Powerful Partnerships: Strengthening Research Through Collaboration

"The power of collaboration is ultimately the power to improve patient care," says Joe V. Selby, MD, MPH, director of Kaiser Permanente Northern California's Division of Research (DOR). Selby's own experience as both a family physician and a clinical epidemiologist convinces him that the quickest route to better prevention and treatment often lies in research carried out in alliance with other HMOs and universities.

The drive to collaborate is accelerating nationwide, as the federal government increasingly demands that researchers break out of the silos of their own organizations and begin working in larger, inter-disciplinary and inter-institutional teams. In some instances, pooling data across institutions allows for more statistically powerful analyses or for studies in more representative populations.

Pooling can also capture variations in treatment patterns that are valuable for answering certain questions. More often, though, it is the collaborative, intellectual capacity that makes the study more powerful. Researchers collaborating across a broader span of the clinical research spectrum can increase the "translational" impact of their work and speed potentially life-saving findings into clinical practice.

HMO Partnerships

To accelerate collaboration, Kaiser Permanente Northern California (KPNC) and eight other HMOs around the country formed the HMO Research Network in 1994. The network, which includes six of Kaiser Permanente's regional research centers, now has 15 research centers located in not-for-profit health plans and draws from a patient population that spans from Hawaii to New England.

With the ability to pull from the medical records of nearly 11 million patients, the network's potential research power far surpasses that of typical research studies done by single institutions. HMO Research Network studies are helping define what is the best care for patients with such diseases as hypertension, diabetes, cardiovascular disease, and cancer.

The Cancer Research Network

The HMO Research Network conducted important research regarding cervical and breast cancer screening through its Cancer Research Network (CRN). Carried out between 1995 and 2000 at seven HMO Research Network member sites, these two studies aimed to identify persisting challenges in the cervical and breast cancer screening programs of these health plans.

Researchers wanted to know if the screenings were not as effective as they could be, or if some women were simply failing to go in for screenings. "Within these health care systems, mammography and Pap smears were essentially free. Nevertheless, our linked cancer registries were telling us that a number of women were still presenting with advanced-stage breast or cervical cancer," says Selby, who recently served as the network's governing board chair. Network scientists concluded that for both types of cancer, the explanation in more than 50 percent of cases appeared to be that women had simply failed to get screened.

This research was important because it pointed to the need for more intense outreach to enrolled women members who have not been screened in several years or at all. "It is also important on a broader scale because if this problem exists within these high-quality health plans, it is almost certainly worse in the more fragmented US health care system," says Selby.

Two papers on the research appeared in the Journal of the National Cancer Institute in 2004 and 2005. "The studies have really made an impact, both inside and outside these systems," Selby says.

Collaborating on Heart Disease Research

The Cardiovascular Research Network (CVRN) is a powerful new research arm of the HMO Research Network that was formed at the end of 2007 in partnership with the National Heart, Lung and Blood Institute. The collaboration includes 15 HMO Research Network sites and provides a rich source for very large studies of common cardiovascular risk factors, conditions, and treatments, while also offering a patient pool large enough for studies involving rarer cardiovascular diseases.

CVRN research success, as well as that of the HMO Research Network overall, depends a great deal on the volume and thoroughness of linkable patient medical records.

Alan S. Go, MD, is director of the CVRN and also the director of the Comprehensive Clinical Research Unit at the DOR. He praises the network's ability to conduct population-based research studies by using database and electronic medical information across member research sites. "Having a robust electronic health record and in-depth clinical information allows us to answer important research questions about why certain people suffer from various cardiovascular diseases and how to prevent and treat these conditions more effectively. We are also able to track the epidemiology of cardiovascular risk factors and diseases over time," says Go.

A CVRN-leveraged study initiated in 2006 focused on the optimal duration of use of the antiplatelet drug clopidogrel in people with coronary disease treated with drug-eluting intra-coronary stents. As it turned out, the health plans in the CVRN were the only ones that possessed longitudinal individual-level medication data comprehensive enough to find the answer.

The study clarified that the short-term risk of failure of drug-eluting stents was low and that some patients were not taking clopidogrel long enough. Go says the research informed the US Food and Drug Administration's decision to recommend keeping patients who receive drug-eluting stents on clopidogrel for at least a year after their stent is implanted.

Go currently leads a five-health plan CVRN study looking at the use of the blood thinner warfarin in patients with atrial fibrillation or venous thromboembolic disease. The study seeks to determine the risks of bleeding and blood clot formation associated with taking the drug.

Clinical and Translational Science Awards

Another type of collaboration is demonstrated by the partnership of KPNC and the DOR with the University of California, San Francisco (UCSF) through its Clinical and Translational Science Institute (CTSI). The CTSI is an award from the NIH that aims to strengthen inter-disciplinary research and speed translation across academic research campuses and between academic institutions and their community partners.

As part of the ambitious new effort, the DOR has established the KP CTSI Clinical Research Center.

The DOR's outpatient clinical research unit has joined with UCSF and other community-based clinical research centers in a network that supports inter-institutional clinical research as well as the training of students, residents, fellows, and faculty in clinical and translational research.

The KP CTSI Clinical Research Center hosts a wide range of collaborative studies on everything from kidney and pulmonary disease to women's health, osteoporosis, and diabetes. Current studies include research pertaining to chronic obstructive pulmonary disease outcomes, type 2 diabetes risk among women with gestational diabetes, and the epidemiology of chronic kidney disease.

Community Engagement

KPNC is also a partner with UCSF in the CTSA Community Engagement Program. Together, the two institutions develop ways to ensure full, two-way exchanges between researchers at the DOR and at UCSF, while also exploring ways to strengthen research partnerships with Bay Area patient groups, schools, community-based organizations, safety net clinics, and other affected community members.

In one project, a KPNC medical team is working with UCSF scientists to find new ways to increase colorectal screening. In another study, scientists are recruiting families in which two or more siblings have epilepsy for research to identify possible genetic markers for the disease.

"Research benefits if the community is engaged," says Selby. "This means that community members understand and agree with the ethics and logistics of the research, they participate in designing some of the research, and, ideally, they help to determine what research gets done. I think the NIH deserves credit for recognizing the importance of community involvement, and we are proud to be a partner with UCSF in the Community Engagement Program."

Selby concludes, "Multidisciplinary collaboration is the future of medical research. It makes sense and, frankly, it is more exciting, too."