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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.

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. 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: The interdisciplinary character of HSR draws on methods and data sources common to the many disciplines that form the intellectual underpinnings of the field. 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.

An important distinction is made between efficacy and effectiveness of health services. 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. 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 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. 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. The economic impact of receiving free care in one plan versus being in a plan requiring payment out-of-pocket of deductibles and co-insurance had the expected impact on utilization.

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. 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.

Operations research uses methods for creating homogeneous groups predictive of cost or disease outcomes. 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.

Other disciplines also contribute to our understanding of risk factors for the range of health outcomes, including mortality, health and functional status, quality of life, and rehabilitation and return to work.

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. A range of data sources is used in effectiveness research, including administrative and billing data, chart reviews and electronic health records, and survey questionnaires.

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. 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. The primary limitation is the data set collected by administrative systems is very limited and lacks the detail of the medical record. Administrative data systems can provide some insights into quality and outcomes of care. AHRQ has developed software that provides quality indicators and patient safety measures using one administrative data set, hospital discharge abstracts.

Administrative data can efficiently provide quality and outcomes indicators for defined populations and for health systems. Other applications of administrative data include assessing efficiency, timeliness, and equity. The limitation is that there are many health conditions and health outcomes that cannot currently be measured using administrative data. Survey questionnaires are routinely used to obtain information on patient satisfaction in health plans. Information on the impact of health conditions on health and functional status has to come from the patient.

This may be obtained at the time of a visit or hospitalization. However, to assess patient outcomes of care, systematic followup of patients after the completion of treatment is generally required.

This can be done using mail questionnaires, telephone interviews, or in-person interviews. The HSR field has developed health-status and quality-of-life measures that can be used no matter what health conditions the patient has.

Effectiveness research relies on a range of data sources. Some are routinely collected in the process of medical care and patient billing. Efficient strategies for examining effectiveness may use administrative data to examine a limited set of data on all patients, and a statistically representative sample of patients for in-depth analysis using data from chart abstracts and survey questionnaires.

HSR research tools can be applied in clinical settings to improve clinical practice and patient outcomes.

These tools are used as part of quality improvement programs in hospitals, clinics, and health plans. Two examples illustrate applications to improve quality-of-care performance. For many chronic medical conditions, clinical research has evaluated the efficacy of diagnostic methods and treatment interventions.

As a result, evidence-based reviews of research literature can provide a basis for establishing quality-of-care criteria against which to judge current practice.

In a national study of quality of medical care, it was found that only 55 percent of patients received evidence-based treatments for common disorders and preventive care. For each quality criterion, a classification was applied to determine if the quality-of-care deficiency was one of underuse, overuse, or misuse. Greater problems were found with underuse 46 percent than with overuse 11 percent. Quality of care varied by condition: Overall, only about half of recommended care was received, frequently due to underuse of services.

Researchers have sought to identify why rates of conformance with evidence-based treatments are low. Frequently cited barriers to evidence-based practice include physician disagreement with the evidence, perception that patients will not accept treatment, low ratings of self-efficacy as a provider of the treatment, and difficulty of integrating the evidence-based treatment into existing practice.

The described data sources and methods can be applied in clinical settings to assess conformance to evidence-based quality criteria and provide feedback to clinicians. If electronic health records are available, the feedback and reminders may be directly incorporated into the medical record and seen by the clinician at the time of a visit. Intermountain Health Care utilizes its electronic health records to monitor adherence to evidence-based quality standards and to provide decision support to clinicians when seeing patients.

This strategy has contributed to substantial improvements in their quality performance. In , the Managed Health Care Association, an employer organization, brought together a group of employers and their health plan partners who were interested in testing the OMS concept in health plans.

The methodology chosen was for each of 16 health plans to identify all adult enrollees with at least two diagnoses of asthma over the previous 2 years. A stratified sample was chosen with half of the enrollees having more severe asthma e. Each adult received a questionnaire asking about their asthma treatment and health status. Followup surveys were done in each of 2 successive years to track changes over time. The findings were compared to national treatment recommendations for adult asthma.

Approximately half of adults with asthma reported having the information they needed to avoid asthma attacks, to take appropriate actions when an asthma flare-up occurs, and to adjust medications when their asthma gets worse. Health plans used the baseline findings to develop quality-improvement interventions, which varied across health plans.

Followup surveys of the patient cohort provided feedback to health plans on their success in improving asthma treatment and outcomes over time. This chapter has provided a definition and history of the field of health services research and discussed how this field is examining quality-of-care issues and seeking to improve quality of care.

Comparisons of current practice to evidence-based standards with feedback to clinicians and the integration of patient-reported outcomes are two examples of how HSR tools can be used to provide quality-improvement information for health care organizations.

These examples utilize multiple data sources, including medical records, patient surveys, and administrative data. The opportunities for nurse researchers to provide invaluable contributions to the growing field of health services research are innumerable.

Turn recording back on. National Center for Biotechnology Information , U. Show details Hughes RG, editor. Chapter 8 Health Services Research: Scope and Significance Donald M. Author Information Donald M. Background The provision of high-quality, affordable, health care services is an increasingly difficult challenge. This was expanded upon in by AcademyHealth, the professional organization of the HSR field, with the following definition, which broadly describes the scope of HSR: History of Health Services Research The history of HSR is generally considered to have begun in the s and s with the first funding of grants for health services research focused on the impact of hospital organizations.

Goals for Health Services and Patient Outcomes The goal of health services is to protect and improve the health of individuals and populations. Patients should not be harmed by health care services that are intended to help them. Subsequent research has found medical errors common across all health care settings. 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. 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. The health care system should benefit all people. In some schools around the country serious obstacles such as those mentioned above are more commonplace than others, and less serious problems are routine.

Depending on its severity, the problem can affect the entire school community. A comprehensive school health services program is designed to be proactive and attempt to troubleshoot these types of situations. Good health is best defined not just as the lack of sickness and disease. Good health is a mandatory ingredient for successful learning and many factors can weaken it. School health services work toward that goal.

School health services are found in some form in every school throughout the United States. Most children in the United States spend more than half their waking hours at school.

Besides an already-full school day, many students are also involved with regular sports and social activities before and after school while older students often have part-time employment during those hours they are not in high school. Since students at school are a captive audience, schools should be important providers of health services. To do this, the health services should be able to diagnose and prevent various health problems and preventable injuries as they strive to make certain those attending school receive the type of health care they need.

Taken individually, each component has unique and important characteristics. The staff of the school health office provides the core services of screening, diagnostic treatment, and health counseling services within the school. At given times, this office will also provide:.

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In most areas of the country, the role and scope of school health services have evolved according to the changing social environment of the population. School health services' main objectives are. View Mental Health Services Research Research Papers on for free.