A goal for health care access is the timely receipt of appropriate care, and criteria for evaluating the appropriateness of service use have been developed and are widely applied for utilization review. With fee-for-service financial incentives and comprehensive insurance coverage having the potential to encourage overuse of services, the measurement of appropriateness has been applied to identify unnecessary admissions and days of inpatient care. In contrast, those without health insurance are likely not to seek needed services or to delay doing so until severely ill, and methods have been applied to assess the consequences of inadequate access to primary care. Future work will need to provide better metrics of timeliness and appropriateness, and from a patient’s perspective, measuring appropriateness needs to take into account desired outcomes and social context.

From another perspective, advances in measuring quality of care have provided tools to evaluate the processes of care and patient outcomes. Clinical research provides the foundation for establishing diagnostic and treatment criteria based on scientific evidence. In the absence of strong consistent evidence, clinical expert consensus has been used to set quality standards. One largely unanswered question is whether process standards can be expected to apply to 90 percent of patients, 80 percent, or less. Research is needed to improve our capability to match treatments to patients and minimize the need to try multiple treatments before achieving desired outcomes.


In 1968 Congress recognized the emerging role of health services research for improved health care delivery in the United States and created the National Center for Health Services Research and Development (NCHSRD) in the U.S. Department of Health, Education, and Welfare. During those years, NCHSRD sought to develop research on issues of access, cost, and quality and to develop data systems to support research on utilization and cost of care.7 However, in the years that followed, the budget for NCHSRD declined and the future of the NCHSRD and its funding were uncertain. Private foundations played a critical role in sustaining the health services research field.8

In 1989 health services research once again found strong support in Congress, and a new vision for health services research was created in the authorization for the Agency for Health Care Policy and Research. Congress directed the agency, subsequently renamed the Agency for Healthcare Research and Quality (AHRQ), to undertake research on patient outcomes, develop practice guidelines, and disseminate research to change the practice of medicine.9 The agency placed greater emphasis than previously on the examination of clinical practices, decision making, and comparing the cost effectiveness of alternative approaches to diagnosis and treatment.

While the National Research Service Award (NRSA) program included support for health services research from its inception (see, for example, NRC, 1977), Congress specified in 1989 that one-half of 1 percent of the NRSA budget for training be allocated for training health services researchers through AHRQ, subsequently expanding that allocation to 1 percent of NRSA funding in 1993. By August 2003, AHRQ had provided support for research training through the NRSA program to nearly 800 individuals in the form of predoctoral/postdoctoral traineeships and to another 80 individuals in the form of individual fellowship awards.10

It should be noted that in the early 1990s Congress authorized a 15 percent set-aside for NRSA training in service-related research supported by the National Institute of Mental Health (NIMH), the National Institute of Drug Abuse (NIDA), and the National Institute of Alcohol Abuse and Alcoholism (NIAAA) as part of the reorganization of the former Alcohol, Drug Abuse, and Mental Health Administration into the NIH. Nonetheless, AHRQ is seen as the lead agency in the area of health services insofar as NIH funding for health services research focuses on questions related to the delivery of health care related to NIH-specific diseases and disorders.


Health services researchers work in a variety of settings, including academic health centers, the policy and planning offices of the federal and many state and local governments, throughout the health care delivery sector, and in the phar-


The center initiated large-scale demonstrations, including the Experimental Medical Care Review Organization (EMCRO) to develop tools for quality measurement and their evaluation. The EMCRO demonstrations provided the Medicare program with the methodologies it needed in the Professional Standards Review Organization (PSRO) to evaluate hospital use. The NCHSRD also competitively funded health services research centers in academic institutions and for Kaiser Permanente.


See the NIH/NLM-sponsored database, “HSRProj,” for details regarding health services research projects supported by various sectors: http://www.nlm.nih.gov/hsrproj. It should be noted that health services research in focused areas like mental health services, alcohol and drug abuse treatment services, and veterans’ health care continued throughout this time. Health services research funding also comes from the Centers for Medicare and Medicaid Services, the Centers for Disease Control and Prevention, the Department of Defense, and other NIH institutes.


In 2001 the reauthorization of Agency for Health Care Policy and Research led to a name change to the Agency for Healthcare Research and Quality (AHRQ). The word policy was dropped from the title and quality was added to reinforce the quality-of-care research mission of this agency.


These counts are based on the number of individuals who completed a minimum of 6 months of NRSA training, beginning their training sometime after August 1986 and completing their training by August 2003. P. Flattau, personal communication, September 2004.

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