8
Health Services Research

Health services research (HSR) provides the information needed to understand the effectiveness and efficiency of our health care delivery system and its impact on the health and well-being of individuals and populations.1 Health services research documents deficiencies in patient and population health and in the provision of health services and seeks to identify contributing factors. There are many examples: being uninsured in America reduces access to health care and contributes to poorer health outcomes (Institute of Medicine [IOM] reports on uninsured); medical errors too frequently occur in hospitals and many patients suffer injury or death (IOM, 1999); and in the community, only half of the time are individuals receiving preventive and chronic disease care consistent with scientific evidence (McGlynn, 2003).

Health services researchers seek solutions to these and other problems that adversely affect access to care, quality, safety, and cost of care. Health services research evaluates the impact of government and private-sector health policies, designs and evaluates innovations in health care organization and financing, and examines the effects of new technologies or new uses of existing technologies. Assessing the impact of health services on population health requires health services researchers to go beyond disease outcomes to examine health status and health-related quality of life outcomes, assess delivery system quality and efficiency, as well as focus attention on prevention and health promotion services.

The contributions of health services research to policy, management, and clinical care have been diverse. Planners and policy makers, for example, are frustrated by the inability to generalize and use findings from efficacy studies: persons recruited to randomized control trials testing new treatments typically are not representative of the larger population expected to benefit from the treatment. Thus, it is up health services research to fill this information gap by assessing the impact of diagnostic and treatment technologies on patient outcomes and costs across real-world practice settings and diverse populations.

Translational research has emerged as an important dimension of health services research design and analysis; translational research provides the knowledge base to move scientific discoveries from laboratory, clinical, or population studies into clinical applications at the National Cancer Institute. Yet translation alone is generally not sufficient to ensure these services are available across America. Implementation research is needed to effectively adapt new clinical applications to diverse real-world practice settings in which programs, tools, and guidelines will be utilized and need to be integrated into the existing hospitals and community practice settings (Rubenstein and Pugh, 2006). Together translation and implementation research are gaining greater visibility as we have come to recognize that many Americans are failing to receive consistent high-quality health care based on the latest scientific knowledge. Meeting the challenges of translation and implementation research requires additional disciplinary breadth, drawing on areas of organizational and operations research, psychology, marketing, education, and adult learning. Also expanded applications of health information technology are needed in support of consumer-patient decision making and real-time decision support for health care providers. The rapid growth and continuing change in scientific health information will result in the translation and implementation processes being continual and not one-time or infrequent events. The capacity to achieve this goal may require fundamental re-thinking of information flow and how it supports all aspects of health services.

Central to advances in all scientific fields are measurement tools, and for health services research measurement tools span payment and financing, appropriateness of utilization (overuse, underuse, and misuse; IOM, 2001), quality of care, and patient outcomes of care. Health services research

1

Many definitions of this multidisciplinary field are available in the literature, including those developed by previous NRC committees on personnel needs in the biomedical and behavioral sciences; see, for example, NAS 1977, 1983, 1989 and 1994. Other authors include the Institute of Medicine 1995. A recent definition circulated within the community was developed by K.N. Lohr and D.M. Steinwachs (2002).



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8 health Services research Health services research (HSR) provides the information expected to benefit from the treatment. Thus, it is up health needed to understand the effectiveness and efficiency of our services research to fill this information gap by assessing the health care delivery system and its impact on the health and impact of diagnostic and treatment technologies on patient well-being of individuals and populations.1 Health services outcomes and costs across real-world practice settings and research documents deficiencies in patient and population diverse populations. health and in the provision of health services and seeks to Translational research has emerged as an important identify contributing factors. There are many examples: dimension of health services research design and analysis; being uninsured in America reduces access to health care and translational research provides the knowledge base to move contributes to poorer health outcomes (Institute of Medicine scientific discoveries from laboratory, clinical, or population [IOM] reports on uninsured); medical errors too frequently studies into clinical applications at the National Cancer Insti- occur in hospitals and many patients suffer injury or death tute. Yet translation alone is generally not sufficient to ensure (IOM, 1999); and in the community, only half of the time these services are available across America. Implementation are individuals receiving preventive and chronic disease care research is needed to effectively adapt new clinical applica- consistent with scientific evidence (McGlynn, 2003). tions to diverse real-world practice settings in which pro- Health services researchers seek solutions to these and grams, tools, and guidelines will be utilized and need to be other problems that adversely affect access to care, quality, integrated into the existing hospitals and community practice safety, and cost of care. Health services research evaluates settings (Rubenstein and Pugh, 2006). Together translation the impact of government and private-sector health policies, and implementation research are gaining greater visibility designs and evaluates innovations in health care organization as we have come to recognize that many Americans are fail- and financing, and examines the effects of new technologies ing to receive consistent high-quality health care based on or new uses of existing technologies. Assessing the impact of the latest scientific knowledge. Meeting the challenges of health services on population health requires health services translation and implementation research requires additional researchers to go beyond disease outcomes to examine health disciplinary breadth, drawing on areas of organizational and status and health-related quality of life outcomes, assess operations research, psychology, marketing, education, and delivery system quality and efficiency, as well as focus atten- adult learning. Also expanded applications of health informa- tion on prevention and health promotion services. tion technology are needed in support of consumer-patient The contributions of health services research to policy, decision making and real-time decision support for health management, and clinical care have been diverse. Planners care providers. The rapid growth and continuing change in and policy makers, for example, are frustrated by the inability scientific health information will result in the translation and to generalize and use findings from efficacy studies: persons implementation processes being continual and not one-time recruited to randomized control trials testing new treatments or infrequent events. The capacity to achieve this goal may typically are not representative of the larger population require fundamental re-thinking of information flow and how it supports all aspects of health services. Central to advances in all scientific fields are measure- Many definitions of this multidisciplinary field are available in the litera- 1 ment tools, and for health services research measurement ture, including those developed by previous NRC committees on personnel needs in the biomedical and behavioral sciences; see, for example, NAS tools span payment and financing, appropriateness of utiliza- 1977, 1983, 1989 and 1994. Other authors include the Institute of Medicine tion (overuse, underuse, and misuse; IOM, 2001), quality of 1995. A recent definition circulated within the community was developed care, and patient outcomes of care. Health services research by K.N. Lohr and D.M. Steinwachs (2002). 0

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0 RESEARCH TRAINING IN THE BIOMEDICAL, BEHAVIORAL, AND CLINICAL RESEARCH SCIENCES has provided the measurement tools being used in payment translation and implementation research, intensifying the for inpatient hospital services, outpatient services, and nurs- focus on research driving health system transformation to ing home care, as well as capitation payment methods for achieve better health outcomes for all Americans and greater persons enrolled in health plans. Improved payment methods efficiency. are making it possible to adjust payment for quality of care and to better reward efficiency. These measurement tools, federal SuPPort of health ServiCeS reSearCh and others to be developed, will be needed to monitor and evaluate the impact of the 2010 Health Reform legislation In 1968, Congress recognized the emerging role of health and how well it achieves its goals. Examples of quality-of- services research for improving health care delivery in the care measures that will require further development include: United States and created the National Center for Health Ser- assessing the timeliness of health care, measuring coordina- vices Research and Development (NCHSRD) in the Depart- tion of patient care when multiple providers are involved ment of Health, Education, and Welfare (DHEW). During the in diagnosis and treatment, providing patient-centeredness years 1968-1989, NCHSRD sought to develop research on of care, and equity of health care. Although these are not issues of access, cost, and quality, and to develop data systems new, there are few if any accepted measurement tools to to support research on utilization and cost of care.2 However, assess deficiencies and progress toward the goals of health over time the budget for NCHSRD declined and the future of reform. The training and support of researchers who focus the NCHSRD became uncertain. Private foundations played on measurement is a continuing and growing need in health a critical role in sustaining the health services research field services research. during these years.3 Since 2003 Congress has provided support to the Agency In 1989, health services research once again found strong for Healthcare Research and Quality (AHRQ) to develop support in Congress and a new vision for health services and fund comparative effectiveness research (CER). In 2009, research was created in the authorization of the Agency the American Recovery and Reinvestment Act (ARRA) for Health Care Policy and Research (AHCPR). Congress augmented CER support with $1.1 billion for research and directed the Agency—subsequently renamed the Agency training through AHRQ, the National Institutes of Health, for Healthcare Quality and Research—to undertake research and the Office of the Secretary of Health and Human Services on patient outcomes, develop practice guidelines, and dis- (HHS). CER as defined by HHS combines key elements of seminate the research to change the practice of medicine.4 health services and clinical research: The agency placed greater emphasis than previously on the examination of clinical practice, decision making, and com- Comparative effectiveness research is the conduct and syn- parative effectiveness of alternative approaches to diagnosis thesis of research comparing the benefits and harms of dif- and treatment. The funding for AHRQ has grown over the ferent interventions and strategies to prevent, diagnose, treat years from $128 million in fiscal year 1993 to $397 million and monitor health conditions in “real world” settings. The in fiscal year 2010, plus $300 million in CER funding from purpose of this research is to improve health outcomes by the ARRA appropriation. developing and disseminating evidence-based information to While the National Research Service Awards (NRSA) patients, clinicians, and other decision-makers, responding program included support for health services research from to their expressed needs, about which interventions are most its inception (see, for example, NRC, 1977), Congress effective for which patients under specific circumstances. specified in 1989 that one-half of 1 percent of the NRSA budget for training be allocated for training health services • To provide this information, comparative effectiveness researchers through AHRQ, subsequently expanding that research must assess a comprehensive array of health-related outcomes for diverse patient populations and sub-groups. • Defined interventions compared may include medica- The center initiated large-scale demonstrations, including the Experi - 2 tions, procedures, medical and assistive devices and tech- mental Medical Care Review Organization (EMCRO) to develop tools for nologies, diagnostic testing, behavioral change, and delivery quality measurement and their evaluation. The EMCRO demonstration system strategies. provided the Medicare program with the methodologies it needed in the Professional Standards Review Organization (PSRO) to evaluate hospital • This research necessitates the development, expan- use. The NCHSRD also competitively funded health services research sion, and use of a variety of data sources and methods to centers in academic institutions and Kaiser Permanente. assess comparative effectiveness and actively disseminate It should be noted that health services research in focused areas like 3 the results. mental health services, alcohol and drug abuse treatment services, and vet - erans’ health care continued throughout this time. Health services research The expectation is that CER will provide new informa- funding also comes from the Centers for Medicare and Medicaid Services tion that is not currently available about what treatments (CMS), Centers for Disease Control and Prevention (CDC), Department of Defense (DoD), and several NIH institutes. and services work best for individuals across America’s In 2001, the reauthorization of AHCPR led to a name change to the 4 diverse populations, taking into consideration the person’s Agency for Healthcare Research and Quality (AHRQ). The word policy was circumstances and the timing of services. The new CER dropped from the title and quality was added to reinforce the quality-of-care mandate complements the initiatives discussed above in research mission of the agency.

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0 HEALTH SERVICES RESEARCH allocation to 1 percent of NRSA funding in 1999, which has Using a more expansive definition of the field by including remained unchanged. researchers in disciplinary associations with subgroups that It should be noted that in the early 1990s Congress autho- sometimes do health services research, such as the American rized a 15 percent set-aside for both research and NRSA Public Health Association, the American Society of Health training in service-related research supported by the National Economists, the American Statistical Association, and the Institute of Mental Health (NIMH), the National Institute of American Sociological Association, there could be an addi- Drug Abuse (NIDA), and the National Institute of Alcohol tional 6,000 intermitted members of the field (Moore and Abuse and Alcoholism (NIAAA) as part of the reorganiza- McGinnis, 2009). tion of the former Alcohol, Drug Abuse and Mental Health The best data available on the composition of health Administration into the National Institutes of Health. Even services research workforce5 likely comes from the most with this congressionally mandated set-aside for these r ecent AcademyHealth membership survey in 2008 NIH institutes, AHRQ remained the lead agency for health (AcademyHealth, 2008). AcademyHealth draws its members services research. NIH funding has been directed at HSR from both health services research and health policy, and focused on questions related to the delivery of health care includes student memberships. Although this database more for specific diseases/disorders. AHRQ and NIH fund comple- than likely underestimates the total size of the workforce, it mentary research and in many instances have co-funded does provide some insights into its composition. major health services research studies. As of 2008, 51 percent of AcademyHealth’s 3,500 individual members report having a Ph.D., Sc.D., or other doctoral-level training in science. There are another 12 per- health ServiCeS reSearCh WorkforCe cent reporting an M.D. Table 8-1 shows the distribution of No national statistical system reports on the size and com- health services researchers by employment sector. position of the health services research workforce (Moore AcademyHealth membership has greater female rep- and McGinnis, 2009; Pittman and Holve, 2009). Obtaining resentation (60.7 percent) than male (39.3 percent). This information on the workforce in this field is a challenge. representation has changed slightly from AcademyHealth’s Identifying scientists who primarily do health services survey of members in 2002, when 55 percent of the respon- research is complicated by the interdisciplinary nature of the dents were women and 45 percent were men. Of note is that field. Health services research is an applied field, and so most the youngest members were twice as likely to be female as health services researchers have another unique discipline to be male, while the oldest respondents were twice as likely or profession that they bring to health services research. to be male as to be female. The ethnic mix of members is Workforce data usually classify health services researchers 21 percent from minority ethnic backgrounds, including by their primary discipline or profession and often are unable Asian/Pacific Islanders (10.6 percent), African Americans to identify the field of scientific inquiry as health services (5.2 percent), and Hispanics/Latinos (2.6 percent), plus 79 research. As NIH moves more toward trans-disciplinary percent Caucasian and 2.5 percent other. Representation of research, the problem of not having multiple classifica- all minorities has increased since 2002—to 21 percent from tions incorporating both discipline and field of application 12.8 percent. may be an issue faced by many basic sciences and clinical Table 8-2 shows the primary field of interest by the researchers, as well as health services research. members of AcademyHealth, and the largest share of the In addition, anecdotal evidence suggests that some inves- members classify their primary discipline as public health tigators involved in health services research studies do not (21.5 percent). Only 13.3 percent of members identify their identify themselves as health services researchers, nor do primary discipline as health services research. they necessarily belong to the only national professional In a study on the demand for health services researchers, association in this area, namely AcademyHealth. This partial Thornton and Brown (2009) found that the demand from or part-time involvement of many scientists in health services both universities and non-academic employers is expected research only further complicates efforts to estimate the size to increase. Based on their work one can anticipate there and composition of the health services research workforce. will be a growing demand for “people who can analyze McGinnis and Moore addressed this issue in their the effectiveness of health service systems from disease study on the current status of the health services research management firms; investment firms with a large stake in workforce. In a conservative estimate of the field, count- the health care sector; state and local government; hospitals ing HSRProj investigators (since 2004), speakers from and providers that will be implementing quality reporting AcademyHealth’s Annual Research Meeting in 2007, and systems and pay-for-performance systems;” and the health AcademyHealth members whose membership has lapsed or joined in 2000 or later, Moore and McGinnis found that Jeanne Moore and Sandra McGinnis’s analysis in 2007 uses data from the field has more than doubled in size since the IOM’s 5 AcademyHealth membership as well as participants from AcademyHealth estimate in 1995, growing from approximately 5,000 health meetings and principal investigators listed in HSRProj. AcademyHealth’s services researchers to more than 13,000 researchers in 2007. data solely represent its membership as of 2008.

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0 RESEARCH TRAINING IN THE BIOMEDICAL, BEHAVIORAL, AND CLINICAL RESEARCH SCIENCES TABLE 8-1 Setting of Primary Employment, 2008 general training in health services research. An example of additional training opportunities is illustrated by Veterans Sector Percent Administration’s description of a new fellowship program: College/University 48.8 Government 10 VA Advanced Fellowship Program in Health Services Research Health Care Delivery Organization 9.3 and Development (HSR&D): This includes 16 training sites Research Organization 7.4 for Ph.D. associated health professionals, 8 training sites for Other (please specify) 4.5 post-residency physician associated health professionals, and Association 4.3 3 sites for post-doctoral physician associated health profes- Consulting Firm 4.3 sionals. HSR&D also participates in the VA Advanced Fellow- Foundation 3.5 ship Program in Medical Informatics which includes 7 training Health Policy Center 2.5 sites for post-doctoral and physician health professionals in Insurance 2 Pharmaceutical or Biotechnology 1.5 medical informatics. Quality Improvement 1.2 Professional Society 0.8 The NRSA program provides support for training in SOURCE: AcademyHealth Member Survey, 2008. health services research. As discussed above, the AHRQ has received funding equal to one percent of all NRSA funds for NIH. AHRQ supplements NRSA funding with $500,000 annually. As shown in Table 8-3, both NIH and AHRQ are TABLE 8-2 Primary Field of AcademyHealth Members, funding HSR training at predoctoral and postdoctoral levels. 2008 Taken together, there were 107 predoctoral training positions Sector Percent in 2008, 68 percent of them funded by AHRQ. There were Public Health 21.5 also a total of 85 postdoctoral positions, of which 49 percent Public Policy 16.7 were funded by AHRQ. The agency accepts new and renewal Other (please specify) 15 training grant applications every 5 years. In general, the Health Services Research 13.3 agency has been able to fund only two-thirds of the requested Medicine 10.9 training positions, and this is very similar to the rate for all Nursing 7.1 NIH training awards. In addition, several NIH institutes Sociology 4 Economics 3.8 provide NRSA awards in health services research, includ- Psychology 2.3 ing NIMH, NIAAA, and NIDA. Overall, the total number Public Administration 1.6 of trainees is likely less than 2 percent of all NRSA training Political Science 1.1 positions. No data are available on graduates of doctoral Operations Research 1 programs who are not funded by the NRSA program but who Law 0.7 plan to pursue health services research careers. It would be Business Administration 0.6 expected that these numbers far exceed NRSA recipients, as Anthropology 0.4 they do in other health research fields. SOURCE: AcademyHealth Member Survey, 2008. Although there is incomplete information on the char- acteristics and careers of all individuals with training in h ealth services research, there is some information of NRSA trainees supported by AHRQ. In particular, AHRQ industry including equipment manufacturers, pharmaceutical commissioned an outcome study in 1999 of NRSA trainees firms, and insurers. between 1986 and 1997, which used information from the curricula vitae (CV) of the traimees. The results of this study were reported in the last assessment of the NRSA graduate Programs in health Services research program. These data were updated in 2005 when data on Graduate programs in health services research are not trainees from 1998 to 2003 were added and data on the separately accredited, and because many graduates could earlier trainees were made current to 2003. From 1986 to come from doctoral programs with a different specialty than August 2003, AHRQ supported more than 1,000 individuals health services research, there is no accurate tally of doctoral through different funding mechanisms. The NRSA program students earning degrees in health services research (Ricketts, T32 institutional awards supported 346 predoctoral and 2009). However, in its 2009 online directory of master’s 435 postdoctoral trainees through 27 university-based or and doctoral programs in HSR, AcademyHealth reports that university-affiliated training sites. Another 81 AHRQ F32 there are now 41 schools providing HSR doctoral programs individual NRSA postdoctoral fellowships and 5 pred- and 22 schools with postdoctoral training programs. Doc- octoral fellowships were awarded. Some individuals had toral programs are mainly Ph.D. programs, including both multiple awards under different mechanisms. A total of 854 disciplinary (e.g., health economics, medical sociology) and individuals had support.

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0 HEALTH SERVICES RESEARCH TABLE 8-3 Health Services Research Training Positions Funded by AHRQ and the NIH Positions 1990 1995 2000 2005 2006 2007 2008 NIH Predoctoral Trainees 11 6 0 20 27 28 28 NIH Predoctoral Fellows 1 4 8 14 7 8 8 AHRQ Predoctoral Trainees 22 19 3 71 67 76 71 AHRQ Predoctoral Fellows 0 0 0 1 2 1 2 Predoctoral Subtotal 34 29 11 105 101 112 107 NIH Postdoctoral Trainees 31 16 0 31 39 29 40 NIH Postdoctoral Fellows 2 1 1 4 3 3 5 AHRQ Postdoctoral Trainees 5 1 3 40 35 37 40 AHRQ Postdoctoral Fellows 3 0 0 2 2 3 2 Postdoctoral Subtotal 38 18 4 75 77 69 85 SOURCE: NIH database, 2008. In 2000, AHRQ launched its career development (K) remainder earned them in a variety of health or other fields. award program and by August 2003 had made 48 awards. The other half of the AHRQ NRSA T32 postdoctoral trainees T he majority of AHRQ-supported NRSA trainees and had clinical doctorates, and about half of these were earned fellows between 1986 and 2003 were female (502 of 854, or in internal medicine; another 20 percent were earned in pedi - 59 percent), a difference especially evident among T32 pre- atrics and another 6 percent were earned in family practice, doctoral trainees (229 of 346, or 66 percent) and F32 fellows with the remainder earned in a wide variety of other clini- (45 of 76, or 58 percent). There were almost even numbers of cal specialties. About 20 percent, or 59, of the 241 clinical males (203) and females (225) with T32 postdoctoral trainees doctorates with CV information earned a joint M.D./Ph.D. during this period. Just over half of the AHRQ NRSA F32 fellows held clinical The CVs of 709 trainees provided information on career doctorates, and more were in internal medicine. progression and research productivity. CVs were received The study also showed that the AHRQ NRSA trainees and from 850: 346 had T32 predoctoral support, 428 had T32 fellows actively pursue research careers through a variety postdoctoral support, and 76 had F32 fellowships. Of those of employment paths. Most AHRQ NRSA T32 predoctoral who earned a doctorate by 2003, about 75 percent or 244 trainees who completed their doctorates by 2003 did not pur- of the doctorates with a known degree field earned their sue formal postdoctoral research training. First employment doctorate in a health science field, including: health services data were available for 555 of the predoctoral and postdoctoral research (81); related multidisciplinary health fields such as trainees, and a large majority of both groups where employed health policy, health administration, or public health (118); in academic institutions. For the postdoctorates, 71 percent of or one of the other health sciences (45). Over 90 percent 382 trainees were in academe, 23 percent were in for-profit or of the T32 predoctoral trainees earned their baccalaureate non-profit organizations, and 5 percent were in government. degrees in one of the sciences, with 42 percent in the social Of those in academic positions, 76 percent were Ph.D.s and sciences, 15 percent in the health sciences, and 19 percent 72 percent had clinical degrees. Most of the clinical doctor- in other scientific fields, including the physical and math- ates that complete training began their academic career as an ematical sciences. The degrees of those with baccalaureate instructor. The percentage for the 165 predoctoral trainees degrees in non-sciences were either in education, humanities, formed a similar pattern, but only 57 percent had an academic or professional fields. Length of time in training for T32 and position and 29 percent were in for-profit or non-profit orga- F31 predoctoral students averaged about 20 months, but 36 nizations. The current employment of postdoctoral trainees percent were only in training for 12 months. There was some at the end of 2003 closely resembles their first employment difference in length of training by gender, with 81 percent of with 79 percent in academic positions and 13 percent in females in training for 24 months or less and 75 percent of health-related employment. The remaining 8 percent were in males for this period. At the postdoctoral level, 84 percent for-profit or other organizations. For T32 predoctoral trainees, of F32 fellows were in training for 24 months or less, and 86 academic employment was almost as high at 67 percent, with percent of the T32 awardees were in training for this period. 21 percent in health-related employment and the remaining For both the T32 and F32 trainees, about half were in train- 11 percent in for-profit or other organizations. ing for 24 months. Of the employed NRSA T32 predoctoral trainees, about Half of the AHRQ NRSA T32 postdoctoral trainees half (48 percent) reported having received post-training with research doctorates earned them in the social sciences research support, and about 77 percent reported at least one (sociology, economics, or the other social sciences); the post-training scientific journal publication. For NRSA T32

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08 RESEARCH TRAINING IN THE BIOMEDICAL, BEHAVIORAL, AND CLINICAL RESEARCH SCIENCES postdoctoral trainees with research doctorates, 72 percent • H ealth Resources and Services Administration reported having received post-training research support, and (HRSA)—$9 million; 85 percent listed at least one scientific journal publication • National Institutes of Health (NIH) (All Institutes)— following training. About 60 percent of the employed NRSA $779 million; T32 postdoctoral trainees with clinical doctorates reported • Veterans Health Administration (VHA)—$75 million; having received post-training research support, and about and 78 percent had at least one scientific journal publication fol- • The Department of Defense (DoD)—$17 million. lowing training. Two-thirds of the employed former AHRQ NRSA F fellows reported having received grant support. Despite repeated calls from the Coalition for Health Services In general, 90 percent of all trainees had at least one post- Research that federal agencies use a standard definition or training scientific journal publication. uniform categories to report their expenditures, the data presented above are measured by these agencies using their own unique definition for what constitutes health services federal health ServiCeS reSearCh fuNdiNg research. Only with a uniform definition and standard catego- The broad relevance of health services research has con- ries, would it be possible to assess how the current funding tributed to federal funding through multiple agencies, unlike meets emerging needs. the funding of most other areas of health research. AHRQ’s Comparing the health services research funding of $1.5 research is expected to address cross-cutting issues such as billion to total federal health research funding of $35 billion access, quality and cost issues that are faced by the entire in 2005 (Global Forum for Health Research, 2005) shows American health care system. Other funding sources seek that approximately 4 percent of total funding is being devoted to fund health services research in support of their organi- to health services research, based on classifications used zational missions. The VA and DoD focus on their delivery within each agency and institute. systems, CMS on financing Medicare and Medicaid, CDC on NIH institutes report funding health services research as prevention, and the NIH on delivery of services for specific shown in Table 8-4. NIMH, NIDA, and NCI have the largest diseases. These funding sources are complemented by pri- programmatic commitment, ranging from 17 to 23 percent vate sources, including major foundations (e.g., Robert Wood of budget. Other institutes report smaller commitments of Johnson Foundation, Commonwealth Fund, MacArthur budget to health services research. Foundation, Kellogg Foundation, Kaiser Family Foundation, In summary, AHRQ provides 25 percent of all health ser- and a number of state-based foundations) and private corpo- vices research funding as reported by federal agencies. Other rations. The following discussion will be limited to federal federal agencies support more focused program-specific and funding of health services research. disease-specific health services research. Private funding of In 2001 the Coalition for Health Services Research health services research is substantial but no comprehensive (CHSR), the advocacy affiliate of AcademyHealth, began source of information is available on non-federal sources. an initiative to document health services research funding levels across the federal government. The first report was CareerS iN health ServiCeS reSearCh completed in 2003 and now there are annual updates. As of FY 2009, the Coalition estimates that a total of $1.48 billion The employment opportunities and careers in health ser- was expended for health services research and related activi- vices research are widely varied. Academic careers may be in ties by the federal government in as shown below: schools of medicine, nursing, public health, and other health professional schools, as well as engineering and traditional • Agency for Healthcare Research and Quality (AHRQ)— arts and sciences departments, along with business and pub- $372 million; lic policy schools. To effectively manage interdisciplinary • Centers for Disease Control and Prevention (CDC): research, academic institutions usually have organizational — National Center for Health Statistics (NCHS)— structures such as centers or institutes for health services $125 million; research that cross school and departmental boundaries. At — Extramural Prevention Research Program—$31 some institutions there are multiple centers reflecting differ- million; ent areas of specialization and the availability of funding for — Prevention Research Centers—$31 million; specialized centers from federal and private sources. • Centers for Medicare and Medicaid Services (CMS)— Private-sector health services research careers are avail- $39 million;6 able in many areas. Federal contract work evaluating major public policy initiatives are primarily done by private research firms. These organizations include RAND, Mathematica, Abt Associates, Westat, and others. These organizations are orga- Most of the funding in CMS’s research budget actually represents Con- 6 nized to do short-term large-scale studies that are not as easily gressional earmarks for activities that are only remotely related to CMS’s organized and managed in most academic settings. research and demonstration interests.

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0 HEALTH SERVICES RESEARCH TABLE 8-4 NIH Institute Health Services Research Budgets Health Services Research FY 2008 Estimate (Dollars in Thousands) Proportion of Total Institute Budget Proportion of NIH’s Total Health Total Health Services Research Budget That Is Health Services Research Services Research Budget NIMH $94,273 6.67% 12.68% NIDA $61,207 6.08% 8.23% NCI $207,363 4.29% 27.89% NIA $47,696 4.53% 6.42% NIDDK $28,944 1.55% 3.89% NIAAA $22,410 5.10% 3.01% NHLBI $55,968 1.90% 7.53% NINR $21,227 15.38% 2.86% Other NIH HSR $204,298 1.28% 27.48% Total $743,388 SOURCE: Coalition for Health Services Research (2008). Analysis was completed using data from NIH’s Research Portfolion Online Reporting Tools (RePORT). Other private-sector health services research careers are increased demands to monitor the success of health reform in research organizations sponsored by HMOs and health and identify unintended consequences. To achieve goals of plans, hospital systems, pharmaceutical firms, insurers, and greater efficiency in American health care and better quality, other major stakeholders in health care. Health services additional investments in health services research and trans- research positions may involve directing research, translat - lation and implementation in practice will be needed. The ing research into practice and products, and managing and future demand for well-trained health services researchers evaluating health care operations. is currently strong and growing. Associations for professional groups, manufacturers, and advocacy groups recruit people trained in health services reCommeNdatioNS research to strengthen their capacity to use information com- Recommendation 8–1: Health services research training ing from health services research to advance their advocacy should be expanded and strengthened within each NIH objectives and meet the needs of their members. As efforts institute and center. to translate science into practice accelerate, the demand for individuals skilled in health services research and commu- Biomedical research has created a growing gap between nication to users is likely to grow. research advances in biomedical science and the ability to Government agencies recruit substantial numbers of apply them effectively to improve the health of the public. health services research professionals to lead and manage Thus there is a need for more effective health care delivery research programs, to support policy analysis and develop- practices to ensure effective and evidence-based care, and to ment, and to work with managers and providers in the VA reduce waste and unnecessary risk to patients. and DoD health care delivery systems. Recommendation 8–2: AHRQ training programs should New career paths for health services research profes- be expanded, at a minimum commensurate with the sionals may emerge as research into effective translation of g rowth in total federal spending on health services knowledge into practice grows. The 2003 Medicare prescrip- research, including comparative effectiveness research. tion drug legislation mandated in Section 1013 that compara- tive effectiveness studies of health care services including Recognition of the rising costs of care, with concerns prescription drugs increased the need for health services about quality and consistency, have driven increases in ser- researchers trained in pharmaco-economics. The ARRA pro- vices research. Health services research has established an vided a substantial increase in CER funding for both research important evidence base to enable patients and health care and investment in research infrastructure including methods organizations to evaluate benefits and risks of diagnostic and data. The development of tools and techniques to support and therapeutic intervention and to compare relative values translation is likely to become an industry that will require of older and newer approaches as choices proliferate. This research skills in the design, evaluation, and testing of new field can also evaluate different approaches to health care technologies. Translation of knowledge for clinicians may be delivery and financing, which will allow the nation to get the initial priority, but priorities will likely expand to include more benefit from the dramatic advances in biomedical managers, patients, and the public. The passage of the 2010 science. Ideally, the total numbers of persons being trained Affordable Health Care Act for America brings new and in HSR should grow at the same rate as national health

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