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APPENDIX B Survey of Health Services Research - Educational Programsi OBJECTIVES AND METHOD To obtain more information and perspectives on educational programs in health services research, the Institute of Medicine (IOM) Committee on Health Services Research Training and Work Force Issues decided at its first meeting in July 1995 to canvass these programs for additional information. The IOM then requested and received funding for this additional work from the Robert Wood Johnson Foundation. Funds from the Baxter Foundation also helped support this activity. As a starting point, staff used the 121 health services research training programs in the United States and Canada that were listed in the 1991-1992 directory compiled by the Foundation for Health Services Research (FHSR). Although the listing is not all-inclusive, it was the most comprehensive one available to the committee. The list included information on 45 master's programs, 66 doctoral programs, and 26 fellowship programs for a total of 137. The sum of program categories exceeds 121 because some programs offer both a master's and a doctoral program. In early December 1994, the programs listed in the FHSR directory were mailed (1) a copy of their entry in the 1991-1992 FHSR directory for updating and (2) a three-page, open-ended questionnaire developed by the committee. The questionnaire asked about program structure, students' academic and work backgrounds, curriculum, enrollment, financial aid, and post-training careers of graduates. Nonrespondents received follow-up phone calls to encourage them to This appendix was prepared by Jill Feasley of the project staff. 101

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102 /lIEALTH SERVICES RESEARCH return the questionnaire. Sixty-three ofthe 137 programs resumed questionnaires for an overall response rate of 46 percent.2 (Responses were received from 18 master's, 30 doctoral, and 15 fellowship programs for response rates of 40, 45, and 58 percent respectively.) An additional 13 programs returned only their directory update. FINDINGS Program Structure Reflecting the multidisciplinary nature of the health services research field, the structure arid focus of health services research programs vary considerably. Some programs are devoted explicitly to health services research whereas others offer a health services research concentration within a distinct discipline such as nursing, pharmacy, or social work. Some programs are housed in their own academic departments, others draw from several departments in the university, and a few operate under the shared or primary auspices of institutions such as Veterans Affairs- hospitals that are not universities. Table B. 1 displays the areas and disciplines offering programs in health services research as categorized in the FHSR directory. Many programs reported that they are considering changing or already have changed their programs from the traditional fill-time, daytime, Indite format to include alternative offerings that better accommodate students who continue to work or are enrolled on a part-time basis. Classes are now being offered on evenings and weekends, by mail or other distance learning arrangements, and through summer institutes or other types of short and intensive courses. Some programs are specifically designed for business and government executives or midcareer professionals. Academic and Work Backgrounds of Students As might be expected, before entering the health services research educational programs, students had studied a variety of academic disciplines at both the undergraduate and graduate levels. Survey respondents most frequently cited student backgrounds in clinical areas (e.g., nursing, dentistry), with 2The timing of the survey may have contributed to the relatively low overall response rate; the survey was sent out just as most academic programs were finishing the first semester and starting the winter break. Beyond the follow-up phone calls, the study timetable did not allow for intensive follow up.

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108 / HEALTH SERVICES RESEARCH business, administration, and social sciences the next most frequently mentioned (Table B.2). Survey respondents indicated that both master's and doctoral students have often had some type of work experience in health care (Table B.39. Respondents for doctoral programs also cited student work experiences in administration or research. Relatively few students were described as "preservice" (i.e., entering a program without any work experience), and most of these were master's-level students. Curriculum Respondents were asked to identify the core courses for a standard health services research curriculum. The only course cited by a majority of survey respondents for all program levels (master's, doctoral, and fellowship) was research methods, although majorities or near majorities also cited statistics or biostatistics (Table Bob. Health economics was another quantitatively oriented course cited by at least one-third of respondents in each program area. Health care organization was mentioned by the less than one-third of respondents in each of the program areas, although larger proportions mentioned health policy, which may have considerable overlap in course content. In addition to the standard coursework, respondents noted the need for students to be involved in "real world" research under the supervision of a mentor. Ideally, the student should be involved with all phases of the research from initial development to final dissemination. If students plan a career in academia, they should also write articles for scholarly journals and present academic papers at professional conferences. Students who will go on to conduct research should be involved with proposal writing and fundraising. Enrollment Building on information from the 1991-1992 FHSR directory and the responses to the canvass of educational programs, the committee attempted to develop a rough estimate of the health services research pipeline, that is, those who are students in health services research educational programs. For the 76 respondents who submitted an update of the FHSR directory information, the committee used their report of the number of students enrolled in each class. For the 45 respondents who did not return the update, the committee used the enrollment information reported in the 1991-1992 FHSR directory. For the former group, the committee compared their updated and earlier figures and

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APPENDIX B / 109 found little change in enrollments for most programs, but the pattern for nonrespondents might be different. TABLE B.2 Number and Percentage of Survey Respondents Indicating Typical Academic Backgrounds of Their Health Services Research Students Academic Discipline Master's Programs No. (%) Doctoral Programs No. (%) Fellowship Programs No. (%) Clinical sciences 14 (82) 15 (58) 9 (64) Business/administration 4 (24) 11 (42) 1 (7) Social sciences 3 (18) 4 (15) 3 (21) Public health 1 (6) 4 (15) 2 (14) Other 4 (24) 6 (23) 7 (50) NOTE: Number of programs responding to this question were as follows: master's, 17; doctoral, 26; and fellowship, 14. The percentages given are based on the number of programs responding to this question, not on the total number of programs responding to the survey. Respondents could list more than one response. The combined figures on enrollment in each class Dom the two data sources show approximately 1,015 master's students, 511 doctoral students, arid 197 postdoctoral fellows. As an estimate of the health services research pipeline, this number must be interpreted cautiously. On the one hand, for the master's level and other programs that offer concentrations in areas in addition to health services research, the numbers may include students who have concentrations other than health services research. On the other hand, the numbers refer to enrollments in each class, not to total enrollments.3 3To obtain an estimate of total enrollment, the committee considered multiplying the enrollment figure for each program by the reported years to complete a degree (two years for most master' e-level programs and four to five years for doctoral programs). If the latter average were applied to the figure for doctoral enrollment reported in the text (51 1), it would yield an estimated 2,555 doctoral students in the pipeline. Based on committee members' involvement in the field, this number seemed implausibly high, presumably because it would not account for attrition. By way of contrast, for medical and dental school, enrollments are reported for the first through fourth years of school as well as for those graduating in a year (IOM, 1995~.

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1 10 / HEALTH SER VICES RESEARCH TABLE B.3 Number and Percentage of Survey Respondents Indicating Typical Work Backgrounds of Their Health Services Research Students Master's Doctoral Fellowship Work Programs Programs Programs Experience No. (%) No. (DO) No. (%) - Health care 16 (94) 20 (80) 7 (50) Research 1 (6) 6 (24) 3 (21 ) Preservicea 5 (29) 1 (4) 2 (14) Administration 0 (0) 7 (28) 0 (0) Academia 0 (0) 0 (0) 4 (29) Other 2 (12) 6 (24) 3 (21) NOTE: Number of programs responding to this question were as follows: master's, 17; doctoral, 25; and fellowship, 14. The percentages given are based on the number of programs responding to this question, not on the total number of programs responding to the survey. Respondents could list more than one response. aThe student had no prior work experience before entering the program. Financial Aid All of the doctoral and fellowship training programs reported offering some type of financial aid to some or all of their students, as do almost all of the master' e-level programs. The amount of aid, however, varies considerably from program to program. For example, some doctoral programs reported offering a $15,000 stipend and free tuition to all students. Others can only waive the tuition for a few students in each class. In general, the fellowship programs are able to provide a higher stipend (the amounts reported ranged from $17,000 to $40,000), but usually the stipend is considerably less than the participant could be earning in his or her chosen field. The amount of support provided to master's-level students ranges from none to $14,000 plus a tuition waiver. Survey respondents most frequently cited their university as a source of funding for student stipends (Table B.5) The federal government was the next most-often-cited source with financing coming either through explicit education awards such as the National Research Service Award or through research grants to the training institution that allow students to be hired for research projects. Foundations, state government, and private industry also provide funding to trainees. In particular, the Robert Wood Johnson Foundation and Pew Charitable Trusts have supported health services research and related educational programs.

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APPENDIX B / 111 TABLE B.4 Number and Percentage of Survey Respondents Indicating Core Courses for a Standard Health Service Research Curriculum . Master's Doctoral Fellowship Programs Programs Programs Course No. (NO) No. (%) No. (%) Research 11 (73) 22 (1 00) 6 (55) methods Statistics/ 7 (47) 11 (50) 7 (64) Biostatistics Health 6 (40) 12 (55) 4 (36) economics Health policy 4 (27) 8 (36) 6 (55) Epidemiology 5 (33) 4 (18) 7 (64) Health care 3 (20) 7 (32) 3 (27) organization Administration/ 3 (20) 3 (14) 1 (9) Management Ethics 1 (7) 3 (14) 1 (9) Other 6 (40) 5 (23) 4 (36) . _ NOTE: Number of programs responding to this question were as follows: masters 15; doctoral, 22; and fellowship, 11. The percentages are based on the number of programs responding to this question, not on the total number of programs responding to the survey. Respondents could list more than one response. Post-Training Careers According to survey respondents, graduates of health services research training programs will go on to work in three general capacities: as a faculty member of an academic institution; as a researcher for an independent research organization; or as a policy analyst or researcher with a government agency. Others work in clinical or administrative settings, although the responses do not make clear the extent to which they are actually involved in research rather than patient care or management (Table B.6~. Survey respondents indicated that graduates generally continue to hold the same types of jobs five years after completing their academic training.

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1 12 / HEALTH SERVICES SEARCH TABLE B.5 Number and Percentage of Survey Respondents Indicating Source of Funding for Health Service Research Students' Stipends Source of Funding Master's Programs No. (%) Doctoral Programs No. (%) Fellowship Programs No. (%) University 12 (86) 21 (81 ) 4 (27) Federal government 6 (43) 11 (42) 12 (80) Grants, otherwise 1 (7) 5 (19) 0 (0) unspecified State government 2 (14) 3 (12) 2 (13) Foundation 3 (21) 2 (8) 4 (27) Industry 3 (21) 2 (8) 2 (13) Other 0 (0) 1 (4) 0 (0) NOTE: Number of programs responding to this question were as follows: master's, 14; doctoral, 26; and fellowship, 15. The percentages given are based on the number of programs responding to this question, not on the total number of programs responding to the survey. Respondents could list more than one response. TABLE B.6 Number and Percentage of Survey Respondents Indicating Post- Training Employment Settings of Graduates in Health Services Research - Master's Doctoral Fellowship Employment Programs Programs Programs Setting No. (%) No. (%) No. (%) Academic institution 6 (38) 23 (92) 10 (77) Research organization 9 (56) 17 (68) 7 (54) Government agency 6 (38) 8 (32) 6 (46) Clinical setting 3 (19) 1 (4) 2 (15) Administrative setting 1 (6) 4 (16) 0 (0) Not applicable/too new to know 4 (25) 0 (0) 1 (8) NOTE: Number of programs responding to this question were as follows: master's, 16; doctoral, 25; and fellowship, 13. The percentages given are based on the number of programs responding to this question, not on the total number of programs responding to the survey. Respondents could list more than one response.