The importance of the PRACI project for grass roots complementary medicine practice: a call for practitioner involvement.
CM research capacity in Australia
Complementary medicine (CM) is faced with many challenges associated with the evidence based medicine (EBM) movement, including potential conflict with the implementation of EBM into CM approaches to care, (1) risk of a decreased importance being placed on CM practitioners' experience and intuition, (2) and fears from CM practitioners that the EBM model may diminish the holistic patient centred care that is a hallmark of CM. (1) However, EBM is defined as the "conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients". (3) This statement clearly states that the concept behind EBM is to ensure that the clinical decisions being made by the practitioner is done so with the most up to date reliable evidence currently available. (1) In recent years, the perception of randomised placebo-controlled trials as the gold-standard research design to inform clinical decisions has been replaced somewhat with an acknowledgement that more pragmatic research designs, which are embedded in the realities of grass-roots clinical practice, provides a more meaningful answer as to the clinical effectiveness of specific treatments and interventions. This is particularly the case for complex systems of care such is seen in complementary medicine.
The need for research that explores and examines CM practice continues to grow, and whilst the methodologies that are supported within EBM become more aligned with CM practice approaches, the quantity of CM research still lags behind other fields of healthcare. The reasons that are driving this situation vary. One such reason is restricted access to research funding devoted to the advancement of CM research. (4) This funding inadequacy has limited the development of research infrastructure needed for further CM research. Another reason is insufficient engagement in CM research by individuals with a strong understanding of CM clinical practice and with high level research skills. (4)
The solution to both of these challenges lies squarely with the CM community to take responsibility for building research capacity within the CM professions. (1) This can be achieved through practitioners either developing their own research projects to examine real-life clinical questions, or alternatively being involved in CM projects being conducted by skilled researchers. Whilst it is perhaps more reasonable and feasible to develop this latter solution first, this requires a bridge to be built between CM practitioners and researchers. Once achieved, practitioners will have the opportunity to lend the experience and knowledge to researchers and collaborate in the design and implementation of clinically-relevant research projects. The key element that can address these issues is the development of a practice-based research network (PBRN) for the CM professions.
What is a PBRN?
A practice based research network (PBRN) is defined as a group of practices that collaborate together for the sole purpose of conducting and developing research by drawing on data collected from practitioners and their patients in grass roots practice. (5) PBRNs are well situated for truly clinically-relevant research studies as they allow for research questions to be generated, answered and further executed into real world clinical settings. (6) Research questions employed using the PBRN infrastructure can target a wide range of clinical topics, including but not limited to comparative effectiveness, clinical effectiveness, safety, and efficacy of interventions, (6) all of which aim at improving patient outcomes.
The key advantage to implementing a PBRN into CM practice is the ability to develop new clinical knowledge (3) that can be implemented into clinical practice and in turn improve the quality of patient care and outcomes. (1) Importantly, this is achieved by enabling clinical practitioners to be involved, collaborate and create new knowledge or advancements in their profession (5) without requiring that they have personal skills or experience in research (see Figure 1).
However, in order to ensure the effectiveness of the PBRN and further clinical research development, a PBRN requires a highly collaborative approach between researchers, PBRN infrastructure teams and clinical practitioners. (6) Without these 3 main factors, a PRBN cannot work to its full potential and enhance the quality and quantity of research being conducted.
CM professions in Australia
In Australia there is a vast diversity of CM professions. According to the Australian Bureau of Statistics (ABS) in 2006, the main primary health care providers in CM included chiropractors, naturopaths, acupuncturists, osteopaths, traditional Chinese medicine practitioners, homoeopaths, and massage therapists. (7) From the ABS data there is approximately 19,401 practitioners in the CM workforce. (7) However, currently this figure is only an estimate as it only identifies the practitioners listed as primary health care provider as recognized by the ABS and there are a number of other professions within CM not included in this list. (5) Although Australia has a diverse range CM professions as primary health care providers, there is still limited evidence of effectiveness, utilisation and safety associated with care from practitioners in some of these professions. In order to address these significant issues, CM practitioners and academic researchers have developed the Practitioner Research and Collaboration Initiative (PRACI) project, a diverse research network that is committed to enhance and facilitate CM research in Australia.
What is PRACI and its significance?
The PRACI (Practitioner Research And Collaborative Initiative) project is a multi-modality PBRN for CM professions, which harnesses the diversity of CM in Australia by housing 14 modalities including acupuncturists, aromatherapists, Ayurveda practitioners, Bowen therapists, Chinese herbalists, homoeopaths, kinesiologists, massage therapists, musculoskeletal therapists, myotherapists, naturopaths, nutritionists (non-dietetic), reflexologists, Western herbalists, and yoga practitioners. (5) PRACI will undergo a number of stages in order to develop it to its full potential. Initially PRACI will undertake a workforce survey and recruitment of interested practitioners to the PBRN. Following this PRACI PBRN members will be invited to complete a more detailed survey of their profession and practice. By gathering data from practitioner members from the PBRN, PRACI researchers will be able to network with these practitioners and begin facilitating the implementation of new and exciting research projects.
As PRACI provides the infrastructure for several CM modalities, it provides the opportunity to advance CM practice and knowledge by establishing research in grassroots clinical practice and allows for effective relationship building between clinical CM practitioners and researchers. Firstly, researchers can utilise PRACI to recruit practitioner assistance with new research projects in the field. This can either be through inviting practitioner input on the design and implementation of interventions for studies, or simply seeking the assistance of practitioners to recruit participants or participate as practitioner-researchers in exciting initiatives such as multi-centre clinical trials. Secondly, CM practitioners will also have the opportunity to drive research from the ground by developing research questions or establish researching projects with the support of researchers, regardless of their research skills and abilities. This allows for practitioners to take an active part in the development of new knowledge and to enhance research capacity in their profession (see Figure 2).
The projects developed as a result of these practitioner-researcher collaborations can be more readily implemented into clinical practice drawing on real-life CM practitioner patients. As a result, the findings from these projects will display more accurate results of the benefits and effectiveness of care from a qualified CM practitioner--a notable contrast to existing studies which are primarily conducted in a laboratory setting and without the advice and expertise of a trained CM practitioner. Through PRACI a link between researchers and practitioners will exist and as such the research developed and implemented through PRACI will be truly reflective of the realities of the high quality clinical care delivered by CM practitioners. Of equal importance is that by establishing a PBRN in CM practice, it provides further advancement of CM knowledge and more importantly gives the ability to improve the quality of care provided to patients from CM practitioners.
Formation of Research questions within PRACI
With PRACI's sub-study infrastructure, a broad range of research questions and designs can be implemented. PRACI will be able to house research designs such as experimental, observational and qualitative research methods to answer vital questions in contemporary clinical practice. (5) Each research proposal will be reviewed by the PRACI steering committee to ensure it meets the core values of PRACI and will provide new insight into CM grass roots practice. As PRACI houses 14 CM modalities, the types of research proposals and research questions will be vast and can include a range of topics, including safety of treatment or intervention, comparative effectiveness, clinical efficacy (6) or cost effectiveness studies. For example the following could be potential research questions developed within PRACI:
* Is naturopathy a cost effective intervention for allergic disorders?
* What is the clinical effectiveness of naturopathic care in the treatment of patients with cardiovascular disease?
* What are the experiences of patients consulting with a naturopath?
* What are the outcomes of patients receiving individualised herbal medicine treatments compared with 'off the shelf' products for anxiety and depression?
PRACI has the potential to answer an infinite number of research questions that are clinically relevant to their modality and can provide the advancement of CM research in Australia.
A need for practitioner involvement
The key to PRACI's success is support and involvement from the Australian CM practitioner community. As part of effective clinical practice, practitioners are required to enhance their knowledge through continuing professional education and this often means engaging with CM research that does not report the outcomes of practices and methods as they are really used in clinical practice. This is particularly the case where evidence is presented that reports a lack of efficacy for a poorly administered intervention or technique. This error can be quite frustrating for CM practitioners as they rely on the progression of clinical knowledge from researchers who may not be CM practitioners or understand the philosophy, methods and techniques used in clinical practice. The outcomes of studies such as this can also cause substantial damage to the profession when outsiders use such research as broad scale evidence of the ineffectiveness of CM.
These potentially devastating outcomes can be avoided through practitioner consultation and involvement in CM research. Practitioners would be able to provide advice on dosage forms, prescription requirements, practice techniques and other vital factors that enhance the validity of their interventions and thus increase the likelihood of identifying improved patient outcomes. Further to this, practitioners who want to see more research develop in a particular area of their profession can network and collaborate with academics researchers to fill this gap in their profession.
Keeping practitioners in the driver's seat
As a PBRN, PRACI is a very practitioner-centric model of research infrastructure. It supports research in practice, about practice, with practitioners. This commitment to practitioner-centricity permeates all levels of PRACI activity, including empowering its practitioner-members to have complete control over their level of involvement and participation in research projects that utilise the PRACI database. Joining PRACI simply means electing to be on the database and to be open to receiving invitations from the PRACI steering committee about upcoming research projects. Each practitioner can decide on their involvement in specific research projects on a case-by-case basis.
As PRACI continues to be well established within CM research infrastructure, it will be a vital time for CM practitioners to enhance not only their own professional knowledge in their chosen profession but to support the research being developed for their profession across the country. PRACI members will be actively contributing to sustaining their profession by advancing new knowledge of CM clinical practice in Australia. (5)
In order to enhance the available and ongoing CM research, practitioners need to take ownership of their responsibilities to their profession and the development of further research in their field. PRACI is a new and exciting initiative which will allow practitioners to join with active researchers and contribute to the growth and sustainability of their profession in a direct and meaningful way. PRACI has the potential to develop clinically relevant research that can be implemented directly into grass roots practice and will be the key driving force to enhancing and sustaining the viability of the CM professions in Australia. However, this will only be achieved with the support and involvement of CM practitioners across the country.
(1.) Wardle J. 2015. Respecting science, respecting tradition: Evidence-based care in the integrative medicine professions. Australian Journal of Herbal Medicine 27(2).
(2.) Steel A, Adams J. 2011. Approaches to clinical decision-making: A qualitative study of naturopaths. Complementary Therapies in Clinical Practice 17(2):81-84.
(3.) Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. 1996. Evidence based medicine: what it is and what it isn't. British Medical Journal 312(7023), 71-72.
(4.) Bensoussan A, Lewith GT. 2004. Complementary medicine research in Australia: a strategy for the future. The Medical Journal of Australia 181(6):331-333.
(5.) Steel A, Adams J, Sibbritt D. 2014. Developing a multi-modality complementary medicine practice-based research network: The PRACI project. Advances in Integrative Medicine 1(3):113-118.
(6.) Dolor RJ, Schmit KM, Graham DG, Fox CH, Baldwin LM. 2014. Guidance for researchers developing and conducting clinical trials in practice-based research networks (PBRNs). J Am Board Fam Med 27(6):750-758.
(7.) Leach MJ. 2013. Profile of the complementary and alternative medicine workforce across Australia, New Zealand, Canada, United States and United Kingdom. Complement Ther Med 21(4):364-378.
Rebecca Reid 
Amie Steel [1,2]
 Office of Research, Endeavour College of Natural Health, Brisbane, Australia
 Australian Research Centre in Complementary and Integrative Medicine, Faculty of Health, University of Technology Sydney, Australia
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|Title Annotation:||Commentary; Practitioner Research and Collaboration Initiative|
|Author:||Reid, Rebecca; Steel, Amie|
|Publication:||Australian Journal of Herbal Medicine|
|Article Type:||Viewpoint essay|
|Date:||Sep 1, 2015|
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