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APPENDIX A A New Database on the U.S. Health Services Research Work Force Nancy Cross Dunham, Ph.D.' BACKGROUND Little current, definitive information exists about the size arid characteristics of the U.S. health services research work force. This paper describes how a new database was created for the Institute of Medicine (IOM) Committee on Health Services Research: Training and Work Force Issues. The last effort to gather systematic information on the health services research work force dates back to the late 1970s when the National Research Council (NRC) supported a survey of individuals who had received intending for health services research or training Tom the National Center for Health Services Research or the Alcohol, Drug Abuse and Mental Health Administration. That study identified 1,378 health services researchers.2 A 1983 IOM report estimated that there were between 600 and 1,650 health services researchers in 1979.3 The lower estimate was based on the membership of the Committee on Health Services Research of the Medical Care Section of the American Public Health Association, arid the higher estimate was based on assumptions about growth in the group identified in 1977. 'Deputy Director, Wisconsin Network for Health Policy Research at the University of Wisconsin-Madison. This paper has been edited by IOM committee members and staff. 2Ebert-Flattau, P., and Perkoff, G.T. The Health Services Research Labor Force in the United States. Medical Care 21~3~:253-265, 1983. 3Institute of Medicine. PersonnelNeeds and Trainingfor Biomedical and Behavioral Research, Washington, D.C.: National Academy of Sciences, 1983. 91

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92 / HEALTH SERVICES RESEARCH More recently, the membership of the Association for Health Services Research (AHSR), now the major professional organization for the field, has been used as a proxy to estimate trends in the supply of health services researchers. For example, a 1993 report, commissioned by the NRC, noted that AHSR's membership grew from 450 in 1983 to about 2,000 members in 1992.4 DATA SOURCES AND PROCEDURES and . The database created for the study started with the membership files of the AHSR (n = 2,31 1 in early 1995~. The files included addresses and, sometimes, degree information. Not all health services researchers belong to AHSR, and some AHSR members support the organization but are not health services researchers. A second major source of names was HSRProj (n = 1,213 at the end of 1994), a comprehensive database on health services research activities in the United States developed by the Foundation for Health Services Research and the Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill. The database is now a part of the National Library of Medicine's system of on-line information resources. The database contains information on health services research projects funded by the federal government and by six major private foundations.5 Limitations of the HSRProj database include the omission of researchers funded by smaller foundations and industry. In addition, only the principal investigators of the funded research projects are included on the database. When the AHSR alla HSRProj data were combined, duplicate names were dropped, as were listings for those who had addresses outside of the United States; indicated they were students on the AHSR membership application form; did not self-identify as health services researchers on the AHSR membership application fond. 4B.N. Davidson, "Personnel Needs and Training for Health Services Research," background paper prepared for the National Research Council's Committee on National Needs for Biomedical and Behavioral Research Personnel, Washington, D.C., 1993. 5The Pew Charitable Trusts, the Robert Wood Johnson Foundation, the John A. Hartford Foundation, the Henry J. Kaiser Family Foundation, the Commonwealth Fund, and the W.K. Kellogg Foundation.

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APPENDIX A / 93 The resulting data set included 2,200 names. To this database were then added (1) names for those registered for the 1992 and 1993 AHSR annual conferences (n = approximately 700 after elimination of duplicate names and those with foreign addresses); names listed in the brochures of about 50 university-based and private health research "centers" (n = approximately 250 after elimination of duplicate names); and a list of nurse researchers supplied by Sigma Theta Tau International, the nursing honor society (n = 789 before elimination of a small number of duplicate names, the exact number of which was not recorded). The final source of names was a written survey of 496 organizational employers of health services researchers. The list of organizations was compiled from several sources including (1) AHSR's institutional membership list and individuals' organizational affiliations indicated on the AHSR and HSRProj databases, (2) the research "centers" mentioned above, (3) individuals' organizational affiliations indicated on the registration list for the 1994 meeting of the National Association of Health Data Organizations, and (4) lists of relevant federal and state government offices. Survey respondents were asked to supply the names, addresses, telephone numbers, and degrees of the people in their organizations whom they considered to be health services researchers, according to the IOM's definition (see Chapter 1~. They were also asked about their current and planned recruiting efforts. Of the 496 organizations surveyed 154 returned the survey form, for an overall response rate of 31 percent. Because the tight schedule precluded follow-up mailings to nonrespondents, this low response rate was not unexpected. The survey yielded a total of 1,731 names of health services researchers, about 970 of which were not already included in the database. SUMMARY OF RESULTS The final database included 4,920 names, more than double the membership of the AHSR. This list, however, still does not include all those engaged in the field, and it probably includes some individuals who would not self-identify or be identified by others as health services researchers.6 6If it were assumed that nonrespondents to the written survey employed health services researchers at the same rate as respondents, approximately 600 more researchers could be added to the database count.

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94 / HEALTH SERVICES RESEARCH Distribution of Researchers by Region and State Table A.1 presents information on the distribution of the health services researchers in the full database by geographic region and state. Geographically, 27 percent of the researchers in the database are located in the South Atlantic region of the country, primarily because of the concentration of researchers in Maryland and the District of Columbia. The next highest concentrations of health services researchers are seen in the Pacific region (16 percent) and the East North Central region (16 percent). California, with 567 health services researchers, has the largest state contingent, followed by Maryland (423), the District of Columbia (321), Massachusetts (317), and Pennsylvania (3059. Graduate Education The full database included information on graduate degrees for nearly two- thirds (3,203) of the researchers listed. Of this group, 52 percent had doctoral training (including 73 individuals with Sc.D. and 16 individuals with Ed.D. degrees). Another 28 percent had clinical degrees (of which approximately three-quarters were M.D.s). Type of Employer For analytic purposes, organizations responding to the written survey were grouped into the following categories: universities, proprietary and nonprofit health services research organizations and consulting firms, professional groups, health industry organizations (including managed care organizations, insurance companies, and pharmaceutical companies), and federal and state government agencies. Table A.2 presents information on the types of responding organizations and their reported employment of health services researchers. Universities (which comprised 30 percent of the responding organizations) reported the highest numbers of health services researchers, 41 percent of the total and 55 percent of the Ph.D.-level researchers reported. Again, given the low response rate, the percentages reported should be viewed with caution.

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APPENDIX A / 95 TABLE A.1 Number of Identified Health Services Researchers, by Region/State % of % of Region/State No. Total Region/State No. Total New England527 11 East North Central76116 Connecticut80 Illinois226 Maine45 Indiana92 Massachusetts317 Michigan134 New Hampshire34 Ohio129 Rhode Island44 Vermont7 West North Central335 Iowa48 Middle Atlantic694 14 Kansas28 New Jersey118 Minnesota136 New York271 Missouri81 Pennsylvania305 Nebraska26 North Dakota11 South Atlantic1,336 27 South Dakota5 Delaware5 District of Columbia321 Mountain1944 Florida89 Arizona40 Georgia86 Colorado52 Maryland423 Idaho3 North Carolina176 Montana6 South Carolina37 Nevada18 Virginia185 New Mexico31 West Virginia14 Utah38 Wyoming East South Central109 Alabama57 Pacific77E Kentucky19 Alaska Mississippi10 California56 Tennessee23 Hawaii13 Oregon7] West South Central186 4 Washington12( Arkansas27 Louisiana14 Oklahoma15 Texas130 TOTAL4,920101a aTotal does not sum to 100 because of rounding.

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96 / HEALTH SERVICES RESEARCH TABLE A.2 Reported Employment of Health Services Researchers (HSRs) by Organizational Type Responses to Ph.D.-level Questionnaire HSRs Employed HSRs Employed Organizational Type No. (%)No. (%) No. (%) Universities 46 (30)715 (41) 411 (55) Research or consulting 27 (18)513 (30) 164 (22) organizations Federal/state government 45 (29)266 (15) 74 (10) Heals indushya 14 (9)130 (8) 60 (8) Professional groups 22 (14)107 (6) 40 (5) TOTAL 154 (100)1,73 1 (100) 749 (100) aIncludes managed care plans, insurers, pharmaceutical firms, and integrated systems. Current and Future Hiring of Researchers The written survey of employers of health services researchers also included two questions relating to the demand for health services researchers in 13 specific research areas as reported in Tables A.3 and A.4. Respondents were asked if, in the last few years, they have had difficulty in recruiting Ph.D.- level researchers for specific research areas; and i] if, in the next five years, they intended to recruit Ph.D.-level researchers n any of these areas and, if so, how many. Table A.3 shows the number of responding organizations that reported having had difficulty in the last few years in recruiting qualified Ph.D.-level researchers in one or more of the research areas listed in the questionnaire. Overall, more than half of the responding organizations (83, or 54 percent) indicated that they have had problems recruiting Ph.D.-level health services researchers. Universities, which are heavy employers of Ph.D.s, were more likely to report such problems. Over two-thirds of universities (70 percent) reported having difficulties in at least one of these research areas.

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APPENDIX A / 97 TABLE A.3 Organizations Reporting Difficulties in Recruiting Ph.D.-Level Health Services Researchers in the Past Few Years, by Type Organizational Type Reported Difficulties No. (%) Universities Research or consulting organizations Federal/state government Health indusbyh Professional groups TOTAL 32 (70) 1 s (56) 20 (44) 6 (43) 10 (46) 83 (54) aIn at least one area of research. bIncludes managed care plans, insurers, pharmaceutical firms, and integrated systems. Table A.4 shows the specific research areas in which these recruiting problems have been reported by responding organizations. The research areas have been rank-ordered in terms of the number of organizations reporting problems (not the number of positions for which difficulties were experienced). For five research areas, at least 15 percent of the responding organizations reported difficulty recruiting researchers in the last few years. The areas reportedas having presented the greatest problems are outcomes/health status measurement (23 percent), health economics (21 percent), biostatistics (20 percent), epidemiology (18 percent), and health policy analysis (16 percent). Anticipated Future Demand Table A.5 presents information on the numbers of responding organizations that reported that they expected to recruit Ph.D. researchers in the various research areas over the next five years. Sixty-one percent of responding organizations indicated that they anticipated recruiting health services researchers in at least one of these areas of research. Government agencies were the least likely to report such plans.

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98 / HEALTH SERVICES RESEARCH TABLE A.4 Rank Order of Research Areas in Which Recruiting Difficulties Were Reported Research Areas Reported Difficulties No. (%) Outcomes/health status measurement Health economics Biostatistics Epidemiology Health policy analysis Medical informatics Managed care research Gerontology Operations/decision analysis Quality Nursing research Mental health research Dental health research Otherb 35 (23) 32 (21) 3 1 (20) 25 (18) 24 (1 6) 17 (1 1) 14 (9) 13 (8) 10 (6) 9 (6) 8 (5) 6 (4) 4 (3) 17 (1 1) fin at least one area of research. Many organizations reported difficulties in more than one area. Categories listed include actuarial science, bioethics, demography, health care management, health education, health finance, health services research (general), long- term care, pharmacy services research, modeling, and work force planning. TABLE A.5 Number of Organizations Indicating Plans to Recruit Health Services Researchers in the Next Five Years . . Organizational Type Reported Plans No. (%)a Universities Research or consulting organizations Federal/state government Health industryb Professional groups TOTAL 36 (78) 1 8 (67) 16 (36) 13 (93) 11 (36) 94 (61) aReported plans to recruit people for at least one area of research. bIncludes managed care plans, insurers, pharmaceutical firms, and integrated systems.

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APPENDIX A / 99 Table A.6 indicates that the five research areas (outcomes/health status measurement, health economics, biostatistics, epidemiology, and health policy analysis) for which responding employers reported having had difficulty recruiting in the last few years are also the areas in which demand is anticipated to be strongest in the next five years. Based on the estimates of responding organizations, they will hire more than 660 health services researchers in the next five years. TABLE A.6 Research Areas in Which Responding Organizations (n = 154) Expect to Recruit Health Services Researchers in the Next Five Years Research Areas Total Number of Researchers Expected to Be Recruited Nit) Outcomes/health status measurement Health economics Biostatistics Epidemiology Health policy analysis Managed care research Operations/decision analysis Quality Mental health research Medical informatics Nursing research Gerontology Dental health research Other TOTAL 120 (18) 96 (14) 83 (13) 71 (1 1) 62 (9) 49 (7) 39 (6) 38 (6) 26 (4) 26 (4) 17 (3) 14 (2) 1 (<1) 19 (3) 661 (100) . SUMMARY To develop current estimates of the size of the health services research work force in the United States, a variety of sources were used to build a database. The process yielded a database containing information on a total of 4,920 individual health services researchers, a number considerably higher than past estimates. It is important to note, however, that the database is likely to include some individuals who are not health services researchers and to exclude some who are. Moreover, it lacks information (e.g., age) that would be useful in

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100 / HEALTH SERVICES RESEARCH developing estimates of the future supply of researchers. Demand for health services researchers over the next five years is expected to continue, especially in universities and the health industry. Researchers with experience in outcomes/health status measurement, health economics, biostatistics, epidemiology, and health policy analysis will be in particular demand.