1999 AHSR Presidential Address

Health Services Research, April, 2000 by Jack Hadley

Better Health Care Decisions: Fulfilling the Promise of Health Services Research

Two years ago, Bill Roper challenged us with an agenda of ten major research issues for the new health care environment created by the growth of for-profit and private sector activities in health care. Last year, David Kindig encouraged us to think beyond health services research--to focus not just on medical care and medical care financing, but also on taking on the really big issue of what determines health.

I would like to follow in the same vein as those thoughtful and provocative addresses, but from a different vantage point. I think we have more than enough big issues to tackle, so I don't intend to offer any new ones. Instead, I would like to talk about the view from the trenches. What do we need to do and what needs to happen for us to deliver on the promises of health services research?

As background, let me tell you two apocryphal stories from my days as a graduate student. By apocryphal, I mean that as I get older I have a harder and harder time remembering whether these events actually happened. But if they didn't, they should have.

The first took place in the graduate student coffee room. One of the fourth-year students, who later became an editorial writer for the New York Times, was expounding on the nature of research. He declared that "research is not about making great discoveries. It's the painstaking process of reducing how much we don't know; it's shrinking the size of the black hole by nibbling away at the edges."

The second event occurred a year or two later. The Nobel Prize in Economics had just been awarded, and the chairman of the department was asked--by the alumni magazine, I believe--if training Nobel laureates was one of the goals of his department. He said, in effect, that winning the Nobel Prize has much more to do with talent, lots and lots of hard work, and luck than with training per se. "Champions are born, not made." His goal was to produce economists who can solve problems and fix things, who are good mechanics and plumbers. (Just to be clear, he used the word "plumber" in an honorable sense. This was before the original Watergate scandal, and for those of you too young to remember, the word plumber will always have a pejorative connotation to the Watergate generation.) By the way, he won the Nobel Prize about ten years later.

Please keep these stories in mind as I continue.

In a way, I think we suffer from a kind of envy in comparison to our brethren in biomedical research. After all, they search for the cure. Their goal is to eradicate disease. They look for the magic bullet or the Holy Grail. And, you know what? Sometimes they succeed. That's the promise of biomedical research.

But what about our science, health services research? What are the promises we can hope to fulfill? A good starting point is the famous IOM definition (Figure 1). I won't try to read it--my breath would give out before I got to the end--but it's all there, just a little hard to see through the words. I want to emphasize three phases: field of inquiry, to increase knowledge, and effects of health services.

Since a picture is worth a thousand words, Figure 2 depicts my vision of the IOM definition. It posits HEALTH to be a function of (1) genetics and disease, (2) the medical care system, and (3) behavior and environment. We'll cede the first box to the biomedical researchers, and while we ought to spend more time thinking about the third box, our bread and butter is the relationship between the medical care system and health. (The solid lines indicate primary areas of inquiry or causation, and the dashed lines represent secondary relationships. I omit the feedback loops from HEALTH to the second-tier boxes to keep the picture relatively simple.)

So, what is health services research? First and foremost, it is scientific investigation. It is a branch of science. We're right there--at the base of the pyramid, just like biomedical research, epidemiology, biostatistics, and public health. We produce knowledge. We reduce the amount we don't know about how medical care and behavior and environment affect health and about how much those things cost. However, we are not "looking for the cure." The kinds of problems we tackle don't have cures or once-and-for-all solutions. Instead, we try to make temporary gains, until the system responds and we have to start again.

Our goal is to produce information that will help us--society--improve health and the health care system. And we care about how much those improvements cost and how to provide them efficiently. After all, the relationships between behavior and environment and health also involve money. If we can save a few dollars in the medical care box and spend it on fostering healthier behaviors or improving the environment, or simply letting people buy more of whatever else they want, those are good things.

How do we do our research? How do we provide the information that can be used to make decisions about improving health and the health care system?