responsibility to the people who provided the capital underlying the existence of the organization. That obligation cannot be unilaterally waived and may not include education.

In Dr. Broder's view, the question is how to maximize the interactions between academic health centers and private sector organizations to create the types of relationships that many seek. One of key elements is disclosure. Principles should be established to ensure there is disclosure at every phase of the mission statement of both organizations. There should be disclosure to the academicians and administrators of the institution, to the institutional review board and to patients. Disclosure should include information about who is representing whom, relationships between an individual at an academic health center and a private company (or vice versa), and sources of support at an official level, a laboratory level, a clinical level or a personal level. Equity interest by an investigator need not automatically prohibit participation or leadership on a study, but it should be disclosed.

As a final note, Dr. Broder believes that it is important for AHCs and private industry to enter into relationships with mutual acknowledgement of fallibility. Original positions may change as progress on a problem moves forward. In Dr. Broder’s view, some of the most significant problems encountered have originated from a sense of invulnerability. All parties will need to recognize that problems can have many solutions.

Health Services Research

Ralph Horwitz, M.D., Yale University School of Medicine

Dr. Horwitz described health services research as broadly focusing on both the system of health care and the services it provides. This includes issues in organization and financing, access to health care and quality, the efficiency of the system and a focus more on doctors and other providers than on individual patients. This is distinct from clinical epidemiology, which has a focus on patients and outcomes, including the risk for developing disease, susceptibility to treatment, outcomes and technology assessment, and effectiveness of interventions in individual patients. Both omit a focus on public health infrastructure, on populations at risk and patterns of disease, on forces of morbidity and mortality and early warnings of epidemics. The latter point is emphasized to illustrate that much of what AHCs do is very separate and distant from what their fundamental mission ought to be, namely, improving the public’s health.

Dr. Horwitz described the fundamental concepts of health services research in order to understand its role within AHCs. The ethos of the health services is defined by the questions asked, the data collected, the methods used, the inferences drawn and the policy recommendations made. The questions of health services research run the spectrum from effectiveness to efficiency to the organization of care and questions of value. The methods used include experimental trials, such as testing interventions for effectiveness; observational studies; statistical modeling and meta-analyses. Data sources are patients, physicians and other clinicians and large databases. The emphasis on data and data management, and especially the transforming of data to knowledge, is essential to universities and, therefore, to academic health centers.

One of the critical issues in developing inferences and making recommendations is the inability to effectively differentiate the benefits that are found for groups when applied to individuals. If a study claims a 30 percent reduction in mortality from heart attacks as the result of a new treatment, it is not known whether every patient will experience that reduction in risk or whether the population as a whole will experience the reduction, with some patients achieving complete protection and some patients receiving no benefit at all. This is a fundamental issue in how we think about the value of the data and use the knowledge to improve health.



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