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This article examines the use of clinical research in improving performance in health care settings. The diffusion of current findings from researchers to practitioners facilitates the development, implementation, and evaluation of clinical practices and improves the overall quality of care.

Patient-centered health care programs are discussed.

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 [...]

Several Ontario hospitals were studied from June 1996 to Jan 1997 to determine how they were coping with reduced funding. Results show that hospitals were dealing with the existing healthcare environment by implementing CQI programs, emphasizing customer service, strategic planning and communicating plans to stakeholders. Hospitals have also reengineered their operations by shifting from a departmental to program-based structure.

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 [...]

The role of physicians in managing health care facilities is discussed. No systematic strategies for involving physicians in managerial positions have been detected. However, the 'clinical directorate' model developed at Johns Hopkins University gives doctors a chance for playing the role of administrators of health facilities. The clinical directorate delegates physicians as heads of unit with its own budget allocation. They are accountable for financial as well as clinical outcomes.

General practice (GP) fundholding was conceived merely as a 'sideshow' to the main health care reform initiatives in Scotland. However, it has become an important element in the purchaser/provider agenda, with the changes related to GP fundholding expected to play a pivotal role in health care initiatives in the future. A study of the impact of fundholding on primary health care in Grampian, Lothian and Tayside indicates that fundholding is not significant because GPs believe there are benefits for primary health care.

Primary care research consists of four types: basic, clinical, health services, and health systems. Basic research addresses the development of methods to study subjects relevant to primary care services, regardless of whether they deal with a clinical problem or a characteristic of services delivery. Clinical research involves issues relevant to the processes of delivering services, including recognition of people's problems, diagnostic approaches, and types of therapy and their outcomes. Health services research concerns the relationships associated with the organization and financing and their impact on the processes and outcomes of care. Health systems research focuses on understanding how the economic, political, and social milieus influence the structures and processes of the health services system, with specific relevance to its primary care infrastructure. The literature on primary care, as reflected by publications in three major general journals, is notably lacking in many specific areas of study within these types of primary care research, particularly with regard to basic and health services research. Key words. Research; health services research; primary health care; outpatients; inpatients; population. (J Fam Pract 1996; 42:181-185), The Institute of Medicine's Committee on the Future of Primary Care is grappling with the concept of primary care and where primary care fits in the edifice of clinical practice. [...]

Technology is one of the important resources that has to be utilized in improving health care services. Heavy investment in technology by health care providers make it a critical issue. The integration of management of technology and its relationship to the performance of health care organizations is studied.

A research study presents a concurring opinion of some of the assumptions made by Richard Johnson and Montague Brown on the past and future of the health and hospital fields. Emphasis was placed on the act of trying to benefit from past experiences to make health care more accessible and cost-effective. Medicine should be service-oriented as opposed to being profit-oriented. A macromanaged multipayer system that uses worldwide budget goals to control national health care expenditures is expected to take the place of managed care and capitated payment.

Health care practitioners were asked to identify and rank the obstacles that they are likely to encounter when trying to implement the total quality management (TQM) concept in their respective organizations. Health care professionals believed that the lack of proof that TQM could bring success was the greatest barrier to a successful TQM implementation. The study considered several factors that differentiated success from failure in innovation and improvement. Results of research work on innovations showed support for customer and quality mindedness. Future research work is recommended.

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 [...]

Patient-focused care is analyzed with particular attention to its use at the 375-bed Bishop Clarkson Memorial Hospital in Omaha, NE. A study there revealed that the hospital staff spent only 16% of their time in patient care. New goals were set for the institution, which included improving quality of care and doctor efficiency, creating a better work environment for staff and decreasing costs. Some of the ways this was accomplished were by moving services nearer patients, broadening staff skills, grouping like patient populations and simplifying processes. The implementation and relative success of these steps are discussed., G. Kevin Moffitt, CHE, is Director, Neurosensory Services, Bishop Clarkson Memorial Hospital Omaha, Nebraska. Pamela B. Daly, Ph.D., is Patient-Focused Care Research Consultant, Bishop Clarkson Memorial Hospital and University of [...]

Vertical integration of patient care is an essential part of integrating regional health distribution systems. Among the forces that affect this clinical integration are the financial incentive of prospective, risk-based payments and technologically advanced management structures. The ways that these environmental factors affect integration at the institutional level are explained. It is particularly important to establish trust between specialty and primary care doctors and between physician groups and hospitals. The advantages of regional clinical integration and obstacles to implementation are explained., Douglas A. Conrad, Ph.D., is Professor, Department of Health Services, Graduate Program in Health Services Administration, University of Washington, Seattle. He is a Faculty Associate of the College. Summary Regional [...]

Major barriers to integration of healthcare delivery systems are identified, and suggestions for dealing with these obstacles are given. Characteristics of 12 systems were analyzed through interviews and on-site observations. Of particular interest were the number of services and functions performed by the system, the number of units within the system providing these services and the area served in relation to other units. One barrier that was identified was a failure on the part of the system administrators or boards to comprehend and act on the changes that are taking place in US healthcare., Stephen M. Shortell, Ph.D., FACHE, is A.C. Buehler Distinguished Professor of Health Services Management and Professor of Organization Behavior, J.L. Kellogg Graduate School of Management and the Center for Health [...]

Integrated healthcare delivery systems are among the primary ways of offering cost-effective medical care. Integrated delivery systems are defined and divided into three categories: clinical integration, physician-system integration and functional integration. In a study of 12 systems and their efforts toward integration, it was found that more progress was made with integration of functional activities, such as financial management, than in the areas of physician-system integration and clinical integration., Robin R. Gillies, Ph.D., is Research Assistant Professor, Center for Health Services and Policy Research, Northwestern University, Evanston, Illinois. Dr. Gillies is Project Director of the Health Systems Integration Study. [...]

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 [...]

A New Era for Health Services Research? Twenty-five years ago, a series of papers was commissioned by the Health Services Research Study Section of the Public Health Service, and the [...]

Useful, well-demonstrated, well-vetted ideas in clinical practice, disease management, health care management, ideas that would save lives, save money, and make life better for the patient, are sometimes simply ignored, dismissed as radical, as completely unfounded, dangerous, and without merit. Why are new ideas so slow to spread in medicine and health care? Because believing is seeing. We do not look for something we don't believe in. In fact, we do not even see a thing if we don't believe in it. We have dedicated ourselves so powerfully to medicine, to health care as we know it, that we often do not even see any alternatives. A combination of factors makes it likely that, in the coming decade or two, we will change almost everything that is fundamental about health care and medicine. In a time of such rapid change, we desperately need to root out and question our deep assumptions and beliefs, to get off the tracks laid down by training and experience and ask questions we have never asked before.

INTERVIEW WITH REG WARREN, PHD, VICE-PRESIDENT OF OUTCOMES RESEARCH, THE POLARIS GROUP The Medicare Prospective Payment System (PPS) is doing the opposite of what Congress intended - that's the preliminary [...]

In the last decade, there has been an explosion of digital information, and health information is no exception. Aided by the development of technology, vast amounts of data are being [...]

To determine the feasibility of day transfusion programme in children in a developing country like Nigeria, 118 children with severe anaemia were recruited out of 1249 children's emergency ward admissions over a 12-month period giving an incidence of 9.4%. Following blood transfusion and treatment of underlying aetiology of anaemia mean haematocrits at 12, 24 and 48hr post-transfusion were 24.41[+ or -]5.56%, 25.12[+ or -]5.59% and 23.99[+ or -]5.9% respectively. There was high correlation between the three timed post-transfusion haematocrits (p=0.001) but no significant difference between the means of the 12 and 48hr (p=0.854) as well as between 24 and 48hr (p=0.227) post-transfusion haematocrits values. Malaria was the commonest aetiology for severe anaemia in these patients. Fever, the commonest (92.5%) presenting symptom subsided by 24hr in 85.5% of the 62 children in whom it was documented on admission. Mortality from severe anaemia in this study was 1.9%. Keywords: Anaemia | Post-transfusion | Haematocrit | Children | Nigeria, Introduction Severe anaemia remains one of the commonest paediatric emergencies in this country as well as in sub-Saharan Africa, and from our medical records it constitutes over half of all [...]