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OCR for page 81
CHAPTER EIGHT
HEALTH SERVICES RESEARCH PERSONNEL
Health services research is an interdisciplinary field of
research that seeks to understand the impact of organiza-
tional characteristics, financing, health personnel, and tech-
nology on the use of health services, quality of care, patient
outcomes, and cost. The field draws on a wide range of
disciplines, including biostatistics, epidemiology, sociology,
health economics, medicine, nursing, engineering, manage-
ment, and psychology. Its national importance is broadly
recognized by providers, administrators, employers, insur-
ers, and state and national policymakers who are seeking
solutions to problems of escalating health care costs, ero-
sion of access to care, concerns about the quality of care,
and the overall health status of Americans. This field pro-
vides the information that is being used to design health
care reform proposals and will be the source of information
on the impact of any future health care reforms.
In recognition of increasing need for policy-relevant in-
formation that comes from health services research, the
Agency for Health Care Policy and Research (AHCPR) was
established in 1989 as an organizational locus for federal
leadership and funding. In addition, health services research
studies are funded by institutes at the National Institutes of
Health (NIH) in specific disease categories, by the Depart-
ment of Veterans Affairs, by Centers for Disease Control,
and by private foundations and the health industry. Levels
of funding have increased dramatically over the past 5 years,
escalating the demand for well-trained researchers who can
work in interdisciplinary teams.
The committee recommends that training in health ser-
vices research be given higher priority and an increased
allocation of National Research Service Award (NRSA) po-
sitions. In 1992, AHCPR had 92 positions, or approxi-
mately 0.5 percent of all NRSA awards. The NIH Revital-
ization Act of 1993 increased the allocation of NRSA
awards to AHCPR to 1 percent, or approximately 180 posi
81
lions in 1993. It is recommended that this be increased over
the period 1994-1996 to 360 positions. Initially, priority
should be given to increasing postdoctoral training opportu-
nities as predoctoral training opportunities are expanded.
ADVANCES IN HEALTH SERVICES RESEARCH
Health services research has expanded our understand-
ing of organizational and financial factors that affect access
to care, appropriateness of services, quality, cost, and pa-
tient outcomes. Methods have been developed and applied
for comparing the cost and effectiveness of alternative diag-
nostic and treatment technologies and for assessing the im-
pact of health services on health status and quality of life.
Advances in health services research have influenced the
direction of national and state policies and have contributed
to dramatic changes in the health care industry over the past
decade. The rate of change in health care is ever increasing
and the demand for new information on the impact of policy
options and the effects of past changes is growing. The
current national discussions regarding health reform are
sharpening policymakers' understandings of the need for
accelerating the investment in health services research and
in its dissemination.
Organization and Financing
Health services research provides information on the
quality and cost of alternative types of health care organiza-
tions. For example, health services research provides policy-
relevant information on health maintenance organizations
(HMOs) and other managed-care arrangements. Research
has shown HMOs to be effective in controlling costs and
providing high-quality care. However, research has also
shown the rate of inflation in health care costs in HMOs to
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MEETING THE NATION' S NEEDS FOR BIOMEDICAL AND BEHAVIORAL SCIENTISTS
be similar to more traditional fee-for-service care. This has
stimulated innovations in managed care, some of which
come directly from products of research, including the use
of appropriateness criteria for making coverage decisions,
advances in the design of management-information systems
and analytic methods for monitoring quality indicators and
cost, and methods for profiling providers to compare pro
outcomes and cost. Among the products of this research
are best-practice guidelines for specific conditions Hat are
being widely disseminated to providers, insurers, and con-
sumers to improve knowledge and state-of-the-art practice.
Quality of Care and Patient Outcomes
vider performance in terms of cost and quality. These meth
ods are supporting a new generation of managed care that
emphasizes He provision of effective high-quality care at a
reasonable cost.
Our knowledge of the impact of financial incentives on
patient access to care, provider practice patterns, and orga
nizational productivity come from health services research.
For example, research has demonstrated He power of f~nan
cial incentives and disincentives on patient care seeking and
provider practice. Health services researchers developed
the payment classification systems used by Medicare to pay
hospitals (DRGs) and to pay physicians (RBRVs). Current
research work is improving case mix and severity measure
ment in ambulatory care. These measures can be used to
adjust payment to HMOs and other providers and represent
long-term investments in health services research.
Our understanding of public heals issues regarding ac- measurement in organized efforts to improve quality are based
cess to appropriate and needed services comes primarily on what is being learned through health services research.
from health services research. For example, information on
the growing numbers of uninsured people and Heir charac
teristics has been critical to He formulation of heals care
reform proposals. Furthermore, studies have shown that
insurance coverage is necessary, but frequently not suffi
cient to ensure appropriate access to care. High-risk popu
lations will likely require special outreach services and
heals education to gain He full benefit of available services.
These findings are beginning to clarify end redefine He future
role of public health agencies under health care reform.
Medical Effectiveness Research
New initiatives to allow better understanding of the ef
fectiveness of health care services are advancing knowl
edge regarding what works, for whom, and under what cir
cumstances. The AHCPR is supporting a range of studies
on specific conditions and procedures to encourage better
understanding of variations in patterns of provider practice
and their consequences for patient outcomes, both clinical
and patient-reported. Validated measurement scales for pa
tient-reported outcomes, including health status and satis
faction, are products of years of research. Studies of acute
myocardial infarction, cataract surgery, low bird weight,
coronary artery disease, joint-replacement surgery, and
other common conditions are providing new Insights Into
the effectiveness and efficiency of our current health care
delivery system as measured by improvements in patient
Research is contributing to new and improved methods
for measuring quality of heals services, including Heir im-
pact on patient functioning, satisfaction, and quality of life.
Quality of care is broadly conceived to include relevant
characteristics of the organizational structure of Be heals
care provider, the content of the care, and the outcomes
experienced by individuals with specific health problems.
One of He newer areas for research pertains to the use of
patient-reported measures of outcomes in conjunction win
clinical measures of outcome. Patient-reported outcomes
information is being applied in organized efforts to improve
the total quality of services, as well as being used by some
regulatory authorities (e.g., He Food and Drug Administra-
tion) for assessing quality of life effects of new treatments.
The conceptual framework for measuring quality-of-care,
He measures being applied, and the integration of quality
Ethical and Legal Issues
The advances in medical technology and Be need to pro-
vide patients with state-of-the-art care have increased legal
and ethical concerns. Research is clarifying the nature of
ethical concerns with new technologies (e.g., genetic screen-
ing) and providing new understandings regarding the mean-
ing of informed consent and effective procedures for ob-
taining informed consent.
Among legal issues of greatest concern to providers has
been He rapid escalation of malpractice claims and the over-
all cost of malpractice insurance. Research has shown the
importance of effective provider-patient communication in
reducing He occurrence of malpractice claims and has pro-
vided information that has helped shape malpractice reform
legislation in several states. In conclusion, our understand-
ing of the operation of the American health care system, its
effectiveness, and its efficiency relies largely on the prod-
ucts of health services research. Advances in our concep-
tual understanding of the complexities of health care deliv-
ery, methods of measuring quality of care, cost, and patient
outcomes and the development of policy-relevant informa-
tion have been highly significant over the past 25 years.
Even so, there are many questions unanswered regarding
how best to organize and provide health care services to
ensure the highest possible heals status for all Americans
at an affordable cost.
82
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HEALTH SERVICES RESEARCH PERSONNEL
ASSESSMENT OF THE CURRENT MARKET FOR
HEALTH SERVICES RESEARCH PERSONNEL
The need for information coming from health services
research is widely recognized and growing. The size and
scope of He supply of highly trained researchers are not well
documented but are inadequate in the view of the commit-
tee to meet He current or projected future needs. In this
section, He available information on supply is presented. This
is followed by a discussion of factors contributing to an ex-
panding need for well-trained health services researchers.
Supply of Health Services Researchers
Health services research is problem-oriented: practitio-
ners examine and evaluate He delivery of heals care ser-
vices in the United States. It is a distinct area of inquiry in
which systematic methods are applied to problems of the
allocation of finite health resources and the improvement of
personal health care services. Individuals enter the field of
health services research from a variety of backgrounds, in-
cluding biostatistics, epidemiology and bioengineering, the
behavioral sciences (anthropology, sociology, and psychol-
ogy), the social sciences (economics, statistics, and urban
planning), and other fields such as operations research, in-
dustrial engineering, public administration, health educa-
tion, and medicine.
The number of health services research personnel in the
U.S. labor force is not known, although attempts have been
made by the National Research Council (NRC) and others
to describe the composition of certain segments of the labor
force.) The composition of health services research is
largely determined by the availability of support for research
and development. Thus, no stable estimates of He number
of individuals in the work force can be generated unless
specialized surveys are conducted or special estimates are
generated, as demonstrated by previous NRC surveys. Per-
haps the best available estimate of He size of the heals
services research labor force is the membership of the As-
sociation for Health Services Research (AHSR), an organi-
zation established in 1981 to promote the field of heals
services research (Davidson, 19934. Although this most
likely results in an undercount of the heals services re-
search labor force, studying He number of AHSR members
and their characteristics is helpful in understanding the in-
frastructure of at least one segment of the labor force, a
segment we might consider to be He "attentive" workers.2
Composition of the Attentive Health Services Research
Labor Force: 1992
About 2,000 individuals were members of AHSR in
1992. Of these, 100 were students and He remainder were
drawn from medicine, public heals, and research back-
grounds. Most AHSR members hold doctoral degrees,
whether research doctorates (922 members) or clinical doc-
torates (448 members) (Table 8-1~.
When asked to identify Heir discipline of specialization,
TABLE 8-! Distribution of Degrees Among Members of the
Association for Health Services Research: 1992
Degree
Doctorate
Masters
Number
922
720
(Public Health)
(Other Masters)
Bachelors
Practitioner
(M.D. or D.O.)
(Nursing)
(M.S.W.)
(Other)
J.D.
TOTAL
(247)
(473)
78
601
(448)
(108)
(17)
(28)
24
2 ~ 345a
Source: Davidson, 1993
aTotal exceeds 2.000 owing to multiple degrees of some members.
83
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MEETING THE NATION'S NEEDS FOR BIOMEDICAL AND BEHAVIORAL SCIENTISTS
FIGURE 8-1 Disciplines of individual
members (members with multiple disci-
plines are counted more than once), 1992.
SOURCE: Association for Health Servic-
es Research, 1993.
about one-~ird indicated that they work in what AHSR con-
siders to be the social sciences, another third in the health
professions, and He remainder in public health, public
policy, or other health services research specialties. Among
Hose classified as social scientists, about 33 percent work
in economics, 15 percent in sociology, and 12 percent in
psychology. About 22 percent (147 members) of the social
scientists reported their discipline to be health services re-
search, possibly reflecting He participation of that cohort of
individuals formally trained in health services research in
recent decades (Figure 8-1~.
Employment Sector. Most AHSR members were em-
ployed in university settings in 1992 (Figure 8-2~. How-
ever, a host of non-prof~t and propriety health services re-
search fees and non-prof~t professional organizations offer
employment to health services research personnel. In 1988,
the AHSR, together with the Federation for Health Services
Research published the Directory of Health Services Re-
search Organizations. That directory remains "~e only
source of information on health services research centers in
the United S tales" (Davidson, i 993) .
Changes in Composition Over Time
While the lack of data sets prevent an analysis of ~e
composition of the health services research labor force over
Total Individuals = 1,902
Health Care Industry
(222) Health Care Deliverv
Private Organization
(168)
Foundation (43)
Government (208}
University (939)
FIGURE 8-2 Employment settings of members, 1992. NOTE:
Data represents 98% of AHSR membership. SOURCE: Associa-
tion for Health Services Research, 1993.
All Members Social and Statistical
Sciences
Health Profession . -
_ Social
_ Sciences
,(669)
Public Policy Other (55) ~ ~ - - - . HSR (147)
Other (70)
Economics ~
(205) Stats/Math
_Ir ~ (44)
,, _ ,,
r ~ Psychology
=~
|_ Sociology
en_ (99)
Business - ~ -- - Operations Research (25)
(1 1 1)
time, the availability of previous work by the NRC (1977,
1985) suggests that comparative studies might be devel-
oped. Because of He dynamic nature of this "labor force"
and the importance to the national health effort, the Com-
mittee believes Hat some investment in labor force studies
of the health services research community would yield tre-
mendous payoffs and, given the direction of national in-
terest in He improvement of health care delivery, will be
increasingly sought in the coming years.
OUTLOOK FOR HEALTH SERVICES
RESEARCH PERSONNEL
The President's proposal for health care reform as well
as Congressional proposals are pressing for change in the
American health care system to remedy problems of spiral-
ing costs, eroding access for the uninsured and
underinsured, and uncertainty regarding the uniform quality
of services. Many aspects of these proposals draw on infor-
mation derived from health services research, as discussed
above. Market forces are already requiring the pharmaccu-
tical industry to consider issues of cost-effective outcomes
of treatment as part of their business. However, as efforts
are made to predict the consequences of alternative health
care reform proposals, it is evident Hat much more infor-
mation is needed if we are to make informed policy choices.
Congress and the president have recognized this need and
have increased substantially the funding of health services
research by federal agencies and are expected to continue to
increase funding into the future. Parallel increases in He
funding of heals services research in the private sector are
occurring and are likely to continue.
Questions to which better answers are needed include a
spectrum of issues that cut across all health care services.
These include:
· Which models of health care organization and financ-
ing work best and how does this vary across populations
win different socioeconomic, ethnic, and health status char-
acteristics?
· What impact do alternative organizational models
84
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HEALTH SERVICES RESEARCH PERSONNEL
have on the provision of preventive services, acute and long-
term care, and quality of care and costs?
· What are the effects of licensing and regulatory
mechanisms on access to care, quality, and cost and how
should these rules be changed, if at all?
· Which health care professionals, with what types of
training, are needed to provide high quality and efficient
primary care, specialty services, long-term care, and reha-
bilitative services?
· How can accountability be improved? Can a useful
report card on quality of care and costs be provided to pa-
tients and consumers to assist in making informed choices?
What are other mechanisms to improve accountability in
the health care system?
· What would be the impact of global budget con-
straints? Are there other means for reducing the rate of cost
increases while providing appropriate services to all who
need them (e.g., eliminating inappropriate services and re-
ducing administrative inefficiencies)?
These and other questions are sharpening the issues that
need to be addressed through interdisciplinary health ser-
vices research and demonstration studies. As changes con-
tinue to occur in the provision of health care services, there
will be growing needs for rigorous evaluations of the im-
pact of innovations on the quality, cost, and patient out-
comes of care. Evaluations studies can clarify positive and
negative aspects of innovations in health care delivery as
well as point to opportunities to introduce improved models
of care. Numerous organizational and financing changes
are being introduced by states that are seeking tailored ap-
proaches to health care reform. These state initiatives also
will need information on which to shape policy and evalu-
ate progress. The source of this information is the field of
health services research.
Future Employment Conditions
The growing demand for health services researchers can
be seen in multiple areas, including both public and private
sectors. The AHCPR was created in 1989. Since then its
budget for research has doubled and is expected to continue
to grow as the demands for information relevant to health
~ .
care reform Increase.
Other federal agencies fund health services research, but
AHCPR is viewed as the lead agency. Among the NIH
institutes, there are increasing commitments to health ser-
vices research. NIMH, National Institute of Alcohol Abuse
and Alcoholism, and the National Institute on Drug Abuse
were mandated by Congress to spend 12 percent of their
budgets in 1993 and 15 percent in 1994 and 1995 to support
services research in their respective areas. In 1994 this will
amount to over $200 million in research funding. Other
85
institutes fund health services research but do not identify it
as such. The National Cancer Institute, National Heart,
Lung, and Blood Institute, and National Institute on Aging
all have significant research activities concerned with the
provision of services and the effectiveness of care within
their categorical disease responsibilities. It is anticipated
that health services research funding will grow to represent
a small but significant proportion of NIH funding. NIH
currently spends substantially more on health services re-
search than does AHCPR and is expected to continue to be
a major source of funding for studies concerned with the
organization of services, treatment, and outcomes of care
for individuals with specific diseases and injuries.
In addition to NIH, other components of the Department
of Health and Human Services fund health services research.
The Centers for Disease Control are making new invest-
ments in preventive services research and the Office of Re-
search and Demonstrations at the Health Care Financing
Administration supports a substantial health services dem-
onstration and evaluation research program. Other federal
agencies also fund health services research, including the
Department of Veterans Affairs, which has an expanding
health services research program.
The investment of private industry in health services re-
search also is rapidly growing. Insurers are seeking im-
proved methods for reviewing claims and profiting provid-
ers. Managed care organizations are investing in improved
methods for monitoring services, provider practices, and
patient needs. The pharmaceutical industry is assessing out-
comes of care related to drug therapies by using health sta-
tus instruments and is investing in cost-effectiveness stud-
ies to demonstrate the comparative benefits of treatment.
Every indication is that these investments will increase as
managed care organizations demand better information to
guide decisions regarding preferred treatments, appropriate-
ness of services for different patients, and Heir impact on
total costs of care.
The health care industry accounts for 14 percent of He
gross domestic product and is growing, possibly reaching
19-20 percent of He GDP early in the next century. Not
only is it a large domestic industry, it is a significant source
of international Bade. Methods and techniques developed
in America (e.g., DRGs for hospital payment) are being
adapted and used in many other countries. Health status
measurement indices developed here are being translated
and validated for use in other languages. There is general
consensus that there are similar problems being faced by all
nations as each attempts to meet He growing needs for heath
care services. Our past investments in health services re-
search have made us an international leader. Other coun-
tries have begun to make investments in this area because
of their needs for information and the demonstrated success
of the American investments.
OCR for page 86
MEETING THE NATION' S NEEDS FOR BIOMEDICAL AND BEHAVIORAL SCIENTISTS
ENSURING DIVERSITY OF HUMAN RESOURCES
There is limited information currently available on the
supply of heals services researchers. Efforts need to be
made to improve the completeness of information on indi-
viduals being trained in health services research and ac-
tively involved in research careers. On the basis of avail-
able information, it appears Hat career opportunities are
open for women and men in this field. However, there is no
information available regarding ethnic minorities. It is rec-
ommended that efforts be made to expand opportunities for
ethnic minorities to pursue education and careers in this
field. The NRSA awards can be used to leverage increased
diversity among individuals entering this field and this
should be encouraged.
Training of Health Professionals
Another concern relates to the lack of active involve-
ment of the full range of health professions in the conduct
of health services research studies. Much of past research
has focused on physician-provided services or Rose del-
egated by physicians to physician assistants or nurse practi-
tioners. The breadth of research needs to be expanded to
include services provided by the full range of health profes-
sions, including occupational therapy, optometry, podiatry,
physical therapy, and social work. In addition, services pro-
vided by practitioners of alternative medicine need to be
included. A recent national survey reported that one-third
of all Americans have used alternative medicine services
and paid for most of this care out-of-pocket.
One way to increase He diversity of research on the full
range of heals services provided in this counay is to attract
practitioners in these professions into heals services re-
search careers. The NRSA awards should be used to ac-
complish this goal.
THE NRSA PROGRAM IN HEALTH
SERVICES RESEARCH
The information on current NRSA awards and the rec-
ommendations for future award levels in health services re-
search relate solely to those awards made by AHCPR. The
numbers of awards and funding levels of the program within
AHCPR are shown in Table 8-2. The numbers of awards
have grown rapidly yet remain small relative to He total
needs for heals services researchers. The current AHCPR
program funds about 35 predoctoral and 59 postdoctoral
positions, up from only 12 postdoctoral awards in fiscal
1990. The AHCPR program is relatively young and has
given priority to postdoctoral Gaining, particularly of health
professionals, as an efficient strategy for more rapidly ex-
panding He numbers of qualified health services research-
ers. It is expected Hat this should change over time to give
increased emphasis to predoctoral Gaining of individuals
for careers in health services research. This Gaining may
occur either in academic disciplinary departments Hat have
the capacity to Lain in health services research or in aca-
demic health services research departments that draw to-
ge~er faculty representing the range of disciplines applied
in this field.
NRSA awards in the NIH institutes also support the train-
ing of some heals services researchers. NIMH supports
TABLE 8-2 Aggregated Numbers of NRSA Supported Trainees and Fellows
in Health Services Research for FY 1991 through FY 1993
Fiscal Type of Support
TOTAL Tra~neeship Fellowship
12
Year Level of Tra~n~g
1991 Number of awards
Predoctoral
Postdoctoral
o
12
o
o
o
12
o
12
1992 Number of awards 94 82 12
Predoctoral 35 35 0
Postdoctoral 59 47 12
1993 Number of awards 96 79 17
Predoctoral 30 30 0
Postdoctoral 66 49 17
NOTE: Based on estimates provided by the National Institutes of Health. See Summary Table 1
86
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HEALTH SERVICES RESEARCH PERSONNEL
training in mental health services research, and the National
Institute of Alcohol Abuse and Alcoholism is now solicit
ing Gaining grant proposals in alcohol services research. In
addition, He National Institute of Nursing Research sup
ports training in health services research and to a lesser
extent so do other institutes. NRSA Paining supported by
the institutes should be encouraged; He numbers of current
trainees is unknown because the classification of training
awards in behavioral, clinical, nursing, and oral health does
not discriminate which programs and fellows are pursuing RECOMMENDATION: The committee recommends
training in heals services research methods and their ap- that He number of NRSA positions allocated to AHCPR
plication. increase to 360 in fiscal 1996. These positions should be
phased in yearly as properly qualified candidates and
training sites present themselves.
to examine the impact of organization, finance, and use of
technology on the utilization, cost, and quality of care. This
field of research will need to grow substantially to meet the
ever expanding demands for information by policymakers,
administrators, providers and consumers. The questions
raised regarding what impact different proposals for health
care reform will have on access, cost, and quality of care
are largely questions that will be answered by this field of
research (Table 8-3~.
RECOMMENDATIONS
Program Size
Health services research is critical to the future of heals
care delivery in this country. Health services research is a
relatively young field that uses interdisciplinary approaches
TABLE 8-3 Committee Recommendations for Relative Distribution of
Predoctoral arid Postdoctoral Trusteeship and Fellowship Awards for
Health Services Research for FY 1994 through FY 1999
115
55
60
1995Recommended number of awards
Predoctoral
Postdoctoral
1996Recommended number of awards
Predoctoral
Postdoctoral
1997Recommended number of awards
Predoctoral
Predoctoral
1998Recommended number of awards
Predoctoral
Postdoctoral
1999Recommended number of awards
Predoctoral
Postdoctoral
240
180
60
360
300
60
300
60
60
360
300
60
360
300
60
95
45
50
145
95
50
190
140
50
140
50
50
190
140
50
190
140
50
20
10
10
95
85
10
170
160
10
160
10
10
170
160
10
170
160
10
Fiscal
Year Level of Training
1994 Recommended number of awards
Predoctoral
Postdoctoral
Type of Support
TOTAL Traineeship Fellowship
87
Traineeships and Fellowships
The institutional Raining grant permits the development
of innovative interdisciplinary research training programs,
OCR for page 88
MEETING THE NATION'S NEEDS FOR BIOMEDICAL AND BEHAVIORAL SCIENTISTS
an essential feature of research in this area. However, given
the anticipated growing demand for skilled specialists in
health services research, the committee concludes that
AHCPR should place significant emphasis on individual fel-
lowships in He next few years in order to encourage quali-
fied individuals win some experience in the area of heal
care policy to pursue advanced Gaining.
RECOMMENDATION: The committee recommends
that individual fellowships represent about 45 percent of
total NRSA support available through AHCPR in fiscal
1996, up from approximately 15 percent in fiscal 1993.
NOTES
1. For example, in 1977 the NRC identified and surveyed about 900
individuals who had received support from the National Center for Health
Services Research (NCHSR) between 1960 and 1976 and about 1000 indi-
viduals who had received research training support from NCHSR or Alco-
hol, Drug Abuse, and Mental Health Administration in the area of health
services research between 1970 and 1977. About 77 percent of the former
trainees and 81 percent of the former principal investigators were engaged
in health services research at the time of the survey. (See NRC, 1977;
Ebert-Flattau, 1981).
2. The concept of the "attentive" public was developed by Gabriel
Almond, who applied it to understanding attitudes of Americans toward
foreign policy issues (Almond, 1950). Jon Miller applied the concept to
the formulation of science policy and has expanded the original conception
88
into a broader model of political specialization (Miller, 1983). The con-
cept is extended for use here to refer to those members of the health ser-
vices research labor force sufficiently interested in being identified as mem-
bers of the field to have become members of AHSR.
REFERENCES
Association for Health Services Personnel
1993 AHSR Membership Directory. Washington, D.C.: Associa-
tion for Health Services Research.
Almond, G.
1950
Davidson, B.
1993
The American People and Foreign Policy. New York:
Harcourt, Brace and Company.
Personnel Needs and Training for Health Services Research.
Paper prepared for the Committee on National Needs for Bio-
medical and Behavioral Research Personnel.
Ebert-Flattau, P.
1981 Some preliminary data on the health services research labor
force in the United States. In Systems Science in Health Care,
C. Tilquin (ed.), New York: Pergamon Press.
Miller, J.
1983 The American People and Science Policy. New York:
Pergamon Press.
National Research Council
1977 Personnel Needs and Training for Biomedical and Behav-
ioral Research. Washington, D.C.: National Academy Press.
1985 Personnel Needs and Training for Biomedical and Behav-
ioral Research. Washington, D.C.: National Academy Press.
Representative terms from entire chapter:
heals services
