Health Services Research in Improving the Delivery of Care for Patients with Cardiovascular Diseases
Moving From Observation to Innovation to Action
Health services research (HSR) is a multidisciplinary field of scientific inquiry that examines how people access health care, how that care is delivered, how much it costs and, ultimately, what happens to patients as a result of this care. Put simply, it asks what works, in whom, at what cost, and under what circumstances.1 Accordingly, HSR can provide important insights into the current delivery of health care, identify areas where current care falls short, and guide interventions for improvement in care delivery.
HSR has a particularly valuable role in cardiovascular care. The prevalence, associated morbidity and mortality, and large financial costs incurred by cardiovascular disease make its impact on health and medical costs significant. As a result, HSR insights into improvement opportunities for cardiovascular care delivery can lead to large gains in healthcare value. For example, HSR insights into acute stroke care deficiencies led to the American Heart Association Get With the Guidelines Stroke quality improvement program. Over a 5-year period, the program significantly increased adherence to best acute stroke care practices.2 Another successful application of HSR methodologies in cardiovascular disease has been to ST-elevation myocardial infarction door-to-balloon times.3 HSR investigators identified significant barriers to achieving goal door-to-balloon times of <90 minutes, designed interventions to overcome these barriers, and systematically implemented and evaluated them. As a result, the majority of patients with ST-elevation myocardial infarction in the United States now receive guideline-concordant care, with an attendant improvement in clinical outcomes.
However, these examples actually serve more as the exception than the rule in HSR efforts. One reason for this is the nature of academia, where HSR mainly lives. Academia’s reliance on grant funding for support and success measured by publication of peer-reviewed manuscripts provide important “checks” on the validity of HSR ideas and projects, but they often hinder the translation of HSR observations into meaningful action. For example, it is not uncommon for observational and interventional HSR studies to be conceived independently from those who oversee the delivery of care. Funding and publication decisions are often led by HSR investigators without insights or input from healthcare delivery operational partners. Accordingly, these operational leaders may not see the relevance of the research findings or have any incentives to implement their results into practice. Accordingly, its potential to optimally inform healthcare delivery is often undermined.
For HSR to move from potential irrelevance to significant impact, innovation in how HSR ideas are generated, designed, executed, and incentivized is required. In his book How to Kill a Unicorn, innovation consultant Mark Payne4 describes how successful innovation requires equal parts “magic” and “money.” Magic refers to the creative idea at the heart of all innovations, and money to the practical reality of finding and deploying resources to support a specific innovation. To satisfy both parts, it is critical to design innovations with their users in mind. Thus, HSR projects that ask relevant and impactful questions to generate innovative insights and actions (ie, the “magic”) are necessary first steps. However, HSR projects also need to ensure that insights are provided in a cost-conscious and timely fashion for operational needs (ie, the “money”) (Table).
To achieve these ends, HSR investigators will need to expand their efforts to determine the “return on investment” that their proposed interventions will generate, taking into account both the benefits and costs of their proposal. To speed up the research timeline, investigators can report interim results to inform operational priorities and offer an opportunity to implement “midstream” modifications to the approach. HSR can also be designed to generate “good enough” data, sufficient to provide practically useful information but without requiring endless investigation.5 HSR investigators can also generate presentations and white papers aimed at operational leadership to speed the dissemination of results to practice, rather than relying solely on journal publication. Finally, the incentive structure for HSR investigators will also require reform. Impact on operational efficiencies should augment the traditional publication and grant metrics of success. In addition, the sole reliance on external grant funding to underwrite HSR needs reconsideration. Instead, a portion of healthcare operational budgets should be dedicated to supporting HSR investigators, analogous to research and development divisions in private industry.
Although these changes for investigators are important for the ongoing relevance of HSR, its operational partners in healthcare delivery will also need to reconsider their traditional modus operandi to maximize the potential insights from HSR. For example, the “bias to action” that drives many operational decisions will need replacement with a commitment to thoughtful, data-driven decisions informed by insights from their HSR colleagues. This will require a commitment from senior leadership to clearly articulate strategic direction, support HSR efforts to investigate and implement their insights, and channel resources accordingly. These commitments by operational leadership can provide an optimal environment to leverage the true strengths of HSR to flourish.
Of course, research is rarely linear in its conduction. Many important insights occur by serendipity, rather than solely from meticulous planning and strategic alignment. Many industries have recognized this fact and organized their efforts accordingly. For example, Google has launched a variety of experimental and risky “moonshot” initiatives under their parent company, Alphabet. HSR is no different, and this “freedom to innovate” approach should be supported to harness the ingenuity of HSR investigators. Nevertheless, the focus of HSR remains on the mission of impacting healthcare delivery, which requires tighter alignment with those who deliver it. The current siloing of HSR and operations impedes the ability of both entities to maximize the impact of healthcare delivery. By partnering more closely with more of the HSR end users, investigators can holistically consider the “magic” and “money” of successful innovations to maximize the impact of their work and its effect on optimal healthcare delivery.
The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.
Circulation is available at http://circ.ahajournals.org.
- © 2017 American Heart Association, Inc.
- 1.↵What is HSR: About us: AcademyHealth [Internet]. http://www.academyhealth.org/About/content.cfm?ItemNumber=831. Accessed July 2, 2016.
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