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Research Training in the Biomedical, Behavioral, and Clinical Research Sciences
has provided the measurement tools being used in payment for inpatient hospital services, outpatient services, and nursing home care, as well as capitation payment methods for persons enrolled in health plans. Improved payment methods are making it possible to adjust payment for quality of care and to better reward efficiency. These measurement tools, and others to be developed, will be needed to monitor and evaluate the impact of the 2010 Health Reform legislation and how well it achieves its goals. Examples of quality-of-care measures that will require further development include: assessing the timeliness of health care, measuring coordination of patient care when multiple providers are involved in diagnosis and treatment, providing patient-centeredness of care, and equity of health care. Although these are not new, there are few if any accepted measurement tools to assess deficiencies and progress toward the goals of health reform. The training and support of researchers who focus on measurement is a continuing and growing need in health services research.
Since 2003 Congress has provided support to the Agency for Healthcare Research and Quality (AHRQ) to develop and fund comparative effectiveness research (CER). In 2009, the American Recovery and Reinvestment Act (ARRA) augmented CER support with $1.1 billion for research and training through AHRQ, the National Institutes of Health, and the Office of the Secretary of Health and Human Services (HHS). CER as defined by HHS combines key elements of health services and clinical research:
Comparative effectiveness research is the conduct and synthesis of research comparing the benefits and harms of different interventions and strategies to prevent, diagnose, treat and monitor health conditions in “real world” settings. The purpose of this research is to improve health outcomes by developing and disseminating evidence-based information to patients, clinicians, and other decision-makers, responding to their expressed needs, about which interventions are most effective for which patients under specific circumstances.
To provide this information, comparative effectiveness research must assess a comprehensive array of health-related outcomes for diverse patient populations and sub-groups.
Defined interventions compared may include medications, procedures, medical and assistive devices and technologies, diagnostic testing, behavioral change, and delivery system strategies.
This research necessitates the development, expansion, and use of a variety of data sources and methods to assess comparative effectiveness and actively disseminate the results.
The expectation is that CER will provide new information that is not currently available about what treatments and services work best for individuals across America’s diverse populations, taking into consideration the person’s circumstances and the timing of services. The new CER mandate complements the initiatives discussed above in translation and implementation research, intensifying the focus on research driving health system transformation to achieve better health outcomes for all Americans and greater efficiency.
FEDERAL SUPPORT OF HEALTH SERVICES RESEARCH
In 1968, Congress recognized the emerging role of health services research for improving health care delivery in the United States and created the National Center for Health Services Research and Development (NCHSRD) in the Department of Health, Education, and Welfare (DHEW). During the years 1968-1989, 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.2 However, over time the budget for NCHSRD declined and the future of the NCHSRD became uncertain. Private foundations played a critical role in sustaining the health services research field during these years.3
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 of the Agency for Health Care Policy and Research (AHCPR). Congress directed the Agency—subsequently renamed the Agency for Healthcare Quality and Research—to undertake research on patient outcomes, develop practice guidelines, and disseminate the research to change the practice of medicine.4 The agency placed greater emphasis than previously on the examination of clinical practice, decision making, and comparative effectiveness of alternative approaches to diagnosis and treatment. The funding for AHRQ has grown over the years from $128 million in fiscal year 1993 to $397 million in fiscal year 2010, plus $300 million in CER funding from the ARRA appropriation.
While the National Research Service Awards (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
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 demonstration 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 Kaiser Permanente.
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 (CMS), Centers for Disease Control and Prevention (CDC), Department of Defense (DoD), and several NIH institutes.
In 2001, the reauthorization of AHCPR 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 the agency.