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Research Training in the Biomedical, Behavioral, and Clinical Research Sciences 8 Health Services Research Health services research (HSR) provides the information needed to understand the effectiveness and efficiency of our health care delivery system and its impact on the health and well-being of individuals and populations.1 Health services research documents deficiencies in patient and population health and in the provision of health services and seeks to identify contributing factors. There are many examples: being uninsured in America reduces access to health care and contributes to poorer health outcomes (Institute of Medicine [IOM] reports on uninsured); medical errors too frequently occur in hospitals and many patients suffer injury or death (IOM, 1999); and in the community, only half of the time are individuals receiving preventive and chronic disease care consistent with scientific evidence (McGlynn, 2003). Health services researchers seek solutions to these and other problems that adversely affect access to care, quality, safety, and cost of care. Health services research evaluates the impact of government and private-sector health policies, designs and evaluates innovations in health care organization and financing, and examines the effects of new technologies or new uses of existing technologies. Assessing the impact of health services on population health requires health services researchers to go beyond disease outcomes to examine health status and health-related quality of life outcomes, assess delivery system quality and efficiency, as well as focus attention on prevention and health promotion services. The contributions of health services research to policy, management, and clinical care have been diverse. Planners and policy makers, for example, are frustrated by the inability to generalize and use findings from efficacy studies: persons recruited to randomized control trials testing new treatments typically are not representative of the larger population expected to benefit from the treatment. Thus, it is up health services research to fill this information gap by assessing the impact of diagnostic and treatment technologies on patient outcomes and costs across real-world practice settings and diverse populations. Translational research has emerged as an important dimension of health services research design and analysis; translational research provides the knowledge base to move scientific discoveries from laboratory, clinical, or population studies into clinical applications at the National Cancer Institute. Yet translation alone is generally not sufficient to ensure these services are available across America. Implementation research is needed to effectively adapt new clinical applications to diverse real-world practice settings in which programs, tools, and guidelines will be utilized and need to be integrated into the existing hospitals and community practice settings (Rubenstein and Pugh, 2006). Together translation and implementation research are gaining greater visibility as we have come to recognize that many Americans are failing to receive consistent high-quality health care based on the latest scientific knowledge. Meeting the challenges of translation and implementation research requires additional disciplinary breadth, drawing on areas of organizational and operations research, psychology, marketing, education, and adult learning. Also expanded applications of health information technology are needed in support of consumer-patient decision making and real-time decision support for health care providers. The rapid growth and continuing change in scientific health information will result in the translation and implementation processes being continual and not one-time or infrequent events. The capacity to achieve this goal may require fundamental re-thinking of information flow and how it supports all aspects of health services. Central to advances in all scientific fields are measurement tools, and for health services research measurement tools span payment and financing, appropriateness of utilization (overuse, underuse, and misuse; IOM, 2001), quality of care, and patient outcomes of care. Health services research 1 Many definitions of this multidisciplinary field are available in the literature, including those developed by previous NRC committees on personnel needs in the biomedical and behavioral sciences; see, for example, NAS 1977, 1983, 1989 and 1994. Other authors include the Institute of Medicine 1995. A recent definition circulated within the community was developed by K.N. Lohr and D.M. Steinwachs (2002).
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Research Training in the Biomedical, Behavioral, and Clinical Research Sciences has provided the measurement tools being used in payment for inpatient hospital services, outpatient services, and nursing home care, as well as capitation payment methods for persons enrolled in health plans. Improved payment methods are making it possible to adjust payment for quality of care and to better reward efficiency. These measurement tools, and others to be developed, will be needed to monitor and evaluate the impact of the 2010 Health Reform legislation and how well it achieves its goals. Examples of quality-of-care measures that will require further development include: assessing the timeliness of health care, measuring coordination of patient care when multiple providers are involved in diagnosis and treatment, providing patient-centeredness of care, and equity of health care. Although these are not new, there are few if any accepted measurement tools to assess deficiencies and progress toward the goals of health reform. The training and support of researchers who focus on measurement is a continuing and growing need in health services research. Since 2003 Congress has provided support to the Agency for Healthcare Research and Quality (AHRQ) to develop and fund comparative effectiveness research (CER). In 2009, the American Recovery and Reinvestment Act (ARRA) augmented CER support with $1.1 billion for research and training through AHRQ, the National Institutes of Health, and the Office of the Secretary of Health and Human Services (HHS). CER as defined by HHS combines key elements of health services and clinical research: Comparative effectiveness research is the conduct and synthesis of research comparing the benefits and harms of different interventions and strategies to prevent, diagnose, treat and monitor health conditions in “real world” settings. The purpose of this research is to improve health outcomes by developing and disseminating evidence-based information to patients, clinicians, and other decision-makers, responding to their expressed needs, about which interventions are most effective for which patients under specific circumstances. To provide this information, comparative effectiveness research must assess a comprehensive array of health-related outcomes for diverse patient populations and sub-groups. Defined interventions compared may include medications, procedures, medical and assistive devices and technologies, diagnostic testing, behavioral change, and delivery system strategies. This research necessitates the development, expansion, and use of a variety of data sources and methods to assess comparative effectiveness and actively disseminate the results. The expectation is that CER will provide new information that is not currently available about what treatments and services work best for individuals across America’s diverse populations, taking into consideration the person’s circumstances and the timing of services. The new CER mandate complements the initiatives discussed above in translation and implementation research, intensifying the focus on research driving health system transformation to achieve better health outcomes for all Americans and greater efficiency. FEDERAL SUPPORT OF HEALTH SERVICES RESEARCH In 1968, Congress recognized the emerging role of health services research for improving health care delivery in the United States and created the National Center for Health Services Research and Development (NCHSRD) in the Department of Health, Education, and Welfare (DHEW). During the years 1968-1989, NCHSRD sought to develop research on issues of access, cost, and quality, and to develop data systems to support research on utilization and cost of care.2 However, over time the budget for NCHSRD declined and the future of the NCHSRD became uncertain. Private foundations played a critical role in sustaining the health services research field during these years.3 In 1989, health services research once again found strong support in Congress and a new vision for health services research was created in the authorization of the Agency for Health Care Policy and Research (AHCPR). Congress directed the Agency—subsequently renamed the Agency for Healthcare Quality and Research—to undertake research on patient outcomes, develop practice guidelines, and disseminate the research to change the practice of medicine.4 The agency placed greater emphasis than previously on the examination of clinical practice, decision making, and comparative effectiveness of alternative approaches to diagnosis and treatment. The funding for AHRQ has grown over the years from $128 million in fiscal year 1993 to $397 million in fiscal year 2010, plus $300 million in CER funding from the ARRA appropriation. While the National Research Service Awards (NRSA) program included support for health services research from its inception (see, for example, NRC, 1977), Congress specified in 1989 that one-half of 1 percent of the NRSA budget for training be allocated for training health services researchers through AHRQ, subsequently expanding that 2 The center initiated large-scale demonstrations, including the Experimental Medical Care Review Organization (EMCRO) to develop tools for quality measurement and their evaluation. The EMCRO demonstration provided the Medicare program with the methodologies it needed in the Professional Standards Review Organization (PSRO) to evaluate hospital use. The NCHSRD also competitively funded health services research centers in academic institutions and Kaiser Permanente. 3 It should be noted that health services research in focused areas like mental health services, alcohol and drug abuse treatment services, and veterans’ health care continued throughout this time. Health services research funding also comes from the Centers for Medicare and Medicaid Services (CMS), Centers for Disease Control and Prevention (CDC), Department of Defense (DoD), and several NIH institutes. 4 In 2001, the reauthorization of AHCPR led to a name change to the Agency for Healthcare Research and Quality (AHRQ). The word policy was dropped from the title and quality was added to reinforce the quality-of-care research mission of the agency.
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Research Training in the Biomedical, Behavioral, and Clinical Research Sciences allocation to 1 percent of NRSA funding in 1999, which has remained unchanged. It should be noted that in the early 1990s Congress authorized a 15 percent set-aside for both research and NRSA training in service-related research supported by the National Institute of Mental Health (NIMH), the National Institute of Drug Abuse (NIDA), and the National Institute of Alcohol Abuse and Alcoholism (NIAAA) as part of the reorganization of the former Alcohol, Drug Abuse and Mental Health Administration into the National Institutes of Health. Even with this congressionally mandated set-aside for these NIH institutes, AHRQ remained the lead agency for health services research. NIH funding has been directed at HSR focused on questions related to the delivery of health care for specific diseases/disorders. AHRQ and NIH fund complementary research and in many instances have co-funded major health services research studies. HEALTH SERVICES RESEARCH WORKFORCE No national statistical system reports on the size and composition of the health services research workforce (Moore and McGinnis, 2009; Pittman and Holve, 2009). Obtaining information on the workforce in this field is a challenge. Identifying scientists who primarily do health services research is complicated by the interdisciplinary nature of the field. Health services research is an applied field, and so most health services researchers have another unique discipline or profession that they bring to health services research. Workforce data usually classify health services researchers by their primary discipline or profession and often are unable to identify the field of scientific inquiry as health services research. As NIH moves more toward trans-disciplinary research, the problem of not having multiple classifications incorporating both discipline and field of application may be an issue faced by many basic sciences and clinical researchers, as well as health services research. In addition, anecdotal evidence suggests that some investigators involved in health services research studies do not identify themselves as health services researchers, nor do they necessarily belong to the only national professional association in this area, namely AcademyHealth. This partial or part-time involvement of many scientists in health services research only further complicates efforts to estimate the size and composition of the health services research workforce. McGinnis and Moore addressed this issue in their study on the current status of the health services research workforce. In a conservative estimate of the field, counting HSRProj investigators (since 2004), speakers from AcademyHealth’s Annual Research Meeting in 2007, and AcademyHealth members whose membership has lapsed or joined in 2000 or later, Moore and McGinnis found that the field has more than doubled in size since the IOM’s estimate in 1995, growing from approximately 5,000 health services researchers to more than 13,000 researchers in 2007. Using a more expansive definition of the field by including researchers in disciplinary associations with subgroups that sometimes do health services research, such as the American Public Health Association, the American Society of Health Economists, the American Statistical Association, and the American Sociological Association, there could be an additional 6,000 intermitted members of the field (Moore and McGinnis, 2009). The best data available on the composition of health services research workforce5 likely comes from the most recent AcademyHealth membership survey in 2008 (AcademyHealth, 2008). AcademyHealth draws its members from both health services research and health policy, and includes student memberships. Although this database more than likely underestimates the total size of the workforce, it does provide some insights into its composition. As of 2008, 51 percent of AcademyHealth’s 3,500 individual members report having a Ph.D., Sc.D., or other doctoral-level training in science. There are another 12 percent reporting an M.D. Table 8-1 shows the distribution of health services researchers by employment sector. AcademyHealth membership has greater female representation (60.7 percent) than male (39.3 percent). This representation has changed slightly from AcademyHealth’s survey of members in 2002, when 55 percent of the respondents were women and 45 percent were men. Of note is that the youngest members were twice as likely to be female as to be male, while the oldest respondents were twice as likely to be male as to be female. The ethnic mix of members is 21 percent from minority ethnic backgrounds, including Asian/Pacific Islanders (10.6 percent), African Americans (5.2 percent), and Hispanics/Latinos (2.6 percent), plus 79 percent Caucasian and 2.5 percent other. Representation of all minorities has increased since 2002—to 21 percent from 12.8 percent. Table 8-2 shows the primary field of interest by the members of AcademyHealth, and the largest share of the members classify their primary discipline as public health (21.5 percent). Only 13.3 percent of members identify their primary discipline as health services research. In a study on the demand for health services researchers, Thornton and Brown (2009) found that the demand from both universities and non-academic employers is expected to increase. Based on their work one can anticipate there will be a growing demand for “people who can analyze the effectiveness of health service systems from disease management firms; investment firms with a large stake in the health care sector; state and local government; hospitals and providers that will be implementing quality reporting systems and pay-for-performance systems;” and the health 5 Jeanne Moore and Sandra McGinnis’s analysis in 2007 uses data from AcademyHealth membership as well as participants from AcademyHealth meetings and principal investigators listed in HSRProj. AcademyHealth’s data solely represent its membership as of 2008.
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Research Training in the Biomedical, Behavioral, and Clinical Research Sciences TABLE 8-1 Setting of Primary Employment, 2008 Sector Percent College/University 48.8 Government 10 Health Care Delivery Organization 9.3 Research Organization 7.4 Other (please specify) 4.5 Association 4.3 Consulting Firm 4.3 Foundation 3.5 Health Policy Center 2.5 Insurance 2 Pharmaceutical or Biotechnology 1.5 Quality Improvement 1.2 Professional Society 0.8 SOURCE: AcademyHealth Member Survey, 2008. TABLE 8-2 Primary Field of AcademyHealth Members, 2008 Sector Percent Public Health 21.5 Public Policy 16.7 Other (please specify) 15 Health Services Research 13.3 Medicine 10.9 Nursing 7.1 Sociology 4 Economics 3.8 Psychology 2.3 Public Administration 1.6 Political Science 1.1 Operations Research 1 Law 0.7 Business Administration 0.6 Anthropology 0.4 SOURCE: AcademyHealth Member Survey, 2008. industry including equipment manufacturers, pharmaceutical firms, and insurers. Graduate Programs in Health Services Research Graduate programs in health services research are not separately accredited, and because many graduates could come from doctoral programs with a different specialty than health services research, there is no accurate tally of doctoral students earning degrees in health services research (Ricketts, 2009). However, in its 2009 online directory of master’s and doctoral programs in HSR, AcademyHealth reports that there are now 41 schools providing HSR doctoral programs and 22 schools with postdoctoral training programs. Doctoral programs are mainly Ph.D. programs, including both disciplinary (e.g., health economics, medical sociology) and general training in health services research. An example of additional training opportunities is illustrated by Veterans Administration’s description of a new fellowship program: VA Advanced Fellowship Program in Health Services Research and Development (HSR&D): This includes 16 training sites for Ph.D. associated health professionals, 8 training sites for post-residency physician associated health professionals, and 3 sites for post-doctoral physician associated health professionals. HSR&D also participates in the VA Advanced Fellowship Program in Medical Informatics which includes 7 training sites for post-doctoral and physician health professionals in medical informatics. The NRSA program provides support for training in health services research. As discussed above, the AHRQ has received funding equal to one percent of all NRSA funds for NIH. AHRQ supplements NRSA funding with $500,000 annually. As shown in Table 8-3, both NIH and AHRQ are funding HSR training at predoctoral and postdoctoral levels. Taken together, there were 107 predoctoral training positions in 2008, 68 percent of them funded by AHRQ. There were also a total of 85 postdoctoral positions, of which 49 percent were funded by AHRQ. The agency accepts new and renewal training grant applications every 5 years. In general, the agency has been able to fund only two-thirds of the requested training positions, and this is very similar to the rate for all NIH training awards. In addition, several NIH institutes provide NRSA awards in health services research, including NIMH, NIAAA, and NIDA. Overall, the total number of trainees is likely less than 2 percent of all NRSA training positions. No data are available on graduates of doctoral programs who are not funded by the NRSA program but who plan to pursue health services research careers. It would be expected that these numbers far exceed NRSA recipients, as they do in other health research fields. Although there is incomplete information on the characteristics and careers of all individuals with training in health services research, there is some information of NRSA trainees supported by AHRQ. In particular, AHRQ commissioned an outcome study in 1999 of NRSA trainees between 1986 and 1997, which used information from the curricula vitae (CV) of the traimees. The results of this study were reported in the last assessment of the NRSA program. These data were updated in 2005 when data on trainees from 1998 to 2003 were added and data on the earlier trainees were made current to 2003. From 1986 to August 2003, AHRQ supported more than 1,000 individuals through different funding mechanisms. The NRSA program T32 institutional awards supported 346 predoctoral and 435 postdoctoral trainees through 27 university-based or university-affiliated training sites. Another 81 AHRQ F32 individual NRSA postdoctoral fellowships and 5 predoctoral fellowships were awarded. Some individuals had multiple awards under different mechanisms. A total of 854 individuals had support.
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Research Training in the Biomedical, Behavioral, and Clinical Research Sciences TABLE 8-3 Health Services Research Training Positions Funded by AHRQ and the NIH Positions 1990 1995 2000 2005 2006 2007 2008 NIH Predoctoral Trainees 11 6 0 20 27 28 28 NIH Predoctoral Fellows 1 4 8 14 7 8 8 AHRQ Predoctoral Trainees 22 19 3 71 67 76 71 AHRQ Predoctoral Fellows 0 0 0 1 2 1 2 Predoctoral Subtotal 34 29 11 105 101 112 107 NIH Postdoctoral Trainees 31 16 0 31 39 29 40 NIH Postdoctoral Fellows 2 1 1 4 3 3 5 AHRQ Postdoctoral Trainees 5 1 3 40 35 37 40 AHRQ Postdoctoral Fellows 3 0 0 2 2 3 2 Postdoctoral Subtotal 38 18 4 75 77 69 85 SOURCE: NIH database, 2008. In 2000, AHRQ launched its career development (K) award program and by August 2003 had made 48 awards. The majority of AHRQ-supported NRSA trainees and fellows between 1986 and 2003 were female (502 of 854, or 59 percent), a difference especially evident among T32 predoctoral trainees (229 of 346, or 66 percent) and F32 fellows (45 of 76, or 58 percent). There were almost even numbers of males (203) and females (225) with T32 postdoctoral trainees during this period. The CVs of 709 trainees provided information on career progression and research productivity. CVs were received from 850: 346 had T32 predoctoral support, 428 had T32 postdoctoral support, and 76 had F32 fellowships. Of those who earned a doctorate by 2003, about 75 percent or 244 of the doctorates with a known degree field earned their doctorate in a health science field, including: health services research (81); related multidisciplinary health fields such as health policy, health administration, or public health (118); or one of the other health sciences (45). Over 90 percent of the T32 predoctoral trainees earned their baccalaureate degrees in one of the sciences, with 42 percent in the social sciences, 15 percent in the health sciences, and 19 percent in other scientific fields, including the physical and mathematical sciences. The degrees of those with baccalaureate degrees in non-sciences were either in education, humanities, or professional fields. Length of time in training for T32 and F31 predoctoral students averaged about 20 months, but 36 percent were only in training for 12 months. There was some difference in length of training by gender, with 81 percent of females in training for 24 months or less and 75 percent of males for this period. At the postdoctoral level, 84 percent of F32 fellows were in training for 24 months or less, and 86 percent of the T32 awardees were in training for this period. For both the T32 and F32 trainees, about half were in training for 24 months. Half of the AHRQ NRSA T32 postdoctoral trainees with research doctorates earned them in the social sciences (sociology, economics, or the other social sciences); the remainder earned them in a variety of health or other fields. The other half of the AHRQ NRSA T32 postdoctoral trainees had clinical doctorates, and about half of these were earned in internal medicine; another 20 percent were earned in pediatrics and another 6 percent were earned in family practice, with the remainder earned in a wide variety of other clinical specialties. About 20 percent, or 59, of the 241 clinical doctorates with CV information earned a joint M.D./Ph.D. Just over half of the AHRQ NRSA F32 fellows held clinical doctorates, and more were in internal medicine. The study also showed that the AHRQ NRSA trainees and fellows actively pursue research careers through a variety of employment paths. Most AHRQ NRSA T32 predoctoral trainees who completed their doctorates by 2003 did not pursue formal postdoctoral research training. First employment data were available for 555 of the predoctoral and postdoctoral trainees, and a large majority of both groups where employed in academic institutions. For the postdoctorates, 71 percent of 382 trainees were in academe, 23 percent were in for-profit or non-profit organizations, and 5 percent were in government. Of those in academic positions, 76 percent were Ph.D.s and 72 percent had clinical degrees. Most of the clinical doctorates that complete training began their academic career as an instructor. The percentage for the 165 predoctoral trainees formed a similar pattern, but only 57 percent had an academic position and 29 percent were in for-profit or non-profit organizations. The current employment of postdoctoral trainees at the end of 2003 closely resembles their first employment with 79 percent in academic positions and 13 percent in health-related employment. The remaining 8 percent were in for-profit or other organizations. For T32 predoctoral trainees, academic employment was almost as high at 67 percent, with 21 percent in health-related employment and the remaining 11 percent in for-profit or other organizations. Of the employed NRSA T32 predoctoral trainees, about half (48 percent) reported having received post-training research support, and about 77 percent reported at least one post-training scientific journal publication. For NRSA T32
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Research Training in the Biomedical, Behavioral, and Clinical Research Sciences postdoctoral trainees with research doctorates, 72 percent reported having received post-training research support, and 85 percent listed at least one scientific journal publication following training. About 60 percent of the employed NRSA T32 postdoctoral trainees with clinical doctorates reported having received post-training research support, and about 78 percent had at least one scientific journal publication following training. Two-thirds of the employed former AHRQ NRSA F fellows reported having received grant support. In general, 90 percent of all trainees had at least one post-training scientific journal publication. FEDERAL HEALTH SERVICES RESEARCH FUNDING The broad relevance of health services research has contributed to federal funding through multiple agencies, unlike the funding of most other areas of health research. AHRQ’s research is expected to address cross-cutting issues such as access, quality and cost issues that are faced by the entire American health care system. Other funding sources seek to fund health services research in support of their organizational missions. The VA and DoD focus on their delivery systems, CMS on financing Medicare and Medicaid, CDC on prevention, and the NIH on delivery of services for specific diseases. These funding sources are complemented by private sources, including major foundations (e.g., Robert Wood Johnson Foundation, Commonwealth Fund, MacArthur Foundation, Kellogg Foundation, Kaiser Family Foundation, and a number of state-based foundations) and private corporations. The following discussion will be limited to federal funding of health services research. In 2001 the Coalition for Health Services Research (CHSR), the advocacy affiliate of AcademyHealth, began an initiative to document health services research funding levels across the federal government. The first report was completed in 2003 and now there are annual updates. As of FY 2009, the Coalition estimates that a total of $1.48 billion was expended for health services research and related activities by the federal government in as shown below: Agency for Healthcare Research and Quality (AHRQ)—$372 million; Centers for Disease Control and Prevention (CDC): National Center for Health Statistics (NCHS)—$125 million; Extramural Prevention Research Program—$31 million; Prevention Research Centers—$31 million; Centers for Medicare and Medicaid Services (CMS)—$39 million;6 Health Resources and Services Administration (HRSA)—$9 million; National Institutes of Health (NIH) (All Institutes)—$779 million; Veterans Health Administration (VHA)—$75 million; and The Department of Defense (DoD)—$17 million. Despite repeated calls from the Coalition for Health Services Research that federal agencies use a standard definition or uniform categories to report their expenditures, the data presented above are measured by these agencies using their own unique definition for what constitutes health services research. Only with a uniform definition and standard categories, would it be possible to assess how the current funding meets emerging needs. Comparing the health services research funding of $1.5 billion to total federal health research funding of $35 billion in 2005 (Global Forum for Health Research, 2005) shows that approximately 4 percent of total funding is being devoted to health services research, based on classifications used within each agency and institute. NIH institutes report funding health services research as shown in Table 8-4. NIMH, NIDA, and NCI have the largest programmatic commitment, ranging from 17 to 23 percent of budget. Other institutes report smaller commitments of budget to health services research. In summary, AHRQ provides 25 percent of all health services research funding as reported by federal agencies. Other federal agencies support more focused program-specific and disease-specific health services research. Private funding of health services research is substantial but no comprehensive source of information is available on non-federal sources. CAREERS IN HEALTH SERVICES RESEARCH The employment opportunities and careers in health services research are widely varied. Academic careers may be in schools of medicine, nursing, public health, and other health professional schools, as well as engineering and traditional arts and sciences departments, along with business and public policy schools. To effectively manage interdisciplinary research, academic institutions usually have organizational structures such as centers or institutes for health services research that cross school and departmental boundaries. At some institutions there are multiple centers reflecting different areas of specialization and the availability of funding for specialized centers from federal and private sources. Private-sector health services research careers are available in many areas. Federal contract work evaluating major public policy initiatives are primarily done by private research firms. These organizations include RAND, Mathematica, Abt Associates, Westat, and others. These organizations are organized to do short-term large-scale studies that are not as easily organized and managed in most academic settings. 6 Most of the funding in CMS’s research budget actually represents Congressional earmarks for activities that are only remotely related to CMS’s research and demonstration interests.
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Research Training in the Biomedical, Behavioral, and Clinical Research Sciences TABLE 8-4 NIH Institute Health Services Research Budgets Health Services Research FY 2008 Estimate (Dollars in Thousands) Total Health Services Research Budget Proportion of Total Institute Budget That Is Health Services Research Proportion of NIH’s Total Health Services Research Budget NIMH $94,273 6.67% 12.68% NIDA $61,207 6.08% 8.23% NCI $207,363 4.29% 27.89% NIA $47,696 4.53% 6.42% NIDDK $28,944 1.55% 3.89% NIAAA $22,410 5.10% 3.01% NHLBI $55,968 1.90% 7.53% NINR $21,227 15.38% 2.86% Other NIH HSR $204,298 1.28% 27.48% Total $743,388 SOURCE: Coalition for Health Services Research (2008). Analysis was completed using data from NIH’s Research Portfolion Online Reporting Tools (RePORT). Other private-sector health services research careers are in research organizations sponsored by HMOs and health plans, hospital systems, pharmaceutical firms, insurers, and other major stakeholders in health care. Health services research positions may involve directing research, translating research into practice and products, and managing and evaluating health care operations. Associations for professional groups, manufacturers, and advocacy groups recruit people trained in health services research to strengthen their capacity to use information com-ing from health services research to advance their advocacy objectives and meet the needs of their members. As efforts to translate science into practice accelerate, the demand for individuals skilled in health services research and communication to users is likely to grow. Government agencies recruit substantial numbers of health services research professionals to lead and manage research programs, to support policy analysis and development, and to work with managers and providers in the VA and DoD health care delivery systems. New career paths for health services research professionals may emerge as research into effective translation of knowledge into practice grows. The 2003 Medicare prescription drug legislation mandated in Section 1013 that comparative effectiveness studies of health care services including prescription drugs increased the need for health services researchers trained in pharmaco-economics. The ARRA provided a substantial increase in CER funding for both research and investment in research infrastructure including methods and data. The development of tools and techniques to support translation is likely to become an industry that will require research skills in the design, evaluation, and testing of new technologies. Translation of knowledge for clinicians may be the initial priority, but priorities will likely expand to include managers, patients, and the public. The passage of the 2010 Affordable Health Care Act for America brings new and increased demands to monitor the success of health reform and identify unintended consequences. To achieve goals of greater efficiency in American health care and better quality, additional investments in health services research and translation and implementation in practice will be needed. The future demand for well-trained health services researchers is currently strong and growing. RECOMMENDATIONS Recommendation 8–1: Health services research training should be expanded and strengthened within each NIH institute and center. Biomedical research has created a growing gap between research advances in biomedical science and the ability to apply them effectively to improve the health of the public. Thus there is a need for more effective health care delivery practices to ensure effective and evidence-based care, and to reduce waste and unnecessary risk to patients. Recommendation 8–2: AHRQ training programs should be expanded, at a minimum commensurate with the growth in total federal spending on health services research, including comparative effectiveness research. Recognition of the rising costs of care, with concerns about quality and consistency, have driven increases in services research. Health services research has established an important evidence base to enable patients and health care organizations to evaluate benefits and risks of diagnostic and therapeutic intervention and to compare relative values of older and newer approaches as choices proliferate. This field can also evaluate different approaches to health care delivery and financing, which will allow the nation to get more benefit from the dramatic advances in biomedical science. Ideally, the total numbers of persons being trained in HSR should grow at the same rate as national health
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