Biocollections, BioProject, BioSample, BioSystems, Books, ClinVar, Clone Health Serv Res. AcademyHealth Annual Research Meeting (ARM) comprised of peer-reviewed research selected through the call for abstracts. Jack Needleman, Ph.D., associate professor in the Department of Health Services, School of. Health services researchers have an important role to play in helping health Health services research: building capacity to meet the needs of the health Abstract. Health services researchers have an important role to play in Southampton, UK: NIHR Journals Library, dayline.info NBK/ ( The Health Status Questionnaire , or HSQ, is a method for measuring health attributes, health status Abstr Book Assoc Health Serv Res Meet., 15,
Effective care is based on scientific evidence that treatment will increase the likelihood of desired health outcomes.
Evidence comes from laboratory experiments, clinical research usually randomized controlled trialsepidemiological studies, and outcomes research. The availability and strength of evidence varies by disorder and treatment. Failure to provide timely care can deny people critically needed services or allow health conditions to progress and outcomes to worsen. Health care needs to be organized to meet the needs of patients in a timely manner.
Health care services should be personalized for each patient, care should be coordinated, family and friends on whom the patient relies should be involved, and care should provide physical comfort and emotional support.
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The health care system should benefit all people. The evidence is strong and convincing that the current system fails to accomplish this goal. The IOM report, Unequal Treatment, 32 documented pervasive differences in the care received by racial and ethnic minorities. The findings were that racial and ethnic minorities are receiving poorer quality of care than the majority population, even after accounting for differences in access to health services.
Crossing the Quality Chasm concludes that for the American health care system to attain these goals, transformational changes are needed. Evaluating the Quality of Health Care HSR evaluation of quality of care has proven to be an inexact science and complex, even though its definition is relatively simple: The goal of quality care is to increase the likelihood of achieving desired health outcomes, as expressed by the patient.
The complexity in measuring quality comes from gaps in our knowledge regarding which services, for which patients, will actually improve the likelihood of desired health outcomes.
Also, patients need not have the same desired health outcomes and therefore might not receive the same care for an identical health problem, further complicating the measurement of quality of care.
Quality measurement has advanced substantially, but it remains early in its development.
The conceptual framework widely applied in evaluating quality comes from years of research and the insightful analysis of Avedis Donabedian. This model is applied in the evaluation of health services and the accreditation of health care providers and organizations.
Seminal research about variation in the quality of care patients received brought to focus the need to monitor and improve the quality of health care. Wennberg and Gittelsohn 3435 found wide variation in practice patterns among community physicians, surgical procedures, and hospitals.
Brook and colleagues 36 found that a small number of physicians were responsible for a large number of improperly administered injections. This was the precursor to research on the appropriateness of procedures and services under specific circumstances 3637 as well as the development of practice guidelines and standards for quality care.
The challenge is determining whether there is a direct relationship between rates of utilization, variations in appropriateness, and quality of care. One of the challenges in understanding quality, how to measure it, and how to improve it is the influence of physical, socioeconomic, and work environments. Income, race, and gender—as well as individuals within society and organizations—influence health and risks to health.
The structure, process, and outcome dimensions of quality are influenced by both internal and external factors. Structure of Health Care The structure of health care broadly includes the facilities e.
Structural characteristics are expected to influence the quality of health care services. One component in the accreditation of health care facilities e. The structural resources of health care facilities and organizations are the foundation upon which quality health care services are provided.
Process of Care The interactions between the health care providers and patients over time comprise the process of health care. The process of care may be examined from multiple perspectives: Examining the time sequence of health care services provides insights into the timeliness of care, organizational responsiveness, and efficiency.
Linking services to a specific patient complaint or diagnosis provides insights into the natural history of problem presentation and the subsequent processes of care, including diagnosis, treatment, management, and recovery. Examining the natural history of a presenting health complaint across patients will reveal variations in patterns of care. For example, presenting complaints for some patients never resolve into a specific diagnosis.
An initial diagnosis may change as more information is obtained. Patients may suffer complications in the treatment process. Also, the process of care may provide insights into outcomes of care e. Generally it is not possible to examine the process of care and determine how fully the patient has recovered prior health status by the end of the episode of treatment.
For this reason, special investigations are needed to assess outcomes of care. Evaluation of the process of care can be done by applying the six goals for health care quality. Was care timely and not delayed or denied? Were the diagnosis and treatments provided consistent with scientific evidence and best professional practice?
Was the care patient centered? Were services provided efficiently?
Was the care provided equitable? Answers to these questions can help us understand if the process of care needs improvement and where quality improvement efforts should be directed. Outcomes of Care The value of health care services lies in their capacity to improve health outcomes for individuals and populations. Health outcomes are broadly conceptualized to include clinical measures of disease progression, patient-reported health status or functional status, satisfaction with health status or quality of life, satisfaction with services, and the costs of health services.
Historically, quality assessment has emphasized clinical outcomes, for example, disease-specific measures. However, disease-specific measures may not tell us much about how well the patient is able to function and whether or not desired health outcomes have been achieved. HSR has developed valid and robust standardized questionnaires to obtain patient-reported information on these dimensions of health outcomes.
As these are more widely applied, we are learning about the extent to which health care services are improving health. Public Health Perspective on Health Services Another perspective on health care services comes from the field of public health in which preventive health services are conceptualized at three levels: Primary prevention seeks to prevent disease or delay its onset.
Examples of primary prevention include immunizations against infectious disease; smoking prevention or cessation; and promotion of regular exercise, weight control, and a balanced diet. Secondary prevention includes the range of interventions that can reduce the impact of disease morbidity once it occurs and slow its progression. With the increasing burden of chronic diseases, much of the health care provided is directed at secondary prevention.
Tertiary prevention is directed at rehabilitation for disabilities resulting from disease and injury. The goal of tertiary prevention is to return individuals to the highest state of functioning physical, mental, and social possible. The public health framework expands the structure, process, and outcome conceptual model by identifying the role and value of health services at three stages: Methodologies and Data Sources Used in Health Services Research The interdisciplinary character of HSR draws on methods and data sources common to the many disciplines that form the intellectual underpinnings of the field.DR MICHAEL GREGER - HOW NOT TO DIE - Part 1/2 - London Real
This section discusses the measurement of effectiveness and efficacy of health services and some of the methods and data sources used to understand effectiveness. Effectiveness is one of the six goals of health services. Effectiveness is interrelated with the other five goals, and some of these interrelationships are discussed. Efficacy and Effectiveness An important distinction is made between efficacy and effectiveness of health services.
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Efficacy is generally established using randomized controlled trial RCT methods to test whether or not clinical interventions make a difference in clinical outcomes. A good example is the series of studies required for Food and Drug Administration approval of a new drug before it is certified as safe and efficacious and allowed to be used in the United States. Efficacy research is generally done with highly select groups of patients where the impact of the drug can be validly measured and results are not confounded by the presence of comorbid conditions and their treatments.
The efficacy question is: What impact does a clinical intervention have under ideal conditions? In contrast, effectiveness research is undertaken in community settings and generally includes the full range of individuals who would be prescribed the clinical intervention.
Many of these individuals will have multiple health problems and be taking multiple medications, unlike those who were recruited to the RCT. Effectiveness research is seeking to answer the question: Who will benefit from the clinical intervention among all those people in the community who have a specific health problem s?
Both efficacy and effectiveness questions are important. Logically, effectiveness research would be conducted after finding the clinical intervention to be efficacious. However, there are many treatments for which no efficacy information exists; the treatments are accepted as common practice, and it would not be ethical to withhold treatments from a control group in an RCT.
As a result, effectiveness research may not have the benefit of efficacy findings. The routine use of an RCT to evaluate efficacy began in the s and is the accepted procedure for evaluating new medications.
However, this standard is not applied across all health care services and treatments. Most surgical procedures are not evaluated using an RCT. Intensive care units have never been evaluated using an RCT, nor are nurse staffing decisions in hospitals or the evaluation of many medical devices. We currently accept different standards of evidence depending on the treatment technology.
As a result, the level of evidence guiding clinical and public health decisionmaking varies. Methods for Effectiveness Research A variety of methods are used to examine effectiveness of health services. RCT methods are not usually applied in effectiveness research because the intervention being studied has demonstrated efficacy or is acknowledged as accepted clinical practice. When this is true, it would be unethical to randomly assign individuals who would be expected to benefit from the intervention to a control group not receiving an efficacious treatment.
We will discuss when RCT methods can be used to test effectiveness and provide several examples. More commonly, effectiveness research uses statistical methods for comparing treatments across nonequivalent groups. RCT and Policy Research RCT study methods can be used to compare the effectiveness and costs of services across randomly assigned representative population groups.
In an RCT, study participants are randomly assigned to two or more groups to ensure comparability and avoid any selection bias.
Health insurance experiment Probably the first application of RCT methods in effectiveness research was undertaken in the s as a health insurance experiment. The experiment was designed to test the impact on cost and health outcomes of different levels of insurance deductibles and copayment rates. A total of 3, people, ages 14—61, were randomized to a set of insurance plans and followed over 3 to 5 years. Those paying a share of their medical bills utilized approximately one-third fewer doctor visits and were hospitalized one-third less frequently.
The impact on 10 health measures of free health insurance versus paying a portion of medical care costs out of pocket was evaluated.
The findings were that there was largely no effect on health as measured by physical functioning, role functioning, mental health, social contacts, health perceptions, smoking, weight, serum cholesterol, diastolic blood pressure, vision, and risk of dying.
The study evaluated the impact on cost and outcomes of offering a defined preventive services package to Medicare beneficiaries. This was compared to usual Medicare coverage, which paid for few preventive services. The preventive services coverage being evaluated included an annual preventive visit with screening tests and health counseling. The physician could request a preventive followup visit during the year, which would also be covered.
Sixty-three percent of those in the intervention group had at least one preventive visit. Significant differences were found in health outcomes between intervention and control groups.
Among the 45 percent with declining health status, as measured by the Quality of Well-Being scale, 47 the decline was significantly less in the group offered preventive services. Mortality was also significantly lower in the intervention group. There was no significant impact of preventive services on utilization and cost. Comparative effectiveness studies ask the question: Which of the alternative treatments available is best and for whom?
Interest in this question reflects how advances in science have provided multiple treatment options for many conditions. Currently, there is no systematic process by which treatment options are compared and matched to the needs of different types of patients.
Frequently, patients are started on one treatment and then may be prescribed alternative treatments if they cannot tolerate the treatment or if it is not as effective as expected.
RCT methods can be used to evaluate comparative effectiveness of an intervention in treatment and control populations. This is ethical to do when there is no evidence that the treatments are not equivalent. An example of a comparative effectiveness study using RCT methods is the CATIE study, testing alternative antipsychotic medications in the treatment of schizophrenia.
A study of 1, persons with schizophrenia compared five of the newer antipsychotic medications second generation and also compared them against one of the first-generation antipsychotic medications. The second-generation antipsychotics were no more effective in controlling psychotic symptoms than the first-generation drug.
There was one exception, the drug Clozapine. These included weight gain, metabolic changes, extrapyramidal symptoms, and sedation effects. Each medication showed a somewhat different side-effect risk profile. From a positive perspective, the findings indicated that the clinician and patient can choose any of these medications as first-line treatment except Clozapine, which is generally used for treatment-resistant cases due to more intensive clinical monitoring requirements.
The conduct of any RCT is resource intensive, requiring the recruitment of participants, and participants must give informed consent to be randomized.
The rationale for making this investment may depend on the importance of the policy or practice issue. As shown, RCT methods can be applied to address policy and clinical care concerns with effectiveness.
To the extent that the RCT includes a broad cross-section of people who would be affected by a policy or receive a clinical treatment, this methodology provides robust effectiveness findings. Comparing Effectiveness and Costs Across Nonequivalent Groups A range of statistical methods can be used to compare nonequivalent groups i. It is not practical to review all the specific statistical approaches that can be applied.
In general, the statistical methods seek to adjust for nonequivalent characteristics between groups that are expected to influence the outcome of interest i. Epidemiologic methods are routinely used to identify and estimate disease and outcomes risk factors. These methods are applicable in comparative effectiveness evaluations.
These methods are used to make fair comparisons across provider practices and health plans and to control the cost of health care. Diagnostically related groups are used to standardize and rationalize patient care in hospitals—provided largely by nurses and other health professionals—and resource-based relative value scales are used to standardize and rationalize patient care in outpatient settings—care provided largely by physicians and nurse practitioners.
After adjustment for risks factors, variations in access to care and quality of care e. Ideally, the nonequivalent group comparison makes it possible to compare the effectiveness of alternative treatments and assess the impact of poor access to care. One limitation of this methodology is the limit of current knowledge regarding all relevant disease risk factors. Even when risk factors are known, limits on data availability and accuracy of risk factor measurement have to be considered.
Risk adjustment methods are also used to make cost comparisons across health care providers to determine which providers are more efficient. Instead of adjusting for disease risk factors, adjustments are made for the costliness of the patient mix case mix and differences in costs of labor, space, and services in the local area. Comparisons may be made to assess efficiency of providing specific services e.
These comparisons would use case-mix measures that adjust for the costliness of different mixes of hospital episodes. The following discussion identifies major attributes of each category of data source.
However, medical records are generally not structured to ensure the physician or other provider records all relevant information. The completeness of medical record information can vary considerably.
If the patient does not return for followup care, the medical record may provide no information on outcomes of care. If a patient sees multiple providers during the course of treatment, each with its own separate medical record, complete information on treatment requires access to all the records. Lack of standardization of medical records also can make abstracting records for research very resource intensive. Administrative and billing data Health care providers generally have administrative and billing data systems that capture a limited and consistent set of data on every patient and service provided.
These systems uniquely identify the patient and link information on insurance coverage and billing. Each service received by the patient is linked to the patient using a unique patient identifier. Services are identified using accepted codes e. Administrative data make it possible to identify all individual patients seen by a provider and produce a profile of all services received by each patient over any defined time period. Administrative data are comprehensive and the data are generally complete i.
In Baltimore USA, [ 10 ] the effect of health insurance on utilization pattern of the emergency department was probed into. It was reported that health insurance increased utilization of non-urgent use of the emergency department i. In a similar report in Taiwan, [ 11 ] the utilization of prenatal and intra-partum care services especially for the more expensive services substantially increased upon implementation of NHIS. Reports from Carolina USA [ 12 ] also revealed that publicly insured children were more likely to have a non urgent emergency department visit than un-insured children.
This was followed by hypertension and respiratory tract infections. This is similar to the finding in Ghana [ 8 ] where malaria, respiratory problems and diarrhea were the top three diseases that made respondents seek health care under the NHIS in Ghana.
This is at variance with the temporal variability found in a study on time of the day, day of the week analysis of out-of-hospital cardiac arrest frequency. This variation might be due to the nature of Cardiac arrest compared to outpatients which is the focus of this study. In addition, full clinical work in the hospital is not usually available during the weekend; and Monday is usually used to address some accumulated work in the duty post of hospital workers and as such Tuesday be. More studies need to be done to probe into factors responsible for this increase and to rule out possible of this scheme.
National Health Insurance Scheme in Nigeria. MedilorJounal ; 7 1: Nigerian Medical Practitioner ; 43 2: Ministry of Health, Federal Republic of Nigeria. National Health Insurance Scheme Handbook. The Social Science ; 4 2: The impact of health insurance on outpatient utilization and expenditure: Health Research Policy Systems ; 5: The economics of health and health care. Strengthening Health Systems, Chapter 3.
Whither employer based health insurance? The current and future role of United States Companies in the provision and financing of health insurance. The Commonwealth Fund Publication Number Insurance coverage and health care consumers? J Hosp Mark Public Relations ; 15 1: The impact of National Health Insurance on the Utilization of National Health Insurance on the utilization of health care services by pregnant women: The Case in Taiwan.
Maternal And Child Health Journal ; 5 1: Paediatrics ; 2: The effect of Evercare on Hospital use. J Am GeriatrSoc ; 51 Ibiwoye A, Adeleke IA. The Geneva Papers ;33 2: Patterns of utilization of general practitioners under Universal Health Insurance. Time of the day, day of the week analysis of out-of-hospital arrest OCHA frequency and viability.