The provision of high-quality, affordable, health care services is an increasingly difficult challenge. Due to the complexities of health care services and systems, investigating and interpreting the use, costs, quality, accessibility, delivery, organization, financing, and outcomes of health care services is key to informing government officials, insurers, providers, consumers, and others making decisions about health-related issues. Health services researchers examine the access to care, health care costs and processes, and the outcomes of health services for individuals and populations.

The field of health services research (HSR) is relied on by decisionmakers and the public to be the primary source of information on how well health systems in the United States and other countries are meeting this challenge. The “goal of HSR is to provide information that will eventually lead to improvements in the health of the citizenry.”¹ Drawing on theories, knowledge, and methods from a range of disciplines,² HSR is a multidisciplinary field that moves beyond basic and applied research, drawing on all the health professions and on many academic disciplines, including biostatistics, epidemiology, health economics, medicine, nursing, operations research, psychology, and sociology.³

In 1979, the Institute of Medicine defined HSR as “inquiry to produce knowledge about the structure, processes, or effects of personal health services”⁴ (p. 14). This was expanded upon in 2002 by AcademyHealth, the professional organization of the HSR field, with the following definition, which broadly describes the scope of HSR:

Health services research is the multidisciplinary field of scientific investigation that studies how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviors affect access to health care, the quality and cost of health care, and ultimately our health and well-being. Its research domains are individuals, families, organizations, institutions, communities, and populations.⁵

More specifically, HSR informs and evaluates innovations in health policy. These include changes in Medicare and Medicaid coverage, disparities in access and utilization of care, innovations in private health insurance (e.g., consumer-directed health plans), and trends among those without health insurance.^6–10 The health care industry continues to change, and HSR examines the impact of organizational changes on access to care, quality, and efficiency (e.g., growth in for-profit hospital systems). As new diagnostic and treatment technologies are introduced, HSR examines their impact on patient outcomes of care and health care costs.

The definition of HSR alAso highlights the importance of examining the contribution of services to the health of individuals and broader populations. HSR applied at the population level is particularly important in understanding health system performance and the impact of health policy on the public’s health. In the United States, the National Healthcare Quality Report,¹¹ National Healthcare Disparities Report,¹² and Healthy People Year 2010¹³ exemplify our capacity for monitoring quality and assessing change. These reports tell us that the American quality of care is inconsistent and could be substantially improved.Differentiate Health Services Research From Clinical Research Essay. The associated cost of health care services is monitored by the Centers for Medicare & Medicaid Services (CMS). CMS reports tell us that American health care is the most expensive in the world, consuming approximately 16 percent of America’s gross domestic product.¹⁴

Beyond health policy, HSR examines the process of care and the interactions of patients and providers. For example, HSR methods have been developed to describe doctor-patient communication patterns and examine their impact on patient adherence, satisfaction, and outcomes of care.^15–17

Advances in HSR measurement methodologies have made possible policy innovations. Prospective payment of hospitals, nursing homes, and home health care by Medicare became possible with the development of robust case-mix measurement systems.¹⁸ CMS was able to initiate a pay-for-performance demonstration, rewarding hospitals with better quality performance, using valid and robust measures of quality.¹⁴ Innovations in health care policy are frequently made possible by advances in measurement of indicators of health system performance.

History of Health Services Research

The history of HSR is generally considered to have begun in the 1950s and 1960s with the first funding of grants for health services research focused on the impact of hospital organizations.^19, 20On the contrary, HSR began with Florence Nightingale when she collected and analyzed data as the basis for improving the quality of patient care and outcomes.²¹ Also significant in the history of HSR was the concern raised about the distribution, quality, and cost of care in the late 1920s that led to one of the first U.S. efforts to examine the need for medical services and their costs, undertaken in 1927 by the Committee on the Costs of Medical Care.²² The committee published a series of 28 reports and recommendations that have had a significant impact on how medical care is organized and delivered in the United States.²³ Other key reports of historical importance to HSR were, for example, the national health survey in 1935–1936 by the Public Health Service, the inventory of the nation’s hospitals by the American Hospital Association’s Commission on Hospital Care in 1944, and studies by the American Hospital Association’s Commission on Chronic Illness on the prevalence and prevention of chronic illness in the community.²³

In 1968, the National Center for Health Services Research and Development was established as part of the U.S. Public Health Services to address concerns with access to health services, quality of care, and costs. Differentiate Health Services Research From Clinical Research Essay. The Center funded demonstration projects to measure quality and investigator-initiated research grants. In 1989, Congress created the Agency for Health Care Policy and Research and broadened its mission to focus attention on variations in medical practice, patient outcomes of care, and the dissemination of evidence-based guidelines for the treatment of common disorders. Later Congress reauthorized and renamed the agency, Agency for Healthcare Research and Quality (AHRQ). AHRQ provides Federal leadership for the field, investing in methods for quality measurement, development of patient safety methods, and health information technology (e.g., electronic health records and decision support systems).

The Federal role in HSR has expanded over time, and investments in HSR are made by multiple Federal agencies. In addition to AHRQ, the U.S. Department of Veterans Affairs, Centers for Disease Control and Prevention, the National Institutes of Health, CMS, and other Federal agencies fund HSR. The diversification of funding comes, in part, from the recognition that HSR is important in managing health care systems, such as the Veterans Health Administration, and provides essential information on the translation of scientific discoveries into clinical practice in American communities, such as those funded by National Institutes of Health. It is estimated that total Federal funding of HSR was $1.5 billion in 2003, of which AHRQ was responsible for approximately 20 percent.²⁴

Private funding of HSR has also grown over time. Funding by private foundations has a significant role and complements Federal funding. Among the many foundations funding HSR are the Robert Wood Johnson Foundation, Commonwealth Fund, Kaiser Family Foundation, Kellogg Foundation, and Hartford Foundation. Other private funding sources include the health care industry, for example, pharmaceutical companies, health insurers, and health care systems.

Goals for Health Services and Patient Outcomes

The goal of health services is to protect and improve the health of individuals and populations. In a landmark 2001 report, Crossing the Quality Chasm: A New Health System for the 21^st Century,²⁵the Institute of Medicine (IOM) of the National Academy of Sciences proposed that the goals for health services should include six critical elements:

1. Patient Safety: Patients should not be harmed by health care services that are intended to help them. The IOM report, To Err Is Human,²⁶ found that between 46,000 and 98,000 Americans were dying in hospitals each year due to medical errors. Subsequent research has found medical errors common across all health care settings. The problem is not due to the lack of dedication to quality care by health professionals, but due to the lack of systems that prevent errors from occurring and/or prevent medical errors from reaching the patient.
2. Effectiveness: 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 trials), epidemiological studies, and outcomes research. The availability and strength of evidence varies by disorder and treatment. Differentiate Health Services Research From Clinical Research Essay.
3. Timeliness: Seeking and receiving health care is frequently associated with delays in obtaining an appointment and waiting in emergency rooms and doctors’ offices. 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.
4. Patient Centered: Patient-centered care recognizes that listening to the patient’s needs, values, and preferences is essential to providing high-quality care. 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.
5. Efficiency: The U.S. health care system is the most expensive in the world, yet there is consistent evidence that the United States does not produce the best health outcomes^27–30 or the highest levels of satisfaction.³¹ The goal is to continually identify waste and inefficiency in the provision of health care services and eliminate them.
6. Equity: 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.²⁵ The field of HSR provides the measurement tools by which progress toward these goals is assessed, as seen in the National Healthcare Quality Report.¹¹Equally important, health services researchers are developing and evaluating innovative approaches to improve quality of care, involving innovations in organization, financing, use of technology, and roles of health professionals. Differentiate Health Services Research From Clinical Research Essay.

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: “Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”¹ This definition draws attention to the importance of the application of current professional knowledge in the diagnostic and treatment processes of health care. 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.³³ He formalized the conceptual model for describing, analyzing, and evaluating the quality of care using three dimensions: (1) structure, (2) process, and (3) outcome.Differentiate Health Services Research From Clinical Research Essay.  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^34, 35 found wide variation in practice patterns among community physicians, surgical procedures, and hospitals. Brook and colleagues³⁶ 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^36, 37 as well as the development of practice guidelines and standards for quality care.³⁸ Yet the challenge of research on variations in care is the implication of the inappropriateness of 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.⁴⁰ Researchers have found that differences in internal factors, such as collaborative relationships with physicians, decentralized clinical decisionmaking, and positive administrative support, impact nurse and patient outcomes^41, 42 and the quality and safety of care.⁴³ Differences in external factors, such as insurance and geographic location, can influence access to available health care professionals and resources, what type of care is afforded patients, and the impact of care on patients. The structure, process, and outcome dimensions of quality are influenced by both internal and external factors. Differentiate Health Services Research From Clinical Research Essay.