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26 Gaining Acceptance for Effectiveness and Outcomes Research John D. Stobo Effectiveness research has come a long way in terms of developing mea- surement scales that are reliable, somewhat easy to obtain, and pertinent. It is clear to me that further research in effectiveness and outcomes clearly needs to be done. It needs to be done, in my mind, for two reasons. REASONS FOR PURSUING RESEARCH First, as a profession, we physicians should be committed to providing the highest quality of care to our patients. Effectiveness and outcomes research will affect the question of quality and provide a rationale for deciding what the highest quality care is. Second, it will provide a rationale for discussing the cost of health care. Like Henry Aaron (1), I am not convinced that outcomes research will substantially decrease the cost of health care. Nevertheless, it clearly will rationalize discussions of what is appropriate health care and what is not. The caution of Henry Aaron and others echoes the good advice that Holly Smith, my previous mentor and Chief of Medicine at the University of California at San Francisco, gave me: "Never promise more than you can give, and always give more than you can promise." Do not promise that outcomes research will significantly lower the cost of health care. WHO MUST BE CONVINCED? My concern is that effectiveness research be accepted by other groups who must be involved in it, of which there are three. First are the payers. I do not foresee any problem there. I think the payers of health care are thirsty for this information and will readily accept it. 224

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WlIERE DO WE GO FROM HERE? 225 The second group is the recipients of health care. Here, I think, is a major challenge: to provide the results of outcomes and effectiveness research to those individuals. A significant impact on cost can be achieved by educating recipients of care about utilization. The last group that is crucial to outcomes research represents the biggest challenge. This is the providers of health care, particularly physicians. At my institution, Johns Hopkins, there is a lot of discussion about research into quality of care, effectiveness of care, outcomes of care, but it is done by a relatively small number of individuals. The majority of the faculty have not bought into outcomes research. What will it take to get providers of care to accept this type of research? Again, I agree with others that there is going to be a pull and push phenomenon here. I think the pull will have to come from the persons who are already convinced of the value of outcomes research. Physicians have to buy into it. This is evident from the study of the Harvard Community Health Plan (2~. Physicians have to be involved early on in these studies; they have to feel some ownership of them so that they are not always in a reacting mode. It is important to train physicians in methodologies that are used in out- comes research. Most physicians, like myself, have been trained in areas related to biomedical research and are not conversant with methodologies that are important for carrying out and understanding other types of research. A major effort should be made to educate physicians about the methodology and interpretations of outcomes research. WHO WILL PUSH FOR RESEARCH? The push phenomenon is going to come from several areas, three in particular. One is the government: this prodding by the Health Care Financing Administration is important. There will be a push from employers. They, because of an interest in cost of care and also, I hope, because of an interest in quality of care for their employees, will be interested in effectiveness and outcomes research. Employers may push their employees in the direction of institutions that can document that they are as good as they say they are. Finally, the push will come from hospitals, probably because they are being pressured by the government and by employers. Hospitals will pres- sure influential individuals to adopt practices that have been documented to provide the most effective care and the best outcomes. Four years ago, effectiveness and outcomes research was an area that was completely foreign to me. It is one I have become interested in over the last two years and one I have become very excited about. It is going to be critical for American medicine in the future- and we are fortunate that there are such good people doing such good work in this area.

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226 EFFECTIVENESS AND OUTCOMES IN HEALTH CARE REFERENCES 1. Aaron, H.J. The Need for Reasonable Expectations. Pp. 215-217 in Electiveness and Outcomes in Health Care. Heithoff, K.A. and Lohr, K.N., eds. Washington, D.C.: National Academy Press. 2. Schoenbaum, S.C. An Attempt to Manage Variation in Obstetrical Practice. Pp. 190-200 in Effectiveness and Outcomes in Health Care. Heithoff, K.A. and Lohr, K.N., eds. Washington, D.C.: National Academy Press, 1990.