Massive savings could wreck decades of research tradition at mega-hospital

By Ole Steen Nielsen, vice-dean for research at Aarhus University

The announced cost reductions of more than DKK 300 million on research and treatment at Aarhus University Hospital are deeply worrying. Such comprehensive and far-reaching cost reductions will not only threaten the part of healthcare research which involves patients. They can also mean that future generations of medical doctors and others who carry out research will find it difficult to do this research as part of their professional healthcare work. The worst-case scenario is that it will cost Denmark its leading position in international clinical research.

Clinical research is research involving patients in trials and studies. It can cover everything from research into acute cardiac patients to pain relief in childbirth. ?We have grown more and more anxious seeing the pressure that the conditions for clinical research have been under in the hospital departments over a number of years.

Paradoxically, the explanation for this development can be partly found in our enormously effective healthcare system in Denmark. By a European yardstick, Danish hospital patients spend the fewest number of days in a hospital bed, only being outdone by Holland and Bulgaria. This is not only due to the Danish regions tight management of the hospitals and financial considerations which do not encourage long patient stays at the hospitals. There is strong evidence that it is beneficial for patients to leave their hospital bed drip etc. as quickly as possible. Doing so lessens the risk of bacterial infections, and the majority of patients benefit from starting rehabilitation quickly, for example following an operation. On top of this, improved treatment methods and surgical techniques help to reduce the number of hospital bed days.

But an effective hospital system has an increasingly negative effect on the research environment. In contrast to basic research at the universities, clinical research at the hospitals is often based around the patient's involvement in studies and trials. With patients spending less time in hospital, it has become increasingly difficult for medical doctors with research obligations to recruit patients to clinical research. There is no time to discuss things with the patients – neither when they are hospitalised nor in outpatient departments. This is a major barrier as the patient needs to feel he or she is fully informed and so they are confident about participating in a study which does not necessarily have an impact on treatment here and now. The consequence is that some studies fail to find the requisite number of patients. More specifically, this means that research studies which are based on a good idea and observations of individual patients are not scaled up and tested on a larger group.

One example of successful point-of-care clinical research at the hospitals is the treatment of blood clots in the heart. This is a disease that affects more than 8,000 Danes annually, and without rapid medical intervention, it is very often fatal. On the other hand, the method of treatment with balloon angioplasty of the narrowed arteries is effective and always preferable, even if the method means that the patient has to be transported a long way to one of the four heart centres in Denmark. This was shown by a very large research study from Aarhus University and Aarhus University Hospital that involved many hospitals in Denmark and hundreds of patients.

The result of the research has now been incorporated in the national strategy for a round-the-clock highly-specialised balloon angioplasty treatment of the coronary arteries and is the reason why Denmark has experienced the biggest decrease in cardiac mortality in the whole of Europe. Denmark is also a leader in the use of telemedicine in ambulance emergency response, which ensures direct and fast visitation at the highly specialised cardiac centres. This would not have happened if hospital doctors and nurses from the emergency response and cardiac units had not set aside time to participate with their own piece of the big jigsaw puzzle. Or if the patients had not been involved in the research.

If health science research is not to become an exclusive discipline for researchers working at the university, we must first of all discuss the dilemma that exists between an extremely structured and streamlined hospital system and the need for research. There is therefore a requirement to look into the way in which we organise patient-related research in Denmark.

Secondly, the politicians with responsibility for the area should ensure they understand the fundamental conditions for clinical research at the hospitals and organise the running of the hospitals accordingly.

Patients spending more days in costly hospital beds is not the solution. One the other hand, we should re-examine the requirement for medical doctors and other groups such as e.g. clinical research nurses who undertake research activities to be production units delivering services which live up to target figures. They should also be viewed as potential or active researchers – both in name and deed.

To begin with, we should take the issue up with the healthcare sector’s parties and discuss whether the big spreadsheet for running the hospitals has remembered to include research activities. They are fundamentally the basis for the research-based Danish healthcare system, where patients are entitled to access the newest and evident treatment. Part of the discussion should also cover whether Denmark as a research nation can subject clinical research to such massive savings as those announced at Aarhus University Hospital.

The contribution to debate is published in Jyllands-Posten 16 May 2019