care organization and delivery. Finally, this paucity of primary care research and development leaves primary care insufficiently prepared to confront the challenges and opportunities inherent in the committee's definition.

One broad explanation for the mismatch between the bulk of clinical care and the bulk of health-related research is the misperception that primary care is already sufficiently understood (Nutting, 1996). Discussions in the workshop and elsewhere during this study made clear, however, that primary care is a distinct and quite complex field, that it is inadequately described to and poorly understood by the broader health care community and the public generally, and that it is apparently an important source of variation leading to different health (or disease) states and clinical management strategies. For all these reasons, the committee determined that setting out a coherent program for research and evaluation in primary care would be an important contribution of its report.

In this regard, the committee took note of Starfield's position (Starfield, 1996) that primary care research is "research done in a primary care context." Starfield argues that it is a fallacy to conclude either that primary care research can be done in anything other than primary care settings or that information purportedly about primary care that is drawn from research not done in primary care settings is a priori valid for the primary care clinician. With those cautions in mind, one can draw a reasonable inference that the nation has engaged in little primary care research.

To help redress this imbalance, this chapter explores the need for a primary care research infrastructure and identifies key areas of primary care research that warrant high-priority attention. In the first main section, the committee discusses four topics relating to the necessary infrastructure for primary care research and offers four recommendations designed to overcome existing barriers to such work and foster a stronger framework within which a broad range of studies might be conducted. In the second main section, the committee identifies high-priority areas of research. Although these topics are often in the health services research arena, they are highlighted here for two reasons: (1) to draw attention to the core elements of the committee's definition of primary care, and (2) to underscore the importance of conducting much of this work in settings that deliver primary care as conceived by this committee. The chapter ends with some commentary about the long-term impact of primary care research on the quality and costs of health care in this nation.

The committee's views on primary care research and an appropriate infrastructure in which to pursue it do not imply that the committee believes this part of the research enterprise should be separated from the rest of the research effort in this nation. Primary care research cannot be done in a vacuum. Rather, this work should be done in the context of developing data and insights for the entire approach to health care in this country—the realm of health services research (IOM, 1995)—so that a responsive, cost-effective, and high-quality system can be built in the ensuing years.



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