Attitudes toward comparative effectiveness research and patient engagement among reproductive health clinicians

This study assessed a sample of reproductive health clinicians’ knowledge of and attitudes toward CER, PCOR and patient engagement in research. The findings expand upon the limited literature on providers’ attitudes toward CER and patient engagement more generally, and offer further insight into attitudes among nonphysician clinicians and among reproductive healthcare providers, specifically.

Survey respondents were overwhelmingly female and predominantly composed of nonphysician clinicians, such as nurse practitioners, certified nurse midwives and physician assistants. This demographic composition is representative of clinical staff at Planned Parenthood health centers, but differs from other clinician populations previously studied, which included more male and physician representation [18,19], and may not be representative of clinicians in reproductive healthcare more broadly. For instance, the gender distribution among obstetrician–gynecologists in the USA is nearly equal [23].

Familiarity with CER and PCOR was moderate in our sample and was higher for PCOR than CER. The higher familiarity with PCOR could be due in part to the emphasis on patient-centered care at Planned Parenthood. Nonetheless, familiarity with CER was somewhat higher among this population than in prior research with primary care clinicians. While similar proportions of respondents from the two studies reported not being at all familiar with CER (44% in this study vs 45% in Forsythe et al.), a higher proportion of our respondents reported being very familiar (8 vs 5%) or moderately familiar (27 vs 17%) with CER [19]. This increased familiarity with CER may reflect trends of increasing awareness of CER in clinical practice in general.

Overall, Planned Parenthood clinicians in our sample held positive attitudes toward CER, PCOR and patient engagement in research once definitions were provided. Across all questions, the majority of respondents agreed or strongly agreed with the potential positive impacts of CER and patient engagement on research, as well as the importance of the principles of PCOR. When compared with research conducted among physicians prior to passage of the Affordable Care Act and among primary care clinicians in 2012–2013, a higher proportion of our survey respondents agreed that CER can improve the quality of patient care [18,19]. Similarly, views on patient engagement in research were positive; however, there was more variability in attitudes toward patient engagement within our study population than in attitudes toward CER or PCOR.

Planned Parenthood clinicians may have highly positive views on these measures for several reasons. First, our survey participants were overwhelmingly comprised of nonphysician clinicians; past research suggests that physicians report less favorable views on CER than other types of clinicians, and that nurse practitioners and physician assistants are particularly positive toward the value of engaging patients in health research [19]. Thus, strong agreement in these areas may be reflective of the make-up of the underlying clinician population. Second, Planned Parenthood health centers are often involved in research; clinical staff may, therefore, be more receptive to these research methods and the value of research in clinical practice and decision making. Third, as stated earlier, the preference-based nature of much of reproductive health decision making may make this area particularly receptive to CER and PCOR methods and principles. Fourth, those individuals who completed the survey may have had more positive views toward the content of the survey than individuals who chose not to complete it, with potential for response bias. However, this is mitigated by the fact that the survey invitation and introductory language did not include any mention of PCOR, CER or patient engagement. Finally, some of the more positive views toward CER and patient engagement in our study as compared with prior studies may also be due to the later date of our survey and increased visibility of these concepts.

Past research has assessed barriers for clinicians to engage in research as stakeholders [19] or researchers’ perceptions of barriers for stakeholder engagement in research [5]. Here we sought to assess how clinicians – who may understand the willingness and interest of their patients to engage in research – perceive barriers to patient engagement. Additionally, nearly half of Planned Parenthood clinicians had experienced engaging patients in research as more than study subjects. While clinician perceptions of patient attitudes should not be interpreted as a direct proxy for patient attitudes, it is important to consider, and perhaps compare in future research, the difference between provider-mediated attitudes and attitudes directly from patients.

Despite identifying potential barriers, it is notable that when asked if they thought their patients would be interested in future research engagement, 93% of clinicians responded “yes” or “maybe”. Planned Parenthood clinicians also reported an interest in conducting research themselves. The results from our study may indicate a patient and clinician population who are interested in and willing to engage in research on reproductive healthcare; future engagement should be considered and advanced.

Our study had several limitations. The demographic characteristics of respondents, and the underlying population of Planned Parenthood clinicians, may not be reflective of the reproductive healthcare or general healthcare provider community, limiting our ability to generalize our findings to other populations. However, findings may be more easily extrapolated to health centers with similar clinician groups, such as Title X or other safety net family planning providers. Further, the modified snowball recruitment methodology allowed us to increase our reach but limited our ability to assess the response rate. The number of respondents was relatively small, and it is possible that those who completed the survey may not be representative of all Planned Parenthood clinicians.

Where possible, questions were adapted from existing survey instruments on awareness of and attitudes toward PCOR, CER and patient engagement in research, allowing for comparison between our results and others’ findings. Highly positive responses throughout our survey could be due to phrasing of questions or reporting bias related to social desirability of responses. Past surveys using similar statements have found greater variability in agreement, indicating that past respondents were willing to report more neutral or negative views [18,19]. Nonetheless, we can be confident that attitudes toward CER, PCOR and patient engagement are generally positive among this population and the results are comparable to other studies. The present study was quantitative in nature; further exploration of attitudes using qualitative methodology may offer insights into the complexities or nuances of clinician attitudes.

Studies of providers’ attitudes toward CER, PCOR and patient engagement in research have been limited, especially among nonphysician clinicians and reproductive health specialists. However, available information indicates that providers are a stakeholder group that sees the value in CER and PCOR and could benefit the research community through its engagement in research. We did not assess either potential barriers or facilitators to clinicians’ engagement as stakeholders or patient-identified barriers or facilitators for engagement in research activities. While these have been assessed to some extent elsewhere [19,5], future research could explore these factors in the reproductive health field. Assessments of patient attitudes and willingness to engage in reproductive health-related research should also be explored. Though lack of engagement in research may be due to challenges in resourcing and operationalizing engagement activities, clinician attitudes toward engagement are positive. Researchers should take advantage of this support to meaningfully engage clinicians and patients in research.

Given the preference-based nature of reproductive healthcare (e.g., choosing a contraceptive method), reproductive health research may be a natural fit for PCOR and CER. Understanding providers’ views on these topics is an important step in ensuring reproductive health research translates to evidence that is useful for both clinicians and their patients. Attitudes toward CER, PCOR and patient engagement in research were highly favorable among this nonrandom sample of Planned Parenthood clinicians and may demonstrate a population interested in and willing to engage in future research. The principles and methods of CER, PCOR and patient engagement could be harnessed within the reproductive health field to facilitate patients’ and their caregivers’ ability to make informed decisions about their health and the care they receive.

We would like to acknowledge AcademyHealth's Consumer Patient Researcher Roundtable members, who contributed to the development of this survey instrument.

The first author (J Kohn) has received an engagement award from the Patient-Centered Outcomes Research Institute (PCORI). The other authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

The authors state that they have obtained appropriate institutional review board approval or have followed the principles outlined in the Declaration of Helsinki for all human or animal experimental investigations. In addition, for investigations involving human subjects, informed consent has been obtained from the participants involved.