Health Services Research: History

1
Health Services Research History Landmark
Studies

• Mark E. Kunik, MD, MPH

2
Health Services Research Defined

• HSR is the Basic Science of Health Policy
• the impact of the organization, financing, and
  management of health services
• on
• the quality, cost, access to, and outcomes of care

3
Health Service Research Goal

• The problem is our inability to measure and
  understand the effect of the choices of patients,
  payers, and physicians on the patients
  aspirations for a better quality of life. The
  result is that we have uninformed patients,
  skeptical payers, frustrated physicians, and
  besieged health care executives.
• Ellwood, 1988
• provide information that will eventually lead to
  improvements in the health of the citizenry
• US National Library of Medicine, 1997

4
Comparison to Other Research
Focus
Research Type

• Disciplinary Theory
• Biomedical Organism
• Clinical Patient
• Health Services System, Institution
• Public Health Community, population

Aday, 1998
5
Components of HSR

• Describe, analyze,and evaluate the structure,
  process, and outcomes of the healthcare system
• Structure organization and financing of
  programs characteristics of population
  physical, social and economic environment
• Process those things that occur between
  physicians and patients in the course of care
  delivery
• Outcomes results of care

Donabedian 1966,1980
6
Components of HSR Another View

• Effectiveness Efficiency Equity
• Effectiveness examines the benefits produced by
  healthcare, as measured by improvements in
  peoples health
• Efficiency relates these health improvements to
  the resources required to produce them
• Equity is concerned with health disparities and
  the fairness and effectiveness of the procedures
  for addressing them

7
How Is HSR Done?

• A multidisciplinary field of research
• medicine
• biostatistics
• health economics
• sociology
• epidemiology
• psychology (clinical, psychometrics, social)
• others

8
The Early History Pre 20th Century

• William Petty, a physician and economist in 17th
  century England first to assess the benefits of
  physician practice and hospital care
• William Farr in 19th century collected
  statistical data on mortality, morbidity and
  disability and challenged physicians to look at
  their outcomes
• Florence Nightingale joined Farr on a uniform
  reporting system for London hospitals to examine
  life risks

9
20th Century pre WWI

• Impact of disease on society
• National Vitality, Met Life Insurance, and State
  Commissions
• Role of providers on health
• Chicago Medical Soc report on midwifery, AMA data
  on characteristics and distributions of hospitals
• Flexner Report on medical schools
• Drs. Cabot and Codman first to relate physician
  care to outcomes. Led to development of JCAHO
  and systematic quality assurance in hospitals

10
Pre WWII

• Committee on the Costs of Medical Care, a small
  group of physicians funded by several foundations
  (e.g., Rockefeller, Milbank, Carnegie)
• 27 research reports on health service costs and
  distribution including one of the first studies
  to examine the health of the nation, use of
  medical services according to disease,
  availability of medical personnel and facilities,
  and cost
• Established unequal distribution of costs and
  services. Contributed to HSR methodology such as
  chart review and emphasized need for reliable,
  valid data

11
Post WWII

• Donabedian describes the quality of medical care
  as structure, process, and outcomes
• Emphasis on quality leads to development on
  instruments to measure quality such as the
  Karnofsky scale, ADL scale, Quality of Well Being
  Scale, SF-36, and Sickness Impact Profile.
• 1964 NIH starts study section in HSR
• Medicare and Medicaid Legislation in 1965
  expanded demand for health services and costs
• HSR Journal in 1966

12
Post WWII

• Late 60s and early 70s establishment of Social
  Security Administration, Health Care Financing
  Administration. VA enters HSR. Rapid
  development of HSR in research centers and
  Universities
• RAND Health Insurance Experiment(1983).
  Randomized trial of alternative health insurance
  plans. More out of pocket costs lead to less
  health service use. Little effect on average
  person, but adverse effect on sick poor
• Studies on variations (Wennberg, Bunker, Chassin)
  5-6 fold variation in surgical rates between
  geographic areas of US and 2-3 fold between
  countries

13
Post WWII

• 1982 VA establishes HSRD Centers of Excellence
• 1989 Agency of Health Care Policy and Research to
  emphasize outcomes of care, develop and
  disseminate practice guidelines, quality
  standards, performance measures, and medical
  review criteria
• AHRQ initiates 14 patient outcomes research teams
  (PORT) What works and at what cost? For which
  patients or subgroups of patients? When? Why is
  there variation in the use of treatments? What
  can be done to reduce inappropriate variation?

14
Health Care Reform Debates 1990

• health care consumers worried about access to,
  insurance coverage for, and the quality of health
  services.
• business owners concerned with paying for
  employees' health insurance while protecting
  profits.
• the government concerned about the costs and
  needs of vulnerable populations enrolled in its
  federal employee health insurance, Medicare, and
  Medicaid programs.
• the insurance industry with its need to sell
  premiums and control costs.
• clinicians and providers eager to advocate for
  patients, preserve autonomy over medical
  decisions, and maximize reimbursement rates.

15
Questions from Debate

• Who is responsible for providing health services?
  Is "health" the responsibility of the individual
  or the society represented by government,
  employers, unions, religious organizations, and
  other associations?
• Who covers the cost?
• What are the essential components of "good
  health" and "quality" health care? Is it medical
  care or conditions such as housing, employment,
  and nutrition that contribute most to a healthy
  population?

National Library of Medicine, 1997
16
References

• National Institute Center on Health Service
  Research and Health Care Technology(National
  Library of Medicine) Introduction to HSR Class
  Manual
• http//www.nlm.nih.gov/nichsr/ihcm/hsrchist.html