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HEALTH SERVICES RESEARCH PERSONNEL INTRODUCTION Many consume rs are puz zI ed by the pers i stent de f i c i enc ie s in health services in the United States, given the fact that the nation now spends more than $160 billion each year on medical care (Millon, 1975; Enthoven, 197Ba, b). Wh at i s not immed i ately apparent to the casual observer i s the fact that attempts to improve health services can g ive ri se to new problems even as the old ones are being corrected. The deci sion to extend the hours of an ambulatory care center, for example, may introduce temporary, new pressures in an otherwi se smoothly f unct ion i ng hospi tal . Assumi ng that sufficient resources are available, the hospital administrator may have to make adj ustments in the distribution of staf f, equipment, and support services to avoid problems in other parts of the hospi tal wh i ~ e improvi ng ambulatory care . Some attempt s to improve heal th serv i ce s g ive r i se to problems so complex, however, that administrators must first understand the factors involved before further ad j ustments to the heal th system can be made . Thi s i s the domain of health services research ~ HSR) . Medical services, for example, have shi fted over the years from the patient' s home to the physician's office and, more recent, y, to hospital centers. While more patients now have acce s s to the ~ ate st sc i ent i f i c and te chnolog i cal advance s i n the diagnosis and treatment of disease (e.g., mammography testing, g e ne t i c co un se ~ i ng , a nd imag Ed br a i n and body sc an s ~ , t he institutional) zation and modernization of medical services has drast i Cal ly al tered the phys i c i an-pat i ent rel at ionsh i p, the structure and f unction of hospitals and hospital administration, and the self-perceived role of the physician in these settings (Knowles, 1973; Millon, 19751. The subtlety of these new problems has led to such ~ iverse research as: studies of the social structure of the hospital, including physician-nurse interactions (Wilson, ~ 963; Stein, 1967~; quantitative assessments of medical service utilization (Mechanic, 1976 ); and behavioral studies of the psychological needs of the hospitalized child (Johnson, et al., 1976) and the dying patient (Glaser, 1966; Benoliel, 1975) e The revolution in mental health care has also given rise to complex problems that wi ~ ~ require more research in the coming years be fore f urther ad j ustments to the system can be made .

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Widespread appl ication of psychotropic drugs in the mid-1950' s, for example, has since resulted in the release of over 1.5 mill ion long-term residents from American mental institutions ~ Hoyden, 1978 ~ e "Community based care'' is avail able instead on an out-pat lent basi s through Commun ity Mental Health Centers (CHHC's) or on an in-patient basis through nursing homes, boarding houses, residential hotels, or halfway houses scattered throughout the country (President's Commission on Mental Health, 197S, Volume II; Golden, 19 78 ~ . Only now, however, is the impact of deinstitutiona' ization beg inning to be understood. A "stigma" continues to be attached to mentally and emotionally disabled people, resulting in community resistance to deinstitutionalization and in the "warehousing" of these former patients in certain urban programs (Research Task Pane' on CMHC's Assessment, President' s Commission on Mental Health, ~ 978~ . It is clear that research is needed on the mental he e, th services needs of people who are underserved or inappropriately served at this time (President's Commission on Mental Heal th, rat g 7 ~ ~ ~ Heal th se rv i ce s re se ar ch yi e ~ ~ s in format ion about the organization of the heal th care system so that future attempts to make adjustments in the system wit ~ be based on informed judgments. It draws investigators from a variety of scientific di sciplines who are familiar with the system under invest igation by virtue of training or employment experiences For over 2 years the Committee has identif fed health services research as an emerging area of national need and has attempted to describe the importance of federal support for research training in this area so that more sensible e allocations of our finite heal th resources can be made (NRC, 1975-77: 1977 report ~ . However, the federal role in heal th services research training cant inues to remain unclear . Th i s i s ~ ue i n part to the fact that the f i eld cant inue s to face cons iderab!e skept i ci sm among pubI i c of f i ci a ~ s and certa in scientific groups (Lewis, 1977; Last, 1977; Mechanic, 1978) anti, as a resu] t, does not yet have a secure institutional base either in government or in the academi c sector ~ Hamburg and Brown 1978 ~ . A number of federal initiatives currently pending, however, seem to indicate that the c] imate of support for health services research may be chang ing . In response to a request from the White House Office of Science and Technology Policy (OSTP), for example, the IOM is studying the organization and support of health services research,} the results of which wil 1 be available for review by the federal government later this year. De spi te the se uncerta i nt i e s, the Commi thee con t i nue s to bel ieve that federal support of training in health services research is amply justified by national needs for a better understanding of the forces affecting the delivery of health care to the population. The Committee therefore reiterates its recommendat ions for fel lowship and traineeship support under the NRSA author i ty wi th the hope that a f avorab, e cl imate for health ~2

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services research wi ll result eventually in the implementation of the recommendations developed by thi s Committee . DEFINITION OF HEALTH SERVICES RESEARCH AND TRAINING Federal support of health services research is based on the policymakers' concepts of the field, which vary in specificity with the policy issue being decided. In expanding earlier definitions for use in this report, the Committee and its Panel on Health Services Research have tried to make a clear statement which is broad enough to encompass the various health systems stud fed by HER personnel . The Committee recogni zes that there is no universally accepted definition of HSR (Myer, 1973; Rein and White, 1977; Mechanic, 1978) and has chosen the for lowing statement to guide its deliberations: Health services research is theoretical or-applied research which examines the organization and performance of heal th care den ivery systems and makes possible informed health care policy. It is a distinct area of inquiry in which systematic methods are appl fed to probe ems of the allocation of f inite health resources and the improvement of personal health care services . Health services research is most properly understood to be a problem area taken up by an investigator trained in a basic science discipline. In its last report, the Committee introduced the idea that HSR training can also be most easily understood if a two-dimenstional matrix is adopted in which one dimension represents the traditional discipline in which an HSR investigator has been trained. These include: 1 ) the behavioral sciences (anthropology, sociology, and psychology); 2) the social sciences (economics and political science); 3) the biomedical sciences (biostatistics, bioengineering, and epidemiology); 4) public health; and 5) such other fields as operations research, health administration, public administration, and health education. The major problem areas, which comprise the second dimension, fall into seven categories: l) studies of health personnel; 2) studies of various services including mental health and substance abuse programs; 3) economic studies; 4) studies of the quality of care; 5) legal studies; 6) behavioral and social studies of the individual or the community; and 7) innovative studies of health services design, including technology transfer. ~3

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. Figure 5.1 displays the two-dimensional matrix that has been developed. The Committee believes that this classification system has great potential throughout the federal government and in other public and private sectors to identify and support HSR and HSR training in the coming years. Occasionally, health services research has been distinguished from other health research on the basis of its relationship to other health sciences. The following model invokes the concept of a continuum of health sciences: At one end of this spectrum is basic research, usually laboratory-based, which is typically initiated by an investigator with no parti- cular treatment or prevention goal in mind. Next on the continuum are small-scale clinical investigations on a few patients and then large-scale controlled f ield trials . . (involving hundreds or thousands of individuals) that typically seek to delineate the effects of part icular interventions or risk factors in human health. At the far end of the research continuum are health services research, con- - cerned wi th the pract ical problems ar i sing in the provision of health care, and prevention research which explores strategies to prevent di sease in the f irst place (Hamburg and Brown, 1978 ) . It is convenient to c, assify heal th services research along a hypothetical health sciences spectrum such as that described above. However, this unidimensiona~ display may leave the mi sleading impression that health services research is an "applied" activity distinctly unl Ike the activities that comprise the other, more basic, sciences . In actual fact, heal th services research does inch use fundamental inquiry, often using the experimental methods developed by the social and behavioral sc fences. Thi s i st i not ion i s impor tent not one y for the support of health services research, but also for the ultimate acceptance of health services research training in the academic community. What di st ingui shes HSR psychology doctoral students, for example, from non-HSR peers may simply be the probe em area taken up for di ssertat ion study . The Committee and its Panel on Health Services Research have concluded that i t i s important to ~ i st the range of research approaches used by health services research personnel so that the work of these invest igators i s understood to paral lel that of other sc i ent i st s: ~4

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Primary Disc ipl ine of Research Trair~ing Elehavioral sciences Anthropology Soc iology P sychology Social sciences E:conomic s Pol itical sc fence Biomedical sciences Biostatistics Bioengineering Epidemiology Public health Other fields Opera~cions research Health administration Health education Public administration . . . . ~ ~ 1 Figure 5.1 primary disciplines of heal~ch services research ~craining and major researct problem areas. ~5 _ - . 0 c o ~n 0 eC o V P4 5: s ~ S ~ Major Research Problem Areas -- ' 1 c' ~ 0 ~ v a: s u) ~ . - ~n u u, v a1 a 0 ~o ~ ^ 0 ~ U) 0 ~ C) s ~ -~ X ~ ~ C) C) ~ X _ C: ~ C 1 - _~ 4~ ~ ~1 ~ ~ U) .,' ~ ~ ~ ~ ~ ~ ~ a ~ x ~ :3 z tn 0 c, s :~: 0 ..4 U) Q) u' ~c - 0 . ~ 0 u~ ~ i4 0 ~ tJ l ~ ~ :~ u x s ~ a ~o v 0 u, a1 ~ 0 0 c o .,, 0 P. o E eq L~ O ~C er O a ~ 0 E .^ 3 o x V U} ~ U, o 0 C) ~ c-- "a ~ ,4. ~C ~ ~,- U) U) `~ eC ~ ~C V - V X ol :t _ ~1 ~ o U) a, 0 ~ o og a. #S ~ 0 ~ x 0 :~: ~4 o 0 0 ~n 0 c - =~- ~ v ~ ~ ~ o u) o. - - c ~ ~ E ~ ~ ~ ~ U O ~ O X V] O _ u) C ~ u' o a 0 u, ~ v ~ o' v ~ o' -

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Primary Research Approaches of Health Services Research Personnel Health statistics Statistical indicators (including health status indicators) Computer models Case studies Clinical studies Social experimentation Survey research Evaluation research (including program evaluation) Technology assessment Decision analysis Policy analysis In summary, health services research is a distinct area of scientific inquiry that examines health systems to make information available for future adjustments to the system. It- draws scientists from a variety of backgrounds who are distinguishable from their colleagues chiefly on the basis of th problem they elect to study--namely, the health care system. While health services research may be understood to occupy a unique place among the health sciences, its research methods are similar to many basic sciences. CURRENT FEDERAL EFFORTS IN HEALTH SERVICES RESEARCH TRAINING Using the operational definition of health services research training given above, the Committee has reviewed the training programs of a number of federal agencies. NRSA Authority e NIH. The basic mission of NIH is to "advance the Nation's capability for the prevention, diagnosis and treatment of disease through biomedical research" (NIH, 1976a). As the interests and responsibilities of the 12 component institutes have broadened to include activities that transfer and disseminate biomedical research findings, health services research has been supported as part of other NIH clinical research endeavors. In recent years, for example, NIGMS has supported research on the- social and legal problems of human genetics research, including the impact of genetic screening (NIH, 1976a). Similarly, the National Heart, Lung and Blood Institute has begun to support studies that explore different models of service delivery to reduce cardiovascular risk and to control hypertension, obesity, and smoking (Evans, 1978~. ~6

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While the Committee acknowledges that the NIH provides some support for health services research, it has been unable to demonstrate support for HSR training by NIH under the NRSA authority. Although NIH sponsors research training in basic fields related to HSR, such as biostatistics, epidemiology, and public health, a review of the NRSA training grants currently supported under the NRSA authority led the Committee to conclude that these programs do not fit within the definition of HSR training developed in this report. Hence, recommendations for research training in these fields have been developed by the Panel on the Basic Biomedical Sciences (Chapter 2~. It may be possible that HSR training is indeed provided at some institutions receiving NRSA support from NIH in these areas. However' it is not evident from the data provided by the agency. The Committee and its Pane' on Health Services Research would f ind it helpful i f the NIH would use the two-dimensional system described earlier in this chapter when collecting information about their NRSA programs. This system would permit the recognition of any formal health services research training that may be supported by the various institutes, and would permit the development of appropriate recommendations for research training support. - ADAMHAe Since the enactment of the NRSA Act in 1974, the research training programs of ADAMHA have included opportunities for mental health services research evaluation training. The mental health services training programs are an important outgrowth of the evaluation training programs of fered in the social sciences division of the NIMH since the late 1960's and seek to develop a "pool of highly qualified researchers trained to develop, apply and refine appropriate scientific methodologies for the study of problems related to the delivery of mental health systems ''(Appendix B 3.1 and 3.2~. HSR training opportun ities are also provided to study health care delivery systems in the field of alcoholism and drug abuse and preventive and rehabilitative services in this area. As part of its 1978 report, the President's Commission on Mental Health outl ined a national plan to meet the needs of people with chronic mental illness. As a first step in implementing the plan the Commission recommended that the Department of Health, Education, and Welfare, in consultation with state and local governments, develop a national plan for: a) the continued phasing down, and where appropriate, closing of large state mental hospi tat s; ~7

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b) the upgrading of service quality in those state hospitals that remain; and c) the allocating of increased resources for the development of comprehensive, integrated systems of care that include community-based services and the remaining smaller state hospitals. - If implemented, these recommendations suggest a continued prominent role for HSR and HSR training in ADAMHA. Division of Nursing. The Committee notes that the HRA - Division of Nursing supports nursing health services research and urges that the number of awards for training in nursing health services research be increased. The Committee notes that of the 120 approved NRSA fellowship applications in FY 1977, only 4 were approved for health services research training (Gortner and Bourgeois, 1978~. Because of the increasingly prominent role nursing services play in the delivery of health care, the need continues for available skilled personnel whose professional training prepares them to conduct research relevant to the improvement of the nursing health services. Other Federal Efforts In addition to the HSR training opportunities offered under the auspices of the NRSA authority, HSR training support has been identified in a few other federal agencies. The Veterans Administration (VA), for example, has a program to train HSR personnel for research pertinent to improvement of VA health services.' Twenty individuals presently receive such support through the general education authority of the VA.2 The Stealth Services Research, Health Statistics and Medical Libraries Act of 1974 (PL 93-353~3 authorizes intramural and extramural HSR training authority for the NCHSR, although lack of funding since FY 1973 has virtually eliminated this program of research training even though the training authority continues.4 This review of HSR programs may not be complete if opportunities for HSR training are available in other federal agencies not yet examined by the Committee, such as the Health Care Financi ng Admini stration (HCFA) . In the coming year the Committee ant] its Panel on Health Services Research will study this further.

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FI ND INGS F ROM TH E INVI TAT IONAL CONE ERENC E ON HEALTH SERVICES RESEARCH PERSONNEL In its 1977 report, the Committee provided findings from its survey of 500 individuals who had once received support for HSR training.5 Over 65 percent of the former trainees responded, with 80 percent of those indicating that they conducted health services research at the time of the survey, October 1976. The results led the Committee to conclude that current employment conditions for these HSR personnel were "good" (NRC, 1975-77: 1977 report). Because it has been difficult to develop a statistical base from which market estimates could be made for health services researchers, the Committee took a new approach to labor market discussion. Together with its Panel on Health Services Research, the Committee convened a l-day-Invitational Conference on Health Services Research Personnel (Appendix C) which brought together representatives from-public and private organizations that employ and/or train HSR personnel.6 Discussions focused on four major areas of concern: 0 How many people are engaged in health services research? How large is the pool of available HSR personnel? What creates the demand for HSR personnel? What is the current demand? Is this expected to change? O What attracts people to careers in health services research? o How has declining federal support in health services research training through NCHSR affected the insti- tutional training environment? Estimating the Number of HSR Personnel Any study that attempts to guide federal policies for research training support on the basis of market descriptions requires such minimum information as the estimated number of investigators in the U.S e labor force in a given year.7 Because of the peculiar way in which health services research personnel are identified, however, the Committee believes that an estimate of the pool of these scientists will not be readily forthcoming, if it can be achieved at all. As a result it will be necessary to develop alternative approaches to labor force discussions in this area. 119

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As the definition' introduced earlier in the chapter suggests, HSR personnel are trained in a basic science discipline while they apply their research skills to some aspects of 'the health system. The identification of these personnel is hampered by the fact that'.most sta,tistica' data' sources estimate the number of scientists in-a given field on the basis of their main field of training (e.g.,.the Doctorate Record File) or their.m-ain field of employment (e.g., the Comprehensive Employment Roster). No data base exists that collects information on the number of doctoral scientists who conduct health services research as their primary specialty area.- . Earlier in the chapter the Committee identified a number of disciplines that typically represent fields in which HSR may be trained, such as anthropology, biostatistics, or public health. It would beta gross error to use tine' estimated number of doctoral scientists in each discipline tin a particular year as an estimate of the pool of,avaiJab~e HSR personnel, since health services research personnel differ' from their discipline colleagues in their familiarity with the operation of the various health care ' systems. For over 2 years the Committee has worked.cl.osely with representatives from the NCHSR and ADAMHA in developing a statistical data base that would begin 'to describe the number of doctoral~y trained scientists who conduct hea'1th,services research. Over 1,700 individuals have been identified thus far as once having received,support from the NCHSR as principal investigators on health services research grants or contracts or as having, rece ived federal f unds from the NCHSR or ADAMHA to train in health servi ces research. An extension of the prel iminary s urvey of the se per sonne 1 re port ed by the Commi ttee last year is being conducted at this time and should be useful in describing the current research act ivities of these personnel . While the survey responses of past recipients of federal support shout ~ be a f ir'st important stem in est imating the number of available HSR -in the U.S. doctoral ~ abor force, it is' uncertain at this point how much further statistical analysis can be achieved. Other approaches to describing the pool of these investigators will be examined by the Committee in the coming year. Est imat ing Employment Opport uni t ie s in HSR . , . In recent years, opportunities for employment in health services research have 'become expl icit as research and evaluation personnel have been sought by CMHC' s, the VA, Health Systems Agencies (HSA's), and state and local departments' of health. Academically affi1 fated Centers for Health Services Research have been established at eight institutions in recent years, and it is 120

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clear that they will serve as.both "users. and "producers" of HSR personnel.8 Finally, for profit research firms and third party payors have created job categories which' at least implicitly, suggest another market for HSR personnel At the HSR Invitational Conference, every representative from the public sector described multiple statutory requirements to conduct health services research that cannot be fulfilled without increased numbers of personnel who are.familiar with the ' structure and operation of the health system to be studied. 'In some instances, where funds are available for hiring HSR personnel, such personnel have had to be trained on the job, often retarding completion of the research task within the time required. ~ . ' , '' According to several conference participants, the'market for mental health services research personnel in particular is "booming" and may be expected to continue to expand following the release of the report by the President's Commission on Mental Healthy Mental health services research, it must be added, further requires familiarity with human services delivery systems, narrowing employment opportunities further to those with relevant training. - On the whole, public sector employment in health services research revealed a shortage of personnel with the skills '' necessary to take up legally mandated assessments of the healt'h-'' system in question, whether CMHC's, HSA's, or VA hospitals. ' Representatives from the private sectori indicated that employment opportunities in health services research were ' directly related to the funds available from government' end other sources to conduct this research.' At the present time employment' conditions appear to be in equilibrium. ' In summary, the findings from the Invitational Conference on HSR Personnel convened by the Committee reveal that these investigators are being sought by a variety of employers.' Furthermore, while on-the-job training has been provided in Certain instances, it was not the preferred approach to hiring investigators by the majority of employers who participated in the conference.' Impact of Lost Training Grant Support In A number of conference participants once received institutional training grant support from the National Center for Health Services Research to provide HSR training . Wi thdrawal of support from the academic sector by the federal government in recent years was described as having a profound effect on the research tra, Ring environment . Among the consequences of lost training grant support cited by conferees were reductions in enrollments and quality of students; a greater number of part-time students; absence of 121

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travel funds to bring speakers to campus and to provide students with important, off-campus experiences with local health care delivery systems; and lack of funds to buy important support services, such as computer center services, and to hire support Stafford Some program directors have been able to supplement lost training grant support with research assistantships for their students. However, this appears to vary from institution to institution. In contrast to the loss of training grant support for noncategorical HSR training, representatives from mental health services research enjoy a favorable climate for support under the auspices of the MRSA authority. Some noted a proliferation of institutional sites that provide interdisciplinary training in this area as a result of increased funding.~2 In summary, it appears that the availability of NRSA support for training in mental health services research has resulted in expansion of the sites engaged in mental health services research training. In contrast, the dramatic reduction in federal support of HSR training through the NCHSR is beginning to be felt by those institutions that once provided such training. While some departments, especially in the behavioral sciences, have been able to shift to NRSA support by shifting training to mental health services delivery questions, this appears to be the exception rather than the rule. RECOMMENDATIONS Predoctora1/Postdoctoral Training The Committee recognizes that ADA MHA plays a crucial role in delivering mental health and redated services to the nation. Joining with the President's Commission on Mental Health, the Committee calls for a renewed emphasis on mental health services research relevant to the design and evaluation of these services (President's Commission on Mental Health, 1978~. At the present time the Commun ity Mental Health Centers Act of ~ 975 requires the preparation of statewide and regional mental health plans for the purposes of improving the qual ity of mental heal th care through this federal ly subsidi zed system. Recog- niz ing that poor planning can " confuse pr iorities, ~ ivert :~dmin- istrative energies and waste money, " the President' s Commission on Mental Heal th recommended that -: The National Institute of Mental Health al locate to a selected number of programs an award of ~ O percent in excess of their 122

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grant for the purpose of developing and assessing techniques to evaluate mental -heal th service delivery. This recommendation must be applauded, given the urgent need to improve the quail ty of mental health and substance abuse services in this country. However, the Committee would like to stress that. more f unds for research in thi s area can only be effective if there is a larger pool of investigators who are f amili ar wi th the se rvi ce s to be eval uated . In view of these needs, the expansion of HSR training programs by ADAMHA should be continued. The Committee notes, however, that funding has remained level in thi s area in recent years ( Table 5. 1 ) and urges ADAMHA to expand its program of USR support at a rate of 10 percent per year from the level reported in FY 1976. This recommen<3ec] rate of expansion i s based on current perceptions of the rate at which institutions can develop appropriate HSR training programs in this area, given current levels of NRSA support. Careful monitoring of the development of research capabilities in this area will be required so that suitable adjustments to this recommendation can be made. Recommendation. The Committee reaffirms its recommendation that ADAMHA expand its program of HSR training at a rate of 10 percent per year based- on FY 1976 levels of support through FY 1982. The HSR training programs of ADAMHA, the Division of Nursing, and the VA focus on training in problem areas relevant to the health system in which the training is conducted. Hence, this training prepares specialists for employment in such specific locations as CMHC's or the VA hospital, where the special area of expertise can be used. Based on the HSR Conference discussions, these training programs do not appear to satisfy the need for research personnel familiar with the medical and other services monitored by such planning agencies as the RSA. Because the Committee considers the NRSA authority to be appropriate for supporting investigators whose HSR expertise goes beyond mental health services and nursing health services research, the Committee urges that a program of general health services research training be established. Such a program would assure the production of investigators to take up the research and evaluation required by a variety of federal laws, investi- 123

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~4 A o v o A o pi o v to Pi o TO u) o - o pa v o ~ ) A , al v lo; a) EN v2 oO lo Go rid v A Cal us A v) ~ o 3 , REV ~ o V o o o 0 Ln ~n 0 ~ u~ O ~ ~ O 0 U~ U) O ~ \9 ~ t ~ ~1 ; O ~ ~ ~ d. O 0 U~ U) O O O r~ ~ ~ ~ ~ n ln 0 CS) ~ ~ oo ~ U~ ~ C~ ~1 CO ~q O ~ O E~ Q' ~ ~n o . - V . ~ a) ~ k9 0 ~ O E~ ~ ~ ~Q o . - o V ~ O ~ O t~ E~ ~ ~ 124 ~n o .,, a) o v ~ ~ U] o ~ o E~ ~ P~

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gators who appear to be in short supply at this time according to conference participants. Recommendat ion. The Commi ttee recommends that a program of general heal th services research training be established uncier the NRSA author i ty . Traineeshi ps/Fellowshi ps The institutional training grant, which permits the development of innovative interdi sc ipl inary research training programs wh ile it strengthens the research setting, i s viewed as the preferred mechan i sm of support i n th i s emerg i ng re sear ch area . The Committee notes that in FY 1976 the number of traineeships provided by ADAMHA for heal th services research training surpassed the number of fellowships at a ratio of almost I~ traineeships for every fellowship, (Chapter I, Table l.] ). The research training fellowship also plays a role, although it is more limited, in health services research training . The talented investigator who has interest in pursuing a course of health services research training is provided the opportunity to seek such training with a particular investigator or at an institution where a critical mass of investigators may be working on the types of probe ems of interest to the fellow. The Committee views this mechanism of support to be suitable pr imarily for postdoctoral research training, since the availability of fellowship support may encourage individuals with some experience in the area of health care policy to pursue advanced training. Recommendations. The Committee recommends that traineeships - represent no ~ ess than 75 percent of the total number of awards for health services research training. The majority of traineeships should be used to support predoctoral research training . The majority of fellowships should be awarded for postdoctoral tra i n inq . Midc~reer Research Training Many he al th se rv i ce s re se arch pe rsonnel today are i nd iv ice ua1 s who have been trained in a basic science f ield or health profession but who have had little or no formal training in health services research . While cont inued emphasi s ought to be placed on the 125

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development of HSR training programs for predoctoral and postdoctoral training, ~ program of midcareer research training in health serv ices research might provide an important opportunity for employed health services research personnel to obtain formal training. If the funding level were adequate, a program of support for mid career research training could attract physicians wi th experiences as providers in the health care system, academi c doctorates whose research interest have shifted to questions of health care, and nondoctorates who desire to acquire through formal training, research ski 1 Is and advanced techn ique s in health servi ce s re search . Midcareer research training might be provided through short, surruner courses on methodologies relevant to health services research . It might al so include academic training for 1 year during " sabbatical leave r t' or as much as 2 years of work as a postdoctoral appointee in a manner similar to the Robert Wood Johnson C1 inical Scholars Program ~ Beck and Smith, 1978 ~ . The Committee wi 11 explore possible roles for NRSA support for midcareer research training in health services research in the coming year. 126

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FOOTNOTES 1. Thomas Bice, in a statement before the NRC Panel on Health Services Research, January 20, 197S, Washington D.C. The Committee has established informal liaison with the TOM Committee to discuss areas of common concern. 2. Carleton Evans, VA, NRC Invitational Conference on HSR Personnel, May 17, 1978. 3. The Act also provides the National Library of Medicine with the authority for research training in information systems design and development, which undergirds medical record keeping today. 4. All that remains of this once active research training effort is a small research grant program for dissertation study that provides funds to doctoral students whose research is related to the improvement of health care. 5. These individuals received predoctora~ or postdoctoral research training support some time after FY 1970 from-the NCHSR or since FY 1975 from ADAMHA. 6. The May 17 NRC Invitational Conference on HSR Personnel included participants listed in Appendix C as well as observers from such organizations as the American Psychological Association, the Pan American Health Organization, NIH, NCHSR, and the private sector. 7. See the market projections, for example, found in Chapters 2, 3, and 4e B. Sam Shapiro, The Johns Hopkins University, NRC Invitational Conference on Health Services Research Personnel, May 17, 1978. 9. P. Wortman, Northwestern University, and W. Goldman, San Francisco Community Mental Health Services, NRC Invitational Conference on Health Services Research Personnel, May 17, 1978. 10 e These included representatives from the Rand Corporation and the BI ue Cros s/Bi ue Sh i eld As so c i ation. 1 1 . Rober t E i chino rn, Purdue On iver s i ty and Barbar a St ar f i eld , The John Hopkins University, NRC Invitational Conference on Health Services Research Personnel, May 17, 1978. 12. P. Wortman, NRC Invitational Conference on Health Services Research Personnel, By. cit. 127