If health organisations and staff engage in research, does healthcare improve? Strengthening the evidence base through systematic reviews

If health organisations and staff engage in research, does healthcare improve? 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Strengthening the evidence base through systematic reviews Annette Boaz, Belinda Goodenough, Stephen Hanney, Bryony Soper This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4418411/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 19 Aug, 2024 Read the published version in Health Research Policy and Systems → Version 1 posted 9 You are reading this latest preprint version Abstract Background There is a widely held assumption that the engagement of clinicians and healthcare organisations in research improves healthcare performance at various levels. Previous reviews found small numbers of studies that suggest an association between the engagement of individuals and healthcare organisations in research, and improvements in healthcare performance. The current study sought to provide an update. Methods The team updated an existing published systematic review, and addressed the question: Does research engagement (by clinicians and organisations) improve healthcare performance? The search covered the period January 1, 2012 to March 2024, in two phases. First, the formal updated search ran from January 1, 2012 to May 31, 2020, in any healthcare setting or country and focused on English language publications. In this phase two searches identified 66,901 records. Second, a further check of key journals and citations to identified papers ran from May 2020 to March 2024. In total, 168 papers progressed to full-text appraisal; 62 were identified for inclusion in the update. Results Fifty-eight of the 62 papers report positive results, of which 48 are purely positive and 10 positive/mixed meaning that there are some negative elements (i.e., aspects where there is a lack of healthcare improvement) in their findings. In the updated review, the literature is still dominated by papers from the US (35/62) and is mostly drawn from the Global North. The papers cover a range of clinical fields but with considerably more on cancer than any other field. Conclusions The updated review collates a substantial pool of studies, especially when combined with our first review, which are largely positive in terms of the impact of research engagement on processes of care and patient outcomes. Of the potential engagement mechanisms, the review highlights the important role played by research networks. The review also identifies various papers which consider how far there is a “dose effect” from differing amounts of research engagement. Additional lessons come from analyses of equity issues and negative papers. This review provides further evidence of the contribution played by systems level research investments such as research networks on processes of care and patient outcomes. Clinical trials clinicians health equity healthcare organisations networks oncology patient outcomes processes of care research engagement systematic review Figures Figure 1 Figure 2 BACKGROUND There is a widely held assumption that the engagement of clinicians and healthcare organisations in research improves healthcare performance at various levels. Three systematic literature reviews [ 1 – 4 ] provided the first analyses of the empirical evidence available to support this assumption, albeit with differing scopes. The 2011 Cochrane Methodology review by Clarke and Loudon [ 1 ] examined the influence of ‘trial active’ practitioners or institutions on patient outcomes and/or care processes. The review focused on participation in randomised controlled clinical trials (RCTs) by the service provider, not by the patient. From more than 15,000 records (to January 2009), Clarke and Loudon identified 13 studies. Broadly, while they suggested that care processes (e.g. guidelines adherence) might be better when service providers take part in trials, they claimed that the magnitude of this effect and the consequences for patient health were uncertain. In a 2013 literature review, Hanney et al. [ 3 ] identified 33 studies [ 5 – 37 ], from more than 10,000 records (to March 2012). Not restricted to RCTs, it included 12 of the 13 RCTs identified by Clarke and Loudon [ 1 ] and 21 additional papers. In 2015, key findings from this full research report (which had also included a wider analysis of related studies that did not quite meet the review’s inclusion criteria) were then published in a more accessible form as Boaz et al. [ 2 ]. As in the previous review, most included papers were analyses at the level of the organisation rather than individual clinicians (approximate 2:1 ratio). The majority of studies (28/33) identified a positive association between research engagement and improvements in healthcare. However, most of these improvements were improvements in processes of healthcare, only a quarter of the positive papers (7/28) reported improvements in health outcomes. A further review in 2017 by Harding et al. [ 4 ] from Australia examined potential benefits of a “strong research culture” on health service performance. It identified eight studies from 3,015 records (to June 2015). In comparison with the prior reviews by Clarke and Loudon [ 1 ], and Boaz et al. [ 2 ], the search strategy used fewer databases and targeted different organisational metrics (e.g. staff satisfaction and retention). The review found an association between health service performance and activities representing organisational investment in research culture - in which the authors claimed being “research active” was a component. As far as we are aware, these literature reviews provided the first systematically collated accounts of the healthcare performance benefits associated with research engagement. But the evidence was not mature enough to support statements about causality, nor large enough from consistent designs to estimate effect sizes through meta-analysis [ 2 ]. More positively, however, there was evidence of efforts to move towards more formalised attempts to boost the role of health research systems in accelerating science and facilitating the translation of research into practice. Within this overall picture, an important but somewhat under-explored theme was the role of research networks [ 2 ]. The eight network examples described by Boaz et al. [ 2 ] all came from the US, where various research networks had been established in the second half of the last century. They are described in the “Glossary of the US & UK Research Organisations and Networks Discussed in the Papers” [see Additional file 1], which also shows the national research networks in the UK, which were not created until this century. Our first review also included two papers from Germany focusing on cooperative study groups to which, at that point, we did not apply the term network [ 13 , 34 ]. However, when exploring this issue further in the light of the continued development of research networks, we have found it helpful to adopt Laliberte et al.’s inclusive approach to research networks [ 24 ]. We have applied the term to various arrangements that, however loosely, give some measure of commonality to the research of multiple healthcare organisations that not only enhance science production, but also share a concern to transfer research findings into clinical practice. Our first review also featured a study by Majumdar et al. that was conducted in the US, but led from Canada, and showed the association between research engagement and improved healthcare outcomes increased with greater amounts of research participation [ 26 ]. We argued that further data on this effect, and on the time an institution was research active, “are needed to provide evidence of causation” (p.12) [ 2 ]. While our original review identified networks/partnerships as a potential engagement mechanism in general, there did not appear to be a well-structured, steadily accumulating body of knowledge about the benefits of research engagement. In the succeeding years, we identified a continuing interest in this topic, including increased attention to the differential effects of different levels of research engagement, and other new studies on the effects of the developing research networks, especially in the UK. In 2020, we decided to explore these changes further and update the review published by Boaz et al. [ 2 , 3 ] through a new systematic search. In addition to the developing research networks, there were other significant developments. In 2021, a UK qualitative systematic review explored the impact of research activity by healthcare professionals other than medical professionals [ 38 ], and in 2023 another UK review focused on research engagement by Allied Health Professionals (AHPs) [ 39 ]. With few exceptions the papers specifically on nursing and AHPs in these reviews were typically smaller scale than the papers included in our review, and/or usually did not include the quantifiable comparisons that featured in most of our included papers. Nevertheless, these reviews usefully illustrate the growing interest in the contribution of these healthcare professionals in countries such as Australia, Canada and the UK. In 2022, a large-scale study from the US by Shahian et al. [ 40 ] examined the link between research engagement and improved healthcare performance in 5 major medical fields across 1,604 Medicare-participating hospitals. To ensure our updated review adequately reflected these latest developments, we conducted a further search in March 2024. The review presented here is based on papers identified in both phases of the updated review, the findings of which are then combined with those from our first review. Review question To identify studies, the primary research question used the same approach as Boaz et al. [ 2 , 3 ]. Does research engagement (by clinicians and organisations) improve healthcare performance? By research engagement, we mean, as in our first review, engagement in research rather than the broader concept of engagement with research, and we are referring to participation in research by healthcare organisations and staff rather than patient participation in trials. Engagement in research is taken to mean, “a deliberate set of intellectual and practical activities undertaken by healthcare staff (including conducting research and playing an active role in the whole research cycle) and organisations (including playing an active role in research networks, partnerships or collaborations)” (p.2) [ 2 ]. METHODS Design The decision to complete an update of the previous review [ 2 , 3 ] was informed by a published decision framework for updating systematic reviews [ 41 ]. Search strategy and information sources Search 1 (update) The first step in syntax development used the Medline Ovid strategy published by Boaz et al. [ 2 ]. Initial diagnostic testing indicated issues preventing code execution. Due to the syntax comprising several nested terms and Boolean operators, it was rebuilt using recommendations for ‘single-line’ optimisation for debugging complex code [ 42 ]. Search 2 (modified) The syntax for Search 2 was a term modification to capture papers that more explicitly indexed research networks and collaborations. Search 2 necessitated a deeper dive into the full-text content of papers. The decision to search full-text articles reflected observations that the sensitivity of Search 1 was potentially affected by the variable quality (and relevance for our review) of abstracts – a consistent challenge for reviewers [ 43 ]. As a second search also adapted published syntax, the PRIMA-S reporting protocol was followed: Preferred Reporting Items for Systematic reviews and Meta-Analyses Literature Search - Extension Checklist [ 44 ]. (The full text for search strategies is provided in “Search Strategy and Syntax Sensitivity” [see Additional file 2]). Electronic databases Nine electronic records collections were used in Search 1: Medline (OVID and EBSCO), EMBASE, PsycInfo (OVID and EBSCO), CINAHL, Web of Science, Health Management and Information Consortium, and British Nursing Institute. The mix provided parity with previous reviews and mitigated risk of missed papers by combining general and specialised databases. Different interfaces (e.g. OVID, EBSCO) for the same collection were also included to offset variations due to platform [ 45 ]. Grey literature was not searched: these collections failed to uniquely identify papers in previous reviews on this topic. Search 2 was restricted to the Medline EBSCO Full Text records, which was the collection which yielded the highest hit ratio for relevant papers [see Additional file 2]. Other sources Manual and snowball searching were used in three ways. Firstly, a range of search engines (Google Scholar, PubMed, ProQuest Central, Scopus, the Web of Science ‘Cited Reference Search’) were used to track citations for (a) prior reviews as whole papers (b) the individual studies within these reviews, and (c) article reference lists. Secondly, key journals that published studies shortlisted in the previous reviews were hand-checked, including: Implementation Science, PLOS One, BMJ Open, BMC Health Services Research, Thirdly, topic experts suggested papers for consideration. Eligibility Criteria The following limiters were applied: Timeframe: January 1, 2012 to May 31 2020 (inclusive of eprint) Population: Human (any setting) Language: English (any country) Paper type: Academic Journals (scholarly works). Conference papers were admitted as flags for accessible peer-reviewed works (e.g. preprint) or key teams. Three criteria were defined, guided by definitions from the original review [ 3 ]. Criterion A: Study Design: Empirical studies using method/s aligned with health services research, including clinical trials, retrospective cohort and survey methods. Studies with only patient reported outcomes (e.g. satisfaction) were excluded. Criterion B: Healthcare performance: Studies must report an outcome indexing performance assessment for a care process or healthcare improvement. The following were excluded: staff-specific reports alone, (e.g. job satisfaction or morale), policy impacts alone (no flow through to healthcare), descriptions of networks without outcomes data. Criterion C: Research Engagement: Explicit demonstration of engagement in research including: agenda setting, conducting research, participation in action research or in networks where the research involvement is noted. This criterion also allowed engagement implicitly through research network membership - even if a specific study was not recorded, but there was a comparison of healthcare between member and non-member settings. More details about examples that were in scope can be found in Hanney et al. (p2) [ 3 ]. Records management To efficiently manage the export of the large records, Endnote X9 (Clarivate) was used to combine downloads from different databases and discard software detected duplicates. The endnote library was imported into Rayyan, a free multi-collaborator online screening tool [ 46 ]. Study selection procedures for Searches 1 and 2 followed the same screening/eligibility check sequence. Screening and eligibility/quality checking In Rayyan, titles were scanned to exclude papers that were irrelevant, did not meet criteria, or non-exact duplicates. Abstracts of retained records were then screened and classified as ‘include’, ‘exclude’, or ’maybe’. A third screening of ‘maybe’ classifications forced a binary coding of ‘include’ or ‘exclude’, with comment flags on issues. A final records’ sweep with the Rayyan query function checked for misclassified studies. This four-step screening process was completed by a single reviewer (BG). Full-text for each provisionally included study was uploaded into Rayyan. The initial eligibility check was completed by three experts who were involved in article screening for Hanney et al. [ 3 ]. As a criterion check and to orient reviewers to the Rayyan platform, a practice phase used 10 randomly sampled records. The abstract was the primary source for expert reviewers, with full-text also available. After the practice task and consensus discussion of criteria, a batch of records (alphabet determined) was assigned to each expert reviewer, to rate each paper as ‘include’, ‘exclude’, or ‘maybe’ (ratings were unblinded). If the rating pair (i.e. BG and an expert from the original review) were both ‘include’, the paper was progressed to full-text appraisal. If there was disagreement, papers rated as ‘maybe’ were reassigned to another expert reviewer for an opinion, and those rated as ‘exclude’ by an expert reviewer were marked for discard. If consensus for a ‘maybe’ paper could not be reached by discussion, it was progressed to a full text appraisal - conducted by a single reviewer (BG) using all available information sources and reviewer ratings. A final review of all potential ‘includes’ was jointly conducted by team members, including a few papers identified by continued manual snowballing from key papers. Subsequently, we conducted a further search covering May 2020-March 2024. This consisted of: a hand-search of three of the journals in which papers from the first phase of the updated review had been published (Health Research Policy and Systems, Implementation Science and Medical Care); a check of papers in the two reviews published in this period [ 38 , 39 ]; and a check of citations in this period to all the papers identified both in our first review and in the update’s initial phase. Study quality was assessed using the Mixed-Methods Appraisal Tool (MMAT v2018), on a rating of 1 (low) to 5 (high) [ 47 , 48 ]. The MMAT accommodated all designs in the paper set. Quality ratings were not used to exclude papers, but formed part of the discussion about the quality and contribution of the papers. Data extraction, coding and ethics As Rayyan is only a screening platform, a data extraction sheet was created in Excel (v2016) for each included paper. A university research ethics committee deemed the project as not requiring formal ethical approval, due to secondary data mining on anonymised aggregated records. Analysis A heterogeneous mix of papers was identified with a range of different outcomes and outcome measures. A standard meta-analysis was not possible, but the papers were combined through a process of interpretive synthesis. Following analysis of the papers in the updated review, we collated the results from the updated review with those from our first review to create one combined set of papers for overall analysis. RESULTS Figure 1 summarises the review literature flow. The two formal searches identified 66,901 records, with 68 further papers coming from other sources, including the March 2024 extension. From these, 168 papers progressed to full-text appraisal, and 62 were identified for inclusion [40, 49-109]. PLEASE ADD FIGURE 1 ABOUT HERE Updated review This review updates the previous review conducted by the team [2], and details of the 62 additional papers are outlined in Table 1. Brief notes on the development and scope of key US and UK research networks/organisations discussed in the papers are provided in the “Glossary of the US & UK Research Organisations and Networks Discussed in the Papers” [see Additional file 1]. Different levels of analysis are explored in different papers: some compare clinicians, others organisations - with an even higher proportion in the updated review at the organisational level (50/62, 81%) than in our first review (22/33, 67%). Fifty-eight of the 62 papers report positive results, of which 48 are purely positive and 10 are positive/mixed meaning that there are some key negative elements in their findings, i.e., important parts of the analysis where there is a lack of healthcare improvement. Four are negative, of which two are negative-mixed. In our first review 22 of the 33 papers had been positive, six positive/mixed, and five negative (or negative/mixed). A higher proportion of the positive papers in the updated review (30/58, 52%) than in our first review (7/28, 25%) describe improved health outcomes - in terms of reduced mortality or morbidity. There is a corresponding reduction from three-quarters (21/28) to a half (28/58) in the proportion of papers solely describing improved processes - in terms such as applying proven interventions. There has also been a shift in the updated review to a higher proportion of the papers describing research engagement leading to a broader impact on healthcare performance, rather than specific impact. Broad impacts arise when the improved healthcare goes more widely than just being linked to clinicians or healthcare organisations implementing the findings, or processes, from their own research more rapidly/extensively than do others. When the improved healthcare is linked to the results or processes of their own research, that is categorised as specific impact. Using these various categories, Figure 2 outlines the findings from the updated review, alongside the findings from our first review, and the combined set of both findings. PLEASE ADD FIGURE 2 ABOUT HERE In the updated review, the literature is still dominated by papers from the US (35/62, 56%) and is mostly drawn from the Global North. The exceptions are studies from Africa [88], China [97] and a Canadian led study that includes data from Africa and Central America [50]. A further paper focuses on a First Nation population in Australia, and encapsulates the Aboriginal community’s principle of “no research without service” [109]. The review also includes 14 papers from the UK (up from 3/33 in our first review), three each from the Netherlands and Spain, a second Canadian one, and one each from Germany and Sweden. As in our first review, the papers cover a wide range of clinical fields but with considerably more papers on cancer than any other field. The biggest difference from our first review is that in the update there are 16/62 papers that cover healthcare in general (or in multiple fields) in a single hospital or multiple sites across a healthcare system. Thirteen of these 16 papers on broad areas of healthcare have one, or two, characteristics that are more common in the updated review than the first. Seven are from the UK [51,67-69,85,95,101]. And eight include bibliometric analysis as an indicator of the extent, and/or quality, of research engagement as an input into comparison with the healthcare processes and outcomes provided by the clinicians and organisations who produced the academic papers [40,51,65,76,95-97,100]. In total, 10/62 papers in the updated review used bibliometric analysis [40,50,51,56,65,76,95-97,100] (whereas just one [30] did so in our first review). All these 10 papers are positive, but various types of bibliometric analysis are used to measure the extent of research engagement compared to some measure of the performance in terms of healthcare processes and/or outcomes. The broad categories of academic indicators used are: publication volume [95,96]; publication “quality” (for example, as measured by citations) [51]; and a combination of volume and “quality” [40,50,56,65, 76, 97,100]. Of the latter, four, relatively small, studies suggested that the association with “quality” was stronger than with volume. The bibliometric studies also illustrate the varying levels of analysis at which the included studies in the review are conducted. Four of the 10 papers compare the academic outputs of clinicians [50,56,96,97] and six make comparisons at an organisational level [40,51,65,76,95,100], focusing variously on academic outputs at ward, department, or hospital/Trust level. Overall, our first review was not a single coherent body of studies that could be built upon in the updated review. It was challenging to draw strong conclusions from the mixed bag of studies. Whilst the updated review adds studies that are still very diverse, some of the streams of research identified in our first review have continued into the updated review, especially those involving research networks. We have, therefore, collated the findings from our first review and the updated review in order to present a combined set of papers that can be further analysed. Combined Review Table 2 outlines the details of each of the 95 papers in the original and updated reviews combined into one dataset. Of the 95 papers, 86 are positive (of which, 16 are positive/mixed) and nine negative (of which four are negative/mixed). Of the 86 positive papers, 37 report improved outcomes and 49 go only as far as reporting improved processes. PLEASE ADD TABLE 2 ABOUT HERE Across the 95 papers, 12 countries are either the location for the research engagement described in a single-country study, or the location from which a multi-country study was led, with one paper led from South Africa having authors from a range of African countries (and The Yemen) [88]. The 12 countries are: US (50 papers), UK (17), Canada (7), Spain (5), Germany (4), The Netherlands (3), Australia (2), Denmark (2), South Africa (2), China (1), Finland (1) and Sweden (1). In both reviews, cancer was the most common field, with 32/95 papers overall. Next came hospital care in general/multi-field/acute care with 16 papers, cardiovascular/stroke (12), substance use disorder (7), dentistry (3), mental health/psychiatry (3), obstetrics (3). The combined review allows a range of issues to be analysed more thoroughly than they had been in our first review. Two such issues highlighted in the Background are the role of networks and the “dose effect”. These are examined in turn below, followed by consideration of how far the included studies have addressed various aspects of health equity, and finally an analysis of lessons from the overall portfolio of positive and negative studies. The role of research networks The initial papers on research networks in our first review are supplemented by further studies in the updated review, and their full significance is seen when the reviews are combined. Using the inclusive definition mentioned in the Background section, we identify about two-thirds of the papers in the updated review as network papers, meaning that about half the papers in the combined review analysed research activity by clinicians or healthcare organisations who were part of research networks of various types. In the US, the National Cancer Institute (NCI) cancer research networks include the NCI-designated Comprehensive Cancer Centres, the NCI Cooperative Groups, and collaborative groups of community hospitals affiliated to the NCI’s Community Clinical Oncology Program (CCOP- see the Glossary for its new name). In various ways these networks all include outreach and the engagement of community physicians in their brief – see the Glossary for more details. Their potential was recognised early: the combined papers include the influential 2005 study by Laliberte et al. [24] that looks at these networks and concludes that network membership may influence compliance with treatment guidelines and should, therefore, be taken into account in predictive models of compliance. Seven included papers illustrate various aspects of the issue by comparing the processes and outcomes for patients treated at NCI-designated (comprehensive) cancer centres with those treated elsewhere. Six of these studies show better outcomes for patients treated at NCI centres [52,64,80,84,86,106], while one paper suggests that despite better processes, patient outcomes were worse at NCI centres – this paper is considered in the section on negative papers below [81]. Of the positive papers, Paulson et al. show how the NCI designation was “associated with lower risk of postoperative death and improved long-term survival” (p.675) [86], identify possible factors such as better adherence to guidelines, and demonstrate that the better outcomes at NCI-designated centres remained even when compared to non-NCI designated centres with a similar high volume of cases [86]. Wolfson et al. identify the requirements that underpin the positive association between high-quality research and high-quality care [106]. These include the mandate NCI centres have to “lead clinical trials, exchange ideas, disseminate findings” (p.3892), which show how the centres can act as part of a network. Wolfson et al. continue: “The NCI operates on the belief that a culture of discovery, scientific excellence, transdisciplinary research, and collaboration yields tangible benefits extending far beyond the generation of new knowledge” [106]. Building on Laliberte et al. [24], Carpenter et al. demonstrate an association between CCOP membership and accelerated innovation adoption but add the important codicil that it is not possible to “definitively ascertain whether there is a direct causal relationship between the two” [54]. Improved healthcare has also been associated with membership of the US practice-based research networks (PBRNs). These networks cover family practice/primary care, dentistry, mental health and substance abuse. Like the CCOP and its affiliates, PBRNs involve practising clinicians in the community who conduct research. The combined review includes seven PBRN papers covering primary care and dentistry, all of which are positive [32,36,66,78,83,92,108] and one of which describes an international dental PBRN led from the US that includes three Scandinavian countries [66]. Seven papers from the National Institute on Drug Abuse’s Clinical Trials Network (CTN) PBRN also provide evidence of accelerated translation, identify mechanisms through which this might work, and discuss the theoretical frameworks within which those operate [5,14,23,49,63,90,91]. Thus, Ducharme et al. [14] and Knudsen et al. [23] explore Rogers’ notion of the ‘trialability’ [110] of innovations, i.e. how far an innovation may be experimented with on just a limited basis, and Abraham et al. [5] discuss the role of absorptive capacity [111,112], which they summarise as an organisation's ability to assess and use information [5]. Rieckmann et al. note that although the mechanisms involved were not fully understood they appeared “to be influenced by core experiences from network participation” (p.894) [91], and Fields et al. [63] use insights from implementation science to explore the influence of a set of organisational characteristics (including network membership) on innovation adoption [113]. In an analysis of data on 12,993 transplants conducted in 162 US centres, the 32 centres in the Bone Marrow Transplant trials network were found to have significantly better survival rates than others [77]. Marmor et al. report that there was not an association between procedure volume and survival. Rather, they suggest, the better outcomes for those treated in centres in this network could be linked to the nature of trials that require “higher levels of national clinical collaboration and standardization of protocols”, and such collaboration is “likely to generate higher levels of innovation and excellence among clinical colleagues” (p.92) [77]. In Germany, one team produced three papers on the improved healthcare performance of hospitals that were part of clinical trials organisations [13,34,94]. Two papers describe the improved outcomes for patients with ovarian cancer if they were treated in a hospital that belonged to one of two German ovarian cancer clinical trials organisations, in effect research networks [13,34]. They note that the improved outcomes were not related to patient volume, suggesting instead that possible factors may include hospitals’ participation in the study group’s quality assurance programs and team members attending regular and scientific and educational meetings [13]. In a follow-up study, the data are analysed in more detail using mediation analysis that shows not just that the research participation of a hospital contributes to superior patient survival, but also begins to unpick how it happens, including through better use of surgery and chemotherapy [94]. Downing et al. note that, following the 2006 establishment in the UK of the National Institute for Health Research (now National Institute for Health and Care Research) (NIHR), the increase in research activity in networks throughout the English NHS has also increased the scope for analysing the benefits of research engagement [58]. The role of NIHR networks in boosting research engagement, which is then linked to improved healthcare, also covers clinicians such as nurses and AHPs who had traditionally had limited research opportunities. Studies are now showing how they can play an important role by engaging in research because, according to Trusson et al. reporting on a research network for nurses and AHPs, people working in such roles “have opportunities to explore possible solutions to issues that they encounter in their clinical role through academic study” (p.1) [101]. Such opportunities can also enhance their clinical skills. More broadly, Downing et al. claim that, in relation to the NIHR’s clinical trials network, “This natural experiment, presented by the rapid expansion of trial activity across a whole national health system, is perhaps the best opportunity to address the subject though outcomes research” (p.95) [58]. This development is discussed in the next section. The “dose effect” of the extent of research engagement Evidence indicating a link between the extent of research engagement and the degree of improved healthcare has been accumulating for some time. In the US, the 1996 study by Brown and Griffiss found that the average acute length of stay (LoS) in Department of Veteran Affairs hospitals was inversely related to the size of research programmes [53]. Majumdar et al. [26] used a tertile approach to show that in-hospital mortality decreased as the rate of trial participation increased for patients with unstable angina. In the substance abuse field, early CTN studies also contributed: thus Knudsen et al. [23] noted that the adoption of buprenorphine therapy by practitioners within the trials’ network was much greater in those programmes in the network that participated in the specific buprenorphine trial than those that had not. In a 2006 study of a sexual health trial in Australia, Morton et al. [28] identified improved post-trial clinical practice by high-recruiting clinicians, but not by low-recruiting ones. In our paper set the first use of the specific term “dose effect” to describe the effects of differing amounts of research engagement occurs in Downing et al. who tested the hypothesis that for colorectal cancer (CRC) “high, sustained hospital-level participation in interventional clinical trials improves outcomes for all patients with CRC managed in those research-intensive hospitals” (p.89) [58]. They found that high participation in such clinical trials was independently associated with better outcomes and that these effects were not restricted to academic centres or large institutions but were seen across all the NHS Trusts that conducted research on, and treated, colorectal cancer patients. They extended their analysis to look at the effects of different levels of research participation and found that the highest levels of participation led to the highest levels of improved outcomes. However, in relation to these findings, Downing et al. are careful to say that, in the absence of the possibility of an RCT, caution is needed if attempting “to infer a causal contribution” (p.89) from participation in research activity to improved healthcare [58]. Other UK database studies support the findings of Downing et al. For example, Ozdemir et al. [85] compare mortality with research funding per hospital bed in hospitals with high, medium and low levels of research funding and show that not only was mortality lower in high-funded research hospitals than in other hospitals, but also, on average, hospitals in the middle category had a lower mortality rate than ones with the least research funding. In two studies using NIHR research study activity data from different years, Jonker and Fisher [68,69] show an inverse correlation between the number of clinical trials/patient participation levels in UK hospitals and the mortality rate. Lin et al. [73], use retrospective data to examine the survival rate of the 465 patients (recruited by 60 hospitals) who had participated in an RCT in the NIHR Clinical Research Network (CRN). While they identify a significant association between low trial recruitment and lower survival rates, looking at the volume of patients treated in the disease area by the respective hospitals they report that “no significance was found between hospital throughput and outcomes” (p.40) [73]. Further support for the “dose effect” concept comes from the US and elsewhere. According to Abraham et al., in the substance abuse field “treatment programs participating in a greater number of CTN protocols had significantly higher levels of treatment quality, an association that held after controlling for key organizational characteristics” (p.232) [49]. Similarly, Gilbert et al. [66] report that members of a dental PBRN who fully participated in the network, were more likely to move evidence-based care into everyday practice than members who only partially participated. Seaburg et al. [96] show an association between the quantity of resident physicians’ publications and their clinical performance scores during training, and García-Romero et al. claim that increases in the scientific output of Spanish hospitals made a significant contribution to a reduction of hospital LoS [65]. In Canada, Tsang et al. [103] conducted a pre-planned observational study nested within a clinical trial in order to test how well traditionally non-research active community hospitals could participate in an RCT alongside the traditional RCT sites in academic hospitals. But while that aspect of the study did show that, in terms of adherence to trial metrics, the community hospitals could successfully participate in studies, outcomes for patients in the trial were significantly better in the traditional research hospitals, although the full reasons for this will need further exploration [103]. Health equity Various aspects of health equity are considered in the included papers, and some of these report attempts to improve health equity. Some population groups are particularly vulnerable. In the US, for example, Wolfson et al list the following groups: “underrepresented minorities, those with low SES [socio-economic status), those with public or no insurance, and those with a significant distance to care” (p.3886) [106]. Based on its long-held assumption that patient access to research active healthcare providers is beneficial, the NCI has attempted to reduce geographic inequalities in access. In a 1995 paper, Warneke et al. note that the CCOP was established by the NCI in 1983 with the deliberate intention of spreading the benefits of the clinical research conducted in NCI centres: “The program was designed with the assumption that by participating as equals in the research process, community physicians would be more likely to accept and implement the results in their practices with non-protocol patients” (p.336) [37]. Similar moves to encourage wider participation in clinical trials have recently been made in Canada in the nested study described above [103]. And a recent analysis showing higher levels of research activity within the English healthcare system are associated with lower mortality, notes that although the NIHR CRN was established to promote research participation across England, there is still some way to go to ensure greater geographical equity [69]. Other papers address racial inequalities in relation to access to timely evidence-based healthcare, which sometimes overlap with geographic inequalities. Some of the papers on the NCI designated cancer centres observe with concern that the proportion of certain racial/ethnic groups, including African Americans, who received treatment at these centres compared to non-NCI centres was lower than for other racial groups [64,80,106]. Having noted that African Americans with colon cancer experienced worse outcomes than Caucasian Americans, and suggested that this was partly due to differential treatment, a study by Penn et al. finds evidence that African Americans receiving treatment from CCOP providers had benefitted from early access to a recently recommended innovative treatment [87]. In Australia, Young et al. [109] report that the health services, and health research system, of the Aboriginal community work together to try to ensure health research is embedded into activities that improve health, and describe a specific example in relation to Ear, Nose and Throat surgery and speech-language pathology services. Lessons from the overall collection of studies: positive and negative A wide variety of papers contribute to the combined review’s overall finding that the included studies are overwhelmingly positive. As the section on health equity demonstrates, throughout the time covered by the combined review individual papers have contributed to a wider understanding that goes beyond specific issues about research networks and discussions of the “dose effect”. For example, a 2019 US positive study by Fanaroff et al. [60] identifies improved care and outcomes for patients with acute myocardial infarction who were treated at research active hospitals, even after accounting for potential confounders. The authors encapsulate some of the key thinking on research engagement with their conclusion that participation in clinical trials by hospitals "may be emblematic of a culture that embraces novel therapeutics, engages both clinicians and patients, and incentivizes continuous improvement in care" (p.191) [60]. While overall the 95 studies included in the combined review are positive, about 10% were categorised as negative. These nine negative papers also provide important insights [7,11,15,20,25,67,79,81,99]. For example, existing widespread use of one proven intervention prior to a company-sponsored clinical trial exploring physicians’ adherence to international treatment recommendations meant that the trial had no significant impact on that adherence, although it did increase use of the trial sponsor’s drug [7]; physicians adopted another trial intervention before it was proven one way or another [11]; more positively, a unique policy and regulatory environment governing the adoption of another intervention ensured that all hospitals benefited, not just those in the trial [79]. Two teams with negative results later conducted further, more comprehensive, studies, with positive conclusions [25,26,67-69]. Six of the seven papers examining whether NCI-designated cancer centres provided patients with better healthcare processes and outcomes are positive [52,64,80,84,86,106]. However, one paper suggests that outcomes were worse in these accredited hospitals despite the better healthcare and, in seeking to explain this, draws attention to the factors considered in the accreditation processes used by different organisations, and how far they accurately capture the most relevant data [81]. DISCUSSION Our first review set out to find if there was empirical evidence that supported the widely held assumption that engagement by clinicians and healthcare organisations in research improves healthcare performance at various levels. It concluded that there was some positive evidence but that systematic analysis of the data related to this engagement was in its infancy [ 2 ]. The 62 papers in the updated review show a similar demographic profile to those in our original review [ 2 , 3 ]: a dominance of USA settings (n = 35) and cancer as the most common topic area (n = 22). Fifty-eight of these later papers provide further empirical evidence to support the positive conclusions of the original review. When the papers from both reviews are considered together, they provide a more complete dataset than previously available [ 1 – 4 ], and trends identified in our initial analyses [ 3 ] become more apparent. They show how this field of research has developed over the last decade with a better, although still limited, understanding of the relation between enhanced research engagement and improved healthcare. The combined papers provide further examples reflecting policy shifts and organisational changes that occurred first in the US and later in the UK and elsewhere, and were designed to address the time lag between the production of research and its use in practice. These include the development of research networks and their associated databases (accompanied by an improved understanding of their strengths and limitations [ 54 , 64 , 77 , 106 , 108 ]) and efforts to strengthen links between academic centres and community services [ 61 , 87 ]. More recent developments, especially in the UK, encouraged further deliberate attempts to identify and explore the impacts of research engagement. Research teams were, for example, better able to study the real-world impacts of system-level mechanisms such as research networks as they became more formalised and embedded in national health and science structures [ 58 , 67 , 68 , 85 , 93 , 101 ]. Across the board, within and beyond networks, there is also further evidence about the mechanisms, including the ones identified in our first review. The role of strong evidence-based protocols developed for RCTs, but contributing to improved healthcare more widely in research active healthcare sites, was highlighted in various studies [ 77 , 98 , 105 ]. Papers also identified the importance of providing evidence-based/guideline consistent care, which could also be linked to a culture of discovery, excellence and collaboration [ 40 , 60 , 62 , 64 , 77 , 84 , 86 , 87 , 106 ]. There were also more nuanced mechanisms at specialty and clinician level, such as the use of multi-disciplinary coordination of care in radiation therapy treatment [ 107 ], and practitioner skill development in substance abuse work [ 90 ]. Similar practitioner skill development was also reported among nurses and AHPs, including in the wider literature [31;38,39,62,70,101]. In the combined set of papers, it became easier to see connections across in this diverse literature. It was possible to identify research teams that had worked together on multiple studies and to explore the extent of cross referencing. In the US, for example, the CTN of the drug abuse institute had been created to emulate the CCOP, and a centre was established to assess the CTN’s impact [ 114 ]. Many of the papers from this substance abuse CTN [ 23 , 49 , 90 ] referenced each other and also cross-referenced key cancer papers [ 8 , 24 , 54 ]; and there was common use of the same early sources [ 110 , 112 , 115 , 116 ]. These interactions prompted ongoing methodological development, strengthened understanding of theoretical concepts, and supported shared learning across the specialties. Elsewhere, themes that had been recognised in the original review, including concepts such as absorptive capacity [ 5 , 111 ], were further explored and tested in new contexts, even if the same literature was not always drawn upon [ 40 , 65 ]. The important concept of the “dose effect” had been, in effect, recognised in our first review, even if it was not specifically labelled as such [ 26 ]. But the combined review can now more fully consider the concept because evidence about this greatly increased in the updated review. Partly, this is because the scope of the papers included has increased. There are many more studies where all the clinicians or organisations compared are engaged in research but to varying extents and/or with different levels of resources, for example within a trial [ 28 , 50 , 59 , 73 , 93 , 103 , 107 ], or within a network [ 23 , 33 , 49 , 51 , 66 , 68 , 69 , 85 , 95 ]. The inclusion of papers about differences within trials, and the emergence of the importance of the “dose effect”, have implications for both a) how the issue of research engagement is analysed, and b) how far efforts to enhance research engagement should be concentrated or spread widely across a system. In relation to the first issue, when considering the dose effect, the key question morphs somewhat: it is no longer simply whether research engagement improves healthcare performance compared to no research engagement, rather, it is whether a larger amount of research engagement improves healthcare performance by more than a smaller level of engagement (and, if so, by how much). Answers to these questions could then feed back to strengthen the evidence for a positive association between research engagement and improved healthcare performance. In relation to the second question, about the concentration or wide distribution of research funding, analyses might have to consider the context and trade-offs in terms of benefits for improved health, and health equity. The widespread distribution of research funding across the health system could maximise the number of patients who might benefit, but a more concentrated approach, with a higher dose of research engagement in a smaller number of hospitals, could maximise the benefit for patients in such centres. Research infrastructures in countries such as the US and UK have been developed to enhance the relationship health and health research systems, and the evidence from our combined review suggests that these changes have been positive. In both systems, but particularly in the UK, there have been deliberate attempts to fund both, major centres of research in leading healthcare facilities, and also to spread research funding more widely to healthcare organisations across the country. But this impetus needs to be maintained if the full benefits of research engagement are to be realised. Such an argument is reinforced by the conclusions of a major recent analysis of progress in the UK in engaging healthcare staff in research and building capacity. The findings from the study suggest that many healthcare staff in the UK are interested in being involved in research, there are supportive national policies and strategies in place, and there has been some important progress. However, to achieve widespread involvement “will only be possible by focusing more on how healthcare organisations embed and support research activity through organisational policies which are supported by the wider research support and funding infrastructure. This is an essential part of a system-based approach to developing and supporting research engagement" (p.356) [ 117 ]. The progress possible, and the potential benefits of trying to build a health research system embedded into a healthcare system, but also the full range of substantial challenges, have also recently been explored in a hospital and regional healthcare system in northern Queensland, Australia [ 118 , 119 ]. Studies such as these indicate that our updated review could provide timely evidence to further the challenging task of improving healthcare by boosting engagement in health research. Strengths & limitations The updated review adds a considerable number of additional papers from diverse perspectives, but the literature continues to be drawn predominantly from the US and Global North so the conclusions may not be appropriate in different contexts, including in the Global South. Similarly, while the use of bibliometrics as an indicator of research engagement has widened the range of positive studies available, differing claims as to the most appropriate measure of research publications challenge consistent interpretation of the data and indicate there is more work to do. Furthermore, it is important to recognise that the national policy, noted in one paper, of attaching promotion and bonuses for clinicians to publish in journals with an impact factor of at least three [ 97 ] runs contrary to the internationally widely endorsed Declaration on Research Assessment [ 120 ] We included seven papers in this updated review that sat within the time frame of our first review [ 52 , 53 , 55 , 86 , 95 , 104 , 108 ]. We reflected on how we might have missed these and concluded that the complexity of searching in this area (with many generic terms such as ‘research’ and ‘engagement’) and the tangential approach of some papers to the broad question of whether research engagement improves performance may have contributed, as was recognised by the somewhat more extensive methods adopted for the updated review. We believe we are now able, however, to present a more nuanced understanding of the complexities of this field, building on our experience in the original review, and the generally greater clarity in later papers. In particular, we have found considerably more evidence on two topics identified as important in our first review: the role of research networks and consideration of how far there is a dose effect with regard to the degrees of research engagement. On both topics the combined review has strong papers showing important healthcare improvements even after considering potential confounders such as patient volume [ 8 , 13 , 26 , 40 , 58 , 73 , 77 , 84 – 86 ]. However, the failure of some papers to address such confounders [ 59 , 107 ], means some weaknesses in the overall analysis remain, and we are still not able to undertake any meta-analysis as the included literature remains very diverse. Notwithstanding all the additional largely positive papers included in the review, one limitation compared to our first review [ 2 , 3 ] was the lack of resources to undertake a structured analysis of the wider range of papers identified as making many relevant and illuminating points related to the topic, but not meeting the formal review’s inclusion criteria. For example, while this updated review does include some consideration of health equity issues, there were further papers taken to full paper review that were not in the end included but which provide considerably more evidence [ 121 , 122 ]. Future possible work The system-based approaches mentioned above continue to provide important opportunities for further work. Likewise, improvements in the identification and collection of relevant data and developments in statistics have prompted increasingly sophisticated analyses, sometimes using approaches developed in other fields, and could continue to do so [ 65 , 90 , 94 ]. There has also been increasingly sophisticated use of bibliometrics, and there are likely to be continuing opportunities to apply such approaches to more countries. But the warning from Downing et al. that caution is needed if attempting “to infer a causal contribution” from research participation to improved health outcomes [ 58 ], as well as frequent mention of similar disclaimers in other papers [ 8 , 40 , 54 , 59 , 69 , 74 ], is a reminder that more work is needed. While some of our papers have claimed the costs of research engagement are broadly covered by the associated reduced LoS [ 53 , 65 ], further research might be useful around the costs associated with research engagement and how these relate to reported benefits. Such studies could add to the existing large-scale studies showing the considerable monetary value of the health, and economic, gains resulting from health research [ 123 ]. The insights revealed by the negative papers, particularly in relation to the contexts in which research, and research networks operate [ 99 ], could usefully be further explored. Merkow et al. [ 81 ], the one negative paper out of seven papers included on the NCI-designated centres, raises issues about the accuracy, or perhaps appropriateness, of the measurement used by various organisations to accredit cancer centres. The issues have also been explored by various teams [122;124;125], but could perhaps be worth further examination because the findings from Merkow et al. are so starkly different from those of other teams. Finally, there are increasing opportunities, as well as a growing need, to address the limitations identified above (and also noted in the review by Chalmers et al. [ 39 ]) and go beyond the formal inclusion criteria of this review. A major area that could usefully be incorporated into an overall analysis of the field relates to the impact of the growing interest in research engagement strategies [ 126 ]. This includes the efforts to enhance research roles for healthcare professionals other than medical professionals [ 38 ], and the increasing number of organisational arrangements within health and health research systems for partnerships that seek to boost the production, and use, of relevant evidence [ 127 , 128 ]. CONCLUSION Previous reviews [ 1 – 4 ] have investigated the association between research engagement and improvements in healthcare performance. This study updates and extends the most comprehensive of these reviews conducted by Boaz et al. [ 2 , 3 ]. The updated review, especially when we combine the findings with those from our first review, collates a more substantial pool of studies, which are largely positive in terms of the impact of research engagement on processes of care and patient outcomes. Of potential mechanisms, the review highlights the important role played by research networks, and further identifies the various ways the research engagement facilitated by them operates to improve healthcare. The review also draws together a set of papers which consider how far there is a research engagement “dose effect”. Given the difficulty of conducting randomised controlled trials of large-scale research engagement initiatives, studies of dose effect offer another approach to understanding the potential contribution and complexities of research engagement. This review provides further evidence of the important contribution played by systems-level research investments such as research networks on processes of care and patient outcomes. Abbreviations AHP Allied Health Professionals CRN Clinical Research Network CTN Clinical Trials Network CCOP Community Clinical Oncology Programme LoS Length of Stay MMAT Mixed-Methods Appraisal Tool NCI National Cancer Institute NHS National Health Service NIHR National Institute for Health (and Care) Research PBRN practice-based research network R&D research and development RCTs: randomised controlled trials. Declarations Ethics approval Not applicable Patient consent for publication Not applicable Availability of data and materials Data sharing is not applicable to this article as no data sets were generated and/or analysed for this study beyond the tables included in the paper. Competing interests The authors declare they have no completing interests Funding None Authors’ Contributions All authors were involved in planning the study. BG conducted the searches, with all authors involved in screening and analysis. BG produced an initial draft of the paper. The final version of the paper was produced collaboratively by all the authors. Acknowledgements The authors would like to thank Teresa Jones for her expert advice on the search strategy. The review was completed as partial fulfilment of Belinda Goodenough’s Masters dissertation at King’s College London. In the original full report for our first review [3], we gratefully acknowledged the valuable help we had received from our expert Advisory Group. The members included two patient representatives who were consulted at various stages throughout the project, especially around the necessity of having our systematic review focus on the complexities of benefits from research engagement by healthcare organisations and staff, while separate reviews and analyses focused on the benefits of PPI in health research. References Clarke M, Loudon K. Effects on patients of their healthcare practitioner's or institution's participation in clinical trials: a systematic review. 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BMC Health Serv Res. 2021;21:1057. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8493726/ Yoong SL, Bolsewicz K, Reilly K, et al. Describing the evidence-base for research engagement by health care providers and health care organisations: a scoping review. BMC Health Serv Res. 2023;23:75. https://doi.org/10.1186/s12913-022-08887-2 Soper B, Yaqub O, Hinrichs S, Marjanovich S, Drabble S, Hanney S, et al. CLAHRCs in practice: combined knowledge transfer and exchange strategies, cultural change, and experimentation. J Health Serv Res Policy. 2013;18:53–64. https://doi.org/10.1177/1355819613499903 Kislov R, Wilson PM, Knowles S, Boaden R. Learning from the emergence of NIHR Collaborations for Leadership in Applied Health Research and Care (CLAHRCs): a systematic review of evaluations. Implement Sci. 2018;13:111. https://doi.org/10.1186/s13012-018-0805-y Additional Declarations No competing interests reported. Tables 1-2 are available in the supplementary files section. Supplementary Files RERUpdateTable1May24Listof62paperssubmitted.docx RERUpdateTable2May24combinedreview95paperssubmitted.docx RERUpdateAdditionalfile1GlossaryMay24submitted.docx RERUpdateAdditionalfile2searchinformationMay24submitted.docx Cite Share Download PDF Status: Published Journal Publication published 19 Aug, 2024 Read the published version in Health Research Policy and Systems → Version 1 posted Editorial decision: Revision requested 12 Jun, 2024 Reviews received at journal 11 Jun, 2024 Reviews received at journal 27 May, 2024 Reviewers agreed at journal 21 May, 2024 Reviewers agreed at journal 21 May, 2024 Reviewers invited by journal 20 May, 2024 Editor assigned by journal 20 May, 2024 Submission checks completed at journal 20 May, 2024 First submitted to journal 14 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4418411","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":307284927,"identity":"ee6a2481-dced-49e0-bf3c-5a798f65aaa0","order_by":0,"name":"Annette Boaz","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+klEQVRIie2SMWsCMRTHnxzo8uDWK4ifIUHQDsfdVwkEziVbl46Cg4vdHfwW/QJPDm4KnQM6KIKTQ0qX29qkrW4XO3bIbwgvJL+8/4MARCL/kP61KP1iCYY/W+pW0u9zAcDnAL01Ad5VHua/CnOXEvyLwnYv29N7mwNfLk4fuS4QBvUhQR1Q9m+SkaigxIaNlZEIWLEETUAxapKRqIGvBZPKkgumXELbrZRGTVsSn86d2frRK+klrPgubnzyBV+AcUrmu4SDjTNdSeQr/dRbaYn97My2m9D47nH7nBejcrB8tW1TjNJUHg+Xplu5grfK/we6L0QikUgkxBd8DFUTWurmpwAAAABJRU5ErkJggg==","orcid":"","institution":"King’s College London","correspondingAuthor":true,"prefix":"","firstName":"Annette","middleName":"","lastName":"Boaz","suffix":""},{"id":307284928,"identity":"694a5631-6702-49eb-abaf-3a617fa90772","order_by":1,"name":"Belinda Goodenough","email":"","orcid":"","institution":"The Sax Institute","correspondingAuthor":false,"prefix":"","firstName":"Belinda","middleName":"","lastName":"Goodenough","suffix":""},{"id":307284929,"identity":"21b1eec4-5a35-4804-81ea-40c89a7cd9a6","order_by":2,"name":"Stephen Hanney","email":"","orcid":"","institution":"Brunel University London","correspondingAuthor":false,"prefix":"","firstName":"Stephen","middleName":"","lastName":"Hanney","suffix":""},{"id":307284930,"identity":"ded321ba-aab1-4bf3-ada6-a8c56754c1ad","order_by":3,"name":"Bryony Soper","email":"","orcid":"","institution":"Brunel University London","correspondingAuthor":false,"prefix":"","firstName":"Bryony","middleName":"","lastName":"Soper","suffix":""}],"badges":[],"createdAt":"2024-05-14 10:21:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4418411/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4418411/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12961-024-01187-7","type":"published","date":"2024-08-19T15:57:40+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":57280330,"identity":"88ea76d1-bff9-43c5-bd13-aa946d3af051","added_by":"auto","created_at":"2024-05-28 14:51:43","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1003606,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlow diagram for literature search\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4418411/v1/4babc2e4e512cd83a5aed1af.jpeg"},{"id":57280336,"identity":"bd4d4fd4-be26-445b-b40b-ecd8d7f8902c","added_by":"auto","created_at":"2024-05-28 14:51:43","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":102621,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eResults from Boaz et al. systematic reviews of whether research engagement by health organisations and staff improves healthcare: \u0026nbsp;Analysis of First; Updated and Combined Reviews (and of the 86 positive papers)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLegend: Green rows (top): First review; Brown rows (middle): Updated review; Blue rows (bottom): Combined review\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4418411/v1/91f9e529dd26840ac74372f8.png"},{"id":63300633,"identity":"b613e18a-2f07-4040-96ea-481a3d5cadd9","added_by":"auto","created_at":"2024-08-26 16:15:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1814934,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4418411/v1/7bb1a254-953f-4a91-8bfd-ad8e9ea8c66c.pdf"},{"id":57280783,"identity":"7bc767fa-e303-4073-af8b-687b88241a88","added_by":"auto","created_at":"2024-05-28 14:59:43","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":137729,"visible":true,"origin":"","legend":"","description":"","filename":"RERUpdateTable1May24Listof62paperssubmitted.docx","url":"https://assets-eu.researchsquare.com/files/rs-4418411/v1/a9dd5583c781dbe295614d68.docx"},{"id":57280333,"identity":"e77926ec-ea4e-4f2a-8510-ba269e774753","added_by":"auto","created_at":"2024-05-28 14:51:43","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":162472,"visible":true,"origin":"","legend":"","description":"","filename":"RERUpdateTable2May24combinedreview95paperssubmitted.docx","url":"https://assets-eu.researchsquare.com/files/rs-4418411/v1/8e3388f95b7898eb2ce2e245.docx"},{"id":57280784,"identity":"8c355d74-b92b-43d7-b18a-1ffd9d750ed3","added_by":"auto","created_at":"2024-05-28 14:59:43","extension":"docx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":24216,"visible":true,"origin":"","legend":"","description":"","filename":"RERUpdateAdditionalfile1GlossaryMay24submitted.docx","url":"https://assets-eu.researchsquare.com/files/rs-4418411/v1/649fd7d4e204e2adbf8146f4.docx"},{"id":57280334,"identity":"2540f7df-fe56-46cd-a898-b41e9bb2f87a","added_by":"auto","created_at":"2024-05-28 14:51:43","extension":"docx","order_by":7,"title":"","display":"","copyAsset":false,"role":"supplement","size":104587,"visible":true,"origin":"","legend":"","description":"","filename":"RERUpdateAdditionalfile2searchinformationMay24submitted.docx","url":"https://assets-eu.researchsquare.com/files/rs-4418411/v1/a1a79ecb7e547e63621bfd96.docx"}],"financialInterests":"\u003cp\u003eNo competing interests reported.\u003c/p\u003e\n\u003cp\u003eTables 1-2 are available in the supplementary files section.\u003c/p\u003e","formattedTitle":"If health organisations and staff engage in research, does healthcare improve? Strengthening the evidence base through systematic reviews","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eThere is a widely held assumption that the engagement of clinicians and healthcare organisations in research improves healthcare performance at various levels. Three systematic literature reviews [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] provided the first analyses of the empirical evidence available to support this assumption, albeit with differing scopes.\u003c/p\u003e \u003cp\u003eThe 2011 Cochrane Methodology review by Clarke and Loudon [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] examined the influence of \u0026lsquo;trial active\u0026rsquo; practitioners or institutions on patient outcomes and/or care processes. The review focused on participation in randomised controlled clinical trials (RCTs) by the service provider, not by the patient. From more than 15,000 records (to January 2009), Clarke and Loudon identified 13 studies. Broadly, while they suggested that care processes (e.g. guidelines adherence) might be better when service providers take part in trials, they claimed that the magnitude of this effect and the consequences for patient health were uncertain.\u003c/p\u003e \u003cp\u003eIn a 2013 literature review, Hanney et al. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] identified 33 studies [\u003cspan additionalcitationids=\"CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30 CR31 CR32 CR33 CR34 CR35 CR36\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], from more than 10,000 records (to March 2012). Not restricted to RCTs, it included 12 of the 13 RCTs identified by Clarke and Loudon [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] and 21 additional papers. In 2015, key findings from this full research report (which had also included a wider analysis of related studies that did not quite meet the review\u0026rsquo;s inclusion criteria) were then published in a more accessible form as Boaz et al. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. As in the previous review, most included papers were analyses at the level of the organisation rather than individual clinicians (approximate 2:1 ratio). The majority of studies (28/33) identified a positive association between research engagement and improvements in healthcare. However, most of these improvements were improvements in processes of healthcare, only a quarter of the positive papers (7/28) reported improvements in health outcomes.\u003c/p\u003e \u003cp\u003eA further review in 2017 by Harding et al. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] from Australia examined potential benefits of a \u0026ldquo;strong research culture\u0026rdquo; on health service performance. It identified eight studies from 3,015 records (to June 2015). In comparison with the prior reviews by Clarke and Loudon [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], and Boaz et al. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], the search strategy used fewer databases and targeted different organisational metrics (e.g. staff satisfaction and retention). The review found an association between health service performance and activities representing organisational investment in research culture - in which the authors claimed being \u0026ldquo;research active\u0026rdquo; was a component.\u003c/p\u003e \u003cp\u003eAs far as we are aware, these literature reviews provided the first systematically collated accounts of the healthcare performance benefits associated with research engagement. But the evidence was not mature enough to support statements about causality, nor large enough from consistent designs to estimate effect sizes through meta-analysis [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMore positively, however, there was evidence of efforts to move towards more formalised attempts to boost the role of health research systems in accelerating science and facilitating the translation of research into practice. Within this overall picture, an important but somewhat under-explored theme was the role of research networks [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The eight network examples described by Boaz et al. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] all came from the US, where various research networks had been established in the second half of the last century. They are described in the \u0026ldquo;Glossary of the US \u0026amp; UK Research Organisations and Networks Discussed in the Papers\u0026rdquo; [see Additional file 1], which also shows the national research networks in the UK, which were not created until this century. Our first review also included two papers from Germany focusing on cooperative study groups to which, at that point, we did not apply the term network [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. However, when exploring this issue further in the light of the continued development of research networks, we have found it helpful to adopt Laliberte et al.\u0026rsquo;s inclusive approach to research networks [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. We have applied the term to various arrangements that, however loosely, give some measure of commonality to the research of multiple healthcare organisations that not only enhance science production, but also share a concern to transfer research findings into clinical practice.\u003c/p\u003e \u003cp\u003eOur first review also featured a study by Majumdar et al. that was conducted in the US, but led from Canada, and showed the association between research engagement and improved healthcare outcomes increased with greater amounts of research participation [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. We argued that further data on this effect, and on the time an institution was research active, \u0026ldquo;are needed to provide evidence of causation\u0026rdquo; (p.12) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile our original review identified networks/partnerships as a potential engagement mechanism in general, there did not appear to be a well-structured, steadily accumulating body of knowledge about the benefits of research engagement. In the succeeding years, we identified a continuing interest in this topic, including increased attention to the differential effects of different levels of research engagement, and other new studies on the effects of the developing research networks, especially in the UK. In 2020, we decided to explore these changes further and update the review published by Boaz et al. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] through a new systematic search.\u003c/p\u003e \u003cp\u003eIn addition to the developing research networks, there were other significant developments. In 2021, a UK qualitative systematic review explored the impact of research activity by healthcare professionals other than medical professionals [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], and in 2023 another UK review focused on research engagement by Allied Health Professionals (AHPs) [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. With few exceptions the papers specifically on nursing and AHPs in these reviews were typically smaller scale than the papers included in our review, and/or usually did not include the quantifiable comparisons that featured in most of our included papers. Nevertheless, these reviews usefully illustrate the growing interest in the contribution of these healthcare professionals in countries such as Australia, Canada and the UK. In 2022, a large-scale study from the US by Shahian et al. [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] examined the link between research engagement and improved healthcare performance in 5 major medical fields across 1,604 Medicare-participating hospitals. To ensure our updated review adequately reflected these latest developments, we conducted a further search in March 2024. The review presented here is based on papers identified in both phases of the updated review, the findings of which are then combined with those from our first review.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eReview question\u003c/h2\u003e \u003cp\u003eTo identify studies, the primary research question used the same approach as Boaz et al. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eDoes research engagement (by clinicians and organisations) improve healthcare performance?\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eBy research engagement, we mean, as in our first review, engagement in research rather than the broader concept of engagement with research, and we are referring to participation in research by healthcare organisations and staff rather than patient participation in trials. Engagement in research is taken to mean, \u0026ldquo;a deliberate set of intellectual and practical activities undertaken by healthcare staff (including conducting research and playing an active role in the whole research cycle) and organisations (including playing an active role in research networks, partnerships or collaborations)\u0026rdquo; (p.2) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eDesign\u003c/h2\u003e \u003cp\u003eThe decision to complete an update of the previous review [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] was informed by a published decision framework for updating systematic reviews [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSearch strategy and information sources\u003c/h2\u003e \u003cp\u003eSearch 1 (update)\u003c/p\u003e \u003cp\u003eThe first step in syntax development used the Medline Ovid strategy published by Boaz et al. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eInitial diagnostic testing indicated issues preventing code execution. Due to the syntax comprising several nested terms and Boolean operators, it was rebuilt using recommendations for \u0026lsquo;single-line\u0026rsquo; optimisation for debugging complex code [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSearch 2 (modified)\u003c/p\u003e \u003cp\u003eThe syntax for Search 2 was a term modification to capture papers that more explicitly indexed research networks and collaborations. Search 2 necessitated a deeper dive into the full-text content of papers. The decision to search full-text articles reflected observations that the sensitivity of Search 1 was potentially affected by the variable quality (and relevance for our review) of abstracts \u0026ndash; a consistent challenge for reviewers [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. As a second search also adapted published syntax, the PRIMA-S reporting protocol was followed: \u003cem\u003ePreferred Reporting Items for Systematic reviews and Meta-Analyses Literature Search - Extension Checklist\u003c/em\u003e [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. (The full text for search strategies is provided in \u0026ldquo;Search Strategy and Syntax Sensitivity\u0026rdquo; [see Additional file 2]).\u003c/p\u003e \u003cp\u003eElectronic databases\u003c/p\u003e \u003cp\u003eNine electronic records collections were used in Search 1: Medline (OVID and EBSCO), EMBASE, PsycInfo (OVID and EBSCO), CINAHL, Web of Science, Health Management and Information Consortium, and British Nursing Institute. The mix provided parity with previous reviews and mitigated risk of missed papers by combining general and specialised databases. Different interfaces (e.g. OVID, EBSCO) for the same collection were also included to offset variations due to platform [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Grey literature was not searched: these collections failed to uniquely identify papers in previous reviews on this topic. Search 2 was restricted to the Medline EBSCO Full Text records, which was the collection which yielded the highest hit ratio for relevant papers [see Additional file 2].\u003c/p\u003e \u003cp\u003eOther sources\u003c/p\u003e \u003cp\u003eManual and snowball searching were used in three ways. Firstly, a range of search engines (Google Scholar, PubMed, ProQuest Central, Scopus, the Web of Science \u0026lsquo;Cited Reference Search\u0026rsquo;) were used to track citations for (a) prior reviews as whole papers (b) the individual studies within these reviews, and (c) article reference lists. Secondly, key journals that published studies shortlisted in the previous reviews were hand-checked, including: Implementation Science, PLOS One, BMJ Open, BMC Health Services Research, Thirdly, topic experts suggested papers for consideration.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eEligibility Criteria\u003c/h2\u003e \u003cp\u003eThe following limiters were applied:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eTimeframe: January 1, 2012 to May 31 2020 (inclusive of eprint)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePopulation: Human (any setting)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eLanguage: English (any country)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePaper type: Academic Journals (scholarly works). Conference papers were admitted as flags for accessible peer-reviewed works (e.g. preprint) or key teams.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThree criteria were defined, guided by definitions from the original review [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCriterion A: Study Design:\u003c/p\u003e \u003cp\u003eEmpirical studies using method/s aligned with health services research, including clinical trials, retrospective cohort and survey methods. Studies with only patient reported outcomes (e.g. satisfaction) were excluded.\u003c/p\u003e \u003cp\u003eCriterion B: Healthcare performance:\u003c/p\u003e \u003cp\u003eStudies must report an outcome indexing performance assessment for a care process or healthcare improvement. The following were excluded: staff-specific reports alone, (e.g. job satisfaction or morale), policy impacts alone (no flow through to healthcare), descriptions of networks without outcomes data.\u003c/p\u003e \u003cp\u003eCriterion C: Research Engagement:\u003c/p\u003e \u003cp\u003eExplicit demonstration of engagement in research including: agenda setting, conducting research, participation in action research or in networks where the research involvement is noted. This criterion also allowed engagement implicitly through research network membership - even if a specific study was not recorded, but there was a comparison of healthcare between member and non-member settings. More details about examples that were in scope can be found in Hanney et al. (p2) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eRecords management\u003c/h2\u003e \u003cp\u003eTo efficiently manage the export of the large records, Endnote X9 (Clarivate) was used to combine downloads from different databases and discard software detected duplicates. The endnote library was imported into Rayyan, a free multi-collaborator online screening tool [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Study selection procedures for Searches 1 and 2 followed the same screening/eligibility check sequence.\u003c/p\u003e \u003cp\u003eScreening and eligibility/quality checking\u003c/p\u003e \u003cp\u003eIn Rayyan, titles were scanned to exclude papers that were irrelevant, did not meet criteria, or non-exact duplicates. Abstracts of retained records were then screened and classified as \u0026lsquo;include\u0026rsquo;, \u0026lsquo;exclude\u0026rsquo;, or \u0026rsquo;maybe\u0026rsquo;. A third screening of \u0026lsquo;maybe\u0026rsquo; classifications forced a binary coding of \u0026lsquo;include\u0026rsquo; or \u0026lsquo;exclude\u0026rsquo;, with comment flags on issues. A final records\u0026rsquo; sweep with the Rayyan query function checked for misclassified studies. This four-step screening process was completed by a single reviewer (BG).\u003c/p\u003e \u003cp\u003eFull-text for each provisionally included study was uploaded into Rayyan. The initial eligibility check was completed by three experts who were involved in article screening for Hanney et al. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. As a criterion check and to orient reviewers to the Rayyan platform, a practice phase used 10 randomly sampled records. The abstract was the primary source for expert reviewers, with full-text also available. After the practice task and consensus discussion of criteria, a batch of records (alphabet determined) was assigned to each expert reviewer, to rate each paper as \u0026lsquo;include\u0026rsquo;, \u0026lsquo;exclude\u0026rsquo;, or \u0026lsquo;maybe\u0026rsquo; (ratings were unblinded). If the rating pair (i.e. BG and an expert from the original review) were both \u0026lsquo;include\u0026rsquo;, the paper was progressed to full-text appraisal. If there was disagreement, papers rated as \u0026lsquo;maybe\u0026rsquo; were reassigned to another expert reviewer for an opinion, and those rated as \u0026lsquo;exclude\u0026rsquo; by an expert reviewer were marked for discard. If consensus for a \u0026lsquo;maybe\u0026rsquo; paper could not be reached by discussion, it was progressed to a full text appraisal - conducted by a single reviewer (BG) using all available information sources and reviewer ratings. A final review of all potential \u0026lsquo;includes\u0026rsquo; was jointly conducted by team members, including a few papers identified by continued manual snowballing from key papers.\u003c/p\u003e \u003cp\u003eSubsequently, we conducted a further search covering May 2020-March 2024. This consisted of: a hand-search of three of the journals in which papers from the first phase of the updated review had been published (Health Research Policy and Systems, Implementation Science and Medical Care); a check of papers in the two reviews published in this period [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]; and a check of citations in this period to all the papers identified both in our first review and in the update\u0026rsquo;s initial phase.\u003c/p\u003e \u003cp\u003eStudy quality was assessed using the \u003cem\u003eMixed-Methods Appraisal Tool\u003c/em\u003e (MMAT v2018), on a rating of 1 (low) to 5 (high) [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. The MMAT accommodated all designs in the paper set. Quality ratings were not used to exclude papers, but formed part of the discussion about the quality and contribution of the papers.\u003c/p\u003e \u003cp\u003eData extraction, coding and ethics\u003c/p\u003e \u003cp\u003eAs Rayyan is only a screening platform, a data extraction sheet was created in Excel (v2016) for each included paper. A university research ethics committee deemed the project as not requiring formal ethical approval, due to secondary data mining on anonymised aggregated records.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eAnalysis\u003c/h2\u003e \u003cp\u003eA heterogeneous mix of papers was identified with a range of different outcomes and outcome measures. A standard meta-analysis was not possible, but the papers were combined through a process of interpretive synthesis. Following analysis of the papers in the updated review, we collated the results from the updated review with those from our first review to create one combined set of papers for overall analysis.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eFigure 1 summarises the review literature flow. The two formal searches identified 66,901 records, with 68 further papers coming from other sources, including the March 2024 extension. From these, 168 papers progressed to full-text appraisal, and 62 were identified for inclusion [40, 49-109].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePLEASE ADD FIGURE 1 ABOUT HERE\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUpdated review\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis review updates the previous review conducted by the team [2], and details of the 62 additional papers are outlined in Table 1. Brief notes on the development and scope of key US and UK research networks/organisations discussed in the papers are provided in the \u0026ldquo;Glossary of the US \u0026amp; UK Research Organisations and Networks Discussed in the Papers\u0026rdquo; [see Additional file 1].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Different levels of analysis are explored in different papers: some compare clinicians, others organisations - with an even higher proportion in the updated review at the organisational level (50/62, 81%) than in our first review (22/33, 67%). Fifty-eight of the 62 papers report positive results, of which 48 are purely positive and 10 are positive/mixed meaning that there are some key negative elements in their findings, i.e., important parts of the analysis where there is a lack of healthcare improvement. Four are negative, of which two are negative-mixed. In our first review 22 of the 33 papers had been positive, six positive/mixed, and five negative (or negative/mixed).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA higher proportion of the positive papers in the updated review (30/58, 52%) than in our first review (7/28, 25%) describe improved health outcomes - in terms of reduced mortality or morbidity. There is a corresponding reduction from three-quarters (21/28) to a half (28/58)\u0026nbsp;in the proportion of papers solely describing improved processes - in terms such as applying proven interventions.\u003cem\u003e\u0026nbsp;\u003c/em\u003eThere has also been a shift in the updated review to a higher proportion of the papers describing research engagement leading to a broader impact on healthcare performance, rather than specific impact. Broad impacts arise when the improved healthcare goes more widely than just being linked to clinicians or healthcare organisations implementing the findings, or processes, from their own research more rapidly/extensively than do others. When the improved healthcare is linked to the results or processes of their own research, that is categorised as specific impact. Using these various categories, Figure 2 outlines the findings from the updated review, alongside the findings from our first review, and the combined set of both findings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePLEASE ADD FIGURE 2 ABOUT HERE\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the updated review, the literature is still dominated by papers from the US (35/62, 56%) and is mostly drawn from the Global North. The exceptions are studies from Africa\u003csup\u003e\u0026nbsp;\u003c/sup\u003e[88], China [97] and a Canadian led study that includes data from Africa and Central America [50]. A further paper focuses on a First Nation population in Australia, and encapsulates the Aboriginal community\u0026rsquo;s principle of \u0026ldquo;no research without service\u0026rdquo; [109]. The review also includes 14 papers from the UK (up from 3/33 in our first review), three each from the Netherlands and Spain, a second Canadian one, and one each from Germany and Sweden.\u003c/p\u003e\n\u003cp\u003eAs in our first review, the papers cover a wide range of clinical fields but with considerably more papers on cancer than any other field. The biggest difference from our first review is that in the update there are 16/62 papers that cover healthcare in general (or in multiple fields) in a single hospital or multiple sites across a healthcare system. Thirteen of these 16 papers on broad areas of healthcare have one, or two, characteristics that are more common in the updated review than the first. Seven are from the UK [51,67-69,85,95,101]. And eight include bibliometric analysis as an indicator of the extent, and/or quality, of research engagement as an input into comparison with the healthcare processes and outcomes provided by the clinicians and organisations who produced the academic papers [40,51,65,76,95-97,100]. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn total, 10/62 papers in the updated review used bibliometric analysis [40,50,51,56,65,76,95-97,100] (whereas just one [30] did so in our first review). All these 10 papers are positive, but various types of bibliometric analysis are used to measure the extent of research engagement compared to some measure of the performance in terms of healthcare processes and/or outcomes. The broad categories of academic indicators used are: publication volume [95,96]; publication \u0026ldquo;quality\u0026rdquo; (for example, as measured by citations) [51]; and a combination of volume and \u0026ldquo;quality\u0026rdquo; [40,50,56,65, 76, 97,100]. Of the latter, four, relatively small, studies suggested that the association with \u0026ldquo;quality\u0026rdquo; was stronger than with volume. The bibliometric studies also illustrate the varying levels of analysis at which the included studies in the review are conducted. Four of the 10 papers compare the academic outputs of clinicians [50,56,96,97] and six make comparisons at an organisational level [40,51,65,76,95,100], focusing variously on academic outputs at ward, department, or hospital/Trust level.\u003c/p\u003e\n\u003cp\u003eOverall, our first review was not a single coherent body of studies that could be built upon in the updated review. \u0026nbsp;It was challenging to draw strong conclusions from the mixed bag of studies. Whilst the updated review adds studies that are still very diverse, some of the streams of research identified in our first review have continued into the updated review, especially those involving research networks. We have, therefore, collated the findings from our first review and the updated review in order to present a combined set of papers that can be further analysed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCombined Review\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 2 outlines the details of each of the 95 papers in the original and updated reviews combined into one dataset. Of the 95 papers, 86 are positive (of which, 16 are positive/mixed) and nine negative (of which four are negative/mixed). Of the 86 positive papers, 37 report improved outcomes and 49 go only as far as reporting improved processes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePLEASE ADD TABLE 2 ABOUT HERE\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAcross the 95 papers, 12 countries are either the location for the research engagement described in a single-country study, or the location from which a multi-country study was led, with one paper led from South Africa having authors from a range of African countries (and The Yemen) [88]. The 12 countries are: US (50 papers), UK (17), Canada (7), Spain (5), Germany (4), The Netherlands (3), Australia (2), Denmark (2), South Africa (2), China (1), Finland (1) and Sweden (1).\u003c/p\u003e\n\u003cp\u003eIn both reviews, cancer was the most common field, with 32/95 papers overall. Next came hospital care in general/multi-field/acute care with 16 papers, cardiovascular/stroke (12), substance use disorder (7), dentistry (3), mental health/psychiatry (3), obstetrics (3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe combined review allows a range of issues to be analysed more thoroughly than they had been in our first review. Two such issues highlighted in the Background are the role of networks and the \u0026ldquo;dose effect\u0026rdquo;. These are examined in turn below, followed by consideration of how far the included studies have addressed various aspects of health equity, and finally an analysis of lessons from the overall portfolio of positive and negative studies.\u003c/p\u003e\n\u003cp\u003eThe\u0026nbsp;role of research networks\u003c/p\u003e\n\u003cp\u003eThe initial papers on research networks in our first review are supplemented by further studies in the updated review, and their full significance is seen when the reviews are combined. Using the inclusive definition mentioned in the Background section, we identify about two-thirds of the papers in the updated review as network papers, meaning that about half the papers in the combined review analysed research activity by clinicians or healthcare organisations who were part of research networks of various types.\u003c/p\u003e\n\u003cp\u003eIn the US, the National Cancer Institute (NCI) cancer research networks include the NCI-designated Comprehensive Cancer Centres, the NCI Cooperative Groups, and collaborative groups of community hospitals affiliated to the NCI\u0026rsquo;s Community Clinical Oncology Program (CCOP- see the Glossary for its new name). \u0026nbsp;In various ways these networks all include outreach and the engagement of community physicians in their brief \u0026ndash; see the Glossary for more details. \u0026nbsp;Their potential was recognised early: the combined papers include the influential 2005 study by Laliberte et al.\u003csup\u003e\u0026nbsp;\u003c/sup\u003e[24] that looks at these networks and concludes that network membership \u003cem\u003emay\u003c/em\u003e influence compliance with treatment guidelines and should, therefore, be taken into account in predictive models of compliance. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSeven included papers illustrate various aspects of the issue by comparing the processes and outcomes for patients treated at NCI-designated (comprehensive) cancer centres with those treated elsewhere. Six of these studies show better outcomes for patients treated at NCI centres [52,64,80,84,86,106], while one paper suggests that despite better processes, patient outcomes were worse at NCI centres \u0026ndash; this paper is considered in the section on negative papers below [81]. Of the positive papers, Paulson et al. show how the NCI designation was \u0026ldquo;associated with lower risk of postoperative death and improved long-term survival\u0026rdquo;\u003csup\u003e\u0026nbsp;\u003c/sup\u003e(p.675) [86], identify possible factors such as better adherence to guidelines, and demonstrate that the better outcomes at NCI-designated centres remained even when compared to non-NCI designated centres with a similar high volume of cases [86]. Wolfson et al. identify the requirements that underpin the positive association between high-quality research and high-quality care [106]. These include the mandate NCI centres have to \u0026ldquo;lead clinical trials, exchange ideas, disseminate findings\u0026rdquo; (p.3892), which show how the centres can act as part of a network. Wolfson et al. continue: \u0026ldquo;The NCI operates on the belief that a culture of discovery, scientific excellence, transdisciplinary research, and collaboration yields tangible benefits extending far beyond the generation of new knowledge\u0026rdquo; [106].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBuilding on Laliberte et al.\u003csup\u003e\u0026nbsp;\u003c/sup\u003e[24], Carpenter et al. demonstrate an association between CCOP membership and accelerated innovation adoption but add the important codicil that it is not possible to \u0026ldquo;definitively ascertain whether there is a direct causal relationship between the two\u0026rdquo; [54].\u003c/p\u003e\n\u003cp\u003eImproved healthcare has also been associated with membership of the US practice-based research networks (PBRNs). \u0026nbsp;These networks cover family practice/primary care, dentistry, mental health and substance abuse. Like the CCOP and its affiliates, PBRNs involve practising clinicians in the community who conduct research. The combined review includes seven PBRN papers covering primary care and dentistry, all of which are positive [32,36,66,78,83,92,108] and one of which describes an international dental PBRN led from the US that includes three Scandinavian countries [66].\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eSeven papers from the National Institute on Drug Abuse\u0026rsquo;s Clinical Trials Network (CTN) PBRN also provide evidence of accelerated translation, identify mechanisms through which this might work, and discuss the theoretical frameworks within which those operate [5,14,23,49,63,90,91]. Thus, Ducharme et al.\u003csup\u003e\u0026nbsp;\u003c/sup\u003e[14] and Knudsen et al.\u003csup\u003e\u0026nbsp;\u003c/sup\u003e[23] explore Rogers\u0026rsquo; notion of the \u0026lsquo;trialability\u0026rsquo; [110] of innovations, i.e. how far an innovation may be experimented with on just a limited basis, and Abraham et al. [5]\u003csup\u003e\u0026nbsp;\u003c/sup\u003ediscuss the role of absorptive capacity [111,112], which they summarise as an organisation\u0026apos;s ability to assess and use information [5]. Rieckmann et al. note that although the mechanisms involved were not fully understood they appeared \u0026ldquo;to be influenced by core experiences from network participation\u0026rdquo; (p.894) [91], and Fields et al.\u003csup\u003e\u0026nbsp;\u003c/sup\u003e[63] use insights from implementation science to explore the influence of a set of organisational characteristics (including network membership) on innovation adoption [113].\u003c/p\u003e\n\u003cp\u003eIn an analysis of data on 12,993 transplants conducted in 162 US centres, the 32 centres in the Bone Marrow Transplant trials network were found to have significantly better survival rates than others [77]. Marmor et al. report that there was not an association between procedure volume and survival. Rather, they suggest, the better outcomes for those treated in centres in this network could be linked to the nature of trials that require \u0026ldquo;higher levels of national clinical collaboration and standardization of protocols\u0026rdquo;, and such collaboration is \u0026ldquo;likely to generate higher levels of innovation and excellence among clinical colleagues\u0026rdquo; (p.92) [77].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn Germany, one team produced three papers on the improved healthcare performance of hospitals that were part of clinical trials organisations [13,34,94]. Two papers describe the improved outcomes for patients with ovarian cancer if they were treated in a hospital that belonged to one of two German ovarian cancer clinical trials organisations, in effect research networks [13,34]. They note that the improved outcomes were not related to patient volume, suggesting instead that possible factors may include hospitals\u0026rsquo; participation in the study group\u0026rsquo;s quality assurance programs and team members attending regular and scientific and educational meetings [13]. In a follow-up study, the data are analysed in more detail using mediation analysis that shows not just that the research participation of a hospital contributes to superior patient survival, but also begins to unpick how it happens, including through better use of surgery and chemotherapy [94].\u003c/p\u003e\n\u003cp\u003eDowning et al. note that, following the 2006 establishment in the UK of the National Institute for Health Research (now National Institute for Health and Care Research) (NIHR), the increase in research activity in networks throughout the English NHS has also increased the scope for analysing the benefits of research engagement [58]. The role of NIHR networks in boosting research engagement, which is then linked to improved healthcare, also covers clinicians such as nurses and AHPs who had traditionally had limited research opportunities. Studies are now showing how they can play an important role by engaging in research because, according to Trusson et al. reporting on a research network for nurses and AHPs, people working in such roles \u0026ldquo;have opportunities to explore possible solutions to issues that they encounter in their clinical role through academic study\u0026rdquo; (p.1) [101]. Such opportunities can also enhance their clinical skills. More broadly, Downing et al. claim that, in relation to the NIHR\u0026rsquo;s clinical trials network, \u0026ldquo;This natural experiment, presented by the rapid expansion of trial activity across a whole national health system, is perhaps the best opportunity to address the subject though outcomes research\u0026rdquo; (p.95) [58]. This development is discussed in the next section.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe \u0026ldquo;dose effect\u0026rdquo; of the extent of research engagement\u003c/p\u003e\n\u003cp\u003eEvidence indicating a link between the extent of research engagement and the degree of improved healthcare has been accumulating for some time. In the US, the 1996 study by Brown and Griffiss found that the average acute length of stay (LoS) in Department of Veteran Affairs hospitals was inversely related to the size of research programmes [53]. Majumdar et al.\u003csup\u003e\u0026nbsp;\u003c/sup\u003e[26] used a tertile approach to show that in-hospital mortality decreased as the rate of trial participation increased for patients with unstable angina. \u0026nbsp;In the substance abuse field, early CTN studies also contributed: thus Knudsen et al.\u003csup\u003e\u0026nbsp;\u003c/sup\u003e[23] noted that the adoption of buprenorphine therapy by practitioners within the trials\u0026rsquo; network was much greater in those programmes in the network that participated in the specific buprenorphine trial than those that had not. In a 2006 study of a sexual health trial in Australia, Morton et al.\u003csup\u003e\u0026nbsp;\u003c/sup\u003e[28] identified improved post-trial clinical practice by high-recruiting clinicians, but not by low-recruiting ones. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;In our paper set the first use of the specific term \u0026ldquo;dose effect\u0026rdquo; to describe the effects of differing amounts of research engagement occurs in Downing et al. who tested the hypothesis that for colorectal cancer (CRC) \u0026ldquo;high, sustained hospital-level participation in interventional clinical trials improves outcomes for all patients with CRC managed in those research-intensive hospitals\u0026rdquo; (p.89) [58]. They found that high participation in such clinical trials was independently associated with better outcomes and that these effects were not restricted to academic centres or large institutions but were seen across all the NHS Trusts that conducted research on, and treated, colorectal cancer patients. They extended their analysis to look at the effects of different levels of research participation and found that the highest levels of participation led to the highest levels of improved outcomes. However, in relation to these findings, Downing et al. are careful to say that, in the absence of the possibility of an RCT, caution is needed if attempting \u0026ldquo;to infer a causal contribution\u0026rdquo; (p.89) from participation in research activity to improved healthcare [58].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOther UK database studies support the findings of Downing et al. For example,\u0026nbsp;Ozdemir et al.\u003csup\u003e\u0026nbsp;\u003c/sup\u003e[85] compare mortality with research funding per hospital bed in hospitals with high, medium and low levels of research funding and show that not only was mortality lower in high-funded research hospitals than in other hospitals, but also, on average, hospitals in the middle category had a lower mortality rate than ones with the least research funding. In two studies using NIHR research study activity data from different years, Jonker and Fisher\u003csup\u003e\u0026nbsp;\u003c/sup\u003e[68,69] show an inverse correlation between the number of clinical trials/patient participation levels in UK hospitals and the mortality rate. Lin et al. [73], use retrospective data to examine the survival rate of the 465 patients (recruited by 60 hospitals) who had participated in an RCT in the NIHR Clinical Research Network (CRN). While they identify a significant association between low trial recruitment and lower survival rates, looking at the volume of patients treated in the disease area by the respective hospitals they report that \u0026ldquo;no significance was found between hospital throughput and outcomes\u0026rdquo; (p.40) [73].\u003c/p\u003e\n\u003cp\u003eFurther support for the \u0026ldquo;dose effect\u0026rdquo; concept comes from the US and elsewhere. According to\u0026nbsp;Abraham et al., in the substance abuse field \u0026ldquo;treatment programs participating in a greater number of CTN protocols had significantly higher levels of treatment quality, an association that held after controlling for key organizational characteristics\u0026rdquo; (p.232) [49]. Similarly, Gilbert et al. [66]\u003csup\u003e\u0026nbsp;\u003c/sup\u003ereport that members of a dental PBRN who fully participated in the network, were more likely to move evidence-based care into everyday practice than members who only partially participated.\u0026nbsp;Seaburg et al. [96] show an association between the quantity of resident physicians\u0026rsquo; publications and their clinical performance scores during training, and Garc\u0026iacute;a-Romero et al. claim that increases in the scientific output of Spanish hospitals made a significant contribution to a reduction of hospital LoS\u003csup\u003e\u0026nbsp;\u003c/sup\u003e[65]. \u0026nbsp;In Canada, Tsang et al. [103] conducted a pre-planned observational study nested within a clinical trial in order to test how well traditionally non-research active community hospitals could participate in an RCT alongside the traditional RCT sites in academic hospitals. But while that aspect of the study did show that, in terms of adherence to trial metrics, the community hospitals could successfully participate in studies, outcomes for patients in the trial were significantly better in the traditional research hospitals, although the full reasons for this will need further exploration [103]. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHealth equity\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eVarious aspects of health equity are considered in the included papers, and some of these report attempts to improve health equity. Some population groups are particularly vulnerable. In the US, for example, Wolfson et al list the following groups: \u0026ldquo;underrepresented minorities, those with low SES [socio-economic status), those with public or no insurance, and those with a significant distance to care\u0026rdquo; (p.3886) [106]. Based on its long-held assumption that patient access to research active healthcare providers is beneficial, the NCI has attempted to reduce geographic inequalities in access. In a 1995 paper, Warneke et al. note that the CCOP was established by the NCI in 1983 with the deliberate intention of spreading the benefits of the clinical research conducted in NCI centres: \u0026ldquo;The program was designed with the assumption that by participating as equals in the research process, community physicians would be more likely to accept and implement the results in their practices with non-protocol patients\u0026rdquo; (p.336) [37]. Similar moves to encourage wider participation in clinical trials have recently been made in Canada in the nested study described above [103]. And a recent analysis showing higher levels of research activity within the English healthcare system are associated with lower mortality, notes that although the NIHR CRN was established to promote research participation across England, there is still some way to go to ensure greater geographical equity [69].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOther papers address racial inequalities in relation to access to timely evidence-based healthcare, which sometimes overlap with geographic inequalities. Some of the papers on the NCI designated cancer centres observe with concern that the proportion of certain racial/ethnic groups, including African Americans, who received treatment at these centres compared to non-NCI centres was lower than for other racial groups [64,80,106]. \u0026nbsp;Having noted that African Americans with colon cancer experienced worse outcomes than Caucasian Americans, and suggested that this was partly due to differential treatment, a study by Penn et al. finds evidence that African Americans receiving treatment from CCOP providers had benefitted from early access to a recently recommended innovative treatment [87]. \u0026nbsp;In Australia, Young et al. [109] report that the health services, and health research system, of the Aboriginal community work together to try to ensure health research is embedded into activities that improve health, and describe a specific example in relation to Ear, Nose and Throat surgery and speech-language pathology services.\u003c/p\u003e\n\u003cp\u003eLessons from the overall collection of studies: positive and negative\u003c/p\u003e\n\u003cp\u003eA wide variety of papers contribute to the combined review\u0026rsquo;s overall finding that the included studies are overwhelmingly positive. As the section on health equity demonstrates, throughout the time covered by the combined review individual papers have contributed to a wider understanding that goes beyond specific issues about research networks and discussions of the \u0026ldquo;dose effect\u0026rdquo;. For example, a 2019 US positive study by Fanaroff et al.\u003csup\u003e\u0026nbsp;\u003c/sup\u003e[60] identifies improved care and outcomes for patients with acute myocardial infarction who were treated at research active hospitals, even after accounting for potential confounders. The authors encapsulate some of the key thinking on research engagement with their conclusion that participation in clinical trials by hospitals \u0026quot;may be emblematic of a culture that embraces novel therapeutics, engages both clinicians and patients, and incentivizes continuous improvement in care\u0026quot;\u003csup\u003e\u0026nbsp;\u003c/sup\u003e(p.191) [60].\u003c/p\u003e\n\u003cp\u003eWhile overall the 95 studies included in the combined review are positive, about 10% were categorised as negative. These nine negative papers also provide important insights [7,11,15,20,25,67,79,81,99].\u003csup\u003e\u0026nbsp;\u003c/sup\u003eFor example, existing widespread use of one proven intervention prior to a company-sponsored clinical trial exploring physicians\u0026rsquo; adherence to international treatment recommendations meant that the trial had no significant impact on that adherence, although it did increase use of the trial sponsor\u0026rsquo;s drug [7]; physicians adopted another trial intervention before it was proven one way or another [11]; more positively, a unique policy and regulatory environment governing the adoption of another intervention ensured that all hospitals benefited, not just those in the trial [79]. Two teams with negative results later conducted further, more comprehensive, studies, with positive conclusions [25,26,67-69]. Six of the seven papers examining whether NCI-designated cancer centres provided patients with better healthcare processes and outcomes are positive [52,64,80,84,86,106]. However, one paper suggests that outcomes were worse in these accredited hospitals despite the better healthcare and, in seeking to explain this, draws attention to the factors considered in the accreditation processes used by different organisations, and how far they accurately capture the most relevant data [81].\u0026nbsp;\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eOur first review set out to find if there was empirical evidence that supported the widely held assumption that engagement by clinicians and healthcare organisations in research improves healthcare performance at various levels. It concluded that there was some positive evidence but that systematic analysis of the data related to this engagement was in its infancy [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The 62 papers in the updated review show a similar demographic profile to those in our original review [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]: a dominance of USA settings (n\u0026thinsp;=\u0026thinsp;35) and cancer as the most common topic area (n\u0026thinsp;=\u0026thinsp;22). Fifty-eight of these later papers provide further empirical evidence to support the positive conclusions of the original review.\u003c/p\u003e \u003cp\u003eWhen the papers from both reviews are considered together, they provide a more complete dataset than previously available [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], and trends identified in our initial analyses [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] become more apparent. They show how this field of research has developed over the last decade with a better, although still limited, understanding of the relation between enhanced research engagement and improved healthcare. The combined papers provide further examples reflecting policy shifts and organisational changes that occurred first in the US and later in the UK and elsewhere, and were designed to address the time lag between the production of research and its use in practice. These include the development of research networks and their associated databases (accompanied by an improved understanding of their strengths and limitations [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e, \u003cspan citationid=\"CR106\" class=\"CitationRef\"\u003e106\u003c/span\u003e, \u003cspan citationid=\"CR108\" class=\"CitationRef\"\u003e108\u003c/span\u003e]) and efforts to strengthen links between academic centres and community services [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e]. More recent developments, especially in the UK, encouraged further deliberate attempts to identify and explore the impacts of research engagement. Research teams were, for example, better able to study the real-world impacts of system-level mechanisms such as research networks as they became more formalised and embedded in national health and science structures [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e, \u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e, \u003cspan citationid=\"CR93\" class=\"CitationRef\"\u003e93\u003c/span\u003e, \u003cspan citationid=\"CR101\" class=\"CitationRef\"\u003e101\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAcross the board, within and beyond networks, there is also further evidence about the mechanisms, including the ones identified in our first review. The role of strong evidence-based protocols developed for RCTs, but contributing to improved healthcare more widely in research active healthcare sites, was highlighted in various studies [\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e, \u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e98\u003c/span\u003e, \u003cspan citationid=\"CR105\" class=\"CitationRef\"\u003e105\u003c/span\u003e]. Papers also identified the importance of providing evidence-based/guideline consistent care, which could also be linked to a culture of discovery, excellence and collaboration [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e, \u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e, \u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e, \u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e, \u003cspan citationid=\"CR106\" class=\"CitationRef\"\u003e106\u003c/span\u003e]. There were also more nuanced mechanisms at specialty and clinician level, such as the use of multi-disciplinary coordination of care in radiation therapy treatment [\u003cspan citationid=\"CR107\" class=\"CitationRef\"\u003e107\u003c/span\u003e], and practitioner skill development in substance abuse work [\u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e90\u003c/span\u003e]. Similar practitioner skill development was also reported among nurses and AHPs, including in the wider literature [31;38,39,62,70,101].\u003c/p\u003e \u003cp\u003eIn the combined set of papers, it became easier to see connections across in this diverse literature. It was possible to identify research teams that had worked together on multiple studies and to explore the extent of cross referencing. In the US, for example, the CTN of the drug abuse institute had been created to emulate the CCOP, and a centre was established to assess the CTN\u0026rsquo;s impact [\u003cspan citationid=\"CR114\" class=\"CitationRef\"\u003e114\u003c/span\u003e]. Many of the papers from this substance abuse CTN [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e90\u003c/span\u003e] referenced each other and also cross-referenced key cancer papers [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]; and there was common use of the same early sources [\u003cspan citationid=\"CR110\" class=\"CitationRef\"\u003e110\u003c/span\u003e, \u003cspan citationid=\"CR112\" class=\"CitationRef\"\u003e112\u003c/span\u003e, \u003cspan citationid=\"CR115\" class=\"CitationRef\"\u003e115\u003c/span\u003e, \u003cspan citationid=\"CR116\" class=\"CitationRef\"\u003e116\u003c/span\u003e]. These interactions prompted ongoing methodological development, strengthened understanding of theoretical concepts, and supported shared learning across the specialties. Elsewhere, themes that had been recognised in the original review, including concepts such as absorptive capacity [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR111\" class=\"CitationRef\"\u003e111\u003c/span\u003e], were further explored and tested in new contexts, even if the same literature was not always drawn upon [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe important concept of the \u0026ldquo;dose effect\u0026rdquo; had been, in effect, recognised in our first review, even if it was not specifically labelled as such [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. But the combined review can now more fully consider the concept because evidence about this greatly increased in the updated review. Partly, this is because the scope of the papers included has increased. There are many more studies where all the clinicians or organisations compared are engaged in research but to varying extents and/or with different levels of resources, for example within a trial [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan citationid=\"CR93\" class=\"CitationRef\"\u003e93\u003c/span\u003e, \u003cspan citationid=\"CR103\" class=\"CitationRef\"\u003e103\u003c/span\u003e, \u003cspan citationid=\"CR107\" class=\"CitationRef\"\u003e107\u003c/span\u003e], or within a network [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e, \u003cspan citationid=\"CR95\" class=\"CitationRef\"\u003e95\u003c/span\u003e]. The inclusion of papers about differences within trials, and the emergence of the importance of the \u0026ldquo;dose effect\u0026rdquo;, have implications for both a) how the issue of research engagement is analysed, and b) how far efforts to enhance research engagement should be concentrated or spread widely across a system. In relation to the first issue, when considering the dose effect, the key question morphs somewhat: it is no longer simply whether research engagement improves healthcare performance compared to no research engagement, rather, it is whether a larger amount of research engagement improves healthcare performance by more than a smaller level of engagement (and, if so, by how much). Answers to these questions could then feed back to strengthen the evidence for a positive association between research engagement and improved healthcare performance. In relation to the second question, about the concentration or wide distribution of research funding, analyses might have to consider the context and trade-offs in terms of benefits for improved health, and health equity. The widespread distribution of research funding across the health system could maximise the number of patients who might benefit, but a more concentrated approach, with a higher dose of research engagement in a smaller number of hospitals, could maximise the benefit for patients in such centres.\u003c/p\u003e \u003cp\u003eResearch infrastructures in countries such as the US and UK have been developed to enhance the relationship health and health research systems, and the evidence from our combined review suggests that these changes have been positive. In both systems, but particularly in the UK, there have been deliberate attempts to fund both, major centres of research in leading healthcare facilities, and also to spread research funding more widely to healthcare organisations across the country. But this impetus needs to be maintained if the full benefits of research engagement are to be realised. Such an argument is reinforced by the conclusions of a major recent analysis of progress in the UK in engaging healthcare staff in research and building capacity. The findings from the study suggest that many healthcare staff in the UK are interested in being involved in research, there are supportive national policies and strategies in place, and there has been some important progress. However, to achieve widespread involvement \u0026ldquo;will only be possible by focusing more on how healthcare organisations embed and support research activity through organisational policies which are supported by the wider research support and funding infrastructure. This is an essential part of a system-based approach to developing and supporting research engagement\" (p.356) [\u003cspan citationid=\"CR117\" class=\"CitationRef\"\u003e117\u003c/span\u003e]. The progress possible, and the potential benefits of trying to build a health research system embedded into a healthcare system, but also the full range of substantial challenges, have also recently been explored in a hospital and regional healthcare system in northern Queensland, Australia [\u003cspan citationid=\"CR118\" class=\"CitationRef\"\u003e118\u003c/span\u003e, \u003cspan citationid=\"CR119\" class=\"CitationRef\"\u003e119\u003c/span\u003e]. Studies such as these indicate that our updated review could provide timely evidence to further the challenging task of improving healthcare by boosting engagement in health research.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eStrengths \u0026amp; limitations\u003c/h2\u003e \u003cp\u003eThe updated review adds a considerable number of additional papers from diverse perspectives, but the literature continues to be drawn predominantly from the US and Global North so the conclusions may not be appropriate in different contexts, including in the Global South. Similarly, while the use of bibliometrics as an indicator of research engagement has widened the range of positive studies available, differing claims as to the most appropriate measure of research publications challenge consistent interpretation of the data and indicate there is more work to do. Furthermore, it is important to recognise that the national policy, noted in one paper, of attaching promotion and bonuses for clinicians to publish in journals with an impact factor of at least three [\u003cspan citationid=\"CR97\" class=\"CitationRef\"\u003e97\u003c/span\u003e] runs contrary to the internationally widely endorsed Declaration on Research Assessment [\u003cspan citationid=\"CR120\" class=\"CitationRef\"\u003e120\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eWe included seven papers in this updated review that sat within the time frame of our first review [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e, \u003cspan citationid=\"CR95\" class=\"CitationRef\"\u003e95\u003c/span\u003e, \u003cspan citationid=\"CR104\" class=\"CitationRef\"\u003e104\u003c/span\u003e, \u003cspan citationid=\"CR108\" class=\"CitationRef\"\u003e108\u003c/span\u003e]. We reflected on how we might have missed these and concluded that the complexity of searching in this area (with many generic terms such as \u0026lsquo;research\u0026rsquo; and \u0026lsquo;engagement\u0026rsquo;) and the tangential approach of some papers to the broad question of whether research engagement improves performance may have contributed, as was recognised by the somewhat more extensive methods adopted for the updated review. We believe we are now able, however, to present a more nuanced understanding of the complexities of this field, building on our experience in the original review, and the generally greater clarity in later papers. In particular, we have found considerably more evidence on two topics identified as important in our first review: the role of research networks and consideration of how far there is a dose effect with regard to the degrees of research engagement. On both topics the combined review has strong papers showing important healthcare improvements even after considering potential confounders such as patient volume [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e, \u003cspan additionalcitationids=\"CR85\" citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e]. However, the failure of some papers to address such confounders [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan citationid=\"CR107\" class=\"CitationRef\"\u003e107\u003c/span\u003e], means some weaknesses in the overall analysis remain, and we are still not able to undertake any meta-analysis as the included literature remains very diverse.\u003c/p\u003e \u003cp\u003eNotwithstanding all the additional largely positive papers included in the review, one limitation compared to our first review [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] was the lack of resources to undertake a structured analysis of the wider range of papers identified as making many relevant and illuminating points related to the topic, but not meeting the formal review\u0026rsquo;s inclusion criteria. For example, while this updated review does include some consideration of health equity issues, there were further papers taken to full paper review that were not in the end included but which provide considerably more evidence [\u003cspan citationid=\"CR121\" class=\"CitationRef\"\u003e121\u003c/span\u003e, \u003cspan citationid=\"CR122\" class=\"CitationRef\"\u003e122\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eFuture possible work\u003c/h2\u003e \u003cp\u003eThe system-based approaches mentioned above continue to provide important opportunities for further work. Likewise, improvements in the identification and collection of relevant data and developments in statistics have prompted increasingly sophisticated analyses, sometimes using approaches developed in other fields, and could continue to do so [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e, \u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e90\u003c/span\u003e, \u003cspan citationid=\"CR94\" class=\"CitationRef\"\u003e94\u003c/span\u003e]. There has also been increasingly sophisticated use of bibliometrics, and there are likely to be continuing opportunities to apply such approaches to more countries. But the warning from Downing et al. that caution is needed if attempting \u0026ldquo;to infer a causal contribution\u0026rdquo; from research participation to improved health outcomes [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e], as well as frequent mention of similar disclaimers in other papers [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e], is a reminder that more work is needed.\u003c/p\u003e \u003cp\u003eWhile some of our papers have claimed the costs of research engagement are broadly covered by the associated reduced LoS [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e], further research might be useful around the costs associated with research engagement and how these relate to reported benefits. Such studies could add to the existing large-scale studies showing the considerable monetary value of the health, and economic, gains resulting from health research [\u003cspan citationid=\"CR123\" class=\"CitationRef\"\u003e123\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe insights revealed by the negative papers, particularly in relation to the contexts in which research, and research networks operate [\u003cspan citationid=\"CR99\" class=\"CitationRef\"\u003e99\u003c/span\u003e], could usefully be further explored. Merkow et al. [\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e], the one negative paper out of seven papers included on the NCI-designated centres, raises issues about the accuracy, or perhaps appropriateness, of the measurement used by various organisations to accredit cancer centres. The issues have also been explored by various teams [122;124;125], but could perhaps be worth further examination because the findings from Merkow et al. are so starkly different from those of other teams.\u003c/p\u003e \u003cp\u003eFinally, there are increasing opportunities, as well as a growing need, to address the limitations identified above (and also noted in the review by Chalmers et al. [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]) and go beyond the formal inclusion criteria of this review. A major area that could usefully be incorporated into an overall analysis of the field relates to the impact of the growing interest in research engagement strategies [\u003cspan citationid=\"CR126\" class=\"CitationRef\"\u003e126\u003c/span\u003e]. This includes the efforts to enhance research roles for healthcare professionals other than medical professionals [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], and the increasing number of organisational arrangements within health and health research systems for partnerships that seek to boost the production, and use, of relevant evidence [\u003cspan citationid=\"CR127\" class=\"CitationRef\"\u003e127\u003c/span\u003e, \u003cspan citationid=\"CR128\" class=\"CitationRef\"\u003e128\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003ePrevious reviews [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] have investigated the association between research engagement and improvements in healthcare performance. This study updates and extends the most comprehensive of these reviews conducted by Boaz et al. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The updated review, especially when we combine the findings with those from our first review, collates a more substantial pool of studies, which are largely positive in terms of the impact of research engagement on processes of care and patient outcomes. Of potential mechanisms, the review highlights the important role played by research networks, and further identifies the various ways the research engagement facilitated by them operates to improve healthcare. The review also draws together a set of papers which consider how far there is a research engagement \u0026ldquo;dose effect\u0026rdquo;. Given the difficulty of conducting randomised controlled trials of large-scale research engagement initiatives, studies of dose effect offer another approach to understanding the potential contribution and complexities of research engagement. This review provides further evidence of the important contribution played by systems-level research investments such as research networks on processes of care and patient outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAHP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAllied Health Professionals\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCRN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eClinical Research Network\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCTN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eClinical Trials Network\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCCOP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCommunity Clinical Oncology Programme\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLoS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLength of Stay\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMMAT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMixed-Methods Appraisal Tool\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Cancer Institute\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNHS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Health Service\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNIHR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Institute for Health (and Care) Research\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePBRN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003epractice-based research network\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eR\u0026amp;D\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eresearch and development\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRCTs: randomised controlled trials.\u003c/div\u003e \u003cdiv class=\"Description\"\u003e\u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient consent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData sharing is not applicable to this article as no data sets were generated and/or analysed for this study beyond the tables included in the paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare they have no completing interests\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors were involved in planning the study. BG conducted the searches, with all authors involved in screening and analysis. BG produced an initial draft of the paper. The final version of the paper was produced collaboratively by all the authors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003eThe authors would like to thank Teresa Jones for her expert advice on the search strategy. \u0026nbsp;The review was completed as partial fulfilment of Belinda Goodenough\u0026rsquo;s Masters dissertation at King\u0026rsquo;s College London. \u0026nbsp;In the original full report for our first review [3],\u003csup\u003e\u0026nbsp;\u003c/sup\u003ewe gratefully acknowledged the valuable help we had received from our expert Advisory Group. The members included two patient representatives who were consulted at various stages throughout the project, especially around the necessity of having our systematic review focus on the complexities of benefits from research engagement by healthcare organisations and staff, while separate reviews and analyses focused on the benefits of PPI in health research.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eClarke M, Loudon K. Effects on patients of their healthcare practitioner's or institution's participation in clinical trials: a systematic review. Trials. 2011;12:16 \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/1745-6215-12-16\u003c/span\u003e\u003cspan address=\"10.1186/1745-6215-12-16\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoaz A, Hanney S, Jones T, Soper B. 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Implement Sci. 2018;13:111. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s13012-018-0805-y\u003c/span\u003e\u003cspan address=\"10.1186/s13012-018-0805-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"health-research-policy-and-systems","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"hrps","sideBox":"Learn more about [Health Research Policy and Systems](http://health-policy-systems.biomedcentral.com/)","snPcode":"12961","submissionUrl":"https://submission.nature.com/new-submission/12961/3","title":"Health Research Policy and Systems","twitterHandle":"@HarpsJournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Clinical trials, clinicians, health equity, healthcare organisations, networks, oncology, patient outcomes, processes of care, research engagement, systematic review","lastPublishedDoi":"10.21203/rs.3.rs-4418411/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4418411/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThere is a widely held assumption that the engagement of clinicians and healthcare organisations in research improves healthcare performance at various levels. Previous reviews found small numbers of studies that suggest an association between the engagement of individuals and healthcare organisations in research, and improvements in healthcare performance. The current study sought to provide an update.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe team updated an existing published systematic review, and addressed the question: Does research engagement (by clinicians and organisations) improve healthcare performance? The search covered the period January 1, 2012 to March 2024, in two phases. First, the formal updated search ran from January 1, 2012 to May 31, 2020, in any healthcare setting or country and focused on English language publications. In this phase two searches identified 66,901 records. Second, a further check of key journals and citations to identified papers ran from May 2020 to March 2024. In total, 168 papers progressed to full-text appraisal; 62 were identified for inclusion in the update.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFifty-eight of the 62 papers report positive results, of which 48 are purely positive and 10 positive/mixed meaning that there are some negative elements (i.e., aspects where there is a lack of healthcare improvement) in their findings. In the updated review, the literature is still dominated by papers from the US (35/62) and is mostly drawn from the Global North. The papers cover a range of clinical fields but with considerably more on cancer than any other field.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe updated review collates a substantial pool of studies, especially when combined with our first review, which are largely positive in terms of the impact of research engagement on processes of care and patient outcomes. Of the potential engagement mechanisms, the review highlights the important role played by research networks. The review also identifies various papers which consider how far there is a \u0026ldquo;dose effect\u0026rdquo; from differing amounts of research engagement. Additional lessons come from analyses of equity issues and negative papers. This review provides further evidence of the contribution played by systems level research investments such as research networks on processes of care and patient outcomes.\u003c/p\u003e","manuscriptTitle":"If health organisations and staff engage in research, does healthcare improve? 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