Establishing the research priorities of a national primary care research network in New Zealand: a Delphi exercise

Introduction

Administrative and health data are routinely collected in Aotearoa New Zealand (NZ) by primary health organisations to facilitate the dissemination of primary health care funding. These data can also be utilised to conduct cost-effective research providing real-world health insights. Such insights can improve clinical practice, inform policy, and improve population health.¹ Research endeavours in primary care often use routinely collected data. Primary care research networks (PCRNs) typically collate and administer such data and support researchers.² PCRNs are well established internationally.^3–5

Various research networks have existed in NZ.⁶ Currently NZ has a patchwork of regional organisations conducting primary health care research; however, no current infrastructure supports this work nationally.² The Southern Primary Care Research Network (Southern PCRN) has recently been established in the Otago/Southland region through a collaboration between WellSouth (the regional primary health organisation) and the University of Otago. It is hoped that this network will eventually expand to a national research network. The Southern PCRN aims to improve health outcomes and reduce health inequities through primary health care research. We wish to establish a list of prioritised research topics and questions so these aims can be efficiently and effectively realised.

Research priority setting is a crucial aspect of research planning and can help identify areas of research need for both researchers and funders.^7,8 Research projects informed by priority setting are more likely to generate meaningful impact and achieve feasibility during implementation.⁹ Applying an equity lens to prioritisation exercises can improve health equity outcomes.^7,10

Research prioritisation activities engage stakeholders because of the moral, ethical, and political importance of health research.¹¹ Primary care research has three main groups of stakeholders: patients, clinicians, and researchers. Research using routinely collected data uses anonymised patient information, that clinicians have collected and researchers wish to use.¹² Stakeholder engagement particularly recognises those who contribute and collate the data.¹³ Inclusion of Indigenous perspectives and data sovereignty concepts may help avoid deficit framing.^13,14 Stakeholder engagement can help ensure prioritised research is fit for purpose and has the greatest potential health benefits.¹⁵

This project aims to identify the research priorities of primary health care clinicians and academics. Other projects will engage with Māori and patient stakeholder groups via focus group interviews. The exercise will conclude with a multi-stakeholder workshop, which will be held with stakeholder group representatives to determine the final list of research priorities of the Southern PCRN.¹⁶ Together these projects will provide detailed insight into the research needs of this region and will help construct a research agenda for the Southern PCRN.

Methods

The Delphi process is a research method that can establish consensus amongst experts. It has been used effectively to ascertain stakeholders’ opinions in research agenda development.¹⁷ The Delphi process involves sequential survey rounds that collect and rank participants’ views. At the end of the process, a consensus view is established.¹⁸ This study used the Delphi process to understand the research priorities of primary health care researchers and academics. The study received ethics approval from the University of Otago (D23/027).

Eligible participants were primary health care clinicians working in Southern NZ and academics across NZ. Initially, the Southern PCRN will predominantly use data from this region, therefore the clinicians working here are key stakeholders. However, there is only a small cohort of primary health care academics across NZ; therefore, all were invited to participate.

A recruitment email containing the study invite and a link to the questionnaire (Supplementary File S1) was sent to individual clinicians and academics where possible. Academic and clinical groups were contacted and requested to distribute the email to members or employees. These included primary health care departments in tertiary education institutions, medical professional organisations (such as The Royal New Zealand College of General Practitioners), general practice clinics in Southland and Otago, and the WellSouth Primary Health Network. Recipients were requested to forward the study invite to their colleagues to recruit additional participants in a snowball manner.

Results

Discussion

Primary health care clinicians and academics in NZ considered access to health care, health workforce, health services, mental health, and models of primary health care as the top research areas to improve health equity. Research questions with the highest priority scores include the impact of annual health checks for people with intellectual disability, the role of allied health as front-line primary health care providers, and the role of an embedded social worker in a general practice clinic setting. These research priorities are consistent with those identified in international prioritisation exercises conducted in primary health care.^21–25 To our knowledge, this is the first attempt in NZ to prioritise primary health care research topics and questions.

In terms of study strengths, the sample size is sufficient to obtain consensus in a Delphi survey.¹⁷ Clinicians and academics came from a variety of disciplines. Māori participation was strong (11/58, 19.0%), particularly given the underrepresentation of Māori among health care clinicians and academics.^26,27 The main study limitations relate to non-representative sampling. Snowball sampling methods may have influenced the diversity of the sample. Few males participated (8/58, 13.8%). No participants identified as either belonging to the Pacific community or LGBTQI+ group. Research priorities for those groups may have been omitted. Non-representative sampling may have influenced the final results, limiting their generalisability. Although used in other priority-setting exercises,²⁰ we found requesting the questions in the PICOT format limited the generalisability of the research questions.

Health care access was the highest priority research theme area identified. Health care access is critical to achieving equitable health outcomes.²⁸ Although the health system in NZ is largely government funded, patient co-payments in primary health care present a substantial barrier to access.²⁹ One in eight New Zealand adults (12.9%) report they do not visit a GP due to cost.³⁰ Patients who are not enrolled with a primary health care provider experience increased odds of amenable mortality.³¹ Ongoing research in this area is necessary to evaluate the impact of current health policies and any new initiatives that aim to reduce access barriers to primary health care.²⁸ This is particularly imperative for Māori and Pacific populations, patients who experience socioeconomic deprivation, and those in underserved communities.

Closely related to health care access, the health workforce is a critical element in the health system. It is therefore unsurprising that health workforce was also identified as a priority research area.^28,32 The health workforce fluctuates because of health policy, education, and retention.^28,33 NZ has failed to train adequate numbers of health professionals over many decades, and struggles to recruit and retain primary health care providers in a competitive global economy.³² NZ is ostensibly committed to growing the primary health care workforce, with special attention to training Māori and Pacific clinicians, rural health practitioners, and the training of allied health professionals.³⁴ Inter-professionalism is being promoted as a method of improving health care delivery in areas of need.^34,35 Further research is required to evaluate the outcomes of increased inter-professional care.

Health services was another priority research area identified. Health service research encompasses service scope, quality, and impact on health outcomes. Routinely collected primary health care data have long been used to evaluate health service quality.^36,37 Health services are closely aligned with another prioritised research theme, that of primary health care models. Over the past decade, there has been a substantial push from traditional and corporate practice models to new models of care such as the Health Care Home.²⁸ The drivers for change include several of the other priority research areas identified in this study, including low numbers of primary health care clinicians and difficulty in accessing health care resulting in inequitable care. To date, there is no clear evidence that one model performs better than another, and Māori and Pacific patients and those in poverty still have worse health outcomes.²⁸ Ongoing health care evaluation using routinely collected data is imperative for any emerging primary health care models going forward.

Mental health was the top ranked health condition identified as a priority research topic. Mental health conditions affect approximately one in five New Zealanders of all ages and NZ has one of the highest suicide rates among the Organisation for Economic Co-operation and Development (OECD) countries.^38,39 Poor mental health is a major driver of health care use, and is correlated with premature morbidity and mortality.^40,41 Primary health care plays a critical role in prevention, early diagnosis and intervention, monitoring, and access to secondary care services if needed.⁴² NZ recently launched an integrated model of mental health and addiction services within primary health care settings to address unmet need.⁴³ Ongoing research to monitor the impact of such changes, as well as to identify outstanding unmet mental health needs in primary care, is required to improve equitable mental health care in NZ.

The top-ranked research question proposes evaluating the impact of implementing annual health checks for people with an intellectual disability. People with intellectual disability experience greater barriers to accessing primary health care and higher mortality and morbidity than the rest of the population.^44–46 An annual health check is an effective way to maintain health and identify unmet health needs of people with intellectual disability.⁴⁷ NZ lacks the capacity to track the mortality and morbidity information of people with intellectual disability.⁴⁸ Routinely collected primary health care data could be used to track this information for future research endeavours, to inform health policy and improve health outcomes for people with intellectual disability.

The impact of multidisciplinary teams, including allied health professionals and social workers, was a feature of the subsequent three most highly rated questions (Table 3). Question two considers the role of allied health professionals in chronic overlapping pain conditions. Nearly 20% of the NZ population experience chronic pain, and analgesia is one of the most frequently prescribed medications in primary care.^49–51 There is increasing recognition of the coexistence of overlapping pain conditions, which are likely underdiagnosed.⁵² An interdisciplinary approach is considered the gold standard in chronic pain management and is a feature of secondary pain clinic services.⁵³ Although most patients with chronic pain are treated in primary care, little research on primary care multidisciplinary pain management teams appears to have been undertaken to date.⁵³

The third equally ranked questions consider whether embedded social workers would improve patient health outcomes or ED presentations, and the impact of comprehensive primary care teams on high-use patient visits. Interdisciplinary primary care teams have been widely implemented as a means of improving care quality and patient outcomes, particularly for more complex patients. Evaluation of the impact of interdisciplinary teams is an emerging research topic; findings to date suggest they may be associated with positive patient outcomes.^54,55 Patient experience is improved in interdisciplinary primary care team settings.⁵⁶ Embedding social workers within a primary care team may improve care coordination quality.⁵⁷

Primary health care clinicians and academic staff in NZ identified priority areas and questions requiring research to improve health equity. Specific research questions can guide primary care researchers planning equity-focused outcomes research with a strong primary care mandate. Additional consultation is planned with other stakeholders including patients, Māori, and Pacific community groups. Prioritised general research areas will be used as discussion starters in engagement exercises with other stakeholder groups. Taken together, these stakeholder engagement projects will help establish a formal research agenda for the Southern PCRN in accordance with its mission of improving health equity. To that end, future research should focus on primary health care access; particularly workforce issues and health care models and services, including the embedding of allied health professionals and social workers in primary health care. People with mental illness and intellectual disability were also identified as priority groups for research to improve health equity.

Supplementary material

Supplementary material is available online.