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| EDITORIAL |
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| Year : 2022 | Volume
: 1
| Issue : 2 | Page : 31-33 |
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Prioritizing operational research in hospital settings: Need of the hour
Sonu Goel
Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India; Department of Human and Health Sciences, Swansea University, Swansea, United Kingdom; Department of Education and Health Sciences, School of Medicine, University of Limerick, Limerick, Ireland
| Date of Submission | 06-Jan-2023 |
| Date of Decision | 29-Jan-2023 |
| Date of Acceptance | 06-Jan-2023 |
| Date of Web Publication | 20-Feb-2023 |
Correspondence Address:
Dr. Sonu Goel
Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research (PGIMER), Madhya Marg, Sector 12, Chandigarh 160012
Ireland
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/JIMPH.JIMPH_1_23
How to cite this article:
Goel S. Prioritizing operational research in hospital settings: Need of the hour. J Integr Med Public Health 2022;1:31-3 |
How to cite this URL:
Goel S. Prioritizing operational research in hospital settings: Need of the hour. J Integr Med Public Health [serial online] 2022 [cited 2023 Mar 27];1:31-3. Available from: http://www.jimph.org/text.asp?2022/1/2/31/370071 |
The doctor’s life is faced with numerous challenges. Right from entry into the medical profession through a highly competitive process of undertaking 8–10 years of rigorous medical studies before entry into the job arena makes this profession even more demanding as compared with other white-collar professions. Studying medicine also comes with higher expectations from friends and family to work harder on an average than students from other disciplines. Further, doctors are routinely faced with several problems that include conflicts with their colleagues and/or patients/their caregivers due to lack of adequate communication skills, shortage of drugs and other supplies due to lack of skills for managing inventory, poor diagnosis due to lack of high-tech equipment, overcrowding in various areas of the hospital because of lack of efficient management skills, and insufficient clinical care and rising medical errors due to poor management of data generated in the hospital settings. In addition to it, factors leading to poor adherence to treatment, gaps in care cascade, alarming attrition rate of patients to treatment, dynamics of poor quality of care, false positive or false negative diagnosis, comparative effectiveness of drugs, or other modalities of interventions on treatment outcome are other pressing issues that are concerning clinicians in medical practice. Most of these issues can be addressed by undertaking operational research (OR) in clinical, paraclinical, or preclinical settings.
OR, also known as implementation research or action research or health services research, is a decision-oriented research that aims at value addition to existing knowledge on strategies, interventions, and tools that can enhance the quality, coverage, effectiveness, or performance of health systems or programs.[1] OR can be described as “science of improvement,” “generating evidence-based and practical solutions to a problem” and “science of converting research into policy and policy into practice.” The principle elements of OR (in this case hospital settings) are that the research questions (RQs) are generated within the settings by identifying the constraints and challenges encountered during prevention, diagnosis, or treatment and the solutions provided (after undertaking OR) should have direct and practical relevance in improving clinical care to the patient. This may not happen at once but is a continuous and iterative process. Clinical practitioners that take part in OR can also objectively evaluate their practice and contribute to the development of their discipline.
There are three keys to conducting OR: (1) generating a good quality RQ around the barriers encountered or for improving the patient care, (2) thinking about the study design/methodology that needed to be worked to address the RQ, and (3) generating and/or collating good quality data (through a structured or semi-structured questionnaire). The first step, that is, generating a good quality RQ in OR can be around three barriers in hospital settings: (a) “Is there a lack of knowledge?,” (b) Is there a lack of tools (drug, operative procedure), and (c) Is there insufficient use of the existing tool (Are the existing tools inefficient or inefficiently utilized? All these steps need thorough consultation with all stakeholders of the problem. Let me take an example of each one of them).
Regarding the RQ around the first barrier (lack of knowledge), few examples can be reasons for low uptake of services (e.g., newly opened diabetic clinic) or low uptake of a diagnostic test (e.g., confirmatory test for diabetes) or high attrition rate or loss to follow up. The OR will try to find out the answers to this RQ for the overall improvement of hospital services. For the second barrier (lack of tool or intervention), the examples can be the lack of a diagnostic test for early detection of drug-resistant TB or lack of drug/ operative intervention. The conventional culture method and X-ray provide delayed results or are not very sensitive, respectively. The OR shall try to find the sensitivity, specificity, or timeliness of the new tool as compared to the existing user tools. For the third barrier (inefficient use of the existing tool), the examples can be the inefficient use of existing diagnostic tests or treatment (drugs). For instance, the identified constraint in a hospital setting can be that because of human shortages and a high load of patients, the three smears per patient for diagnosis of tuberculosis is highly demanding. The RQ that arises is whether two sputum smears are as efficient as three sputum smears? The answer to this RQ can lead to the optimization of human resources and supplies.
The investigator also needs to keep in mind three objectives (and three RQ) pertaining to the improvement of either clinical implementation outcomes, or clinical service outcomes or client outcome or the overall impact of the services. If an investigator wants to assess the feasibility of new strategies (e.g., telemedicine in hypertension management, robotic-assisted adrenalectomy, virtual exit exam during COVID-19) or acceptability (e.g., stepping exercise in cardiovascular fitness) or coverage (e.g., vaccination coverage) or adherence (to treatment), it is an example of assessing clinical implementation outcome (OR question-1). If you want to study the effectiveness of a New Drug (or any diagnostic or therapeutic intervention-say counseling, training, or operative procedure) with existing Gold Standard in reducing death rates or morbidity (complications) due to a disease (say tuberculosis), it is an example of improving clinical service outcomes (OR question-2). Say, the new drug was associated with better outcomes in terms of producing an effect (e.g., reduction in hypertension) or reduction of morbidity (e.g., complications) or death rates from X% to Y%, you may advocate the drug for the patients. This may also lead to policy decisions across the medical fraternity. However, if the investigator wishes to assess patient satisfaction with the intervention (drug/ operation/counseling etc.) or the quality of life of the patient after the intervention, it is an example of improving client outcome or overall impact of the services (OR question-3).
Only uncontrolled conditions are evaluated in OR. Therefore, OR encompasses all descriptive and cross-sectional studies, experimental study designs, case-control studies, ecological studies, cohort studies (both retrospective and prospective), exploratory or formative studies, and ecological studies whereas basic science, genetic research, experimental (or clinical) research, and randomized control trials are frequently excluded from this category. OR is not even monitoring and evaluation, formative evaluation, or quality assurance.
The conduction of OR in hospital settings is marred with several challenges that include lack of knowledge among doctors about the systematic process of conducting OR (irrelevant RQ, poor adherence to research protocols, and poor writing skills), poor understanding of the relevance (perceive “research” as another department’s responsibility, OR is not relevant to service implementation, etc.), lack of funding support and other necessary resources to undertake OR, lack of research skills and time, poor quality of data or poorly designed data extraction tools, and lack of coordination. Many of them can be easily solved at the individual or institutional level. I hereby suggest the following solutions to overcome the barriers. First, the institute (or department or an individual) should establish research priorities based on the patient's needs. Second, OR capacity-building workshops should be organized on regular basis in the institute or faculty are encouraged to attend them outside the institute. Third, there should be a provision of dedicated funds for the conduction of intramural research at the institute to promote small OR at the departmental or inter-departmental level. Fourth, a dedicated time slot (perhaps 1–2 days per week for 3–4 h per day) and resources (office space, computer, internet, stationery, and manpower support) should be made available to the faculty so that they can plan OR and develop protocols for extramural funding. Indian Council of Medical Research (ICMR), The Department of Science & Technology (DST), The Department of Biotechnology (DBT) and Science and Engineering Research Board (SERB) are the major organization that are prioritizing their interest in OR and can be a funding agency for your OR project. Fifth, a functional institute ethics committee should be in place which can review OR submitted at least once a month. Sixth, collaborations are key to a successful OR. There should be active discussions between different departments (clinical meet) on important interdisciplinary clinical areas which can lead to relevant OR RQ. Seventh, sufficient financial or non-financial incentives or bonuses (like paying APC charges for the journal, sponsorship to present studies in conference/ meetings, fellowships, and promotion to higher posts) should be kept for the clinicians who undertakes and publishes relevant OR or secure extramural funding. Eight, there is a need to create an OR database of the institute wherein all researchers can design and fill their tools/ data instruments to undertake multi-disciplinary OR on common problems.
Summarily, OR should be embedded within the clinical care of patients. Doctors can evaluate their practice objectively and get involved in efforts to advance their field by participating in research. Doctors can also learn a range of skills that can help them grow in their careers, including analyzing the evidence at hand and exercising critical thought. Therefore, I believe that all medical professionals should participate in OR in some capacity; however, this could differ from individual to individual.
(If you want to know further details on how to conduct OR in hospital settings, please refer to the book: Goel S and Aggarwal AK. Management of Healthcare System. 1st Edition. Oxford University Press; 2022. Chapter 25, Operation Research; p. 625-638).
| References | |  |
| 1. | Zachariah R, Harries AD, Ishikawa N, Rieder HL, Bissell K, Laserson K, et al. Operational research in low-income countries: What, why, and how? Lancet Infect Dis 2009;9:711–7.  |
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