Health services research and clinical practice.

HEALTH SERVICES RESEARCH IS “A MULTIDISCIplinary field of scientific investigation that studies how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviors affect access to healthcare, the quality and cost of health care, and ultimately our health and well-being.” During the last 50 years, health service researchers have developed tools and techniques that have profoundly affected the way medicine is practiced. The field developed measures of health and quality and ways to incorporate risk adjustment as a function of the characteristics that patients bring to a clinical encounter. These techniques have made it possible to increase measures of health as outcomes in clinical trials and to pay physicians based on their performance. Health services research has built an empirical foundation for empowering patients by providing information that compares quality of care or health outcomes across hospitals or physicians. What health services research has not done is revolutionize the way medicine is practiced to increase its value and to moderate costs. The United States spends more than 17% of its gross national product on health care; understandably, individuals and families are concerned that health care in the future will be unaffordable. Policy makers are struggling to bend the cost curve by fundamentally altering how physicians and hospitals deliver care. These efforts assume the existence of a comprehensive science-based framework at the patient-physician level that can be used to change the way medicine is practiced. However, such a framework does not exist. The health services research community and practitioners in academic medical centers have tried to address the issue of value in health care, but their efforts have been focused primarily at the level of a single research grant. An integrated effort is needed that crosses specialties, diseases, and conditions, enabling physicians to help bring about the necessary changes. The purpose of this Commentary is to urge development of an active coalition between leaders in clinical practice and health services researchers to address 5 issues essential for radically changing the practice of medicine: reliability, appropriateness, frequency, labor, and transparency. Reliability Many clinical processes and their health outcomes are not reliable. For example, if 2 physicians listen to a patient’s heart, do they hear the same thing? If they read the results of a coronary angiography, are their readings consistent? Numerous isolated studies have focused on reliability, but there is no integrated science of reliability or a process for incorporating findings from individual studies into clinical practice. A method is needed to ensure that the information used to inform clinical decision making is reliably collected and interpreted. The need is particularly acute because the field of diagnostics will expand substantially in the next 5 years, and the number of diagnostic tests will increase significantly. Wider use of electronic medical records also increases the importance of improving reliability.