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OCR for page 13
Chapter 2
HEALTH SERVICES RE SEARCH DEFINED
The term "health services research" is commonly used to ret er to a broad
and heterogeneous set of activities, but there is no consensus as to
its precise meaning. In a review of the literature, the committee
f ound no def inition that both (1 ) provides criteria to i dentify
studies as health services research and distinguish them from other
types of inquiry and (2) subsumes the entire range of studies that
are conventionally classif fed as health services research.
f or such a def inition is two-f old. As a practical matter
The need
~ the committee
required an understanding of the characteristics of health services
research in order to establish the scope of its study. Beyond this,
because health services research has become an administrative category
f or support of research and training, off icials in the federal gover-~-
ment need a definition upon which to base research funding and related
policy decisions and with which to devise an effective division of
responsibilities for research among the several agencies involved
in health care.
This chapter reviews existing def initions, explains the one adopted
by the committee, and discusses and illustrates various types and
us es of health services res earch .
Existing Def initions
Most existing definitions describe characteristics of the field of
health services research but do not specify the features of studies
that distinguish health services research f rom other types of inquiry.
Such - - - ~ - - - - -
statements typically emphasize the variety ot disciplinary
perspectives and methods employed in the f ield of health services
research and note its broad substantive concerns and purposes.
For instance, the often cited definition of the Panel on Health
Services Research and Development of the President 's Science Advisory
Committee characteriz es health services research and development
as a "broad scientif ic field, the overall ob jective of which is to
improve the provision of health services," [l] and illustrates its
scope with lists of participating disciplines and "representative
questions. " ~ 2 ~
13
OCR for page 14
14
There are several problems with definitions of this sort. First,
they imply that studies in health services research are inherently
multidisciplinary and directly focused on specific programmatic or
policy questions. While many studies do in fact incorporate theoretical
perspectives of several disciplines and are aimed at solving particular
problems, it is equally true that others that should be classified as
health services research employ the conceptual frameworks of particular
disciplines or address problems that have no direct implications for
program or policy decisions.
Second, to define the scope of a field by listing its principal specific
concerns both presumes that issues endure and risks omission of emerging
topics. Priorities for health services research change in response
to new information and changing definitions of problems in health care.
Therefore, illustrations of the core concerns of the field of health
services research based on lists of current issues are likely to
become outdated.
Finally, definitions and critiques of the field frequently use the
terms "health services research and development" and "health services
research" interchangeably. As the former connotes a strategy of
research coupled with systematic interventions in the delivery system,
it should not be confused with research, which may or may not be
focused on planned or conscious changes.
"Health Services Research"
Health services research is inquiry
to produce knowledge about the structure,
processes or effects of personal health
services .
A study is classified as health services research if it satisfies two
criteria:
It deals with some features of the structure, processes, or
effects of personal health services.
At least one of the features is related to a conceptual
framework other than that of contemporary applied biomedical
science.*
*This definition is similar to that proposed by the National Research
Council Committee on National Needs for Biomedical Research Personnel.~3]
The purposes of the IOM and NRC studies differed and the definitions of
health services research were developed to meet the specific study
objectives. In the NRC study a definition was employed that more
directly related to the health policy aspects of health services.
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15
The first criterion defines the core focus of health services research
as a personal health service, which the committee understands to be a
transaction between a provider of health services and a client for the
purpose of promoting the health of the client. Providers include
licensed health care professionals and ancillary personnel as well as
"marginal" and lay practitioners. Hence, health services research
deals with both formal and informal systems of health care. In this
definition, health services are understood to include direct applica-
tions of medical knowledge and technologies and the provision of advice
and assurance. In addition, health services encompass the full range
of personal health care, including dental and mental health services.
As concepts of health and health services change, the scope of health
services research will change accordingly.
The second criterion places in the category of health services research
all studies of personal health services that focus on at least one
feature of their structure, processes, or effects defined in terms of
some conceptual framework other than that of contemporary applied
biomedical science.* That framework views the human organism in terms
of its anatomical structure and physiological processes, and identifies,
classifies, and explains diseases, which usually are defined as struc-
tural malformations, chemical lesions, or behavioral abnormalities.~4]
These two criteria permit one to distinguish the principal emphases
of health services research from other related types of inquiry. The
committee emphasizes, however, that the boundaries of health services
research are neither fixed nor sharply distinct. Similarly, research
in this area draws upon concepts and methods from various fields of
inquiry, frequently attempting to integrate their knowledge and tech-
niques and to investigate their implications for the organization,
processes, and effects of personal health services.
Research on Environmental Health Services
The first criterion differentiates the principal focus of health services
research from that of research on environmental health services, which
concentrates on services that attempt to promote the health of popula-
tions by treating their environments rather than by treating specific
individuals.
Knowledge from studies of environmental causes of health problems is
*"Basic" biomedical science is concerned with development of knowledge
about the fundamental life process.
OCR for page 16
16
obviously important in health services research, because it gives
insight into the kinds of health problems for which people seek care
and the types of services that must be provided by the personal health
services industry. Furthermore, research aimed at assessing the rela-
tive effects of environmental factors and personal health services on
the health of populations combines information from both fields of study.
Studies of effects of fluoridating water supplies on the incidence of
dental caries, for example, would not be thought of as health services
research. However, investigations of the relative costs or effective-
ness of reducing caries by fluoridating community water supplies versus
applying topical fluorides to individuals would be.
Behavioral Research
A portion of the field of health-related behavioral research is con-
cerned with understanding factors influencing individuals' life styles
that, in turn, are associated with their health. Research in this
area draws upon knowledge from epidemiological studies that identify
behavioral determinants of illness, such as diet and smoking habits,
and examines their social and psychological components.
As do studies on environmental health services, behavioral research
often overlaps with health services research. Behavioral studies of
the determinants of smoking behavior, for instance, are not health
services research, according to the committee's criteria. However,
behavioral and health services research interests come together in
studies of effects of life styles on the use of personal health
services and in research on the effects of personal health services
on individual's health-related habits.
Biomedical Research
The second criterion differentiates health services research from
contemporary applied biomedical research. Within the conceptual frame-
work of biomedical research, no explicit attention is given to matters
other than therapeutic interventions and disease processes. Indeed, a
major assumption of the randomized clinical trial is that all factors
that might both influence an organism and be associated with the inter-
vention under investigation are controlled by randomization. To the
extent that this assumption is tenable, the randomized clinical trial
is able to assess the effects of interventions on an individual's
disease free from the disturbing influences of extraneous matters,
such as the characteristics of physicians and hospitals.
Although the randomized clinical trial is considered the ideal method
for assessing the safety and efficacy of therapeutic interventions,
OCR for page 17
17
in practice, relatively few are carried out. In consequence, most
information about the efficacy of medical procedures is from studies
done in practice settings in which the conditions of the randomized
clinical trial cannot be assumed. Nevertheless, these studies are
not considered health services research unless they take explicit
account of factors other than interventions and outcomes conceptualized
in terms of the framework of biomedical science. Studies of the rela-
tive effectiveness of coronary bypass surgery versus drug therapy on
reducing chest pain, for example, are extensions of biomedical research.
Studies that examine characteristics of hospitals or physicians that
affect differential outcomes of surgery fall into the realm of health
services research.
The distinction between biomedical and health services research becomes
somewhat blurred when the outcomes of therapeutic interventions are
conceptualized in terms that are not strictly medical. Studies in this
area seek to evaluate technologies in terms of their efficacy, safety,
and implications for the organization and costs of care. Evaluations
of a surgical procedure might, for example, take into consideration
lengths of recovery time required by patients. Such studies of stays
in hospitals following surgery are in the realm of clinical (rather than
strictly biomedical) research. Because such questions are more closely
aligned with other problems of interest to those who do health services
research than with the principal concerns of biomedical research, the
committee is inclined to make a strict interpretation of its second
criterion and to consider such clinically-oriented studies instances of
health services researche For the example given, one need only change
the research question to a study of differences in postsurgical lengths
of stay of patients in acute-care hospitals versus others in extended
care facilities to place the inquiry squarely in the domain of health
services research.*
When outcomes of medical interventions are defined in terms of costs
of care, patient satisfaction, or other matters of interest to the
social sciences, studies are clearly in the realm of health services
research.
Epidemiological Research
Most contemporary research within the discipline of epidemiology falls
outside the boundaries of health services research. Epidemiology is
*The same reasoning would lead to classifying as health services
research studies of effects of medical interventions on patients'
functional or general health status.
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18
generally viewed as the "study of the distribution and determinants of
disease frequency in man"~5] in which explanatory factors are drawn
principally from individuals' physical, biological, and social environ-
ments and their life style and behavioral patterns.
Epidemiological studies that include features of the structure or
processes of personal health services among their explanatory factors
are instances of health services research if these features satisfy
the second criterion. Investigations of effects of populations' use
of health services on their mortality rates are examples of this type
of research. However, research on the effects of inoculations against
smallpox on the incidence of the disease in populations would not be
classified as health services research. Although such studies would
meet the first criterion of dealing with a personal health service
(i.e., having an inoculation), they would not satisfy the second,
because the provision of an inoculation is a medical intervention.
By contrast, studies employing epidemiological methods to assess the
impacts of particular medical interventions on general health status
or other outcomes that are not defined in strictly medical terms
would be classified as health services research.
Levels of Health Services Research
Studies of health services may be categorized according to the four
general levels of problems they address: clinical, institutional,
systemic, or environmental. These levels are depicted in Figure 1
in order of increasing generality, proceeding from the core of
studies of clinical practice to the most global level of research
on relationships between characteristics of the health services system
and events in the larger social, political, and economic environment
that affect them.
Clinically-Oriented Studies
Clinically-oriented studies attempt to discover the characteristics
of providers and patients and combinations of resources employed in
practice settings that affect the processes and outcomes of care.
Unlike applied biomedical research, which concentrates on developing
procedures and testing their efficacy and safety under controlled
conditions, clinically-oriented studies recognize that the effective-
ness of health services is influenced by conditions in which they
are provided and that criteria other than strictly medical considera-
tions are relevant to outcomes. Accordingly, they deal explicitly
with the circumstances of medical practice and take into considera-
tion a broader range of outcome criteria, including patient satisfac-
tion and the costs of care as well as the effectiveness of treatment.
OCR for page 19
19
FIGURE 1
LEVELS OF HEALTH SERVICES RESEARCH
Health Problems
Environmental
Systemic
/ I Institutional \
I'
,~,
Clinical
\
it:
Social, Political,
Economic Institutions
J
/
OCR for page 20
20
Studies in this category usually concentrate on characteristics
of providers or patients. They deal with such matters as the
influences of physicians' ages, training, and work loads on the
quality of their practice; the effects of using ancillary personnel
or various computer-based techniques on the efficiency and complete-
ness of medical history taking; and the cost-effectiveness of alterna-
tive treatment modalities. Studies focusing on patients investigate,
for instance, characteristics associated with adherence to medical
regimens, use of particular preventive or diagnostic services, and
lengths of hospital stays.
Institutionally-Oriented Studies
While institutionally-oriented studies share many of the concerns
of clinically-oriented research, they are distinguished by their
focus on organizational and administrative features of settings in
which services are delivered. Research at this level examines, for
instance, the productivity and quality of care rendered by physicians
in solo practice compared with those working in group practices,
differences in average lengths of stay in hospitals of varying sizes,
ownership, and complexity, and the costs of custodial care in extended
care facilities compared with those provided in patients' homes.
Studies of populations focus on such matters as why families choose
prepaid group practices and the determinants of utilization patterns
of various providers of services.
Systemic Studies
System studies deal with features of the health services system
that affect the inter-relationships among providers and health care
institutions and the population's aggregate demand for health services.
At this level, attention is given to the influences of financing
mechanisms, regulatory programs, and other features of the system on
such matters as the capital expenditures of hospitals, choices of
specialties and practice sites by physicians, the development of
group practices, and expenditures for various types of personal health
services.
Environmental Studies
Environmental studies seek to understand the circumstances and events in
the larger social, political, and economic contexts that shape the
health services system and define its societal functions. These
include research on the implications of tax policy for the flow
of capital into the health services industry, studies of the legal
OCR for page 21
21
and ethical responsibilities of health care institutions, and research
on the population's preferences for and expectations of health
services. Studies at this level usually deal with matters quite remote
from clinically-oriented research. Whether they are considered health
services research depends ultimately upon their inter-relationships
with other studies at the systemic, institutional, and clinical levels.
The question of tax policy, for instance, becomes relevant to health
services research when it can be shown to have implications for the
ways in which health care is organized, delivered, or used.
Types of Health Services Research
The definition of health services research presented above states that
it is inquiry to produce knowledge. Inquiry refers to the series of
stages ordinarily associated with empirical research, including problem
formulation and conceptualization, measurement and data collection,
and analysis and interpretation. While each of these stages is a
necessary part of the process of inquiry, the crucial ingredients of
research are the analysis and interpretation of data for the purpose of
answering a question.
The collection of data to administer programs does not constitute research
unless it is directed toward answering some question that applies to
groups of units. The Health Care Financing Administration, for instance,
manages the Medicare and Medicaid programs for the federal government.
In this capacity the agency assembles vast amounts of information about
beneficiaries' use of health services and charges for them in order to
determine whether particular services and charges are eligible for
reimbursement. This activity does not constitute research, however,
because it is not directed toward answering broader questions that apply
to groups of Medicare or Medicaid beneficiaries. In general, program
monitoring activities, in which interest is focused on individual
units, are not research.
The nature of the questions or problems that occasion inquiry define
two types of research, descriptive and analytic. Descriptive research
addresses questions of the form "how many (or what) Xs are in A?" The
objective of quantitative descriptive inquiry is to estimate parameters
that apply to groups of cases. For instance, descriptive data may
depict trends over time or compare geographic areas and their popula-
tions.
A great deal of useful health services research is descriptive. The
series of estimates of national health care expenditures produced by
the Social Security Administration (and now by the Health Care Financing
Administration) provide invaluable information on the amounts and
OCR for page 22
22
categories of public and private expenditures for health care.
Similarly, the various series of publications from the National
Health Survey (conducted by the National Center for Health Statistics)
yield useful no tional estimates of the prevalence of illness and the
use of health services. Data from these types of studies identify
trends and variations that raise theoretical and policy questions
that invite further analysis to reveal their correlates and causes.
This is the objective of analytic research.
Analytic research attempts to answer cause-effect questions or to
-
make projections into the future. Descriptive research deals
with questions of "how many" or "how much," but analytic research is
concerned with answering "why" or "what will be" questions. This
type of research is inherently more difficult and abstract than
descriptive research. It requires the use of theoretical models
and designs of proof to demonstrate that causal interpretations
(or projections) are logically consistent with what is already known
and that statements (or assumptions) about the effect of particular
variables are not spurious (i.e., due to circumstances not explicitly
included in the analyses).
Several circumstances combine to complicate analytic research efforts
in health services research, including (1) the complexity of problems
addressed in this area and their variations in time and place; (2) the
states-of-the-art of the theories and methods of disciplines that
contribute to health services research; (3) the specific data avail-
able for research; and (4) the difficulty of establishing truly experi-
mental situations, which frequently requires relying on nonexperimental
research designs.
The logical and practical necessities that set the limits of analytic
studies encourage investigators, working from different theoretical
perspectives, to focus on selected aspects of problems and to disregard
others. As no conceptual framework takes into account all aspects
of a problem or is inherently superior to others, health services
research encompasses a great variety of perspectives. Research, for
instance, relating to the Health Systems Agencies created under the
current health planning act would employ the theories and methods of
economics to assess their effects on hospital cost inflation, the
perspectives and approaches of sociology or political science to study
their influences on community organization, and a variety of disciplines
ranging from clinical medicine to economics to determine the effects
of awarding a certificate of need for the installation of an expensive
new technology. Because health services research takes place in
particular places and periods and is focused on different levels of
and interests
in a particular
, ___,, ~ ,e often are not generalizable to
other settings, because of circumstances that are peculiar to the site
in which the study was done. For the same reasons, data from national
studies often do not apply to local situations.
generality, particular studies cannot satisfy the needs
of all potential audiences. Findings from a study done
health cart ;n.~:ti t~~t;nn hi tar fir =~=
OCR for page 23
23
Since much of health services research is based on the theories and
methods of the social sciences, its ability to explain events is limited
by those sciences' levels of development. Even a cursory reading of the
literature in these fields reveals considerable uncertainty and debate
about the meanings and appplications of fundamental concepts and the
validity of basic propositions. These problems are compounded by the
concerns of much of health services research with such elusive and
judgmental issues as quality and economic value of life, the general
health status of populations, and the humaneness of health services.
Data for health services research are drawn principally from population
surveys, records and documents, and direct observation. Each of these
methods admits various biases and unreliability that militate against
clearcut description and analysis. Answers to such seemingly straight-
forward questions as precisely how many hospital beds or physicians
there are in the United States or how much the population spends on
various types of services are not readily found from existing data
sources, and special studies to determine these numbers are expensive
and time-consuming. Furthermore, the protection of privacy afforded
individuals and institutions by law and the economic and political
advantages that accrue to some from concealing certain types of
information frequently lead to incomplete and biased data that limit
the validity of analyses.
The classic experimental design remains the ideal foundation on which
to conduct research. With few exceptions, however, studies in health
services research are based on nonexperimental designs. As a conse-
quence, it is seldom possible to draw strong conclusions regarding
cause and effect, such as those drawn in the laboratory sciences. The
practical and ethical obstacles that prevent investigators from con-
trolling events and circumstances that are extraneous to their principal
research problems introduce errors into analytic studies whose magnitudes
often cannot be estimated. Because of these problems, analytically-
oriented health services research relies heavily upon the comparative
approaches of studying so-called natural experiments and of applying
complex statistical procedures to historical data to adjust for charac-
teristics of cases and situations that are known or presumed to be
related to the question under investigation.
These difficulties inherent in health services research account to a
large extent for the seeming inconclusiveness of much of the research,
and underscore the need for studies aimed at improving research
methods and for replications using various perspectives and methods.
As the field has developed, significant advances in knowledge have
been achieved through the application and integration of theoretical
perspectives and methods that either were unknown or undeveloped two
decades ago. Advances in computerized multivariate analyses, for example,
opened possibilities for research on certain types of questions that
previously could not be addressed. Likewise, the availability of national
data on use of health services has given impetus to comparative studies
OCR for page 24
24
of national and international scope. Thus, there is unmistakable
evidence of progress within the field and need for continued efforts
for improvement. While that occurs, however, those who sponsor health
services research should recognize the limitations of current theore-
tical and methodological approaches and encourage replications to
validate and extend findings of studies.
Uses of Health Services Research
Most definitions and critiques of the field of health services research
imply that studies in this area have or should have direct implications
for action. The field is characterized as an applied endeavor whose
products should be assessed primarily in terms of their usefulness to
people with decision making responsibilities, whether they be clini-
cians, administrators of health care institutions or government pro-
grams, or officials charged with formulating national health care policy.
Although the committee agrees that these are legitimate expectations and
grounds for assessing health services research, it notes that discus-
sions of the usefulness of studies in this area are often clouded by
simplistic analogies to research and development in the physical and
natural sciences, misunderstandings of decision making processes in
various settings, and narrowly defined conceptions of the audiences for
health services research. In this section, various potential uses of
health services research by decision makers are described when purely
rational models of decision making are assumed. The following section
critiques these models and discusses others.
Evaluation of Technologies and Innovations
The logical sequential linkage of biomedical and health services
research occurs at the point where a technology* is tested in selected
clinical settings, indicated by the "transfer" stage in Figure 2.
At this point, technologies whose efficacy and safety have been
established by trials carried out in the application stage are placed
in clinical settings for further testing. The first step in the transfer
stage involves designing suitable arrangements for the use of the techno-
logy. Once these are developed, the innovation is tested for clinical
effectiveness and cost-effectiveness in terms of the institutions
*Although this discussion refers to biomedical technology, it applies
equally to other types of technology employed in the health services
industry, for instance the uses of computers in institutional management,
geocoding and other computer-based technologies employed by planners,
and architectural innovations. The term technology encompasses know-
ledge and procedures as well as materials and equipment.
OCR for page 25
25
F IGURE 2
EVOLUTION AND DIFFUSION OF HEALTH CARE TECHNOLOGY
RESEARCH STAGE OBJECTIVE EVALUATION CRITERIA
.
Basic research Develop knowledge about New knowledge
z fundamental life
~ processes
o
SAP lied research APP1Y knowledge from New knowledge about
~ basic to research on causes and/or processes
3 particular diseases of particular diseases
I
~ I
¢ (Application Develop and test Efficacy, safety relative
technologies to to existing technologies
~ I diagnose, prevent,
¢ cure, or contain
particular diseases
2
`~ | |Design and test systems Acceptability, efficiency
I for use of technologies of application and effec-
/ \in clinical settings tiveness and safety within
Transfer ~ test sites
¢
u: 1
~ 1
u, /
~ ~ iffusion
u,
:r:
En
System impact
\
iTest cost-effectiveness,
patient and provider
acceptability and
effects on institutions
Develop knowledge about
the diffusion of tech-
nologies
Knowledge about cost-
effectiveness, patient
and provider accepta-
~ and institution-
bility
wide impacts
Knowledge about why
technologies diffuse;
effects of prices,
institutional
resistance, etc.
Develop knowledge about Knowledge about impacts
impacts of technologies of technologies on
due to their diffusion system-wide demand for
and applications services, costs, rela-
tionships between their
supplies and needs of
populations, etc.
OCR for page 26
26
in which it is applied. During this transfer stage, development and
research activities often become intertwined. In fact, much of health
services research involves demonstrations in which developmental and
research activities are closely integrated.
The subsequent stages of research on the diffusion of technologies and
its effects on health services systems are clearly health services
research. At this point, however, attention turns from questions of
efficacy and cost-effectiveness of technologies to studies at the
institutional and systemic levels of health services research. Investi
gations of the features of individuals or institutions that adopt
technologies and of the effects of their adoption are similar to market
research conducted in other industries. At the systemic level, studies
in health services research focus on impacts of such matters as the
influences of financing and regulatory programs on the diffusion of
technologies. Also, they examine the effects of their organization on
the demand for services, per capita expenditures for health services,
and inter-organizational arrangements among health care and other
institutions.
Problem Solving
The use of health services research in assessment of technologies at the
clinical level is a situation in which both the question and the deci-
sion are clearly identifiable and the need for decision making is rela-
tively predictable. At issue is whether a particular technology should
be adopted by a particular individual or institution. The problem
arises from the "knowledge-driven" processes of biomedical research
and development.
Most health services research does not come about in this sequential,
predictable way. Instead, studies in this area are occasioned by
existing problems identified by societal groups and decision makers.
Research is aimed at solving the problems.
Rational problem-solving involves several stages, each of which requires
a particular type of knowledge. These stages and corresponding types
of health services research are shown in Figure 3.
Problem identification typically involves descriptive research to mea-
sure the extent or seriousness of a problem and to locate subgroups
of people, institutions, or geographic areas that are most affected by
it. Findings from such studies occasionally may bring "new" problems
to the attention of decision makers. More commonly, however, they pro-
vide more precise and systematic information about problems previously
identified by affected groups. As these types of studies describe
the nature and extent of a problem, their findings usually are not
amenable to direct translation into decisions about desirable inter-
ventions. The studies of the Committee on the Costs of Medical Care
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27
FIGURE 3
RELATIONSHIPS BETWEEN STEPS IN THE DECISION PROCESS
AND TYPES OF RESEARCH
STEPS IN THE DECISION PROCESS
Recognition of a Problem
Establish Causes of the Problem
Establish Alternative Solutions
Select and Implement Decision
Monitor Effects of Program
TYPE OF RESEARCH
Problem Identification
Problem Specification
Assessment of Alternative
Interventions
< . .
< Evaluation of Implementation
Process
~ Evaluation of Effects
OCR for page 28
28
carried out in the late 1920s and early 1930 s are widely cited examples
of problem identification research. The Committee's studies of
use of personal health services provided the first quantitative infor-
mation in the United States on the distribution of medical services
among income groups. The series of descriptive reports of the National
Center for Health Statistics and of the Center for Health Administration
Studies of the University of Chicago on the use of health services and
those of the Office of Policy, Planning, and Research of the Health Care
Financing Administration (formerly of the Office of Research and Statistics
of the Social Security Administration) on expenditures for health care
are notable contemporary examples of this type of research.
Problem specification moves beyond description to identify causes of
problems. It is analytic insofar as it seeks to quantify the relative
importance of various factors presumed to contribute to a problem.
Studies of effects of health insurance on hospital utilization and costs,
research on factors affecting physicians' choices of practice locations,
and inquiries about determinants of hospital capital expenditures il-
lustrate this type of research.
Assessment of alternative interventions is similar to problem specifica-
~ . . . . . . . . . .
Lion in that it attempts to quantify the relative effects of factors
on a problem. It differs from problem specification in the explicit
attention it gives to effects of alternative potential interventions.
In effect, this type of research attempts to quantify the costs and
benefits associated with various intervention strategies. Comparative
studies of hospital use by health maintenance organizations and insured
populations, and cost-benefit studies of alternative modes of improving
a population's health status are of this type.
Evaluations of implementation processes attempt to assess the degree to
..
which a program operates as intended and to identify causes and con-
sequences of deviations. Unlike the types of research described above,
evaluations follow choices of implementation strategies. Therefore,
researchers have access to plans of action that, in principle, specify
intended modes of implementation that can be used as standards against
which to compare performance. Research of this type can be descrip-
tive, aimed at determining whether the actual process conforms to
the plan, or it can be analytically oriented, aimed at identifying
causes and consequences of the ways in which intervention strategies
are implemented. For instance, studies of the compositions of boards
of directors of Health Systems Agencies and of physicians' conformance
to standards of practice established by Professional Standards Review
Organizations are descriptively oriented evaluation research. Exten-
sions of these aimed at identifying causes of observed behaviors would
be examples of analytically oriented evaluations.
Evaluations of effects attempt to measure the extent to which inter-
ventions attain stated objectives, to identify their unanticipated
consequences, and to explain their causes. Minimally, such research
OCR for page 29
29
describes whether (or the extent to which) a stated objective is at-
tained. More elaborate evaluations examine features of interventions
or their environments that account for observed results.
The series of stages in this process constitute health services
research and development when applied at the clinical or institutional
levels and policy research at the systemic level. Health services
research and development refers to a strategy of cycles of interven-
tions combined with research and evaluation. Its purposes, like
research on the transfer of technology, are to develop and test
innovations in test sites.
The problem solving stages described above are sometimes referred to
as "cyclical policy analysis" to distinguish it from the more general
meaning of policy analysis.~7] Cyclical policy analysis refers to an
orderly strategy of research aimed at providing knowledge based on
experience. It rests on empirical study of situations or events as
they currently exist. Findings from such studies are employed in
policy analysis, which assembles information with which to design
alternative options for action and anticipates the likely effects of
alternative intervention strategies. Because policy analysis usually
takes into account a broader range of criteria in evaluating alterna-
tives than is considered in particular studies, it typically involves
synthesizing findings of existing research and extrapolating their
implications.
Limitations of Rational Models
The foregoing schemes were intended to identify potential uses of health
services research in decision making, not to describe what actually
occurs. It should be noted, however, that these schemes are based on
assumptions that rarely are met in situations for which health services
research is conducted. Furthermore, they overlook uses and users
of health services research other than decision making by decision
or policy makers.
The models of technology evaluation and of problem solving described
above make several assumptions about decision making situations and the
relationship of information from research to decisions:
a person has identified a problem to be solved, has
formulated consistent criteria for valuing alternative
solutions, has the will and -means to implement solutions,
and will base decisions exclusively on results of the
research;
the research was completed before the decision was taken,
dealt with the problem as identified by the person and
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incorporated all of his evaluation criteria, and was
accurately communicated to, understood, and accepted
by the person.
Given these assumptions, the utility of research can be assessed in
objective terms by comparing the problem situation before and after
implementation of the solution. Absent any of these, the utility of
research must be judged on subjective grounds, such as its informative
value to the person. In formulating its assessment of health services
research, the committee took these assumptions as problems to be
addressed.
The principal difficulty in assessing the uses of health services re-
search is that few decision making situations fit the assumptions of
rational problem-solving models. Decisions to adopt or not to adopt
particular technologies are usually made before completion of cost-
effectiveness and institutional studies, and decision makers are
influenced by several factors other than the results of empirical
studies. Because new technologies are developed and marketed through
the private sector, decisions about their adoption or nonadoption are
influenced by competitive pressures and custom, as well as by cost-
effectiveness and other so-called rational criteria.
The same is true of the uses of findings from health services research
in policy making. Policy decisions are a blend of factual information,
values, and expectations about the future effects of alternative courses
of action. Research may point up issues, measure their extent and
seriousness, suggest the likely effects of alternative interventions,
and influence the context and quality of policy debate. It cannot,
however, substitute entirely for the political process through which
value choices and judgments about possible outcomes are explicitly
and implicitly incorporated into policy decisionse
Rational decision models also are limited sources of criteria for
assessing the utility of research because they concentrate exclusively
on formal decision making and official decision makers. Research
findings have informative value whether or not they lead to identifiable
decisions. They are the substance of formal education in health care
administration and much of clinical medicine and a source of know-
ledge, attitudes, and expectations on the part of the public. More-
over, as government involvement in the health care industry expands
and the scope of political decisions affecting health care enlarges,
information from health services research, if effectively transmitted,
becomes an increasingly crucial ingredient of the public's abilities
to choose the types of health services it desires and to hold
providers, planners, and government accountable for what is delivered.
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REFERENCES
1
2
4
5
6
Executive Office of the President, Office of Science and Technology,
Improving Health Care Through Research and Development, Report of
the Panel on Health Services Research and Development of the President's
Science Advisory Committee (March 1972~: 1.
Ibid.
Personnel Needs and Training for Biomedical and Behavioral Research:
flee told Report of the Committee on a Study of National Needs for
-
Biomedical and Behavioral Research Personnel. Commission on Human
Resources, National Research Council, Washington, D.C. (1978~: 113.
Alvan R. Feinstein, "Scientific Methodology in Clinical Medicine II.
Classification of Human Disease by Clinical Behavior," Annals of
Internal Medicine (October-December 1964~: 757-781.
Brian MacMahon and Thomas F. Pugh, Epidemiology: Principles and
Methods (Boston: Little, Brown and Company, 1970~: 1.
Carol H. Weiss, Using Social Research in Public Policy Making
(Lexington, Massachusetts: Lexington Books, 1977~: 13.
Charles O. Jones, "Why Congress Can't Do Policy Analysis (or words
to that effect)," Policy Analysis (Spring 1976~: 251-264.
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Representative terms from entire chapter:
personal health
