In the broader health services literature on CBA/CEA, more global outcomes measures based on consumer input and valuation have only recently become widely recognized. The use of these measures has become the focus of a new subfield within health services CBA/CEA, commonly referred to as "cost-utility" analysis (Russell et al., 1996). Extending this cost-utility literature to rehabilitation services is an important research priority.

Broad Framework of Health Systems Finally, it is important that the effectiveness of rehabilitation services and programs be examined within the broad context of the entire health care system. J. Paul Thomas (p. 36) points to the lack of this broader perspective as a serious deficit in rehabilitation services research and training: "It fails to impart an adequate understanding of the larger American health care system of which we are all a part. If we evaluate the efficacy of our clinical efforts without considering the larger health care system, much of our work may become irrelevant and of little use to our clientele" (Batavia et al., 1991).

In an effort to reduce the lengths of stay for hospitalization, for acute care, patients are being discharged earlier, often with a poorer functional status. This approach to cost-containment for hospitalization for acute care is likely to increase the demand for and expenditures associated with outpatient rehabilitation. In the long run, however, overall costs for achieving equivalent, if not better, outcomes may be lowered. It may well be that in an effort to reduce overall costs of health care, the volume and total expenditures for rehabilitation may, in fact, increase (or remain stable). The appropriate timing, intensity, and mix of rehabilitation services may accelerate the recovery process as well as decrease the long-term demand for acute care services for secondary conditions. Thus, the development and application of an "episode approach" to examining the relationship between the use and costs of services (both acute health care and rehabilitation) and outcomes should be given high priority.

It is also important to emphasize that many of the problems associated with poor outcomes in rehabilitation relate back to problems of access to services and its relationship to health insurance and employment (National Council on Disability, 1993). Clearly, these issues are prominent in the national debate on health care reform. Therefore, any studies of access and its relation to outcome must be undertaken in the context of this debate.

Assessing and Meeting the Primary Health Care and Long-Term Support Needs of People with Disabling Conditions

A much-neglected HSR issue in rehabilitation and engineering is the organization, delivery, and cost-effectiveness of services aimed at the pri-



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