Primary Care America's Health in a New Era (1996) / Chapter Skim
Currently Skimming:
Research and Evaluation in Primary Care
Research and Evaluation in Primary Care
Pages 216-246
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From page 216... ...
For one, current clinical research may have little to offer to primary care clinicians, as evidenced by the observation that "[ailthough primary care practitioners can use some of the knowledge generated by [specialty-oriented] research, in fact, most of it is not relevant to primary care because of its focus on singly developed diseases, carefully selected patients, and the reporting of strictly physiological outcomes" (AHCPR Task Force, 1993, p.
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From page 217... ...
Although these topics are often in the health services research arena, they are highlighted here for two reasons: (1) to draw attention to the core elements of the committee' s definition of primary care, and (2)
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From page 218... ...
primary care research laboratories, such as practice-based research networks that link primary care practitioners with those who carry out scientific investigations; · appropriate data standards and classification systems for primary care; · training programs for primary care clinician-scientists; and · stable career ladders for primary care researchers. The committee found exemplary efforts in each of these areas.
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From page 219... ...
the Department of Health and Human Services identify a lead agency for primary care research and (b) the Congress of the United States appropriate funds for this agency in an amount adequate both to build the infrastructure required to conduct primary care research and fund high-priority research projects.
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From page 220... ...
. In addition, it could assist or advise other agencies on matters relating to the supply of primary care clinicians or of appropriately trained researchers; for example, a lead agency for primary care research could work with the Bureau of Health Professions (B HP)
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From page 221... ...
Other elements of the department also have interests that intersect with primary care research because of their focus on ensuring high-quality services to specific populations; among these are the Administration on Aging and the Administration on Children and Families. A formally designated lead agency could also forge links with two other departments with significant primary care concerns and responsibilities for large numbers of individuals across the age span namely, the Department of Veterans Affairs (VA)
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From page 222... ...
In addition, the committee learned of both medical and nursing schools that support primary care faculty to some extent to carry out research in this field. Finally, as discussed more fully below, more than 30 practice-based research networks are either operating or serving as laboratories for various kinds of primary care research (see Recommendation 8.3~.
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From page 223... ...
, those of AHCPR (the lead agency for health services research) , and those of HCFA (which administers the Medicare program and the federal portion of the Medicaid program)
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From page 224... ...
In addition, they do not include information on nonphysician primary care clinicians at the level of detail necessary to understand who is providing what kinds of services to which patients for which problems; thus, they cannot illuminate the concept of the primary care team. The committee spent some time discussing the strengths and limitations of various large-scale data sources of this type, with specific attention to the national surveys conducted by DHHS agencies.
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From page 225... ...
Episodes of Care Defining episodes of care. Key elements of the committee's definition of primary care involve continuity and coordination of care.
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From page 226... ...
ask respondents to give their answers about events in terms of a recent time frame, the files are not (and cannot be) constructed in a way that would permit care to be viewed as a longitudinal series of visits and activities that occur over time and in different parts of the health care system.
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From page 227... ...
By and large, patient records and data files maintained by health maintenance organizations, physician networks, or integrated delivery systems today cannot provide, in any routine way, the episode-based information that would be needed to measure primary care. In any case, it would be unusual for specialized episode-of-care information to be made available to outside investigators; but as with insurance files, these managed care organizations can and do conduct their own studies on primary care issues (which might be episode based)
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From page 228... ...
It did, however, believe that such a survey should follow a probability sample of individuals of all ages over time and that it should focus on core elements of the primary care definition. One possibility might be for such a survey to be fielded independently of any of the current NCHS surveys but to use the same or a variant of the personspecific (rather than provider-specific)
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From page 229... ...
In addition, the committee calls attention to the opportunities offered by practice-based research networks to be an important source of such survey information (see the discussion for Recommendation 8.3 below)
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From page 230... ...
, studying the relevant phenomena of primary care presents a logistical challenge that might be satisfactorily addressed through the use of practice-based research networks. Analogous to the networks of major tertiary care centers that conduct the great bulk of the nation's basic biomedical research, primary care networks serve as laboratories by which health care events and the health status of many patients might be studied in "real world" settings.
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From page 231... ...
The committee sees practice-based research networks as a significant underpinning for studies in primary care, noting not only their attractiveness conceptually but the growing recognition of their value as reflected in the rise in the number of such entities in recent years. For this reason, the committee reached consensus on a recommendation that these enterprises should receive high-priority attention and funding to carry out the variety of studies that will contribute to the science base of the future for primary care.
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From page 232... ...
If primary care is to take its rightful place in medicine and the healing sciences, then it must contribute to fundamental medical knowledge, not just to knowledge about services, education, and training, and about epiphenomena bearing on its own ministrations. Funding for Research Through Practice-Based Networks A major concern about these research networks which in reality generalize to the entire primary care research enterprise is predictable funding.
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From page 233... ...
One tactic might be to direct a small, specified percentage of whatever sums are raised through an all-payer program for education and training to the "lead agency" specified in Recommendation 8.1 above, for the explicit purpose of broad-scale support of research or more targeted funding of primary care research networks or other centers that may combine training and research. Finally, although Recommendation 8.1 is directed at DHHS, the committee wishes to go on record as urging the nation's premier health care foundations to promote an even greater level of research activity in primary care.
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From page 234... ...
This listing alone makes clear the challenges of adequately meeting the committee' s aspirations in this area. PRIORITY AREAS FOR PRIMARY CARE RESEARCH As noted above, many issues confronting investigators in primary care are similar to those addressed by health services researchers.
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From page 235... ...
Improved data collection and coding standards, especially if linked to primary care research supported by a lead agency, will reinforce efforts to explore issues relating to the large majority of health care needs. Finally, practice-based research networks are intended to provide the venues in which all of the core elements might be studied, but they would be in a particularly good position to investigate issues of access to care, coordination and continuity, sustained partnerships, accountability, and family and community context; a special point about practice-based networks may be their ability to investigate how various parts of the nation differ in these respects.
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From page 236... ...
Links to Health Services Research The scope of primary care research includes or interacts with other major areas of health services research (IOM, 1995~. Among these are outcomes and effectiveness research; quality assessment and improvement; development and dissemination of clinical practice guidelines; a wide array of methodologic questions, including refinement of instruments to measure health-related quality of life, patient utilities and preference weights, and improved methods for severity and risk adjustment; organization and financing of health care delivery and the general area of health economics; health professions workforce (e.g., effective education and training programs, supply and demand modeling)
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From page 237... ...
These limitations do not fit the model of primary care practice and thus are drawbacks from the point of view of primary care research. Patients seen in primary care settings can present with multiple diagnoses, puzzling complaints, and unacknowledged disorders (e.g., mental and emotional trauma)
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From page 238... ...
Of particular concern was the notion that in the future even more physicians (than is true at present) who are trained and practicing in various specialties and subspecialties will be providing primary care services.
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From page 239... ...
The remainder of this chapter identifies high-priority research topics tied to core elements of the IOM definition of primary care in Chapter 2.8 Large Majority of Health Care Needs Documenting and getting consensus on what constitutes the "large majority of personal health care needs" in this country are formidable tasks. The questions (and the answers)
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From page 240... ...
Accessible and Integrated Health Care Services Access to care. The IOM is on record as supporting universal access to insurance and health care (IOM, 1993a, p.
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, or violence-related problems among the young? · What distinguishes an effective primary care team from an ineffective one?
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From page 242... ...
This becomes especially true as the managed care revolution begins to shift incentives away from the utilization- and costinducing ones of the country's traditional fee-for-service system of health care and toward the utilization- and cost-constraining incentives of managed care, and as the language turns more toward informed purchasing and accountability and away from quality improvement. These shifts pose numerous questions, including simply defining accountability, performance monitoring, informed purchasing and clarifying how they are similar to, and how different from, quality assessment and quality improvement.
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How should primary care clinicians harmonize either of those sets of obligations to those posed by society at large? Family and Community Context In this committee's view, primary care must be practiced in the context of family and community.
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development of a national database on pnmary care, ideally through some form of ongoing survey mechanism; (3) support of research through pnmary care practice-based research networks; and (4)
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IOM. Health Services Research: Work Force and Educational Issues.
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From page 246... ...
Primary Care Practice-Based Research Networks Active in North America. Journal of Family Practice 38:425-426, 1994.
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