In contrast, Wisconsin and Wessex formed networks for family physicians and other primary care professionals with an interest in research. The networks provide support for research initiatives by offering opportunities to join studies (including research training) and by supporting their own research initiatives. Involvement is optional and reflects the interests and ambitions of the individual practices. Approximately half of the clinicians (350) in the Wisconsin network have been actively involved in 1 or more studies. To date, 70% of the practices in the Wessex network have been involved in 1 or more projects.
Contributions to the Evidence Base
These networks indicated characteristic studies done by (or in the case of Wisconsin, supported by) their network (Table 2). Two main areas of research are represented in these studies: (1) the quality of the care during the projects on the identification of disease risk (Wisconsin), asthma information,23 and venepuncture25 (Wessex); and (2) prevention and treatment of common morbidity. This covers a wide range of illnesses and addresses an interesting mixture of objectives. The asthma studies in Wisconsin21 and Nijmegen29 and the Wisconsin alcoholism study20 focus on the pathophysiological aspects of the disease and potential intervention effects (efficacy), while the Wessex osteoporosis study and the Nijmegen preventive cardiology study30 assessed the effectiveness of interventions under primary care conditions. Documenting the natural course of the disease and preventive actions are featured in studies on screening15-19 (Wisconsin), hay fever22 (Wessex), childhood morbidity,28 diabetes mellitus,26 and depression31 (Nijmegen). The role of the networks in the conduct of these studies ranges from total responsibility (Wessex, Nijmegen) to a more varied role ranging from total responsibility to recruiting practices only (Wisconsin). Summarizing the research output is difficult given the range of clinical primary care topics covered. The summaries in Table 2 suggest that the research is aimed at addressing essential clinical decisions family physicians are facing in their routine daily care.
Management of the Networks and Relationship to Members
The Wessex and Nijmegen networks are university based. The Wisconsin network was initiated by the Wisconsin Academy of Family Physicians (WAFP) and is managed by and receives support from the University of Wisconsin. All 3 coordinating academic centers promote ownership of network activities by the participating practices. This includes regular exchange of information on new and ongoing research and study-specific instructions. The consent of the participating practices is mandatory before a study can be performed, irrespective of the source of funding or the director of the study. In Wisconsin, the WAFP must approve major commitments of the members’ time and energy. Each network involves participating physicians as principal or co-principal investigators when possible. There are differences in the way regular contacts are maintained, depending on the size of the network and the geography. The small Nijmegen network holds monthly meetings; the larger Wisconsin and Wessex networks organize an annual conference and apply distance communication technology: newsletters, Web sites, E-mail, and an electronic discussion list. They 2 larger networks maintain closer contact with a core group of active researchers through project team meetings.
Data Collection
Data collection methods are varied. The Nijmegen network collects a standard set of patient-related data for every practice on a routine basis. The other networks collect only project-specific data derived from medical records, laboratory tests, physician surveys, and patient interviews. In addition, Wisconsin uses multiple methods ranging from qualitative methods to chart review to review clinical databases. Currently there are projects piloting the application of new technology including interactive voice recording and Internet-based data acquisition.
The Financing of the Networks
The funding of the networks has to cover 2 areas: the network infrastructure and specific research projects. The latter involves the main national funding bodies for biomedical research including scientific foundations and industry (Table 2). The infrastructure costs include co-ordination, methodologic support, and administrative support. Recently limited structural support has been provided by the university (Nijmegen) and the National Health Service Research and Development Program (Wessex). In Wisconsin basic financial support comes from the WAFP, with the university providing senior staff time and office space. This funding, however, is insufficient to provide comprehensive support for the multidisciplinary research that characterises PBRNs. In Nijmegen a contract between the university and the practices determines financial and scientific duties, given their intensive cooperation.
Also, obtaining grant support for projects has proved difficult for all networks. Review committees are often mainly accustomed to reductionistic research about unitary and well-defined problems and have been concerned about pragmatic designs.
Discussion
We used information from 3 networks in 3 countries to describe PBRNs in the context of primary care developments in their country of origin. This enhanced the richness of our data but is also the major limitation of our study because it did not necessarily represent a complete view of a majority of the existing experience. However, our comparison illustrates the common elements of each of the 3 PBRNs: They have each successfully recruited large numbers of unselected patients from different practices for epidemiologic and clinical research, efficacy (and, to a reasonable extent, effectiveness) studies, and studies aimed at improving our understanding of the process of care in family practice.