Successful regional research – due to luck or infrastructure?

Johan Styrke is a researcher and urology specialist at Sundsvall Hospital. Thanks to support from Clinical Studies Sweden among others, he is conducting decentralised research in urology in collaboration with colleagues at the Northern Healthcare Region.

In Sweden, clinical medicine studies in urology are not all that common – for a long time, most of the studies done have been carried out in oncology departments at university hospitals.

– Many places have not had the competence or infrastructure in urology that is required to conduct medicine studies. In recent years, things have changed greatly, however, largely due to the infrastructure for research that has been built up, which facilitates regional collaboration, says Johan Styrke.

He is a urology specialist at Sundsvall Hospital, and an adjunct senior lecturer at Umeå University. He is also the regional process leader for prostate cancer at the Regional Cancer Centre North.

– We have found a good model for carrying out medicine studies and therapy studies at units outside the large university hospital. We have established close collaboration between the urology clinics in Sundsvall, Umeå, Sunderbyn and Östersund. At the moment, they are conducting medicine studies, clinical therapy studies and translational studies, which cover research that means research findings from experimental research are transferred to clinical use for the purpose of creating patient benefit, or observations or problems in healthcare that give rise to new research ideas.

DURONORR is a research network and an abbreviation of the Swedish words for decentralised urological research in the Northern Healthcare Region. The network was established in 2014, with the aim of improving quality and the opportunities to conduct medicine studies in all locations covered by the Northern Healthcare Region.

– We have named our randomised medicine studies in urology DURONORR 1 and 2 respectively. The research network has helped to ensure that studies can be conducted in several locations, and the patient base has consequently multiplied. Rapid inclusion is a key issue for running major studies within a reasonable time frame.

Johan Styrke, specialist i urologi vid Sundsvalls sjukhus samt adjungerad lektor vid Umeå universitet.

Johan Styrke is a researcher and urology specialist at Sundsvall Hospital.

Infections in urology

Johan Styrke started doing research even as a medical student. In 2012, he was awarded a PhD for his epidemiological thesis on head injuries and whiplash injuries, and residual symptoms from such injuries. He showed, among other things, that up to half of those affected report neck pain, headaches, tiredness and impaired memory several years after the injury.

– For me, research is exciting, not least because it opens up so many doors. You also have greater freedom to design your own research programme. I also see research as an important prerequisite for operational development and process-oriented healthcare, which can improve everyday life for patients.

After qualifying as a physician in 2006, Johan Styrke combined research with specialist training in urology. He did, however, change research direction after obtaining his PhD. During his time as locum registrar, he became interested in the field of infection, and decided during his specialist training to focus on research into infection in urology patients.

– There are not many urologists doing research in this field. Infectious diseases are an interesting and important speciality. A large proportion of the patients cared for in urology departments have got cancer, but many – more than 50 per cent – are receiving or have planned treatment with antibiotics due to infection, or as prophylaxis in conjunction with surgery. This is a large and important group in all specialities, and particularly in urology.

Johan Styrke’s current research project is about febrile urinary tract infection immediately following a prostate biopsy. The aim is to find alternative therapy alternatives, to allow the phasing-out of antibiotics, which can produce severe side effects, increase resistance problems, and lead to environmental damage.

– We are facing great challenges, not least in terms of resistance problems, which are becoming an ever-greater challenge. We would therefore like to find other types of antibiotics, to replace the ones we use today. The problem is that there is not a lot of research going on in this area, there is a lack of randomised studies, and we are also lacking register studies. So, my research is about investigating alternatives, and showing scientifically that they work at least as well, or perhaps even better, than today’s therapy options.

Infrastructure for research

Johan Styrke completed his specialist training in 2017, and today divides his time between work as a urologist at Sundsvall Hospital, research, and an adjunct senior lecturership at Umeå University.

– I have worked for around ten years at Sundsvall County Hospital, and during the last few years there have been enormous developments in terms of the preconditions for doing research. A lot is about the infrastructure that has been built up.

Partly, it is about the decentralisation of medical training. Since 2011, medical students at Umeå University can receive their training as from Term 6 at the major county hospitals in Norrland.

– Every term, we receive 10–12 students who do their clinical years in Sundsvall. This means that we have reinforced our resources with senior lecturers, and have also created more teaching rooms. This has led to more students producing a master’s thesis, which has generated more research activity, and more have continued with doctoral projects. We have more associate professors and more professors than before. Medical training has produced a ketchup effect for research!

Another important part of the infrastructure is the support provided within the framework for Clinical Studies Sweden, via the regional nodes that exist in every healthcare region. Forum North is the regional node for Region Norrbotten, Region Jämtland Härjedalen, Region Västerbotten, and Region Västernorrland.

– To enable research, research nurses are needed. This is very apparent in urology – where there are research nurses, more clinical studies are carried out, and it is also easier to recruit patients. Through the node’s contact with regional resources, we received support for various tasks from a centrally employed research nurse.

– Through Clinical Studies Sweden and the regional node, we are getting support to use our clinical research unit to develop the preconditions for conducting clinical studies. This included help with monitoring clinical studies of medicines. We also got help to train our personnel in GCP, Good Clinical Practice. This was really important support, and a precondition for enabling us to conduct clinical studies outside university towns, such as Umeå.

Visare Norr

It is also important to have targeted research funding, Johan Starke thinks. Grants come mainly from ALF funds, and from public agencies, but also from Visare Norr (wiser North) , which awards grants to clinical research in collaboration regions for health and medical care. The purpose is to enable time for research and to strengthen collaboration between those engaged in research in the northern regions.

– Nearly one million persons live in our catchment area for Norrland, and the figure for Västernorrland itself is a quarter of a million. This is a large recruitment pool, and for patients there are advantages with being asked to participate in clinical studies. But if, as a researcher, you only do highly specialised research at a university clinic, then you risk missing out on this large patient pool. Many diseases are not highly specialised. Examples such as diabetes, vascular diseases and urological diseases are not just found in the university towns, but also in smaller towns and villages.

Success factors

The infrastructure for research (the six regional nodes within Clinical Studies Sweden, medical training at Umeå University, Regional Cancer Centre North, and regional research networks) have increased contacts between researchers from different regions in the north, says Johan Styrke.

– Knowing each other is more important that you might think. By meeting at regional conferences and having exchanges between clinics, you get to know each other, and to know what projects are in progress, and where studies are being conducted. We can also help each other to recruit patients for studies.

Johan Styrke highlights the Covidenza study as a good example of how regions have collaborated to recruit patients, and been able to start a medicine study within the course of just a few months.

– The study received very important help via Forum North, for example with constructing an electronic data collection tool, CRF, start-up and monitoring.

The study is a collaboration between Umeå University, Sahlgrenska Academy, and the infection and urology clinics at Umeå University. The purpose of the medicine study is to investigate whether a medicine used for prostate cancer can also be used to treat patients with COVID-19. The hope is that the therapy may shorten the duration of the disease, and reduce the need for intensive care.

– It is a brilliant example of the importance of infrastructure for research. Through our clinical research unit in Sundsvall, and research support from the regional node Forum North, we have helped to recruit patients.

Johan Styrke would like to see research as a priority goal in healthcare organisation.

– Västernorrland uses balanced control cards for operations and control. Here, research forms an important part. This requires managers who have a clear goal of wanting to stimulate research, and there are many ways to do this. For example, clinics can be divided up into different research sectors, with one doctor appointed as responsible for including patients in studies. In brief, it is about creating a clear system for monitoring studies, and identifying patients who are suitable for recruitment.

About Johan Styrke

Age: 40

Family: Wife and four children aged between 3 and 11.

Works: At the urology clinic in Sundsvall, at Umeå University and Regional Cancer Centre North.

Driven by: Learning new methods, making new contacts, and developing the operations I am part of.

Would like: More young physicians to be interested in urology and the major common urological diseases.

Excited by: Listening to and playing music.

Worried by: The snow coverage now being 30 days shorter in southern Norrland compared to 1990, according to SMHI.

Scientific breakthrough I would like to see: An entirely new medicine therapy for chronic pain, and a vaccine against malaria.

Johan’s proposal for three quick measures for improving clinical research:

1. Create combination positions for research physicians, nurses and physiotherapists in locations where research has not been conducted traditionally.

2. Establish regionally funded research nurse positions.

3. Regionalise medical schools in more healthcare regions.