title: Veterans Healthcare Administration providers' attitudes and perceptions regarding pragmatic trials embedded at the point of care.
abstract: Background The Veterans Healthcare Administration (VA) is implementing an adaptation of a pragmatic trial program, Point of Care Research (POC-R). The goal of POC-R is to embed research into clinical practice, contributing to a Learning Healthcare System. Provider acceptance and participation in POC-R is essential to its successful implementation. The purpose of this study is to evaluate provider's perceptions and beliefs regarding the POC-R program. Methods Provider focus groups and interviews were conducted at seven VA medical facilities involving 62 providers. A semi-structured script was used that included descriptions of four use cases and targeted questions regarding perceptions, concerns, and attitudes about the POC-R program. Sessions were audio-taped, de-identified, transcribed, and analyzed using systematic qualitative techniques to create response categories and overarching themes. Results The emergent themes were as follows: (1) POC-R is a valuable component of evidence-based practice, providing an opportunity to base clinical practice on more generalizable evidence as well as providing tools to improve local practice; (2) POC-R highlights the tension between the need for autonomy of practice and compliance with protocols; (3) POC-R may create increased time and burden resulting from added research responsibilities; (4) concern about the scientific validity and reliability of results; (5) potential for a negative impact on the provider-patient relationship; and (6) uncertainty regarding what constitutes equipoise, given differences in provider knowledge and preferences. Despite substantive concerns, barriers were generally felt to be solvable. Implementation should include provider education, careful attention to workflow for all arms of the study, inclusion of the entire team, and adequate oversight. Limitations The study design is qualitative with limited implications for causal inference. Participants are from the VA and may not be representative of other clinicians. Conclusion VA providers are supportive of the importance and value of pragmatic trials in general and of POC-R in particular. However, providers have significant concerns regarding the burden, ethics, and evidence regarding equipoise. Results are discussed in terms of implementation recommendations.
authors.affiliation: a VA Center for Informatics Decision Enhancement and Surveillance (IDEAS) and VA Salt Lake City (SLC) Health Care System Geriatric Research, Education, and Clinical Center (GRECC), Salt Lake City, UT, USA.|b Department of Biomedical Informatics, School of Medicine, University of Utah, Salt Lake City, UT, USA.
authors.forename: Charlene R
authors.initials: CR
authors.lastname: Weir
authors.affiliation: a VA Center for Informatics Decision Enhancement and Surveillance (IDEAS) and VA Salt Lake City (SLC) Health Care System Geriatric Research, Education, and Clinical Center (GRECC), Salt Lake City, UT, USA.
authors.forename: Jorie
authors.initials: J
authors.lastname: Butler
authors.affiliation: a VA Center for Informatics Decision Enhancement and Surveillance (IDEAS) and VA Salt Lake City (SLC) Health Care System Geriatric Research, Education, and Clinical Center (GRECC), Salt Lake City, UT, USA.
authors.forename: Iona
authors.initials: I
authors.lastname: Thraen
authors.affiliation: c Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Cooperative Studies Program, VA Boston Healthcare System, US Department of Veterans Affairs, Boston, MA, USA.
authors.forename: Patricia A
authors.initials: PA
authors.lastname: Woods
authors.affiliation: c Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Cooperative Studies Program, VA Boston Healthcare System, US Department of Veterans Affairs, Boston, MA, USA.|d Department of Medicine, Boston University School of Medicine, Boston, MA, USA.
authors.forename: John
authors.initials: J
authors.lastname: Hermos
authors.affiliation: c Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Cooperative Studies Program, VA Boston Healthcare System, US Department of Veterans Affairs, Boston, MA, USA.|e Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.
authors.forename: Ryan
authors.initials: R
authors.lastname: Ferguson
authors.affiliation: f Department of Veterans Affairs, Office of Research & Development, U.S. Department of Veterans Affairs, Washington, DC, USA.
authors.forename: Theresa
authors.initials: T
authors.lastname: Gleason
authors.affiliation: a VA Center for Informatics Decision Enhancement and Surveillance (IDEAS) and VA Salt Lake City (SLC) Health Care System Geriatric Research, Education, and Clinical Center (GRECC), Salt Lake City, UT, USA.
authors.forename: Robyn
authors.initials: R
authors.lastname: Barrus
authors.affiliation: c Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Cooperative Studies Program, VA Boston Healthcare System, US Department of Veterans Affairs, Boston, MA, USA.|d Department of Medicine, Boston University School of Medicine, Boston, MA, USA.|e Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.
authors.forename: Louis
authors.initials: L
authors.lastname: Fiore
mesh_terms: D001291:Attitude of Health Personnel; D002986:Clinical Trials as Topic; D003469:Culture; D017144:Focus Groups; D006282:Health Personnel / Q000523:psychology*; D006801:Humans; D019095:Point-of-Care Systems; D036301:Qualitative Research; D012107:Research Design; D014481:United States; D014493:United States Department of Veterans Affairs; D014728:Veterans