University of Calgary PRISM: University of Calgary's Digital Repository Graduate Studies Master of Public Policy Capstone Projects 2018-08-01 Funding Leads to Better Health Outcomes – Case study of Alberta Sepsis Network demonstrates how research initiative reduced mortality Haq, Anwar Haq, A. (2018). Funding Leads to Better Health Outcomes – Case study of Alberta Sepsis Network demonstrates how research initiative reduced mortality (Unpublished master's project). University of Calgary, Calgary, AB. http://hdl.handle.net/1880/109331 master thesis Downloaded from PRISM: https://prism.ucalgary.ca
Transcript
University of Calgary
PRISM: University of Calgary's Digital Repository
Graduate Studies Master of Public Policy Capstone Projects
2018-08-01
Funding Leads to Better Health Outcomes – Case
study of Alberta Sepsis Network demonstrates how
research initiative reduced mortality
Haq, Anwar
Haq, A. (2018). Funding Leads to Better Health Outcomes – Case study of Alberta Sepsis Network
demonstrates how research initiative reduced mortality (Unpublished master's project).
University of Calgary, Calgary, AB.
http://hdl.handle.net/1880/109331
master thesis
Downloaded from PRISM: https://prism.ucalgary.ca
MASTER OF PUBLIC POLICY CAPSTONE PROJECT
Funding Leads to Better Health Outcomes – Case study of
Alberta Sepsis Network demonstrates how research initiative
reduced mortality
Submitted by
Anwar HAQ
Approved by Supervisor (Professor Herb Emery)
August 01, 2018
Submitted in fulfillment of the requirements of PPOL 623 and completion of the requirements for the Master of
Public Policy degree
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Acknowledgment
The author particularly acknowledges the advisor of this study,
Professor Herb Emery for his contributions to the knowledge, oversight
and excellent mentorship. Additionally, the author acknowledges
Snyder Institute for Chronic Diseases, University of Calgary for tuition
assistance, ASN Manager Ms. Knight for sharing ASN related
information, AHS DIMR office for the data, Ms. Farahnaz Bandali for her
support and encouragements over the years, and Julie-Anne Babiuk for
reviewing the document.
Last but not least, the support from my family that kept me intact
during some of the toughest moments in our life.
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TABLE OF CONTENTS
EXECUTIVE SUMMARY ............................................................................................. VII
HISTORY OF RESEARCH FUNDING IN ALBERTA......................................................................................................... 3
INTERDISCIPLINARY TEAM GRANTS (ITGS) ............................................................................................................ 4
WHAT IS SEPSIS ............................................................................................................................................... 6
WHY ALBERTA SEPSIS NETWORK (ASN) .............................................................................................................. 7
STUDY POPULATION ......................................................................................................................................... 8
DATA SOURCES ................................................................................................................................................ 9
SEPSIS CASES ACROSS ALBERTA ......................................................................................................................... 10
CONFIRMED DIAGNOSIS SEPSIS CASES AT IN-PATIENT AND EMERGENCY DEPARTMENTS IN ALBERTA ................................ 11
Non-ASN IP and ED Sites - combined ................................................................................................... 11
ASN IP and ED Sites - combined ........................................................................................................... 12
Non-ASN and ASN IP Sites .................................................................................................................... 13
Non-ASN and ASN ED Sites ................................................................................................................... 13
QUERY DIAGNOSIS SEPSIS CASES AT IN-PATIENT AND EMERGENCY DEPARTMENTS IN ALBERTA ....................................... 14
Non-ASN IP and ED Sites - combined ................................................................................................... 15
ASN IP and ED Sites - combined ........................................................................................................... 15
Non-ASN and ASN ED Sites ................................................................................................................... 15
SEPSIS MORTALITY RATE FOR NON-ASN AND ASN SITES ACROSS ALBERTA ................................................................ 17
Non-ASN IP and ED Sites - combined ................................................................................................... 17
ASN IP and ED Sites - combined ........................................................................................................... 18
MORTALITY RATE AMONG CONFIRMED SEPSIS CASES FOR NON-ASN AND ASN SITES ACROSS ALBERTA .......................... 19
Non-ASN IP and ED Sites - combined ................................................................................................... 20
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ASN IP and ED Sites – combined........................................................................................................... 20
Non-ASN and ASN IP Sites .................................................................................................................... 22
Non-ASN and ASN ED Sites ................................................................................................................... 24
MORTALITY RATE AMONG QUERY SEPSIS CASES FOR NON-ASN AND ASN SITES ......................................................... 24
SUMMARY OF RESULTS ............................................................................................ 26
with the range of disease burdens such as prevalence, incidence, mortality, and economic costs
(Vermus 1999, Gross, Anderson and Powe 1999).
Since Zwicker and Emery’s (2015) paper looked at the overall research funding on
health outcomes, the current study takes Zwicker and Emery’s premises a step further. This
paper will look at the impact of the research funding at a program level using an
Interdisciplinary Team Grant (ITG) program funded by the Alberta Innovates Health Solutions3
(formerly known as Alberta Heritage Fund for Medical Research – AHFMR). This study aims to
determine if total funding is contributing to better health outcomes, if this also happens at the
program level. The premise of this paper is that the impact of such research funding goes
beyond traditional peer review publications. As the knowledge generated through these
programs is used to improve patient care and the management of diseases, it results in better
outcomes. This study would further aim to establish a link between random policy shifts in
funding various programs and its unintended consequences of truncated innovation cycle
resulting in larger sunk-costs, poor cost recoveries and negative impact on patients’ outcomes
in the area.
History of research funding in Alberta
On a national level, the Canadian Institute for Health Research (CIHR) is the federal
agency responsible for funding medical research in Canada. Alongside CIHR, larger provinces
also have provincial funding agencies that either fund independent research programs or match
federal funding. In Alberta, this task is undertaken by the Alberta Innovates Health Solutions
(AIHS). AIHS was formerly known as the Alberta Heritage Foundation for Medical Research
(AHFMR).3
In 1980, in order to support biomedical and health research at Alberta universities and
other affiliated institutions, the Alberta government introduced the Alberta Heritage
Foundation Medical Research Act (Revised Statutes of Alberta, 2000).4 This act was the
3 While this report was being written, AIHS went through another transition where all four arms of Alberta
Innovates merged and is now Alberta Innovates (AI). This paper examines how AIHS funding for health research is contributing towards healthcare innovation, reducing suffering and improving the lives of Albertans.
4 Alberta Heritage Foundation for Medical Research Act, RSA 2000, c A-21, http://canlii.ca/t/knwx
Lethbridge, Alberta Health Services, Primary Care Networks, and other groups. The clinicians
and the researchers spanned a wide range of disciplines.
Although the Network had multiple objectives and goals, two9 of the objectives stood
out in terms of health outcomes and their potential spill-over to the most important goal of the
Network, to revolutionize the diagnosis and treatment of septic patients. The ASN promised a
paradigm shift in the way research was conducted at the level of basic science and clinical
practice for sepsis. Over the next six years (after receiving a one-year extension) the Network
used a systematic and coordinated approach to learn how to treat different septic infections
effectively. Each septic patient that entered an Intensive Care Unit (ICU) or pediatric ICU in
Alberta was enrolled in the program and tested for biomarkers. The ASN’s multidisciplinary
program identified ways to treat different septic infections effectively, changing the treatment
plans and making targeted intervention a reality.
What is Sepsis
Sepsis10 and septic shock is a complex medical problem requiring multidisciplinary care
and is one of the top ten leading causes of death in Alberta. Commonly referred as a systemic
infection, sepsis is a generic term to describe a group of infectious diseases. Sepsis occurs when
an infection you already have, in your skin, lungs, urinary tract or somewhere else, worsens
until it involves the whole system of the body.11 In response to this systemic infection, the body
responds in extreme by shutting down various systems and resulting in organ failure. Sepsis
indiscriminately affects individuals of all ages, sexes and socio-economic status. Patients with
sepsis may become critically ill, resulting in single or multiple organ failure and possible
amputation or death. With a 30-50% mortality rate, sepsis occurs in over 18 million individuals
worldwide each year including 750,000 North Americans and 30,000 Canadians.12 In Canada,
9 Objectives - Development of new science and technology, which will serve as the basis for first and foremost
early sepsis detection leading to a complete paradigm shift in clinical trials design. Objective- An integrated clinical network of standardized care to provide optimal care of Albertans with sepsis
10 Adopted from Alberta Sepsis Network, Interdisciplinary Team Grant proposal.
11 Sepsis – Basic Information, Centers of Disease Control and Prevention. Last updated January 23, 2018. https://www.cdc.gov/sepsis/basic/index.html
sepsis is responsible for an estimated 9,320 deaths every year, representing 10.9% of total
deaths occurring in hospitals.13 According to the Canadian Association for Critical Care Nurses
(CACCN), patients who suffered from sepsis during their hospitalization were 56% more likely to
die than those diagnosed on admission.14 The CACCN further elaborated that a typical episode
of sepsis increased hospital resource utilization and prolonged the average stay in intensive
care units by an additional nine days of median hospitalization. While early detection and
interventions with timely antibiotics is associated with enhanced outcomes,15 those who
survive suffer long-term health impairments. In addition, mortality rates are much higher in
rural areas. This is, in part, because early detection is difficult, and management of these
patients require specialized expertise, resources and facilities.
Caring for critically ill patients amounts to approximately 15-30% of all hospital costs.16
With over 65% of all patients with severe sepsis being admitted to ICU, these patients become a
major cost driver for the total ICU costs.17
Why Alberta Sepsis Network (ASN)
With an average cost of $37,000/patient, Alberta spends over $100,000,000 a year on
critical care.18 In terms of mortality, morbidity and cost burden, sepsis ranks closer to cancers,
cardiovascular diseases and other infectious diseases such as HIV-AIDS. However, sepsis has not
received the same level of attention translating into funding for sepsis research or
advancements in new therapies. As the advancements in the technology and treatments have
enhanced the prognosis for cancers and cardiovascular diseases, mortality due to sepsis has not
13 Canadian Institute for Health Information, In Focus: A National Look at Sepsis (Ottawa, Ont: CIHI 2009)
14 D. C. Angus et all., “Epidemiology of Severe Sepsis in United States: Analysis of Incidence, Outcome, and Associated Cost of Care, “Critical Care Medicine 10 (1992): pp. 81-88.
15 Huange, D.T., T.M. Osborn, T. M., Gunnerson, K. J., Gunn, S.R., Trzeciak, S., Kimball, E., Fink, M. P., Angus, D. C., Dellinger, R. P., and Rivers, E. P. (2005). Critical care medicine training and certification for emergency physicians. Crit Care Med., 33:2104 Ref ID:3667
16 Jacobs, P., and Noseworthy, T.W. (1990). National estimates of intensive care utilization and costs: Canada and the United States. Crit Care Med. 18: 1282.
17 Wang, H.E., Shapiro, N. I., Angus, D. C., and Yealy D. M. (2007). National estimates of sever sepsis in United States emergency department. Crit Care Med. 35: 1928. Ref ID:3696.
18 Lee, H., Doig, C. J., Ghai, W. A., Donaldson, C., Johnson, D., and Manns, B. (2004). Detailed cost analysis of care for survivor of sever sepsis. Crit Care Med. 32:981. Ref ID:3680.
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improved for a long time. Worst of all increases in antibiotic resistant in bacteria and
compromised immune systems because of other therapies contribute an increased incidence of
sepsis cases, especially in older patients. As our age demographics change and people are living
longer, we could see a lot more sepsis cases in the future. Programmes such as ASN can have
major impact on early detection and improved treatment of sepsis cases, decreasing the
burden placed on our health system.
Study Population
This study is based on a multi-site retrospective cohort data consisting of adult and
paediatric patients for both confirmed and query sepsis cases for all Alberta provincial sites that
report data to AHS. Data was stratified by fiscal year (April 1 to March 31), AHS zones, age
category (age at time of admission/visit), whether the case was confirmed or a query diagnosis,
and by type of department (acute care in-patient [IP], emergency department [ED], urgent care
centre [UCC], or continuing care [CC]). The volumes of cases reported here are from 2003 to the
most current data in 2016. The start date for reporting varied across facilities.
It is important to know that there was a substantial limitation to the data because the
volumes reported cannot be assumed to be mutually exclusive, or, alternatively, subsets, of
each other. For example, sepsis cases reported in CC facilities might also be the same case(s)
reported in the ED/UCC or IP setting if a resident or patient was transferred from one sector to
another. Since patient data was not collected, the database was unable to sort these
duplications. Therefore, the number of cases reported in IP and ED/UCC were treated
separately instead of adding them together. In addition, cases of a confirmed or query sepsis
diagnosis in ED/UCC cannot be assumed to be the same sepsis case in an IP setting; a sepsis
diagnosis in ED/UCC may be ruled out in an IP setting and thus not coded or captured on the IP
abstract. Alternatively, a patient admitted through ED may not have a sepsis diagnosis
identified until later in their IP visit. In this case, a sepsis diagnosis would not appear on the ED
abstract, but would be coded on the IP record. Sites with fewer than ten sepsis cases for the
fiscal year have been combined to comply with AHS privacy regulations.
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Data Sources
The study population was extracted from AHS’ administrative data system called DIMR
(Data Integration Measurement and Reporting). DIMR helps healthcare providers and clients
collect and report information about health within AHS including health status, health
determinants, and use of healthcare services. The database also consults on epidemiologic
methods.19 Because of the patients’ confidentiality, the DIMR data is not accessible publicly. In
order to request the required sepsis data, an Analysis Reporting form was submitted to the
DIMR intake coordinator in the Calgary region. Since only the volume of patients coded for
sepsis queries, sepsis diagnosis, or mortality numbers were required, without any patient
identifier (such as name or address), no additional ethics approval was required. The data was
Figure 4: Sepsis cases confirmed diagnosed at non-ASN and ASN IP sites across Alberta.
14
Query diagnosis sepsis cases at In-patient and emergency departments in Alberta
The total sepsis cases data shown in Figure 1 includes two major categories; confirmed
sepsis diagnosis and query sepsis diagnosis. Figure 3, Figure 4, and Figure 5 contained data for
confirmed sepsis diagnosed cases for non-ASN and ASN sites. The section below covers another
category of the sepsis cases: query diagnosis sepsis cases. A query diagnosis is one that is
suspected, but not confirmed at the conclusion of a patient visit or at the time of a patient’s
discharge. They may have been later confirmed, ruled out (not the diagnosis), or have no
further diagnosis information (data limitation). These are cases where a diagnosis/medical
condition are possible or likely but have not been confirmed. As mentioned before, due to the
lack of patient identifiers, it is impossible to tell which if these cases were later confirmed and
included in the confirmed data set discussed above.
Similar to confirmed sepsis cases, query sepsis cases data both from IP and ED was
analysed. In light of the ASN program, an increase in query diagnosis should be also be
expected during the ASN program period.20 When the query diagnosis cases from both IP and
ED were clustered and plotted, both non-ASN as well ASN sites showed an upward trend in
20 For example, if a patient came in with tachycardia, elevated BP, high WBCs and had suspected sepsis, this would
be coded as a query sepsis diagnosis. It’s possible that a) the sepsis was confirmed during a later healthcare encounter, b) sepsis was ruled out during a subsequent health encounter and another reason for the symptoms was diagnosed, or another query diagnosis established, or c) there were not any further healthcare encounters recorded and it is not known whether the patient was treated by their family doctor or other community health provider for sepsis (or for another condition), or not treated at all and the symptoms self-resolved (as per DIMR).
decisions so that the infrastructure required to conduct the best research is properly emplaced,
areas of interests and strengths are chosen, and nations’ competitiveness in research and
innovation can be enhanced.
Although very critical, estimating the economic value of research to the public remains
challenging. Some practitioners, such as Buxton et al (2004) state that these practical
challenges are due to the lack of direct relationship between research inputs and impact of
research or its economic value, or even defining the economic value. However, Salter and
Martin (2001) have critically reviewed and highlighted the expected economic benefits of
publicly funded research by using a range of economic studies, surveys, and case studies. In
order to measure the impact of government funded research Manton et al (2009) tracked NIH
funding from 1954 to 2004 and related it to the mortality rate from heart diseases and stroke.
The authors were able to relate positive health outcomes with the funding from NIH during this
period. Similar to this, Zwicker and Emery (2015) used a direct method by studying reduction in
mortality from potentially avoidable causes as funding in research increased. Both of the
studies are able to provide strong evidence that the public research funding has substantial
economic benefits to the system, the public, as well as direct impact on health outcomes.
This particular study is not comprehensive and does not take into the full breadth of
research funding impact, but similar to Zwicker and Emery, it looked into the impact of the
research on health outcomes using a direct method. In doing so, this study has looked at two
factors – number of sepsis patients diagnosed and the mortality rates among various patient
groups within Alberta’s IP and EDs departments. Although numbers of cases diagnosed, and
mortality rate varied over the years, the study was able to find that, not only were more sepsis
cases diagnosed during the ASN period, but mortality rates decreased among adult cases during
this project. Besides the fact that the value of lives saved is enormous, this study was not able
to put a dollar value on the return on government funding. In addition, although the ASN
contributed directly and immediately toward patients’ health outcomes, as well as toward the
direct benefits in the form of peer reviewed papers, graduate training, post graduate training
and career development for researchers and PhDs, this study did not include any payback
arising from them.
30
In general, benefits or paybacks associated with spending on research for health
outcomes seems obvious to understand, benefits from public investment in research can take a
variety of forms. However, critics of the public funding of research often fail to highlight the
spillover benefits and the existence of secondary local effects in research, which are often
substantial. In the case of the ASN, although the provincial funding ended in the 6th year, the
infrastructure, multi-disciplinary team, and methodologies developed during the program are
still adding value to the research program. This enhancement in institution’s R&D capability
indeed was a huge “institutional level” success.
Besides the fact this study was able to establish a link between research and health
outcomes, this study was subject to certain methodological limitations or gaps. The
methodological limitations or gaps are highlighted in APPENDIX II and APPENDIX III).
Why government funding is important
In the eighteenth century, economist Adam Smith argued that, “The Sovereign has the
duty to maintain certain public works and certain public institutions, which can never be for the
interest of any individual because the profit could never repay the expense to any individual
though it may frequently do much more than repay it to a great society”23.
As government plays a significant role in the scientific discoveries, its role is often
understated or misrepresented. The debates around government vs private sector for who is
the real champion of innovation are often filled with a common myth that the source of
innovation is the private sector not the government. Mazzucato (2013) however has debunked
this notion by stating that, “ignoring the key state role in wealth creation creates inequality, as
it allows some hyped up actors to reap a rate of return way beyond their contribution,
therefore, it is the visible hands of the government not the invisible hand of the free market
that is responsible for the breakthrough that define these times”.
Mazzucato (2013) and Weiss (2014) further elaborated on this argument by pointing to
the famous Apple’s smartphone (iPhone), and asked if this phone would still be so smart if it
were not for the government-funded innovations (the touch screen, the GPS, the internet and
23 Taken directly from, GRAEME REID, “WHY SHOULD THE TAXPAYER FUND SCIENCE & RESEARCH.” National Centre
for Universities Business (NCUB) – 2014.
31
even research behind Google) – an excellent example where risk associated to innovation are
socialized while rewards are privatized.24 The same is true for Canada as Buxton (2014)
reminded us that right at the time when the first Macintosh computer was being introduced,
the University of Toronto was well ahead in developing multi-touch screens through a Canadian
government grant in 1984.
In general, benefits associated with spending on research for health outcomes seem
obvious to understand, however benefits from public investment in research can take a variety
of forms. Salter and Martin (2001), while highlighting the expected benefits of research
investments, not only identified six economic benefits of publicly funded research but
estimated private and social rates of returns of privately funded research at 20% to 50%. In a
similar study, Hall (1993) calculated 22% as a gross rate of return on R&D in USA.
In another classical study, Mansfield (1991) sampled 76 US firms in seven industries and
reviewed 15 years of parallel academic research. He found that in the absence of academic
research 11% of the new products and 9% of new process could not have been developed
without substantial delay.
Another misconception is around the total cost of health research and its impact on the
total cost of health care. In Canada, aside from the industry support, a substantial proportion of
health research is funded by the federal and provincial governments. On a federal level, this is
done by the Tri-council25 and Canadian Fund for Innovation (CFI). 26 Although both agencies
have a varying mandate, both have made substantial contributions to the health and social
wellbeing of the Canadians by performing pivotal role in funding research. Bernstein et al
(2006), measured the impact of CIHR investments in health research and concluded that CIHR’s
investment in emerging infectious diseases during SARS breakout in 2003 helped to contain
SARS successfully.
24 Jonathan Sas, “MORE COURAGEOUS BETS AND EQUITABLE RETURNS: Challenging Perceptions about Public
Investment in Innovation.” Atkinson Foundation, (2015). http://atkinsonfoundation.ca/wp-content/uploads/2015/03/betsreturns.pdf
25 Tri-Council is comprised of Canadian Institute for Health Research (CIHR), Natural Sciences and Engineering Research Council of Canada (NSERC) and Social Sciences and Humanity Research Council of Canada (SSHRC).
26 Other agencies such as National Research Council of Canada (NRC), Western Economic Diversification, and Atlantic Canada Opportunity Agency (ACOA) also fund research.
The CFI, a not-for-profit foundation, funds up to 40% of research infrastructure, often
conditional to the remaining 40% being matched by the province and up to 10-20% from
industry or elsewhere. An outcome measurement study for CFI by Tremblay et al (2010) found
that CFI research funding not only enhanced research capacity, highly qualified people,
research productivity and competence, but substantially contributed to innovation that helped
in the improvement of health care and enhanced products. Several other comprehensive
studies27, 28, 29 have linked Canadian international standing, health benefits, research capacity
and socio-economic benefits to the research and research funding.
In Alberta, governmental support of funded research cannot go unnoticed. Since the
creation of AHFMR in 1980 and several other Science & Technology programs,30 Alberta
remained at the forefront of building capacity (infrastructure and HQP) and performing cutting
edge research (such as ASN) for over more than two decades. During this time Alberta
remained so active in building its capacity and strengthening its academic research that by
2005, its share for the provincial R&D was 13%, while the national average was below 5%.31
However, because of provincial deficit that has been haunting Alberta since 2008, the glorious
moments for funding have disappeared. This, along with multiple restructurings of AHFMR to
AIHS to Alberta Innovates (AI), changes in its mandates, and government cut-backs32 have
created substantial anxiety among researchers and research enterprises such as universities.
Research is an expensive proposition and the burden (rather share of investment) is
often shared between national and provincial governments as well private enterprise. Since
government-sponsored research has a higher component of public good, it not only reduces the
reluctance of private sector to fund their own research but motivates them to step-up and
27 Frank, C., (2009) The Impact of Health Research. Canadian Academy of Health Sciences.
28 King, D. A., (2004) The scientific impact of nations. Nature, 430: p.311-316.
29 Ray, D., Cranston L., Sltusky A., and Feasby T. (2007) Moving at the speed of Discovery: From Bench to Bedside to Business. Report of Association of Canadian Health care Organizations.
30 Alberta Ingenuity Fund and Information Circle of Research Excellence (iCORE) to name a couple
31 Creso M. Sa´ (2010) Canadian Provinces and Public Policies for University Research. Higher Education Policy, 23, (335-357).
32 Juris Graney. Universities, school boards told to tighten belts to reduce discretionary spending. In, Edmonton Journal December 11, 2017.
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invest in R&D yielding substantially improved knowledge. This collectively results in significantly
enhanced knowledge, regional assets, targeted competitiveness, and often becomes the
source in creating a lucrative environment for other allied industries such as pharma, biotech,
and manufacturing. However, in the absence of government funding for research, private firms
may hesitate to invest in R&D and wait for others (such as government) to take the risk,
resulting in a free-rider effect giving little or no new knowledge to us. Another serious risk of
not investing in research is losing competitive advantage a nation achieves over years of hard
work and through its investments. Similar to long-term future payback of research investments,
the ugly face of lower productivity and lost competitiveness also comes long after the bad
decisions of not investing. For example, Adam (1990) suggested that 15% of economic and
production slowdown during 1970 could be related to the poor investments in research post
Second World War.
CONCLUSION AND RECOMMENDATIONS
Measuring the impact of publicly funded research is not straight forward because of the
complexity of inputs and understanding of what exactly to measure. Because of this complexity,
the researchers have not agreed upon a single gold standard method for assessing the impact
of publicly funded research. Despite these challenges, this study was able to reference
literature providing consistent evidence of direct and indirect benefits from the publicly funded
research. Collectively, all the studies happen to have a fairly common agreement that
governments’ investments in research offer a wide range of benefits that ultimately improve
innovation and save lives.
One of the notions against government funding research is its payback period. Because
of the short political cycles (often 4-8 years), political objectives and scientific objectives can
easily lead to a lack of patience among governments, the tax payers and policy makers. Short
(2-5 years) funding cycles often with little to no chance of renewal reflects the same pattern
and adds to its complexity. Right after funding expiration, all involved want to see the
immediate and tangible public benefits from the tax dollars invested in research. While doing
so, the government, critics of the funding, and public often overlook the intrinsic benefits of the
research with its future payback. Funding life cycles add further to the complexity. At the end of
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the funded project, the focus remains on the scientific merits and scientific goals as the success
factor of the project without tying them to the merits of innovation success or the innovations
success goals, if established.
In order to foster the research productivity and impact, the congruency between the
three major stakeholders - the funding agencies (government), sponsored institution, and the
researcher, play important roles. While we can argue about the impact of government funding
for health research, the philosophy for the research funding, identification of priority research
areas, as well as distribution mechanism of funds to researchers, is very complex. Although
critiquing the priority research area, funding philosophy or the methods of fund distribution is
not the scope of this study, certain recommendations33 listed below may help enhance the
impact of research in general.
• Debate about the government investing in the basic vs translational vs clinical research
is not going to end soon. Instead of competing interests, all three research areas must
be given full attention, and not at the expense of each other.
• More and more grant applications are tied to and evaluated against their practicality or
benefits to society. However, ambiguity around the “benefit to society” defined by the
funding agency (may be politically influenced) or perceived by the researchers result in
different outcomes for both. There must be a common definition of the
benefits/outcomes combined with subjective and objective parameters.
• In general, the researchers are very good in presenting their research questions
(hypothesis), elaborating how the research will be conducted, and expected results
supplemented by certain outputs (such as bibliographic and training etc.). However,
they often do not relate the outputs with outcomes or how the success will look like
for different stakeholders – an often-missing part on the evaluation of the project.
33 As this report was being written, the Minister of Science Kristy Duncan, established a nine-member advisory
panel (on Federal Support for Fundamental Research) under the leadership of David Naylor. The Panel held round table discussions, accepted over thousand written submissions, engaged 230 researchers and produced about 250-page document. The document “INVESTING IN CANDA’S FURTURE” contains an intensive environmental scan, threats and opportunities for the research in Canada. While broadly advocating for the basic research, the panel has made a score of recommendations along with a complete overhauling of the agencies and substantial increase in funding. Recommendations made through the capstone paper are more operational or policy driven.
35
• Applicants should be asked to provide a detailed sustainability plan for the continuity
of the project. In general, when projects are completed, researchers move on to the
next big question for their research career with minimal to no continuity with the last
project. Often right at the end of the project, researchers and the institutions scramble
to deal with the project’s sustainability or continuity. Instead of leaving the succession
and sustainability of the research program until the end of the project, it must be an
ongoing process and part of the progressive evaluation.
• Funding for public research comes from many sources. Each of the sources, whether
public or private, is accountable for how funds are distributed, why funds are
distributed, and if the purpose of the funding is fulfilled.34 However, a stringent
accountability framework is lacking for the research community. As universities and
other public research enterprises already have a good system of financial control,
accountability, and ethical standards, the accountability mentioned here is not about
business processes but the output, outcomes and impact. Whom does the onus go to
when a project fails? How many times have the project leaders/Principle Investigators
been challenged on the project outputs and outcomes?
• Peer review is one of the most common methods used for funding allocation. Peer
review is done by the researchers and often focuses on the scientific merits. However,
post funding, neither the reviewer, nor the researchers have any accountability if the
project fails. Depending upon the mandate of the funding, the granting agencies must
incorporate other discipline to review and make final decision.
• Cost to run research enterprise is going high. It is not uncommon for a good amount of
research funding to go toward general operations of the institute, leaving less for the
actual research for which funding is provided. Institutes must foster a culture where
cost of research operation is curtailed.
• Certain grants such as CFI have higher percentage of Gift-in-Kind (GIK) from the
industry. Although GIK from the industry engages the industry and may stimulate
stronger partnership, often these partners have no urge to become part of the success
or have fear of loss if project fails. Additionally, GIKs have lower economic value for the
researchers. Government should introduce a better incentive for the industry to have
neck in the game and be part of the success or failure.
34 Naylor’s report has used word “Accountable” for 37 times, however almost every time it is used toward the
funding agencies instead of the frontline researchers.
36
With the capacity to take larger risks, governments should not hesitate to invest in
research because that is what will transform the future of health. For Alberta, besides its
dynamic role and ability to create enormous wealth, Oil & Gas remains a troubling area.
Although this has tempted, rather compelled, the government to diversify Alberta’s economy,
researchers must keep educating politicians and policy makers about the value chain and
working of the science. Studies like this will help to further influence the government’s
willingness to diversify and particularly invest in health research and its allied area research.
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APPENDIX I
Key Objectives of Alberta Sepsis Network
1. Develop an integrated team of basic scientists and bedside clinicians with a purpose to
uncover the mechanisms of disease associated with sepsis, focusing on the relationship
between host innate immunity, the unique characteristics of microbes which commonly
cause severe sepsis, and the unique responses of survivors and non-survivors.
2. Development of new science and technology which will serve as the basis for first and
foremost early sepsis detection leading to a complete paradigm shift in clinical trials design.
3. An integrated clinical network of standardized care to provide optimal care of Albertans
with sepsis.
4. Infrastructure to launch clinical trials to investigate novel treatment plans in the
management of severe sepsis.
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APPENDIX II
Parameters and Limitations for Diagnostic Data
This report contains data for both confirmed and query sepsis cases for all Alberta provincial
sites that report data to AHS. Data is stratified by fiscal year (April 1 to March 31), Zone, age
category (age at time of admission/visit), whether the case was confirmed or a query diagnosis, and
by type of department (acute care - inpatient (IP), emergency room (ED) or urgent care centre
(UCC), or continuing care).
The volumes of cases are provided along with the number of unique patients. Data from
January 4, 2002 to the most current data (2016) is included. The start date for reporting varied
across facilities.
Note: Volumes reported here cannot be assumed to be mutually exclusive, or alternately,
subsets, of each other. For example, sepsis cases reported in continuing care facilities may also be
the same case(s) reported in the ED/UCC or (IP) setting. Also, cases of either a confirmed or query
sepsis diagnosis in ED/UCC cannot be assumed to be the same sepsis case in an inpatient setting; a
sepsis diagnosis in ED/UCC may be ruled out in an inpatient setting and thus not coded/captured on
the inpatient abstract. Alternately, a patient admitted through ED may not have a sepsis diagnosis
identified until later in their inpatient visit. In this case, a sepsis diagnosis would not appear on the
ED abstract, but would be coded on the inpatient record.
Inclusion criteria
Confirmed and query diagnosis sepsis cases for all facilities reporting to AHS for fiscal years
2002/03 to 2016. Also, depending on the start date of reporting, individual facilities may not
contain full fiscal year data until they have been in operation for a full fiscal year.
Exclusion Criteria:
General infection codes which did not specifically identify sepsis were not used (see
ICD10_Code_Reference tab for more details). Sites with fewer than 10 sepsis cases for the fiscal
year have been combined to comply with AHS privacy regulations.
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APPENDIX III
Parameters and Limitations for Mortality Data
This report contains mortality data for both confirmed and query sepsis cases for all Alberta
provincial sites that report data to AHS. Data is stratified by fiscal year (April 1 to March 31), Zone, age
category (age at time of admission/visit), whether the case was confirmed or a query diagnosis, and by
type of department (acute care - inpatient (IP), emergency room (ED) or urgent care centre (UCC), or
continuing care).
Patients who have a discharge disposition of "deceased" cannot be assumed to have died due to
sepsis; they had either a confirmed or query sepsis diagnosis on their abstract, but this was not
necessarily the cause of death.
Data from January 4, 2002 to the most current data (2016) is included. The start date for
reporting varied across facilities.
Note: With the exception of death cases, volumes reported here cannot be assumed to be
mutually exclusive, or alternately, subsets, of each other. For example, sepsis cases reported in
continuing care facilities may also be the same case(s) reported in the ED/UCC or (IP) setting. Also, cases
of either a confirmed or query sepsis diagnosis in ED/UCC cannot be assumed to be the same sepsis case
in an inpatient setting; a sepsis diagnosis in ED/UCC may be ruled out in an inpatient setting and thus not
coded/captured on the inpatient abstract. Alternately, a patient admitted through ED may not have a
sepsis diagnosis identified until later in their inpatient visit. In this case, a sepsis diagnosis would not
appear on the ED abstract, but would be coded on the inpatient record.
A patient may have had prior visits/admissions in which they were discharged alive, and the
same patient may have returned for a later visit/admission and had a discharge disposition of
'Deceased'.
Inclusion Criteria
Confirmed and query diagnosis sepsis cases for all facilities reporting to AHS for fiscal years
2002/03 to 2016. Also, depending on the start date of reporting, individual facilities may not contain full
fiscal year data until they have been in operation for a full fiscal year.
Exclusion Criteria
Confirmed and query diagnosis sepsis cases for all facilities reporting to AHS for fiscal years
2002/03 to 2016. Also, depending on the start date of reporting, individual facilities may not contain full
fiscal year data until they have been in operation for a full fiscal year.
40
REFERENCES
1. Alberta Health Services. Analytics, Data Integration, Measurement & Reporting.
