Why every Canadian hospital should be a ‘research’ hospital

Most Canadian hospitals are “community” hospitals whose mission is to provide health care to local communities. They range from large suburban hospitals, like Surrey Memorial Hospital in Surrey British Columbia, to small rural hospitals, like Twin Oaks Memorial Hospital in Nova Scotia, and everything in between.

In major cities, there are also “academic” hospitals, institutions that are affiliated with medical schools and provide education to medical students and residents, as well as highly specialized care such as advanced surgical procedures and cancer care. Academic hospitals conduct most health research in Canada and are at the forefront of medical innovation. Although community hospitals account for 90 per cent of hospitals in Canada, few are involved in health research.

The disconnect between where research is conducted and where Canadians receive their care means that most patients do not have access to cutting-edge research. It also means that research conducted in academic hospitals may not accurately represent Canadian patients. Including community hospitals in research would increase research equity and greatly accelerate research results.

Research ensures continuous improvement in quality of care and allows patients to receive new therapies earlier. Studies in the United States have shown that hospitals participating in research have better patient outcomes, improved clinical staff satisfaction and retention and improved organizational efficiency. However, many patients live too far from academic hospitals to benefit. As a result, rural patients are less likely than urban patients to be recruited into clinical trials. This likely is also true of suburban and small-town patients.

Geographic distinctions between patients also relate to important sociodemographic and clinical differences. Community hospitals are more likely to serve neighbourhoods with lower socioeconomic status, higher proportions of recent immigrants and limited access to specialized care. On average, patients in community hospitals are also older and have poorer health outcomes. Taking into account these differences, health research conducted in academic hospitals may not reflect the reality of community hospital care or the community hospital patient population.

The COVID-19 pandemic exposed significant limitations in Canada’s existing health research infrastructure. The Canadian Treatments for COVID-19 (CATCO) trial, one of the largest COVID-19 studies in Canada, enrolled patients in 52 hospitals. During the first 10 months of the study, 1,144 patients were recruited, representing three per cent of patients hospitalized with COVID-19 nationwide. By comparison, in the United Kingdom, the Randomized Evaluation of COVID-19 Therapy (RECOVERY) trial enrolled more than 11,000 patients in the first 100 days, representing more than 10 per cent of hospitalized COVID-19 patients. Not surprisingly, the RECOVERY trial was the first to identify corticosteroids as an effective treatment for severe COVID-19 and the first to exclude other treatments, such as hydroxychloroquine, as ineffective.

The success of the RECOVERY trial was a product of how the U.K. has integrated its health research infrastructure with health service delivery. The National Institute for Health Research (NIHR), a national clinical research network, provides infrastructure support to each National Health Service trust, enabling the hiring of permanent research staff at most hospitals. The NIHR sets national priorities on which studies to support, and all hospitals in the NIHR are eligible to participate. When a study is approved at one hospital, it is automatically approved at all hospitals, greatly reducing the complexity of initiating multi-centre studies.

In Canada, the funding model for health research is very different. Individual researchers apply for government grants and then recruit hospitals to participate in their study. No funding is provided to hospitals up front. Instead, they are paid retroactively based on the number of patients they have recruited into the study.

The system is designed to encourage recruitment but favours larger hospitals and those with higher consent rates. Patients from minority populations and those with low socioeconomic status have lower consent rates for research, making recruitment more challenging. Furthermore, hospitals with limited research experience are likely to be less efficient at recruiting, leading to higher costs that are not covered by the per-patient payments. There is also no funding available to hire and train research staff, nor to fund basic research infrastructure such as research ethics boards and research contract review teams.

The demonstrated success of the NIHR model has led to calls for better integration of research and health service delivery in Canada, but so far without appreciable effect.

Canadian community hospitals have the potential to be more involved in research participation and recruitment. First, community hospital professionals are motivated to participate in research. A survey of 73 Canadian community intensive care unit professionals during the pandemic found that 81 per cent were interested in participating in research to improve patient outcomes and advance medical knowledge. Second, in Ontario, annual research publications by community hospital authors have increased by more than 100 per cent since 2015. Finally, among community hospitals that do participate in research, informed consent rates, patient enrollment rates and protocol adherence are equivalent to those at academic hospitals, confirming that community hospitals can conduct high-quality research.

Although the number of community hospitals participating in research is growing, many barriers remain. Strategies such as increases to funding for infrastructure and research team personnel, collaborations with academic hospital research programs and increased research training and mentoring opportunities for hospital staff have been proposed – with limited success.

Since 2020, the Canadian Critical Care Trials Group (CCCTG) and its affiliates, the Canadian Community ICU Research Network (CCIRNet) and the COVID-19 Network of Clinical Trials Networks, have provided support to community hospital research programs. The CCIRNet is a grassroots organization dedicated to supporting community hospitals in their research efforts through knowledge sharing and community building. In 2022, the COVID-19 Networks of Clinical Trials Networks, funded by the Canadian Institutes of Health (CIHR), provided financial support to 18 Canadian community hospitals to facilitate their participation in COVID-19 studies. In 2023, the Accelerating Clinical Trials (ACT) Consortium, also funded by CIHR, provided three years of funding to 20 community hospitals across Canada to enable them to hire full-time research coordinators.

Although these grassroots initiatives are a useful start in promoting community hospital research participation, they have reached only a small proportion of the almost 400 community hospitals in Canada.

Sustainable solutions will require system-level supports. Specifically, policy makers must recognize the value of integrating health research within health service delivery as a way to enhance research efficiency, improve equity in research and health care and optimize health care delivery. This will require a commitment at the national level to fund research infrastructure in hospitals throughout Canada, with the goal of building a research network similar to the U.K.’s NIHR.

Only by embedding research into clinical practice can Canada achieve a “learning health system” and advance quality health care for all Canadians.