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Objective: Designing practical decision support tools and other health care technology in health services research relies on a clear understanding of the cognitive processes that underlie the use of these tools. Unfortunately, methods to explore cognitive processes are rarely used in health services research. Thus, the objective of this manuscript is to introduce cognitive task analysis (CTA), a family of methods to study cognitive processes involved in completing a task, to a health services research audience. This methods article describes CTA procedures, proposes a framework for their use in health services research studies, and provides an example of its application in a pilot study. Data Sources and Study Setting: Observations and interviews of health care providers involved in discharge planning at six hospitals in the Veterans Health Administration. Study Design: Qualitative study of discharge planning using CTA. Data Collection/Extraction Methods: Data were collected from structured observations and semi-structured interviews using the Critical Decision Method and analyzed using thematic analysis. Principal Findings: We developed an adaptation of CTA that could be used in a clinical environment to describe clinical decision-making and other cognitive processes. The adapted CTA framework guides the user through four steps: (1) Planning, (2) Environmental Analysis, (3) Knowledge Elicitation, and (4) Analyses and Results. This adapted CTA framework provides an iterative and systematic approach to identifying and describing the knowledge, expertise, thought processes, procedures, actors, goals, and mental strategies that underlie completing a clinical task. Conclusions: A better understanding of the cognitive processes that underly clinical tasks is key to developing health care technology and decision-support tools that will have a meaningful impact on processes of care and patient outcomes. Our adapted framework offers a more rigorous and detailed method for identifying task-related cognitive processes in implementation studies and quality improvement. Our adaptation of this underutilized qualitative research method may be helpful to other researchers and inform future research in health services research. KEYWORDS care coordination, cognitive task analysis, discharge planning, qualitative research, surgery, 1 | INTRODUCTION Designing practical decision support tools and other types of health care technology for implementation science and quality improvement relies on a clear understanding of the cognitive processes [...]

The majority of health services research focuses on health care-access to it, utilization of it, outcomes from it, and, importantly, disparities in it. Yet, health services research is much broader [...]

Objective: To examine differences in referral patterns in a nationally representative sample between primary care physicians (PCP) practicing in rural vs nonrural areas and changes over time. Study Design: Using the 2005-2016 National Ambulatory Medical Care Survey and multivariate logit regression models, | compare referral patterns of PCPs in rural vs nonrural areas. Data Collection: Multiple years of data were combined. Principal Findings: A PCP visit was 1.9 percentage points (95% confidence interval: 0.1 pp, 3.8 pp) more likely to result in a referral in nonrural areas than rural areas, controlling for physician and patient characteristics, a 17 percent increase. This difference is driven by a widening gap in referral rates between nonrural and rural areas over time, with large differences in later periods. The regression-adjusted predicted probability of a PCP visit resulting in a referral was 71 percent higher in nonrural than rural areas in 2013-2014 and 92 percent higher in 2015-2016. Conclusions: Recognizing that the optimal PCP referral rate is unknown, referrals are less common in rural areas with a widening gap in recent years. This difference may reflect specialist availability, distance to care, or patient preferences. As changes occur to health care financing and delivery, continuing to monitor practice patterns is important to ensure patients are receiving appropriate levels of care across geographic regions. KEYWORDS ambulatory care, physician practice patterns, referrals, rural, 1 | INTRODUCTION Referrals from primary care physicians (PCP) to specialists and among different specialists and subspecialists are important contributors to medical care costs and quality. (1,2) Referrals have increased [...]

Objectives. To discuss issues in studying the effectiveness of health services for children, suggest areas in which more research is needed, and recommend strategies for future research. Principal Findings. Issues that should be considered include the choice of perspective, which will help determine the interventions studied and the measures of effectiveness and cost-effectiveness chosen. Unique challenges in this area include the fact that serious measurable morbidity is relatively uncommon in children, that causal relationships between services and outcomes may be difficult to establish, and that standard measures of cost-effectiveness may fail to accurately measure important benefits, such as reduced parental anxiety. More research is needed on high-risk and health-promoting behaviors, on critical parent behaviors, on classifying children by vulnerability status, on modes of delivery of preventive care, and on violence prevention. Recommendations. Group-randomized designs and observational research designs that take advantage of natural variations in practice may be increasingly useful in effectiveness studies. Parent- and patient-reported measures of health status and quality of life should be made briefer and more practical for routine use, and better measures of cost-effectiveness are needed. Future research efforts can best be supported by the concerted efforts of various constituencies, including health plans, providers, patients, researchers, and the government. Key Words. Effectiveness, health services, research, children, Health policymakers, clinicians, and other advocates need high-quality evidence about effectiveness in order to recommend appropriate services for children. Ongoing changes in healthcare delivery, including the trend toward managed care [...]

Objective. An overview of (1) key trends shaping the healthcare environment and market; (2) ways in which these environmental trends are reflected in changes in the organization and delivery of healthcare; (3) the implications of environmental and organizational changes for older Americans; and (4) the research issues that can be addressed using organizational and behavioral theories. This introductory article sets the healthcare scene for the articles that follow. Key Words. Healthcare organization, healthcare delivery, older Americans, organizational theory, behavioral theory, THE CHANGING HEALTHCARE SYSTEM Given the dynamism of late twentieth-century American society and the many societal factors that influence healthcare, it is not surprising that substantial change has been occurring [...]

The practice population in fee-for-service practice can be determined by using multiyear fee-for-service billings data. The practice population for each physician consists of all the patients for whom the physician billed the provincial health insurance plan for at least one visit. The fee-for-service billings data was taken from the Ontario, Canada, Ministry of Health office. Determining the practice population in fee-for-service practice has been a challenge for health services researchers for almost twenty years., Objective. To develop and validate a technique for defining a practice population of discrete individuals based on multiyear family practice fee-for-service billings data. Data Sources/Study Setting. Nineteen family physicians in Ontario, Canada who converted from fee-for-service to capitation payment. Data sources were fee-for-service billings data for the three-year period prior to the conversion from fee-for-service to capitation payment and the rosters of enrolled patients for the first and third years after the change to capitation payment. Study Design. The billings-based definition of the physician's practice population was compared against the Year 1 roster. We also compared the billings-based practice population and the Year 1 roster to the physician's Year 3 roster to identify patients who might have been missed during the roster development process. Our principal analyses were an assessment of the sensitivity of the billings-based definition of the practice population (EPP), the positive predictive value of EPP, and the agreement between EPP and the rostered patient population (RPP). We also examined the ratio between EPP and RPP to determine EPP's accuracy in estimating the practice denominator. Data Collection/Extraction Methods. The practice population for each physician at the time of conversion from fee-for-service to capitation payment was defined as (a) all persons for whom the physician billed the provincial health insurance plan for at least one visit during the year immediately prior to joining the capitation-funded program; and (b) all additional patients for whom the physician billed the plan for at least one service in each of the two preceding years. Data extraction was carried out within the Ministry of Health in order to preserve the anonymity of patients and physicians. Data were provided to the investigators stripped of patient and physician identifiers. Principal Findings. The mean sensitivity and positive predictive value of EPP were 95.3 percent and 87.4 percent, respectively. The level of agreement between EPP and RPP averaged 84.4 percent. The mean ratio of EPP to RPP was 1.21 (95 percent C.I. 1.030-1.213). Correction for roster false-negatives increased the sensitivity, positive predictive value, and agreement between EPP and the practice population, and reduced the mean ratio of EPP to the practice population to 1.068 (95 percent C.I. 1.010-1.127). Conclusions. The practice population can usefully be defined in fee-for-service family practice on the basis of multiyear fee-for-service billings data. Further research examining alternative encounter-based practice population definitions would be valuable. Key Words. Family practice, practice population, practice denominator, fee-for-service, The task of determining the practice population in fee-for-service practice has challenged health services researchers for the better part of two decades. Kilpatrick (1984a) has defined a practice population as [...]

Dr. Martin Shapiro, an academic health services researcher, discusses issues raised by proprietary product development in health services research and argues that the private sector should not be involved in [...]

Capitalism is not new to clinical research. Many universities have created research parks to exploit "the research of their clinical faculties. Also, small business grants provide public funding to promote [...]

Federal funding is insufficient to support all of the essential health services research (HSR) that the government deems worthy. Federal funds must be supplemented by private sector grants and by [...]

The goal of small area analysis is often to demonstrate that hospital admission rates or procedure rates vary greatly among regions, suggesting the occurrence of unnecessary admissions or procedures in [...]

Objective. To test the hypothesis that surgical services combining relatively high levels of feedback and programming approaches to the coordination of surgical staff would have better quality of care than surgical services using low levels of both coordination approaches as well as those surgical service using low levels of either coordination approach. Study Setting. A study sample of 44 academically affiliated surgical services that are part of the Department of Veterans Affairs. Study Design. In a cross-sectional analysis, surgical services were assigned to one of three groups based on their scores on feedback and programming coordination measures: high on both measures; high on one measure, low on the other; and low on both. Univariate and multivariate analyses were used to assess differences among these groups with respect to three quality indicators: risk-adjusted mortality, risk-adjusted morbidity, and staff perceptions of quality. Data Collection/Extraction Methods. Risk-adjusted mortality and morbidity came from an outcomes reporting program within the Department of Veterans Affairs that entails the prospective collection of clinical data from patient charts. Data on coordination practices and perceived quality came from a survey of surgical staff at each of the 44 participating surgical services. Principal Findings. The group of surgical services using high feedback and high programming had the best perceived quality. This group also had the lowest morbidity, but the difference was statistically significant with respect to only one of the two other groups: the group with low feedback and low programming. No significant group differences were found for mortality. Conclusions. Study results provide partial support for the hypothesis that high levels of feedback and programming should be combined for optimal quality of care. Study results also suggest that staff coordination is more important for improving morbidity than mortality in surgical services. Key Words. Outcomes, surgical care, quality of care, coordination, In recent years, increasing attention has been paid to the coordination practices of healthcare organizations. For example, the Joint Commission on the Accreditation of Healthcare Organizations, as part of its [...]