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Support For The Infrastructure For Primary Care Research
The committee found challenging declarations of research agendas for primary care (e.g., Williams and Brook, 1978; Mayfield and Grady, 1990; AHCPR Task Force, 1993; Starfield, 1996); there is no lack of questions to be asked and answered. What does seem to be missing is a widely held commitment to the exploration and explication of primary care using all the methods of science and the array of settings in which primary care is delivered. At present, no adequate infrastructure exists that is designed to undergird an enduring primary care research enterprise. In this committee's view, it is unlikely that primary care can be grounded in an adequate science base unless such infrastructures are created.
The untapped opportunities in primary care research leave us ignorant about why some people get sick while others stay well and why some people recover from their illnesses and others do not. Primary care research can determine the transition of signs and symptoms and vague concerns into clinically more significant diseases and diagnoses so that prognostication can be improved and the needs of newly forming integrated delivery systems and the patients that they serve can be met. The most urgent need, however, is not for a particular investigation but the building of the nation's capacity to investigate multiple primary care questions. In other words, the overriding goal must be to establish a viable primary care research infrastructure.
Key elements of such an infrastructure have been defined. Among them are
a designated lead agency at the federal level that would be held accountable for advancing primary care research;
national health and health care utilization surveys and databases that capture the relevant aspects of and data on primary care;
primary care research laboratories, such as practice-based research networks that link primary care practitioners with those who carry out scientific investigations;
appropriate data standards and classification systems for primary care;
training programs for primary care clinician-scientists; and
stable career ladders for primary care researchers.
The committee found exemplary efforts in each of these areas. Some are well known, such as the large population surveys of the National Center for Health Statistics (NCHS) or the Agency for Health Care Policy and Research (AHCPR) in the Department of Health and Human Services (DHHS). Similarly, the international classification system for primary care (the International Classification of Primary Care, or ICPC) is widely known in certain circles (especially abroad) and clearly opens the door to the episode-oriented epidemiology critical to capturing the phenomena of primary care.2 Other advances are not widely