Applied health services research: responding to the changing health care environment.

The projects of health services research, a relatively new academic discipline, have the potential to enhance patient outcomes, improve patient satisfaction. In addition, many research studies have demonstrated less costly methods of providing medical care. Unfortunately, much of this research, and the million of dollars it represents, remain secluded in medical journals and is never operationalized by hospitals, HMOs, and other health care systems. This research has enormous potential and may represent a "sleeping giant" in health care and health care reform. One must cull out those aspects of health services research that have the greatest applicability and potential to benefit patients, hospitals, health care organizations, and health care plans throughout the country. The greatest challenge is then to apply these principles and this information to the ongoing care of patients.

An Example: Development and

Evaluation of Practice Guidelines 

For many years, it has been recognized that there are wide and often unexplainable variations in the provision of medical care by physicians. Practice guidelines and expert systems that are based on outcomes research may enable attainment of the goal of providing patients with services that are most likely to improve their outcomes. In a recent health services research study performed at Cedars-Sinai Medical Center (CSMC), we developed guidelines to improve the quality and efficiency of medical care for patients hospitalized with chest pain.[1] Chest pain was chosen because this symptom may signify the presence of diseases as diverse in prognosis as heartburn to "life-threatening" coronary artery disease and because there are approximately 1.5 million patients hospitalized with chest pain in the United States annually. Specifically, we studied the characteristics, clinical courses, and outcomes of more than 900 hospitalized patients.[1-6] These data were transformed into a practice guideline that provides additional information to physicians about each patient's prognosis.

The practice guideline developed was approved by a panel of cardiologists at CSMC. It was made available to physicians to test its effect on patient outcomes, patient satisfaction, and health care costs as part of a controlled interventional trial. Physicians were offered the option of using the guideline to complement their clinical judgment or rejecting the guideline; this decision was left to the discretion of the treating physician.

After implementation of the guideline, health care became more efficient. Total costs, including both direct and indirect costs, were reduced by more than $1,000 per patient.[2] Moreover, the patient complication rate and the mortality rate were very low, and excellent patient outcomes were achieved.[2] Finally, an overwhelming majority of patients were satisfied with the medical care and would choose to return to the same hospital in the future.

Similar studies are currently under way at Cedars-Sinai Medical Center to assist in the care of patients with pneumonia, congestive heart failure, total hip replacement, hip fracture, total knee replacement, and upper gastrointestinal hemorrhage, stroke, TURD, COPD, lumbar laminectomy, and lower gastrointestinal hemorrhage. The development and widespread availability of these guidelines may enable higher quality and less costly medical care.

Applied Health Services Research: The

Collection And Reporting of Patient

Outcomes Information

Another major focus of health services research is to improve the quality of information available to patients who seek or require medical care and to purchasers of health care. Patients frequently perceive that they lack access to adequate information regarding the benefits and the risks of medical care as it relates to their condition. For example, consider the case of a 70-year-old female who is about to undergo hip replacement surgery. This prospective patient is likely to have many questions prior to surgery, including her risk of suffering a postoperative complication. The patient may also have additional questions that relate to her expected quality of life after the operation. How quickly can she be expected to resume her usual recreational activities and/or return to work after the operation? How healthy will she feel one month after the surgery?

Despite the large number of patients who have had hip replacement surgery in the past, there are, unfortunately, limited data to directly respond to these questions. Also, the available data may not be specific to this particular patient's underlying medical condition. Health services research studies have analyzed and reported findings that can give patients a more comprehensive outlook on their expected health outcomes. These data can be used to better assess each patient's predicted physical health, psychological well-being, functional status, and pain after total hip replacement. Furthermore, this information may be used to direct supplemental services to especially needy patients, such as the frail and the elderly.

Outcomes information also has many potential use for payers and other purchasers of health care. Employer groups increasingly are requesting outcomes data from payers. Are our employees receiving the best possible health care and for the best price? Payers can easily respond to issues related to cost, but questions related to patient outcomes and the value of health care remain elusive. Providers able to produce this information in a quantitative and scientifically rigorous manner will be well positioned in an era of managed care.[7] Providers unable to provide this information will not. Because many outcomes measures have been developed and used as part of health services research experiments,[8,9] familiarity with this work may enable the health care provider to produce valid and reliable outcomes information for purchasers of health care.

Conclusion

Our present health care delivery system might be improved by learning from applied health services research and studying the outcomes of patients who have previously undergone medical care. By incorporating this knowledge into operational practice guidelines and clinical pathways, and by making these systems widely available on a concurrent basis to both physicians and patients, we can improve our health care system. Applied health services research can assist hospitals in taking a leadership role in improving the quality and efficiency of health care.

References

[1.] Weingarten, S., and others. "Selecting the Best Triage Rule for Patients with Chest Pain." American Journal of Medicine 87(5):494-500, Nov. 1989. [2.] Weingarten, S., and others. "Practice Guidelines and Reminders to Reduce Duration of Hospital Stay for Patients with Chest Pain.'- Annals of Internal Medicine 120(4):257-63, Feb. 15, 1990. [3.] Weingarten, S., and Ellrodt, A. "The Case for Intensive Dissemination: Adoption of Practice Guidelines in the Coronary Care Unit." QRB 18(12):449-55, Dec. 1992. [4.] Ellrodt, A., and others. "Implementing Practice Guidelines through a Utilization Management Strategy: The Potential and the Challenges." QRB 18(12):456-60, Dec. 1992. [5.] Weingarten, S., and others. "Reducing Lengths of Stay for Patients with Chest Pain Using Medical Practice Guidelines and Opinion Leaders." American Journal of Cardiology 71(4):259-69, Feb. 1, 1993. [6.] Weingarten, S., and others. "A Triage Practice Guideline for Patients with Congestive Heart Failure: Improving the Effectiveness of the Coronary Care Unit." American Journal of Medicine 94(5):483-90, May 1993. [7.] Lansky, D., and others. "Using Health Status Measures in the Hospital Setting: From Acute Care to `outcomes Management.' Medical Care 30(5 Suppl):MS57-73, May 1992. [8.] Tarlov, A., and others. "The Medical Outcomes Study. An Application of Methods for Monitoring the Results of Medical Care." JAMA 262(7):925, Aug. 18, 1989. [9.] Greenfield, S., and Nelson. E. "Recent Developments and Future Issues in the Use of Health Status Assessment Measures in Clinical Settings." Medical Care 30(5 Suppl):MS23-41, May 1992.

Scott Weingarten, MD, MPH, is Director, Department of Health Services Research, and A. Gray Ellrodt, MD, is Director, Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, Calif.