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HEALTH SERVICES PES=RCH In recent years, expenditures for health care have expanded enormously. Each year has also seen new legislation vitally affecting the organization and provision of health care services. At the same time, research appropriations earmarked for understanding how the health care system works and how it can be made to function more effectively in the future have experienced a precipitous decline. Health services research, unlike research on cancer, heart disease, or mental illness, does not have a dramatic purpose that speaks to the direct experience of aillicns of people. Indeed, the public has often been apathetic toward the abi, ity of organized services to meet the needs of the sick and diseased (Shryock, ~ 966, ~ 969} . Nor does health services research have a large, we, 1- organized constituency to advocate funding for it;. Health services research is a hybrid of disciplines that are unified only by common research goals. Health services research seeks to examine the organization and performance of health care delivery systems and to open health car" policy to research which analyzes the components of this system (Black, 1974~. At a time when cor~om~c constraints threaten our ability to bring quality health programs and personnel to individuals and families throughout our nation, it is health services research that seeks to devise more sensible allocations of our collective and finite health resources {White, 1975; White and Henderson, 19761. Through the application of quantitative and systematic research methods, health services research is concerned ultimately with the organization, utilizaticn, and outcomes of health care. Even wel1-informed people, both in government and in the scientific professions, have insufficient know, edge as to what heal th services research is, how it is performed, or the range of disciple ines involved in it. Because of this ~ ack of awareness, they are unfamiliar with the special prob lems of hea Ith se rvice s res earch and the ta rents and resources that are necessary. At the s ame ~ ime there ha s been both a legis lative and an administrative demand for improvements in the delivery of health care. Improving a system that is as complicated, diffuse, and poorly understood as the U. S. health care system cannot be done ef fectively and safely without a much 128

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more subs tantia l information and knowledge bases and analyses of the dynamics of the present system. Prior to a discussion of research training needs in this area, the committee examines what health services research is and what role it can have in providing medical and other health-care services to the population. ORIGINS OF FEDERAL SUPPORT Health care delivery systems are shaped by the historical contexts in which they develop. Such factors as economic organization, ideological forces, available technologies and pre-existing professional organization affect access to medical care, distribution of services, and ultimately the quality of health care (Mechanic, 1975). Indeed, in our own nation, health care policy and delivery systems development are determined today by administrative decisions that must balance "the perceived medical needs of the people, the scientific realities of today and the available money in a political climate which insists on distributional equity" (White, 1977~. Health is the nation's third largest industry today (Altman and Eichenholz, 1976). It is estimated that public and private expenditures for health services and supplies in the U.S. grew from $12 billion, or 4.6 percent of the gross national product (GNP) in 1950, to $139 billion' or 8.6 percent of the GNP, in 1976. At the same time there has been a growth in the proportion of total health outlays borne by the federal government. In FY 1976, for example, the federal government provided support for more than 60 percent of all medical research costs, 45 percent of the costs to construct and maintain health facilities, 40 percent of medical education costs, and 30 percent of the costs for health services. This represents a growth of the federal share of total spending from 12 percent in 1950 to 28 percent in 1976 (office of Management and Budget, Special Budget Analyses, 1977). Implementation of large-scale federal health programs calls for a knowledge of the unique health needs of a region or pcpulation and requires an accurate estimation of the need for new health care services, facilities, and personnel. The federal government has found it necessary to provide for R and D activities useful in guiding this policy and planning process (President's science Advisory committee, 1972~. Indeed, it was in the face of critical health care needs the' the federal government launched the first ma jor program of health services R and ~ in 1955 when Congress appropriated sufficient funds to improve the organization and design of hospitals and related health services. 2 129

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In the absence of specialists to conduct health services research, the government has had to rely on scientists and health professionals from a variety of fields to redirect their activities and interests to the problems of health services development {Eichhorn and Bice,1973~. As a result, a body of knowledge has accumulated over the years, and research techniques have been developed to the point that health services research is now considered a distinct area of scientific inquiry. With the development of its theories and methods, health services research has been established ~ n academic institutions through a I' mined number of programs of training. It is at these institutions and research canters that indiv~ duals can gain expert) se at both the predoctoral and postdoct oral levels in the problems and methods of health services research. Hence, for the first time it has been possible to foster the development of a cadre of Investigators trained to address the complex questions of health care delivery. Because of.th" absence of a supportive constituency, federal support for these programs of training has been diffuse and sporadic. 3 it is the hope of the Committee that a description of the current climate of federal support for this research endeavor, coupled with a discussion of the role this research and training can have in addressing the urgent health care questions today, will lead to a continuity of commitment by the federal government to the development of health services research in the future. NATIONAL CENTER FOR HEALTH SERVICES RESEARCH The Congress iona 1 appropriations of 19 55, which Permitted the implementa-~on of the demonstration provisions of the Hi [l-Burton Act, launched health services research by the federal government. By the late 1950's, the NIH also supported a number of noncategorical health services research projects under the general research authority of the Public Health service Act (PHS Act), and by 1963 the Bureau of State Services began the first organized extramural research program in community health services (Sanazarro, 1973~. The proliferation of these federal programs led the White House Conference on Health in 1965 to recommend the establishment of a single entity to coordinate these activities (PSAC, 19651. Consolidation was achieved in 1967 when Congress directed the Secretary to establish a center for health services research, demonstration and development programs, and the training of research personnel in this area. 4 This was carried out by an order of the Secretary in 130

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~g68 that est abashed the National center for Health Services Research and Development (NCHSED} . s The NCHS~D was formed initially by a transfer of existing programs from the Divi signs of Community Health service, Medical Care Administration, Hospital and Medi cal Faci ~ ities, and from other units of the Department of Health, Education and Welfare tHEW) . The diverse ty and complexity of tasks that resulted from this consolidation is ref. ected in this statement of goals: Thi s new program of health services res earch and deve 1 opment of fers a vehicle through which al ternative means for maintaining and increasing the ava i labi lily of good health care can be achieved; the productivity of health manpower can be increa sea; better hospitals and nursing homes can be designed, and a ful ~ range of alternatives to' costly ins' itutional care can be developed. (U. S . Congress, ~ 9 67) The basi c charge to the center, however, was threef old: to improve access to health care, to guarantee quality, and to moderate rising costs on a national scar e (Sanazarro, ~ 973~ . As a first step in meeting these goals the Center laid out a program of R and D, with a heavy emphasis on development, to identify ma jor health care problems and to a s su rue coop erat i on f rom the pubI i c and pri vat e s ec to' s . Largely through demonstration activities, the Center supported projects to train and deploy physician extenders, to test such new cost containment and f inancing methods as all- incl usive rate reimbursement, to examine the potential of computer technology on health care del ivery, and to standardize the health services data systems withi n state s and nationwide. ~ In ~ 974, Congress clarified the role of the Center through the Health Services Research, Health Stati sties and Medical Libraries Act (PL 93- 353) (Fox, ~ 976} . Today its intramural and extramural research is directed toward the following areas: quality of care; inf ration, productivity, and costs; health care and the disadvantaged; health manpower; health insurance; planning and regulation; ambulatory care and emergency medical services; and long- term care (NCHSR, ~ 9 76) ~ As Figure 6. ~ indicates, budget constraints severely limit the work of the center, making di f ficult the tasks of providing a stable program of re search and of demonstrating the contributions of health services research to health care policy. 131

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70r 60 z 50 o J - 4o 30 ,^ 20 - - - 10 _ o .. 1 1 1 1 1 1 1 1 970 1 971 1972 1973 1 974 1975 1976 1 977PB FISCAL YEAR FIGURE 6.1 NCHSR research funds by fiscal year. PB refers to Me level of funding recommended by the Administration (President's Budget). From PHS (1976a)` HEALTH SERVICES RES=RCH IN ADAMHA Federal programs to provide mental health care Services to the nation r epre s ent a drama tic departure f ram tradi t iota service delivery models and generate for health services research a different set of challenges and research problems. In its ~ 961 report, the Joint Commission on Mental IN Iness and Health called for one fully-staffed full-time mental health clinic for each 50, 000 of the population (Report of the Commission on Mental Iliness and Health, 1 961~ . With the enactment of the Mental Retardation Faci lities and Community Mental Hea Ith Center Construction Act in 1963 {PL B8-1 64}, the federal government became committed for the first time to provide opportunities to treat emotionally and mentally disturbed persons, who might otherwi se require hospitalization, in a community setting . Community Mental Health centers (CMHC' s} were also envi stoned by some a s " socia ~ change agent s " instrumental in lowering the incidence of mental disorder (Caplan, 1964; Arnhoff, 1975; Robin and Wagenfeld, 1977} . Over 600 CMHC's are in place today. Mental health services research personnel are challenged today to provide information on the social, economic, and behavioral factors that render mental health care delivery ef fective . In the f ace of serious economic conditions, such 132

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information will assist the health planner to devi se a coherent federal policy for mental health that will permit the optimum allocation of limited federal resources (PHS, 1976a) . Since 1972, there has also been an ~ ncreasing cornrritment to provide federally funded programs to threat alcoholism and drug addiction in a variety of settings (ADAMHA, ~ 976) . The challenges that face health services research personnel are largely simi lar to those that face individuals studying me no al health ca re de livery. However, the abs en ce of a know 1 ed ge ba s e re ga r d ing the ba s ~ s f or the se a d dic tive behaviors increas es the complexity--and importance--of the tasks facing these research personnel. ADAMHA's interest to improve these programs of care is reflect ed not only in the areas of research and evaluation supported at this time, but also is evident in the current expa nsi on o f re s earch ~ ra ining in thi s area within the f.ramewo ok of the NRSA Act . HEALTH SERVICES RESEARCH TN THE NIH Health information systems can assist individuals operating a variety of heal' h services to gain access to information relevant -o the performance of the health services (Alderson, ~ 974) . While it is clear that it is not the goal of the National LO brary of Medicine (NLM} to enhance the efficiency of health services as such, the work cuff the ELM to develop computer technology for dis seminating medica 1 and other inf ormation serves as an important resource for the development of health care programs throughout the nation. The committee notes that the HEM has provided a limited program of training in the area of computer technology and information science under the auspices of the Medical Libraries Assistance Act in recent years. CURRENT TRENDS IN HEALTH SERVICES RESEARCH The public perceives a variety of serious problems in medical care today. These include the inability to get personal medical care, the rising costs of hospital care, the lack of good medical care for common problems despite the proliferation of advanced technologies to prolong life, evidence of difficulties with Medicare, and many others. Health services research seeks to address these and a wide variety of other problems. In the wake of the social programs of the 1960's for example, health services research has begun to investigate the access to and use of health services by the aged, the 133

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economically disadvantaged, minorities, and geographically isolated populate ens. One recent investigation (Haggerty et al. , ~ 975} has shown that neighborhood health centers increase the access and use of health services by the poor, with a consequent reduction in use of hospital admissions and emergency-room use. In the quality assurance field, a recent study demonstrated that education is not as effective as financial incentives in change ng the behavior of doctors (Brook and WE lliams, 1977} . A group of physicians was found to be administering intramuscular inj ections routinely to' Medicaid pa ~ tents, despi ~ ~ the fact What peer physicians had determined these injections to be unnecessary. It was not until the Medicaid program der.~ ed payment of reimbursement claims that a reduction wa s noticed in the number of in jections reported. An increasing emphasis has been placed on the problems of health costs in recent years. Economists have demonstrated that higher -` nf ration has meant that low-income f ami ~ i e s and the eld er ly-- f or whom hea Ith care bud get s have a i ~ ed to ke ep pa ce wi th servi ce s c o st s - - a re devoting a erg er share of thei r limite ~ incomes to hea lth co st s (Davis, ~1976 ~ . Evidence has also accrued that suggests that certificate-of-need laws have successfully cursed hospital bed expan si o n, but have a Is o motivated hospi ta ~ s to accelerate investment in costly services, facilities, and equipment (Sa ~ Wearer and Bice, ~ 976) . Research on these and related quest ions may lead to a better understanding of ways to abate soaring health-care! costs. A' though ' arge-scale investment in sophisticated new techno~ ogles has contributed to rising health-care costs in general, the apple iced ion of computer technology to hospital information systems may actuate y be a cost-effective way to facilitate the f low of information within the hospital while reducing the time and e f fort spent to store and retrieve such informant on. Recent studies have demonstrated, for example, the uti lity of medical information systems in ambulatory care settings (Barrett, ~1976} '. JUSt as clinical research seeks to test the ef ficacy of a new form of treatment on patients manifesting a particular di sorder, health servic ~ s re search seeks "co improve the ef fecti~renes s of applying the treatment to those who can benefit from it. A recent health services research study has shown, for example, ~ hat the U. S. population has yet to benefit from the use of drugs and treatments for essential hypertension, despite the demonstrated efficacy of the treatment (Weinstein and Stason, ~ 976} . Such research assists the specification of policies and priorities for continued federal investment in health care. Finally, In the area of alcoholism and drug abuse, health services research has led to the establishment of occupational alcoholism services in the industrial setting and to the creak ion of pilot programs to demonstrate methods 134

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to return recovered drug addicts to products ve employment (ADAMHA, ~ 97 5 ~ . THE NATURE OF HEALTH SERVICES RESEARCH TRAINING Health services research training can be offered to a wide range of individuals, including those who hold baccalaureates, masters degrees, academic doctorates, professional doctorates, and ether health professicnals. Trai ning may consti ~ up ~ work towards a ma ster s degree, a research doctorate, or postdoctoral training in (~) the behavioral sciences (including sociology, anthropology, psychology, and population studies]; (2) the biomedical sciences tincturing biostatistics, bioengineering, and epidemiology); (3) the social sciences (primarily economics and political sciences}; {4) public health (including environmental health and maternal and child healths ; and (~) in other research fields (such as operations research, heal th adminis:+ratio~., and health education) . The aspect of health services research training that d~ stinguishes it from other types of research training is the nature of the primary research problem. The health services investigator apple ies research methods from the di scipl~ne of training to on" or more of the health services problem area s li s ted be low: Problem Areas in 7 Health Services Research health facilities health manpower adulatory care dental health services emergency health services health services for the di sadvantaged long- term care nursing health services pharmacy-related health services economics ~ including health insurance), inflation, cost containment and production legal aspects of health care, including regulatory studies quality as surance of health services health services organ) cation, planning and adminis tration utilization of health services 135 health services evaluation health statistics develop- ment health status, including indicators development health systems analysis health care technology and technology assessment medical data systems community studies related to health care sociobehavioral aspects of health care, including compliance.

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Heal th s ervices research training as it is cif ered through such health agencies as ADAMHA dif fers only in that the primary research problem is modified further by the delivery system being analyzed, named y the mental health services system (including substance abuse programs}. Regardless of the source of research training support, however, it i s the research problem that clearly chase erizes the heal th services researcher. CURRENT MARKET STTUATION FOR TRAINED HEALTH SERVICES RE SEARCH PERSONNEL The NCHSP has provided research training support at both the predoc~ora~ and the postdoctoral level for over a decade. Sims lard y, ADAMHA has provided important training in evaluation research since the latter part of the ~ 960' s, when evaluate ion of the programs of mental health care gained momentum. 9 Because these programs of research training represen the first ma jor effort by the federal government to provide funds for formal training in areas relevant to the enhancement of ~ he health care system, the Committee sought to assess the current employment situation of a selected sample of these individuals following their training in thi s area of research. Over 5 0 0 indiv idua ~ s were i dent i f ~ ed a s having re ce ived predoctoral or postdoctoral research support through the programs of the NCHSR or ADAMHA. of these, 396 received support through the NCHSR since FY 1 97 0 3 a, and ~1 0 through the evaluation training programs of ADAMHA since FY ~ 975. A survey instrument wa s bevel oped that inc luded both the questionnaire on training and employment in the biomedical -anti behavioral sciences (Chapters 3 and 4, and Supplement 6}, and an additional one-page form to acquire information Perth nent to the individuals specialization in health services research (see Supplement 6). Over 65 percent of the trainees surveyed responded to this questionnaire. Onl y 1.2 percent of the trainees were seeking employment at this time (Appendix H11. Over 6 5 percent were employed in educationa ~ institutions, with another ~ 5. 5 percent employed in f ederal, state, or local government (Appendix H2) . About ~ 0 per cent report ed that the y were engaged in health services research (Appendix Had. 136

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. Individuals engaged In health services research were rather evenly distributed among the eight broad categories of health services research specialization developed by the Committee {Appendix Hid. The programs of training supported by the NCHSR and -- ADAMHA may be expected to differ with respect JO the areas of specialization emphasis, due to the fact that the systems of health care differ for each supporting agency. Hence, it is not surprising to find that a substantial proportion of individuals who received support from ADAMHA specialize in the sociobehavioral aspects of health services research (Table 6.~), while a number of individuals who received support from the NCHSR wick on problems dealing primarily with the legal aspects of health care, quality assurance, or services organization, planning, and administration (Table 6.2~. Beyond these major categories of emphasis, these individuals tend to be rather well distributed among other areas of research specialization. The Committee has concluded that there is evidence of ow unemploymer ~ among i ndivi due l s who have received federal support for training in health services research and that a large ma Gorily of these individuals have found employment that permits them to engage in health services research. The Committee believes that these federal ly supported Frog rams 0 f t ra i ni ng have be e n s uc ces s f u ~ in provi ~ ing to these individuals research skills that may be used in a variety of employment settings and on a range af probe ems of interest to health planners today. In summary, the Committee has concluded that current employment conditions for these trained health services research personnel are good . ASSES SMENT OF THE LABOR FORCE In addition to those individuals who have received federal support f or training in heal th service s research, the present supply of available personnel ~ ncludes a cadre of inve Litigators who have Proved into heal th servi ces research either by virtue of their employment experiences (e. g., selecting a -opic for study ~ hat contributes to the enhancement of the hea Ith care sys ~ em) or through some f orm of nonfederally supported tray ning (e. g. , selecting a thesis opi c con sidered appropr Ian e to studie s of the h ea Ith care system). Because no data base exists that can be used to estimate the magnitude of the health services research labor force, the committee undertook a second survey directed to acquire ~ his inf orma~ion. 137

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More than 2, COO individuals were identified for the purposes of this survey, either because they had received re search grant or contract support from NCHSR sometime since FY ~ 9 6 0, ~ ~ o r ~ e cans e they had pubIi shed thei r re s ear ch findings in journals relevant to this area after 1967. 12 The same survey instrument described in the previous section was used to gather training and employment data from this sample e of personnel. More than 5 00 individua Is could no ~ be contacted bec ause of i Inadequate addres s e s . Of the remaining 1, 50 0, more than 7 0 0 responded. Because the Committee hopes to complete this study in the coming year, only preliminary data are reported below. Of the 7 00 He spondents, over 25 percent hold doctorates in health care professions, but reported no formal research training . The reman ning respondents repre sensed a varied di st ribut ion among type s and leve ~ s of acaderni c tr airing, with some individuals ho 1ding baccalaureates only, some holding masters degrees, and some possessing acetic doctorates . Appendix H5 provides some information regarding the year in which formal training had been completed by the se respondents. It is interesting to note that professional doc torate s a nd i ndividua Is wi th bac ca ~ aureate trai ning a lone comp, eyed their education larger y before ~ 960, whereas most o f t ho se with ac ademic doctoral e s rece ived the ir degree a f ter that yea r f or the most part . Because these indict duals completed their academic or pro f ess tonal training prior to the development of formal programs of training in health service s research tHaggerty, 1973) , it is ur.1ikely that these individuals have had the opportunity to refine their research skills in light of current theories and methods. ~ ~ The Committee is aware that grave problems arise in any attempt to estimate the current available supply of health se rvice s re s earc h pe rs once ~ . However, data f ram thi s survey suggest that it will be possible eventually to make some statement regarding the current employment situation of inaividua Is who once worked in th i s area . The Committee views ~ hese data as a first important step in understanding the dynamo cs of the system. OUTLOOK FOR THE LABOR MARKET Th ere i s a s igni f ice nt awaken ing o f awarene s s among government aiming strators today of the need to improve national programs of physical and mental health care in the face of inf ration and the high costs of medical care. New approaches to health care are being developed within a very short time frame. Plans are under way to implement as scan as possible the far-reaching network of Health systems Agencies (HSA' s), which provide an opportunity for 140

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cc~mprehersiv" health planning at a ~ ocal level; for Health Maintenance Organizations (~MO's) for free-market competition ~ n health benefit plans; and for Professional S' andards Review Organizations {PSRO's) to assure quality care at a low cost to the taxpayer for Medicare and Medical patients. There is an important need for personnel to conduct research associated with the imps ementation of these and rela ~ ed programs ~ o enhance health care. However, federal interest in providing research support must be tempered by the knowledge that the bulk of avail able health services research personnel have not had the benefit of fcr~ral training in the ~ heories and methods that have been discussed earlier in this chapter. As a result, programs of research support may ultimately lack the availability of personnel whose expertise is of sufficient calibre to tackle sophisticated research problems relating to health care planning. The Committee recommends the support of programs for research training to increase the number and quality of health services research personnel. The importance of quality in heal th services research cannot be overemphasized as the demand for improved health care is heard from al sectors of our society. This challenge can best be met through the continued devel opment of a pool of personnel whose research skills can assure the advancement of heal th care. RECOMMENDATIONS Health services research is an applied activity directly dependent on the availabi~ iffy of federal funds. Because health services research will play an increasingly more significant rod e in the federal effort to provide quality health care at a reasonab' e cost, the Committee believes that such research training represents an important national priority. Extens ion of NRSA Authority Throughout its effort to conduct an assessment of health services research personnel, the Committee has had to expand ts considerations to include important training programs other than those of the NTH and ADAMHA. In last year' s report, for example, the Committee called for the maintenance of the re search training programs in the NCHSR . The Committee notes that the NCHSR has once again failed to rece ive funding to continue i ts once-active re search training effort. ~ 4

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Because the ccrnmit+-e is concerned by the instability of federal commitment to the total health services research effort, and because the programs of health services research training provided by the NTH and ADAMHA only supplement but do not supplant the wide range of program areas supported by the NCHSR, the Committee concludes that an extension of the NF.SA statutory aut. hority to include the NCHSR is warranted. The inc fusion of training through the NCHSR under NRSA will assure the government of the full benefit provided by investment in the training of these personnel. Recommendation. In order to assure the provision of ~ __ urgently required training funds, the Committee recommends a statutory amendment of. the NRSA Act to include all research training provided by the BRA. Because of the role these personnel play in conducting research relevant to national health care concerns, the Committee recommends that stat utory author) ~ y be provided at the earl Yes opportunity through pending ~ egislation, such as the Hospital Cost Containment Act of ~ 977. Modification of the Payback Provision With enactment of the National Health E1anning and Resources Development Act of 1974 (PL 93-641), opportunities for effective planning through research and evaluation activities become available nationally. Similarly, other nonprofit entities require evaluation anti measurement activities that characterize health services research, such as PsPo' s (PL 92-603) and HMO' s (PL 93-222) . Because trained heal th services research personnel contribute to these research efforts, the Committee considers subsequent employment in these kinds of organizations appropriate in meeting the NRSA payback requirement. The Committee believes that, properly interpreted, the payback provision requirements specified in the NRSA Act, as amended by the Health Research and Health Services Amendments of ~ 976 (PL 94-278}, includes employment in such nonprofit organizations as ~ ong as the employment requires and utilizes the research ski lis of the trained health services re searchers. Recommendation. The Committee urges the secretary of HEW to confirm that the NESA payback provisions permit the employment of health services research personnel in such nonprofit entities as Health Systems Agencies tHSA'S}, or to seek suitable legislative modification to provide for such 142

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employment should he conclude that this interpretation is not permitted by the pee sent law. Predoctora 1/Postdoctoral Training The Committee concludes that the research training reported by the NIB and ADA~4HA within the category of health services research is critical to the mission of each agency and shou 1d not be reduced or eliminated. For a number of years the NIMH has provided training for social scien Lists in the broad area of evaluation research, focusing an mental heal th and rel a ted services. This program was broadened by ADAM HA n FY ~ 975 to cover training for a wider variety of services, inch uding alcohclism and drug abuse a s we l l a s mend al heal ~ h. In view of the critical role the ADAMHA programs play in bringing these needed services to the nation, the Committee views the training of personnel to conduct research relevant to mental health services evaluation to require expansion at this time . The Committee approves the growth of the total number of awards for research training in FY ~ 976 from the level reported in FY ~ 975. The committee recommends that this program of res earch training, and that of NTH, continue to expand such that the tote ~ numbe r o f awar ~ s support e ~ r epre se nt s a ~ O pe rc ent per annum increment from the level reported in FY ~ 976. This increment shout ~ continue at the same rate through FY ~ 981, such that the total number of awards f or health services research training represent 250 in FY 1979 and 300 in EY 19 81 . In this way, the opportunity for skilled personnel to take up the sophisticated problems of services evaluation In area s of interest to the NTH and ADAMHA wi ll be as sured. The committee believes that the ma jor health care questions today also require the type of health services research training precariously of fered through the programs of the NCHSR. The Committee urges, therefore, the complete restoration of this program of training as soon as possible to a level that characterize s its peak year of funding (FY 972} at approximately 440 awards. Because of the difficulty involved in making recorrunendations that will permit the rapid but realistic restoration of a former program of training, the Committee vet ews the numerical recommendations developed this year as approximations that must undergo review in. the coming year. Hence, the principal goal that the Committee seeks in making its recommendations this year is the full restoration of research training of fered through NCHSR, at a rate to be determined by the administrative officers, but one that will permit the opportunities for new awards to be made available in each succeeding f ~ seal year. 143

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To penny ~ the entrance of individuals whose current espy oyment experience may be red event to health services research, the Committee recommends that the bulk of research awards in thi s area provided by NIH, ADAMHA, and the NCHSP be made at ~ he po~doc~ora~ level . Because the magnitude of train ~ ng needs is direct] y dependent on the availabi~ ity of federal funds to conduct an active program of health services research, the Committee recommends yearly review of the number of individuals to be trained, with subsequent expansion if research trends indicate such a modificat~ on is warranted. Recommendations. The Committee recommends that the NIB ard ADAMHA expand the program of heals h services research training reported in FY 1976 at a rate of ~ O percent per annum through FY 1981 ~ n accordance w' th the levels suggested in Tabl e 6. 3. At the same time, the Comma t' ee recommends the rapid re storation of the former program of research ~ raining provided by the NCHSR at a level represent ing its peak year ~ 4 4 0 awards) . Of the ~ ota ~ number of awards, the Committee reco~runends that up to 55 percent should be made available at the postdoctoral level. Iraineeships/Fel~ owships Heal th servi ces research requires the applicat ion of a variety of methods to the problems of health care and heal th car" delivery. As a resume t the institutional training grant, which permits the development of innovative interdisciplinary research -raining programs, may be viewed as the preferable e mechanism of support in this emerging research area. Indeed, in FY ~ 976 the number of traineeships provided by NIH and ADAMHA for health services research training surpassed the number of fell owships at a ratio of almost ~ ~ traineeships for every fellowship {see Table 1.11. The program of research training provided by the NCHSR since FY ~ 96 ~ represents a similar emphasis on traineeships (NRC, ~ 976a, Table II . ~ ~ ~ . Whi1 e the network of institutional training sites has been weakened in recent years by the absence of funds for continuing these programs of ~raining, it has not been eliminated. In the view of the Committee, however, there is an urgent need to restore support for institutional training capability in order to assure the continuity of support so important to the maintenance of program stability in this area. The committee suggests that traineeships be awarded primarily at the predoctoral level, although it may be appropriate in some instances for institutions to mix IDs4

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TABLE 6.3 Committee Recommendations for NIH and ADAMHA Predoctoral and Postdoctoral Traineeships and Fellowship Awards in Health Services Research Agency Awards Fiscal Year and Committee Recommendations 1975 1976 1977 1978 1979 1980 1981 Actual awards Total 183 191 Pre 132 121 Post 51 70 1976 recommendations Total 185 lamb 185b Pre 135 135 135 Post 50 50 50 1977 recommendations Total 550 715 740 Pre 225 415 430 Post 225 300 310 Total NIH/ADAMEA 250 275 300 Pre 160 175 190 Post - 90 100 110 Total HRA (NCHSR) 300 440 440 Pre 165 240 240 Post 135 200 200 Y 1976 awards were reported in 1977 subsequent to the release of the 1976 Report of the Committee. FY 1976 awards reflect an increment in the nether of training awards in health services research reported by the NIH. bIn this year's report the Committee has amended the recommendations it made last year so that the total neither of fellowships and traineeships recommended in FY 1977 is 210 and for FY 1978 is 230. 145

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predoc~oral and postdoctcral research traineeshiFs as circumstances dictate. However, predoctoral research that Ding through the institutional training grant works not only to provide the trainee with important interdiscip~ inary research expert ence as thesis work is developed, but al so to advance health service s research through the preparation of ski, led personnel who may move on to provide innovative research and research training following the ccmpletion of t hei r doctora ~ work. The research tra ining fellowship also plays a role, although more limited, in hea Ith service s research training . The talented investigator who has interest in pursuing a course of health service s re search training is provided the opportunity ~ o seek such training with a particular leader in this area or at an. ins ution where a critical mass of inve stigators may be working on the problems that characterize health services research. The Commi' ten views thi s mechani so of support to be suitable primari ly f or postdoctoral research training. In this way the fellowship may encourage the individua ~ we Ah some experience in the area of heal' h care policy to take up advanced training. Recommendations. The Committee recommends that _ trainee ships represent no les s than 75 percent of the total number of awards for health services research training. Up to 6 0 percent of the trainee strips should be made available for predoctoral research training a'_ this time. In contrast, up to 6 0 percent of the individual fellowships shout ~ be made available for postdoctoral research training as specif fed in Table ~ . 3 . Midcareer Re search [raining The Commit'_ee notes that heal ~ h services research Ferscnne] evidence many of the same characteristics of those in other newl y emerging areas of inquiry. Health services research personnel today primarily represent individuals who have been trained in a basic field or profession and who now occupy positions in health service research by virtue of their career paths, together with those whose interest in health services research led them to seek formal research ~raining. Hence, a program of "mid-career" research training in health services research might provide an ~ Important opportunity for number of individuals with similar interests in formal training. Midcareer research training could attract physicians with experiences as providers in the health care system, academi c doctorate s whose re search interest s have shi f ted to questions of head th care, and nondoctorates who desire the ~ 46

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acqui s it ion of r e sea rch ski ~ ~ s through f ormal emphasizes advanced techniques and methods in services research . The Committee recommends that the establishmen ~ of a midcareer research training program on a trial basis would provide opportunities for individuals whose employment experiences qual if ies them f o r advanced training in health services research. training that health Becommendation. The Committee _ ~ percent of the fellowship funds be the training of midcareer ~ health services research at stipend their level of career development. recommends that up to 5 0 set aside to provide for invest~qators in the methods of level s commensurate with Priority Fields Heal th services research personnel are drawn floor a variety of academic disco plines and professional backgrounds on the f ields problems of _ _ cony r i lout e s un ique ly to th e hea lash car" de livery. to work Each of these solution of the complex quests ons that face the health pi anner today. The committee has concluded that it would be inappropriate to single out particular disciplines for research training at this time. Instead, the Committee bed ieves that the professional community wit ~ determine the appropriate mix of disciplines and levels of training as research training proposals are developed for training In phi s area . 147

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FOOl~CIES l" This def Unction was developed for -the Survey of Health services Research Personnel and is based in part on the definition f ounce in the Pres idiot ~ s Science Advisory Comnittee (PSAC, I97 2) . 2. In 1955 the Congress aE:Fropriatec] funds to ir`Flement the demonstration authority of the Hospita ~ Survey and Cons ~ ruc tion Act of ~ ~ 4 6 . 3. For a fuller treatment of the impediments to the conduct of hea ~ th services research, see P SAC ( 1972) ~ 4. See The Part nersnip for Health A~end~rents (PE 90-174) for ~ snecif ication of this authority. 5. In ~ 974 the National Center for Health Services Besearch and I3~lopment (~liSRD) was rer:~amd the Nationa ~ Center f cr Health services Research (NC USP) . Either acronym wil ~ he used in the text to correspond with its use historically. Further, the term '~Center" will be Oslo throughout to refer to this federal unit. 6. These ~ and D activities store designed to f it together ~ the same community as an t'Fxperimental Health Services; Delivery Sys tent' ~ ERSES) . 7. This list of problem areas has been developed by the Panel on Health Services Research as part of its effort to survey the current empl oyment situation for health services research per sonne ~ ~ see Supplement 6) . B. A limited number of research training awards were provided through programs of research and training consolidated into the t3CH,S}RD in ~ 968. For purposes of analysis, the ir:~dividuals in training In EY 19 70 and beyond were utilized in the survey of heal th services research pers onne l. 9. The Social Sciences Divisior~ of the LIMB has provided research training in evaluation methods through such disciplines as sociology and social psychology. However. not all research trainees OCR for page 128
th is survey if tile y had on ly to complete thei ~ qualif ying inco~;pl ete support and failed doctoral exam ideations. 11. Although the NCHSR was established in EY 1968, programs of research Support were continued from the various bureaus and divisions which were comfrey tc ~ corn tale ~CHSR. 12. The aut hc~r inde x Maintained by Dr ~ Gerald the rosa shi not on 71n ivers ity Schoo ~ o f He di cine, Missouri, served as the? bilk iographic source icr sample. Only names with adequate addresses were this source' a nd from that of the NCHSR. Per kof f of st Louis this d :rawn f row 13. of course, some of these individuals are area of healths service s research since it: is their experience and familiarity with the problems of health care delivery that estabI ished this area of enquiry. 149 leaders in the