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5. Health Services Research The field of health services research (HSRJ is in a paradoxical situation. Problems that can be addressed in this field are increasing in number and variety at a time when funds for research have been sharply reduced. The short-run outlook for funding of health services research is not bright, but there is a good chance that the demand for HSR wiZ1 expand substan- tially in the next decade. Training in HSR should be directed to provide broad research skills to health professionals and others. More information is needed about the programs for training and research conducted in university-related health services research centers. UNTRODUCTION Health services research is concerned with issues involved in the health care system. This system is in many respects excellent, yet it has many faults. It is the role of health services research (HSR) to identify, explain, and suggest remedies for those faults. HSR has led to some basic understanding of these problems. For example, those who are both poor and nonwhite receive the least health care in relation to their needs. There are too many hospital beds in some areas. Well tested disease prevention measures are not applied widely enough. Above all, the system of health care and delivery is extremely costly in relation to the volume and quality of care that is delivered. The total health care costs of the nation now exceed S250 billion per year--a quarter of a trillion dollars.) Clearly, the goals, practices, and efficiency of governmental health activities are both a national economic issue of high importance and a major determinant of the quality and availability of health care. iAll figures in this section are from the U.S. Bureau of the Census, 1981, pp. 99, 276, 421, 424. 117

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118 Efforts to make the system more effective should rest upon a research base. Many policy choices of broad scope are properly political decisions because they affect The interests of important contending parties. But the framing of alternative proposals and many of the considerations influencing choices should rest upon research--the collection, analysis and interpretation of relevant facts. Research can illuminate the cost and the effectiveness of alternative approaches, provide a factm 1, analytical base for the debates, and reduce areas of speculation and uninformed polemics. Otherwise choices are made with insufficient information and ~ stakes are made that can cause great harm in both human and economic terms. THE SCOPE OF HEALTH SERVICES RESEARCH Examples Health Services Research, dealing as it does with a diverse and complex area of human activity, encompasses a wide range of inquiry and many research methods. It includes such significant fields of inquiry as the definition and determinants of the effectiveness and efficiency of prepaid medical care plans, various approaches to health insurance, health maintenance organizations and group practice, the role and scope of primary care, the assignment of patient care tasks to various health professionals, the efficiency of hospital operations, and nursing delivery systems. A sense of the breadth of the field and the multiplicity of approaches can be provided by describing a few of these important areas of investigation. Access and Equity The continuing national debate over the availability of medical care to various population groups has been fueled in part by health services research. These studies have also provided one of the bases for legislation and administrative action. For example, Medicare and Medicaid are more than systems which generate problems of cost containment. They are social measures designed to make medical care available to old people and poorer people. Studies which showed that low socioeconomic status was related to low physician utilization were followed by investigations that showed areas of improvement over the years.2 For example, in 1976, the fifth of a series of national household surveys shed further light on 2 One of the most significant of these analyses was: Ronald Andersen, Joanna Kravits, and O. W. Anderson, 1975.

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119 the use of expenditures for and satisfaction with formal medical care and on the appropriateness of the care .3 It showed that there have been substantial improvements in access in the U.S e over the past 25 years, but that pockets of inequity remain. The report was widely disseminated and commented upon. Although the meaning of the findings for health policies was interpreted differently by different interests, the validity and relevance of the study for health services delivery decision making were generally accepted by all. The study contributed vital information to the current debates over national health insurance and other large-scale health policy measures. Cost Containment There is an urgent national need to control hospital costs without reducing the quality or volume of needed hospital services and without disrupting the hospital system itself. One approach is to pay hospitals the same amount for similar cases. This can be done, in theory, by classifying hospital cases into a manageable number of categories that are reasonably homogeneous in resource use and cost, and then establishing how much will be paid for cases in each category. A reduction of the theory to a useable system has been a formidable task. One research team, having worked on the problem for several years (HCFA, 1982, pp. 7 and 48), developed a system of diagnostically related groups (DRG's) using data from 500,000 discharge records. Legislation based upon the concepts and specifications developed by this effort in health services research was enacted on March 9, 1983. High Technology and Health Care While the rapid advance of technology has extended the capability to deal with hitherto intractable health problems, it has raised questions of resource allocation and cost containment. These in turn are complicated by ethical considerations. Health services research has generated information relevant to these problems. Renal dialysis is a case in point. Research showed that between 1973 and 1977, the proportion of patients dialyzing at home dropped from 36 to 13 percent (HCFA, 1982, pp. 7 and 48~. The decline was the result of a Medicare amendment in 1972 which penalized patients who dialyzed at home. Additional research showed that dialysis in a medical facility costs $22,000 per patient per year while home dialysis costs $11,800 per year. As a consequence of these analyses, Congress in 1978 enacted legislation to encourage home treatment, and per patient costs subsequently declined by 3.5 percent in 1979 . 3 The study, Health Care in the United States: Equitable for Whom, was financed by the Robert Wood Johnson Foundation and the National Center for Health Services Research. I t was conducted by the Center for Health Adm nistration Studies of the University of Chicago, and was based upon interviews with 8,000 people in 5,000 families. For an earlier assessment of problems of access, see Thomas W. Bice, Robert L. Eichhorn, and Peter D. Fox, 1972.

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120 Definition, Methods, and Gods Describing the field in more general terms, health services research examines ways in which the organization, delivery, and financing of health services affect the equity, effectiveness, and costs of the personal health services systems of the country. The inquiries produce knowledge about the structure, processes, or effects of personal health services. In other words, systematic methods are applied to problems involved in the allocation of finite health resources with the aim of improving the health care delivery system and making information available for future adjustments to the system. In terms of approach, the special capacities and insights of a wide array of disciplines are brought to bear upon problem areas.4 Most health services research is interdisciplinary. The research techniques include health statistics, statistical indicators (including health status indicators), statistical modeling, case studies, clinical studies, social experimentation, survey research, evaluation research (including program evaluation), technology assessment, decision analysis, and policy analysis. Much health services research, such as that described in the preceding section, involves pathfinding inquiry into basic concepts, the development of new research methods, the solution of definitional problems, and the testing of hypotheses related to important aspects of health care. This can be called policy research. These types of investigations often require collaboration among people from different disciplines. Most of these studies are designed and carried out by investigators associated with organizations (departments, schools, or centers) attached to universities. The principal investigators are most often faculty members engaged simultaneously in research and training of graduate students. 4 The health services chapter of the 1978 Report of this Committee (NRC, 1975-81) presented a cross tabulation of primary disciplines and major research problem areas to define the field. The disciplines include (p. 115~: 1. Behavioral Sciences: Anthropology, Sociology, Psychology; 2. Social Sciences: Economics, Political Science; 3. Biomedical and Clinical Sciences; 4. Public Health Measurement and Analytical Sciences, Epidemiology, and Biostatistics; 5. Other Fields: Operations Research, Health Administration, Health Education, and Public Administration. The problem areas include: Health Personnel, Mental Health Personnel, Ambulatory Care, Child Health Services, Dental Health Services, Emergency Health Services, Indian Health Services, Long-term Care, Nursing Health Services, Pharmacy-related Health Services, Rural Health Care Services, Mental Health Services, Drug Abuse Prevention Programs, Alcoholism Prevention Programs, Access and Equity of Health Services, Inflation and Cost Containment, Health Insurance, Quality Assurance, Legal Aspects of Health Care, Health Politics, Community Studies, Health Education, Sociobehavioral Aspects of Health Care, Health Services Design and Development (including technology transfer).

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121 At the other end of the spectrum are very large numbers of relatively small inquiries whose purpose is to make specific institutions more efficient. This can be called managerial research. It is in a sense more practical than the more widely applicable investigations because it has tangible, immediate effects. Some of this research is carried out by investigators associated with such operating organizations as hospitals, clinics, health maintenance organizations, state planning organizations, and federal agencies. For this report, the entire spectrum is included in health services research. However, as will be pointed out later, the demand and supply situation in the two categories appears to be somewhat different. THE SUPPLY OF INVESTIGATORS Who Is a Health Services Researcher? The diversity of health services research requires investigators with diverse backgrounds and diverse specialized training. A competent principal investigator in health services research must have two sets of qualifications. The first is an adequate grasp of a discipline or profession, such as those listed in Footnote 4, at the undergraduate, masters, or doctoral level. The second set of qualifications is an understanding of some aspects of the delivery and financing of health care and a mastery of suitable research methods. Included are such areas as quantitative measurement of access to health care by various socioeconomic groups, means of assessing the quad ity of health care, medical care ethics and the law, the technical aspects of cost reimbursement, the politics of health care, management of health care delivery organizations and the administration of prepayment and health insurance plans. This training, it should be noted, is not disciplinary although a substantial portion of the students who train for health services research are awarded degrees by disciplinary departments just as in the case of biomedical and clinical sciences. These arrangements further complicate the task of counting the number of investigators capable of conducting health services research. Because of the increasing complexity of the field, it is becoming progressively more difficult for those trained in specific disciplines or professions to conduct health services research without additional formal training to provide the second set of qualifications. University-based investigators (plus a few investigators associated with other institutions which conduct research and related advance training) provide most of the additional HER training. Part of this training is given in courses. However, most of it is derived from seminars, discussions with other students and faculty, field work, and, most important, preparation of a dissertation. Most of these activities are conducted within centers for health services research.

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122 Their prime contribution, realized more fully in some centers than in others, is to provide an environment in which direct, first-hand experience with, and exposure to, the health care delivery system is combined with organized study of health services issues, research problems and appropriate research methods. These are combined at the highest level in the production of the doctoral dissertation, which is the most significant event in the training of new investigators. This evolution of educational patterns towards specialized HSR training added to earlier disciplinary training has produced two kinds of health service researchers. "One, principal investigators, is older, almost exclusively men (91 percent) and is comprised of a large number of medical degree holders (36.8 percent) as well as research doctorate holders (41.3 percent). The second group, former trainees, is younger, includes more women (46 percent), and is comprised predominantly of research doctorate holders (68.4 percent) with a much smaller portion of medical doctorates (9.4 percent) (Ebert-Flattau and Perkoff, 1983~.~ Finally, a distinction must be drawn between the training required to plan and execute the ~policy" and the "managerial" research discussed above in the definition of HSR. The annual number of investigators produced at the doctoral level whose area of expertise is HSR is relatively small. Most of the managerial research is carried out by investigators with masters degrees. The annual number entering the field at the master's level is large relative to the number of Ph.D.s. The Number ofInvestigators The most comprehensive effort to estimate the number of active researchers in HSR fields was a 1978 survey conducted by this Committee which found the following: "Over 1,370 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 received federal funds from the NCHSR or ADAMHA to train in health services research.0 (NRC, 1975-81, 1978 Report, p. 120) The 1,370 figure includes some trainees who did not develop into investigators, and it excludes some investigators whose work was not federally supported. With the reservation that the figure is imprecise, 1,370 is taken for this report as a reasonable estimate of the number of health services researchers in 1977. As a point of comparison, in 1977 there were 31,000 biomedical science Ph.D.s (excluding postdoctoral appointees) in academic employment (NRC, 1975-81, 1981 Report, p. 58) and about 9,800 M.D.S primarily engaged in research (ibid., p. 39~. The health services investigators thus comprise 3.4 percent of all bioscience investigators. By 1979, there were 14,515 M.D.s primarily engaged in research and 33,980 biomedical Ph.D.s in academic employment (ibid., p. 58) for a

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123 total of 48,495. We believe that the number of health services researchers has fallen relative to other fields, but this cannot be verified at present. If we assume that the number of health services investigators remained at 3.4 percent of the combined number of biomedical and clinical investigators, we derive a rough estimate of about 1,650 active investigators in health services research in 1979. The 600 members of the Committee on Health Service Research of the Medical Care Section of the American Public Health Association provide a reasonable lower limit on the number of investigators. A fair approximation of the number of active investigators is about midway between 1,650 and 600, or about 1,100. This includes both junior and senior scientists with a masters degree, a Ph.D. degree, or an M.D. degree. Unless there is a sudden increase in the demand for HSR investiga- tors, the annual number of new entrants needed to sustain the current stock is not large. These new entrants will be from a very large pool of persons in related disciplines who have an M.S., M.P.H., Dr.Ph., Ph.D., or M.D. degree. The central problem in training health services investigators is not the supply of persons capable of being trained for this sort of research but rather attracting candidates of high quality, securing faculty positions for them, and securing funds for the research that is an essential part of advanced training. It should be emphasized that the Committee was unable to find sufficient data to better estimate the current supply of health services researchers, much less to develop reasonable quantitative estimates of future demand. In this sense the situation in hey th services research is very different from the biomedical, behavioral, and clinical sciences discussed earlier. Support of Graduate and Postdoctoral Students Graduate and postdoctoral students trained to perform health services research are the next generation of principal investigators. The number of students in the field, and to some extent the quality of the students, depend to a degree upon the availability of funds to finance their graduate work. Federal Support This Committee has in past reports recommended a modest program for graduate training in HSR under the NRSA authority. Nevertheless, federal traineeships and fellowships for graduate students in health services research have virtually disappeared. From a total of 406 fellowships and traineeships in 1975, there was a drop to 176 (174 traineeships and 2 fellowships) in 1980 and to zero in 1981. Even so, there is reason to believe that some training support in health services research is currently being provided by the NIH and ADAMHA. But because of difficulties with definitions, taxonomy, and the like, such training is not identified by the agencies as being in the category of HSR. Furthermore, this training is narrowly confined to

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124 the special interests of particular Institutes within these agencies. But health services problems tend to be quite broad. We believe that training in HER should be correspondingly broad and should extend beyond the interests of individual Institutes. Thus, as noted in Chapter 1, we have recommended a continuation of NRSA training awards in HER through 1987. Nonfederal Sources Few fellowships are available from university sources for gradm te students training for health services research. A small proportion of the graduate students have jobs as teaching or research assistants. It follows that most graduate students in the field are self-supported with funds derived from their own or their spouses wages or savings, loans, or in relatively rare instances, family support. These observations are based upon the impressions of program directors since no survey of sources of support for graduate students in this field has been conducted. DEMAND FOR HEALTH SERVICES RESEARCHERS The demand for investigators in health services research is derived from the funding of such research by public and private organizations. In measuring this demand, a distinction must be drawn between "need. in the sense of staff required to conduct what may be considered a desirable level of investigation and "demand. in the sense of jobs that must be filled if research actual- funded is in progress. Some may feel that the country would benefit highly from a more intensive health services research program in all of the areas described above. In this sense, the country "needs" more health services research and if this need were met the country would require more trained investigators for health services research. In its discussion of long-term considerations later in this chapter, the Committee has adopted a "needs. approach on the grounds that there will be both wider recognition of dependence on expanded health services research and that increased resources will become available. However, this Committee does not believe that kneads so defined is a sound guide to forecasts of requirements for investigators over the short run. Instead, the Committee has consistently preferred to assess short-range demand in terms of positions required to carry out research that is expected to be funded under realistic assumptions. Federal Funds Budgeted From the ~ d-1960s to the early 1970s, federal expenditures for health services research grew at an average rate of 24 percent per

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125 year in current dollars--faster than either biomedical research or national health expenditures (NRC, 1975-81, 1976 Report, p. 60~. However, since the early 1970s, there has been a steady decrease in federal agency budgets specifically for health services research. The level was an estimated $79 million in 1972 in current dollars. By 1979 it had declined to $54 million.5 In constant 1972 dollars, the 1979 level was only half the 1972 level. Reductions have occurred in the budgets of all federal agencies with health services research programs--the National Center for Health Services Research, the Health Care Financing Administration, the National Institutes of Health, and the Alcohol, Drug Abuse, and Men tat Health Adam nistration. Reductions in the budget of the National Center for Health Services Research, the only entity empowered to finance health services research not linked to the operational responsibilities of an agency, have been particularly sharp. In constant 1972 dollars, the 1981 level was only 27 percent of the $60 million 1972 level. Reductions of this magnitude have affected all phases of the program of the agency. Institutional training grant support has ceased. The consequences for those centers which lost this type of support were reported by center directors (NRC, 1975-81, 1978 Report, pp. 120-122) to be reductions in enrollments and the quality of students, a greater number of part-time students, absence of 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 time and support staff. Some of the centers appear to have survived this loss. A major gap in knowledge about HSR training is the absence of systematic information about the current status of these centers. Finally, NCHSR project support has been cut so sharply that there were no new NCHSR grants awarded in fiscal year 1982. This has further decreased both research opportunities and the training capability of some university centers. The decline in federal support for health services research is attributable to such factors as the diversity of the field, the fact that performers and users of health services research have not presented a strongly unified case for the utility of the product, the absence of strong support for general health services research among the federal agencies with major health responsibilities, concentration on short rather than long-range issues, and the general downward pressure on federal expenditures. Looking at the federal agencies as a whole, the short-run outlook is for level funding, or perhaps very modest increases, for directly budgeted HSR funds. In addition, the total federal effort is s These estimates (Gaus and Bolay, 1981, p. 280) exclude the costs of assessing the costs and benefits of demonstrations, and are therefore on the low side. Just how much of the cost of demonstrations should be considered as HSR is a matter that should be studied in greater detail.

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126 increasingly mission oriented and operations oriented as a consequence of the sharp reductions in the budget for the NCHSR. The implications for training are that the demand for investigators trained for research which does not contribute to the solution of immediate operating problems will probably be down, with the possible exception of research on cost containment. Project and Center Support Grants to centers as such, leaving a substantial degree of freedom to decide priorities locally, are an attractive supplement to the investigator-initiated project grant. So far as training is concerned, the center grants provide wide latitude for designing training experiences tailored to the capacity and the needs of individual students. Beginning in 1968, the NCHSR financed academic centers for health services research, and two nonacademic centers. The grants could be used at the discretion of the recipient for varicus purposes--faculty salary support, promotion of special missions such as development of health care technology, conduct of research, and development of advanced training. The outcome of the experiment in supporting centers was mixed. In terms of producing research and qualified investigators, the centers were productive--some more so than others. However, administrative problems were encountered, most of which derived from unrealistic expectations as to what the centers could be expected to accomplish and lack of common understanding between the centers and NCHSR on goats and research priority s. As of 1% 2, NCHSR funding for centers had been phased out. The question of whether this mode of financing should be reinstated remains. The largest and most stable federal support for a health services research center has been provided to the Rand Corporation by the Department of Health and Human Services. Beginning in 1971, Rand began a program of analysis designed to determine the potential effects of alternative methods of financing health care. The program has been financed at a total cost of approximately $70 million, by far the largest federal amount provided for a single health policy center. For the future, it appears that federal support for the program will diminish or be phased out. But support will be continued on a reduced scale (about $500,000 per year for 6 years) by the Pew Memorial Trust. The prospective smaller program will be more academically oriented and carried out in cooperation with the School of Public Health at UCLA. Indirect Funds A small but unknown fraction of the Medicaid and Medicare funds will be spent for the managerial type of health services research. These funds will provide increasing amounts for research bearing upon the operating efficiency of health care delivery organizations. There will be an effective incremental demand for persons trained for this kind of health services research. The centers which concentrate upon the training of people for such research have been successful in placing virtually all of their graduates in appropriate jobs.

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Private Foundations In 197;, the amount contributed to health services research by private foundations was $26.4 million. These private foundation grants have been sustained while the federal funds have been declining. Recently, the Pew Memorial Trust provided $12 million over a 5-year period to five university centers for training in policy- oriented research. "The emphasis of this program is to stimulate development of multi-disciplinary programs which will help prepare the leadership that will be needed...to resolve the many important health policy issues the nation faces.... Recognizing...that research is an important feature of advanced degree programs in most disciplines, it is hoped that research can be built into the total program, particularly in those that will be granting degrees." (Pew Memorial Trust, 1% 1, pp. 1-2) The foundation funds have supported faculty salaries, curriculum development, innovative approaches to training, promotion of closer contact between industry, government, and universities, and some fellowships. The centers have been allowed to use foundation funds for research, but as an integral part of the graduate training process and not as an activity in itself. It is worth emphasizing that most research supported by foundations is not investigator-initiated and is not peer-reviewed in the same manner as NIH/ADAMHA grants for example. State and Local Support, and Funds from Private In(lustry While most state and local expenditures for health services research are derived from federal sources and are hence accounted for in direct and indirect federal expenditures, some funds are generated locally. The rapidly growing private hospital industry has a health services research component which will probably grow as the industry expands. The same is true of private health care organizations such as Blue Cross and Blue Shield. While the volume of state, local, and industrial support for hem th services research has not been measured, in the judgment of the Committee it is a small part of the total. The Employers The demand for health services investigators is expressed by two types of employers who provide jobs. The first category consists of organizations which use health services research as a management tool. Included are hospitals and clinics (both public and private)

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128 and health maintenance organizations, large prepaid health plans, state and local treat th departments and health planning agencies and some private consulting firms. The second category consists of university-related organizations which typically combine the research and advanced teaching functions. They are, unlike most of the other organizations, both producers and employers of investigators. Included are 23 schools of public health, many medical schools, about 20 major university-based centers devoted to health services research and training, many university departments of economics and sociology, some schools of public administration, government and business administration, and a small number of private institutions, such as the Rand Corporation, which conduct advanced training as well as research. The Importance of University-Based Centers The prospective long-range situation calls for a training and research system operating at a stable, relatively low level and providing a sound base for future expansion. The heart of such a system is university-based health services research. The research base can be built only in a solid institutional home. Stable career opportunities must be available for those who are able and willing to devote themselves to the development of the new field. People active in research in related disciplines must be available for discussion and collaboration. Long-term research that is not necessarily related to current problems as perceived by federal agencies must be possible. The field must be developed and perpetuated by interaction between full-time professionals and advanced students. The research base has two major components. The first is a group of outstanding, creative research leaders, found almost exclusively in university schools or departments, who function primarily as individ- uals with a lid ted number of graduate students. Their contributions have been so fundamental that a prudent research support policy would ensure that the best individm 1 investigators should receive stable support. A second component of the university system for health services research is a set of organized programs or centers associated in varicus ways with universities.6 While some university-based health services centers are being supported in a fashion that virtue lly assures a high level of research and training productivity for several years into the future, this is not true of enough centers to give the nation a vigorous, healthy, stand-by system. The financial problems of virtue lly all universities are inhibiting their ability to provide stable institutional support for research centers of all kinds. The decline in federal funds for health services research has been 6 There is now no consensus as to the definition of a center. Any study of centers would have to frame a definition.

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129 described above. Moreover, the most severe reductions have been in the area most relevant to long range requirements--i.e., research on methods and concepts, generally involving a senior investigator or a small group, and deeply involving graduate and postdoctoral students. As in the case with federal support, the funds provided by public and private health care organizations are concentrated on research related to their current operating problems. Private foundations are giving a few university-based centers the kind of broadly defined, stable support that gives them the opportunity to concentrate on the long-range issues. However, it is unrealistic to expect the foundations to support the entire system at an appropriate level. LONG-TERM CONSIDERATIONS The Committee believes that the long run social and economic problems related to health care will become more acute. There may well be wider recognition of the need to provide a firmer conceptual and factmL base for the inevitable debates over social goals, over the equity of access to medical care, over the quality of medical care, and over differential impacts on socioeconomic groups. Continuing increases in the costs of medical care could generate an intensified program of research on cost containment by both public and private organizations. Privately supported research may expand rapidly as rising costs of health insurance push large unions and employers to begin self-insuring on a larger scale. It is likely, therefore, that the need for health services research will expand substantially in less than a decade. Federal agencies will have a strong tendency to stress short-term, mission- oriented research on operations and cost containment. The Committee recommends a broader agenda. Conscious attention should be paid to support research on issues of long-range importance by both the National Center for Health Services Research and the mission-oriented agencies. Priorities in Support of Students The demand for research will in turn generate an increased demand for well-qualified investigators. Maintenance of the quality of training, and particularly the capacity to provide broad, flexible health services research skills to health professionals (physicians, nurses, holders of M.P.H. degrees, etc.) and other professionals such as engineers and lawyers as well as to those in the social sciences, is a matter of first priority. In this connection, the Committee heartily endorses the $20,000 dissertation grants of the National Center for Health Services Research as an economical, productive contribution to sustaining the quality of doctoral programs related to hem th services.

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130 The Need for Better Information on the Health Services Research System In this report reliance on subjective estimates has been necessary in the case of such key factors as the number and characteristics of - active investigators, the division of effort among various fields of health services research and trends in national expenditures for . health services research. Earlier efforts by this Committee and others to determine these facts should be supplemented by further l investigations, so that data comparable to those presented in earlier chapters are made available to enable the analysis of trends in demand and supply e The recent report of the Institute of Medicine, Nursing and Nursing Education: Public Policies and Private Actions (1983), pro- vides a useful model for the substance and procedures for such a study. The most urgent task at the moment is to determine the status of training and research in the university-related health services centers and the outlook. There does not exist a comprehensive description and analysis of their research and training roles, how well these roles are performed, their strengths and weaknesses, their major accomplishments and problems, sources and volume of support for their research and training activities, and the outlook for the future. Whether there is a need for special added efforts to strengthen the research and training capacity of some or all of the centers and the forms which this support might take cannot be soundly determined in the absence of such a review. Accordingly, the Committee suggests that a meeting be convened under the auspices of the National Academy of Sciences of major interested parties--such as federal officials, leading investigators, some center directors, and officials of private foundations--to explore such matters as the goats and content of a review, of strengths and weaknesses of HER centers, the definition of a center, criteria for selecting centers for support, the structure and auspices for a study, and financing .7 7 The Institute of Medicine report, HeaLth Services Research (1979), did not discuss the roles, strengths, weaknesses and needs of the university-based health services centers.