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There are two curious facts about the state of clinical research in theUnited States. First, basic research is slow to be translated into clinicaltrials and, subsequently, into clinicalpractice.1 The rateof translation "has been inefficient and disappointing," writesJohn P.A. Ioannidis,MD.2 Even whenclinical trials report important results that should change practice, it cantake years or decades before they are incorporated. Approximately 25% ofpromising technologies are published as a randomized clinical trial, and<10% are incorporated into clinical practice within 20 years ofpublication. Case in point—the benefit of a beta-blocker after acutemyocardial infarction was first described in the early 1980s, yet by 1994 itstill was not widelyused.3
Second, U.S. research does not take place in the settings where mostpatients are treated. Although most research is conducted in academic medicalcenters, only 1 adult patient per 1,000 is referred to a university medicalcenter each month, and <1 patient per 1,000 per month is hospitalized in anacademic medicalcenter.4 Of patientswho seek care, approximately two-thirds are seen in physicians' offices.
To address the slow rate of incorporation into clinical practice, theNational Institutes of Health (NIH) developed the Roadmap for MedicalResearch, which has three major components: 1) New Pathways to Discovery, 2)Research Teams of the Future, and 3) Re-engineering the Clinical ResearchEnterprise.5 Thefirst two initiatives are directed mainly at basic research. The third isfocused on generating more translational research and incorporating theresults into clinical practice with new strategies intended to re-energize theclinical researchworkforce.6
NIH plans to establish new partnerships with organized patient communities,community-based health care providers, and academic researchers by"promoting the better integration of existing clinical researchnetworks, encouraging the development of technologies to improve theassessment of clinical outcomes, harmonizing regulatory processes, andenhancing training for clinical researchers." Greater involvement andempowerment of the public in the research process is a major goal.
RESEARCH IN PRACTICE
Fortunately, the re-engineered clinical research enterprise is already herein the form of practice-based research networks (PBRNs). A PBRN is a group ofambulatory practices devoted principally to the primary care of patients. Thepractices are affiliated with each other (and often with an academic orprofessional organization) in order to investigate questions related tocommunity-basedpractice.7
PBRNs are different from a collection of practices that participate in aclinical trial then go their own way. After a PBRN research initiative iscompleted, the practices remain members of the network and may participate inother projects.
An advantage in many PBRNs is the generation of research ideas in both abottom-up and a top-down fashion. Ideas may percolate up from practicingclinicians or be generated from the PBRN's core group of primary careresearchers. Many PBRNs have community advisory boards that review theiractivities and may suggest research topics of community importance.
PBRNs in North America are a relatively recent development. Started in the1970s, the Dartmouth Primary Care Cooperative Information Project (COOP) wasone of the first regional research networks. The Ambulatory Sentinel PracticeNetwork (ASPEN), formed in 1981, was the first national network (it alsoincluded Canadian primary carepractices).8
The PBRN movement has grown significantly in the last 30 years. Althoughnetworks of family practitioners predominate, other efforts include theAmerican Academy of Pediatrics' Pediatric Research in Office Setting (PROS)network and the American College of Physicians' ACPNet. The Federation ofPractice Based Research Networks (FPBRN) promotes the growth and developmentof clinical investigation in practice settings in primary care medicine.Formed in 1997, FPBRN now lists more than 50 member, affiliate, andinternational research networks.
Several PBRNs are involved in research relevant to diabetes. ACPNet's Website (see FYI) lists current and upcoming projects, including a diabetes pilotstudy funded by the Agency for Healthcare Research and Quality, a diabetesreferral study, and an obesity toolkit project.
With funding from the National Institute of Diabetes and Digestive andKidney Diseases, my own PBRN, the Penn State Ambulatory Research Network, isexamining the role of nurse case managers (NCMs) in managing patients withdiabetes in primary care practices.
Soon to start, this study will deploy NCMs into 12 busy practices to helpaddress some of the challenges of caring for patients with diabetes, such asinsufficient physician time to monitor and treat multiple clinical issues (theaverage primary care physician visit is 15minutes9).
GETTING THE WORD OUT
In addition to helping generate new knowledge, PBRNs also play aninfluential role by serving as a mechanism to circulate this new informationamong communities of physicians. Quality guru Donald Berwick, MD, MPP,president and CEO of the Boston-based Institute for Healthcare Improvement,says PBRNs may help smaller physician practices disseminate innovations inhealth care.10
Participating in office-based research by joining PBRNs will expose thesepractices to new treatments. Indeed, as PBRNs evolve, they are becominglearning communities of physicians, proving grounds for new treatments, andagents of change for the practice ofmedicine.11
If you are interested in office-based research about compelling problemsfor you and your patients, I advise you to check out the nearest PBRN. Ifthere is not a network in your local area or state, investigate theopportunities for your discipline offered by national networks. 
Footnotes
Check out the following Web sites for more information about gettinginvolved in practice-based research activities:
NIH's Roadmap for Medical Research,http://nihroadmap.nih.gov.
Federation of Practice Based Research Networks,www.aafp.org/x19544.xml.
ACPNet,www.acponline.org/acpnet/current.html.
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References
2. Ioannidis JP: Materializing research promises: Opportunities,priorities, and conflicts in translational medicine. J TranslMed 2: 5, 2004.
3. Sial SH, Malone M, Freeman JL, et al.: Beta blocker use in thetreatment of community hospital patients discharged after myocardialinfarction. J Gen Intern Med 9:599–605, 1994.[Medline]
4. Green LA, Fryer GE Jr, Yawn BP, et al.: The ecology of medical carerevisited. N Engl J Med 344:2021–2025, 2001.
5. Zerhouni E: Medicine: The NIH Roadmap.Science 302:63–72, 2003.
6. Zerhouni EA: Translational and clinical science—time for anew vision. N Eng J Med 353:1621–1623, 2005.
7. Agency for Healthcare Research and Quality: Fact Sheet: PrimaryCare Practice-Based Research Networks. 2000. Available atwww.ahrq.gov/research/pbrnfact.htm.Accessed November 5, 2005.
8. Lindbloom EJ, Ewigman BG, Hickner JM: Practice-based researchnetworks: The laboratories of primary care research. MedCare 42 (Suppl. 4):III45–49, 2004.
9. Mechanic D, McAlpine DD, Rosenthal M: Are patients' office visitswith physicians getting shorter? N Engl J Med 344: 198–204, 2001.
10. Berwick DM: Disseminating innovations in health care.JAMA 289:1969–1975, 2003.
11. Mold JW, Peterson KA: Primary care practice-based researchnetworks: Working at the interface between research and quality improvement.Ann Fam Med 3 (Suppl. 1):S12–S20, 2005.
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