitals such space includes a research "centre" or "institute." Dedi- cated research space in general, and research institutes specifically, follow the familiar pattern of being increasingly more likely with increasing hospital size (20.5%, and 11.5% for "space" and "institute" respectively in the smallest category, to 78.3% and 69.6% respectively for smallest versus the largest). University affiliation follows this pattern also, with 72.5% and 60.1% of teaching members having "dedicated space" and "institutes" respectively, compared to only 10.7% and 5.4% of non-teaching hospitals.

It is interesting to note that hospitals offering specialized services only, are about twice as likely as general hospitals to have dedicated research space (52.9% versus 26.4%), but only slightly (and statistically non- significantly) more likely to have a hospital-based research institute/ centre (30.9% versus 22%). Moderate geographical differences are difficult to interpret because of the small numbers in some categories (i.e., only two centres/institutes in the Prairies and in the Atlantic region). However, it would appear that Que- bec hospitals are proportionally slightly more likely to have research institutes in their hospitals than the overall average (26.5% versus 16.3% nationally). This is also true of dedicated research space in general (Quebec, 46.9%; national average, 34.4%).

Respondents were asked to classify their dedicated research space into three categories: "dry" (office), "wet" and "animal." While one-third (33.5%) of all respondents indicated that their institution included dry space, only 20.7% and 16.3% had wet and animal labs respectively. All teaching member respondents, and all of the largest hospitals which reported dedicated research space reported having dry research space.

Teaching member and large hospitals were more likely to have animal space (47.8% and 65.2% respectively) and wet labs (55.1% and 56.5%) than non- teaching hospitals (<1% for both animal and wet labs). This type of research space was also uncommon in the smaller hospitals (e.g., for institutions with <200 beds,

~_ ~ - _ _ - _ _ ~ _ _ _ _ ~ 12 Healthcare Management FORUM

Volume 9, No. 3 FalVAutomne 1996

11.5% wet labs, and 8.9% animal labs). Again, geographical comparisons are difficult to make (statistically) because of the small number of these facilities in some regions. However, Quebec seems to have more wet and dry lab dedicated space (i.e., 26.5% and 46.9% versus the national averages of 16.3% and 33.5% respectively). Funding of the indirect costs of CHBR QAIQI, program evaluation, chart audits

As mentioned, the vast majority of respondents report involvement in formal data-based quality assurance, evaluation and audit activities. External grants are rarely reported to be available to support such activities (12.7% overall), although they are com- paratively more available to the largest hospitals (33%). University affiliation does not significantly im- prove chances of receiving money from external sources for these activities (19.4% teaching members, 16.7% teaching non-members).

Likewise, support from universities to hospitals for these activities is uncommon overall (5.7% of respondents), and is only available with any frequency to the teaching member (11.9%) and largest (19%) hospitals. Hospital foundations support these types of investiga- tions in 15.1% of responding institutions, and most often in teaching member, large, and specialized hospitals (25.4%0, 28.6% and 25% respectively).

Some hospitals which recover overhead costs from private corporations conducting research at their institutions, use such funds to support QA/QI and evaluation activities (overall 9.8% of those which carry out corporate-initiated research).

ties is the global budget of the hospital itself (90.6% of those engaging in QA / QI). These activities, however, are not commonly approved ”line items” in hospital budgets (27.8%). Indirect costs of “traditional“ (academic) research

The indirect costs (e.g., non-project specific costs such as investigator salaries, physical plant mainte- nance, administration, support services) of traditional research (clinical trials, epidemiology and in vivo / vitro research) can be substantial, and in the Canadian context, are rarely recoverable from project grants. Forty-two percent of respondents engaging in these sorts of research report that the Health Ministry of their province does support such activities. However, overall only 11.8% of these hospitals report supporting such costs as approved ”line items.” The ability to do so is much more common in the larger hospitals (27.3%) than in smaller hospitals (e.g., <200 beds,

A nearly universal source of funding for these activi-

7.1%). Both teaching member and teaching non-member

hospitals report being able to support the indirect

costs of this kind of research in 16.7% of cases, while only 2.2% of non-teaching hospitals report this. Over half of all hospitals doing traditional research report funding the indirect costs through the hospital global budget (52.2%). Only the smallest hospitals deviate appreciably from this (39.3%).

Twenty-seven percent of respondents report receiving support from their hospital’s foundation to cover the indirect costs of ”traditional” research. Again, large (40.9%) and teaching member affiliated hospitals (40.9%) were most likely to support the indirect costs of these activities with hospital foundation money. Just over half (50.7%) report supporting these activities through ”other” (unspecified) sources, and 42.1% overall report more than one source of support.

Conclusion Overall, responding hospitals indicated a high de-

gree of interest and activity in research and related activities. The degree of university affiliation and the size of the hospital clearly predict a greater likelihood of: (1) official recognition of research, (2) willingness to promote an Association of Canadian Hospital- Based Research, and (3) an expectation of increasing importance of research at individual institutions.

Using a broad definition it can be claimed that research of some kind is a near universal activity of this large sample of Canadian hospitals. Systematic data gathering for the purposes of accountability and plan- ning (QA/QI, audit and program evaluation) are conducted by the vast majority of hospitals, regardless of size, geographic location, type of services offered and university affiliation status.

Activities more traditionally thought of as research (i.e., drug trials, clinical trials, laboratory based research, and epidemiological research) are more commonly reported at larger and university affiliated hospitals than at smaller non-university affiliated hospitals (58% versus l8YO).

Funding of CHBR is highly variable. A lack of grant funding of hospital-based health care delivery research is evident (see also Eni’). Few statistically reli- able patterns differentiating type of research activity with variables such as geographic location of hospital, or types of services offered, are evident.

Using ths information as a base, a second paper in this series will address the following questions in light of the current challenges to health care in Canada:

Why should hospitals engage in research? What should be the subject matters of CHBR? How should research be organized within hospitals?

What are the most efficient and appropriate ways of funding CHBR?

FORUM Gestion des soins de sant6 13

FalUAutomne 1996 Volume 9, No. 3

References and notes 1. Litvack JT. Hospital-based research: Creating a

climate of excellence. Dimensions 1987; September: 7-8.

2. McKiel E, Dawe U. Hospital-based nursing research programs: A requirement for progress. Canadian Journal of Nursing Administration 1991;

3. Hollenberg CH. The uncertain future of Canadian 4(3): 26-28.

academic medicine. Clinical and Investigative Medicine 1990; 13(4): 227-231.

4. Canadian Hospital Association. Guide to Canadian Health Care Facilities 1994-1995. Ottawa, CHA Press, 1994.

5. Dillman DA. Mail and Telephone Surveys: The Total Design Method. New York, John Wiley and Sons, 1978.

6. Too few hospitals from the Northwest Territories and the Yukon met the inclusion criterion of having 100 or more beds, to be included in analysis of the data according to geographic location.

7. Steiber SR, Krowinski WJ. Measuring and Manag- ing Patient Satisfaction. Chicago, American Hospi- tal Publishing, 1990.

8. Medical Research Council of Canada. Guidelines on Research Involving Human Subjects. Ottawa, Medical Research Council of Canada, 1987.

9. Eni GO. Biomedical and health services research in Canada: A review. Healthcare Management Forum 1992; 5(3): 21-30.

Dan W. Harper, PhD, is wi th the Research Department, Sisters of Charity Hospital, Saint-Vincent Pavilion, in Ottawa. Patricia A. O’Hara, MA, is a Research Asso- ciate of the Sisters of Charity Hospital, Saint-Vincent Pavilion, in Ottawa. Jeannine Sigouin is the Secreta y of the Re- search Department a t the Sisters of Charity Hospita 1, Saint-Vincent Pavilion, Ottawa.


purposes and structures of canadian hospital-based research: results of a national survey

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