Time to Take Health Delivery Research Seriously

BIOMEDICAL SCIENCE HAS MADE AMAZING LIFE-SAVING DIScoveries. The science of “omics” offers hope for further improvements in preventing, prognosticating, and personalizing care. Each year, researchers publish approximately 18 000 active clinical trials, yet a gap remains between the development and publication of this new knowledge and better patient outcomes. While clinical translational science awards strive to improve population health, their predominant focus has been on translating basic research findings to humans. Although this Commentary focuses on preventable harm within the health care system, the principles discussed likely apply to optimizing population health using a broader set of public health interventions. Preventable harms from health care–acquired infections, deep venous thrombosis, and pulmonary embolus have been estimated to account for 200 000 deaths annually in the United States, and thousands more deaths are associated with teamwork failures and diagnostic errors. There is limited evidence that outcomes are improving despite abundant activities at federal and state levels and within local hospitals to improve the quality of care. The current approach to biomedical research, including funding priorities and promotion criteria, may partially explain the gap between biomedical advances and health care outcomes. Too often, research ends once researchers and physicians develop and publish new knowledge. For instance, the main finding after decades of federally funded research to reduce mortality in acute lung injury patients was lung protective ventilation. A minority of these patients receive this therapy. Despite individual physicians having significant accountability for their patients, researchers and physicians have been slow to embrace the science of health care delivery—a science that takes a systems view to improve population outcomes. Most academic medical centers have many researchers studying omics, but are largely devoid of human factors and systems engineers, sociologists, psychologists, or health services researchers who could lead health delivery research (also called knowledge translation research or implementation science). This imbalance is likely driven by the limited absolute and relative funding for health delivery research. The need for health delivery research is paramount. Patients receive half of the recommended therapies, health care cost increases are not sustainable, preventable patient harms are increasingly visible, hospitals and other care delivery organizations are increasingly financially accountable for patient outcomes, and an explosion in basic and clinical research makes it impossible for physicians to remember all of the latest therapies. For instance, basic research has revealed that breast, colon, and prostate cancers are not 1 disease but dozens. These medical advances offer more accurate prognostic information and therapies that optimize patient outcomes. Nevertheless, such advances also pose significant risks for diagnostic and therapeutic errors given that clinicians are expected to remember an exploding number of omic diagnostic and treatment combinations. Without health delivery research, patients will predictably not realize the full potential of these scientific advances and health care costs may further increase. Several changes in how health care delivery considers biomedical research could support improvements in patient outcomes. First, researchers should recognize that patient health is the ultimate goal, understanding that health delivery research links clinical research with improved health. This will require adding social scientists, human factors, and systems engineers to the research pool and expanding the capacity to conduct mixed (quantitative and qualitative) methods research to understand whether an intervention works and why. Health delivery research seeks to ensure that patients receive recommended therapies, which involves changing clinician behavior, removing barriers so physicians can comply with best practices, improving teamwork and culture, measuring and providing feedback about performance, and creating incentives (social norms, economics, public policy) for clinicians and patients to encourage the desired behaviors. This research must coexist in the real world of health care delivery, where the context in which an intervention is implemented influences its success. It draws on the expertise of social scientists—experts who are rare in academic medical centers. This research will also require that funding agencies accept multifaceted interventions seeking to optimize patient outcomes, particularly when each component of the intervention is inexpensive, low risk, and low value. When effective interventions are known, the reductionist view of requiring independent evaluations for each component would waste research dollars. Thus, fund-