Health services research (HSR) is broadly focused on characterizing and improving the access, quality, delivery, and cost of health care. HSR is a multidisciplinary field, engaging experts in clinical medicine and surgery, policy, economics, implementation science, statistics, psychology, and education to improve the care of patients across all specialties. This article summarizes the evolution and distinctive attributes of HSR and present several real-world applications.

Keywords

Health services research

Outcomes research

Health care quality

Key points

Introduction

Delivering high-quality, efficient care to all Americans remains an elusive and expensive task. Understanding the organizational structure of our health care delivery system can provide critical insight on strategies to improve the accessibility, effectiveness, and affordability of health care in the United States. In this context, the field of health services research (HSR) is directed at examining all aspects of health care delivery to improve the quality and streamline the allocation of scare resources. This article summarizes the evolution and distinctive attributes of HSR and present several real-world applications.

The history of health services research

The beginning of HSR as a formal entity is difficult to define. For example, the first investigation of treatment effectiveness could be considered as early as biblical times. In the Book of Daniel, King Nebuchadnezzar of Babylon decreed that only wine and meat should be consumed to maintain health and prevent disease.1 Early examples of evidence-based medicine can also be found in the first century AD, when members of the Song dynasty advocated the health benefits of ginseng through comparative, albeit anecdotal, accounts.2 Regardless of its true beginning, throughout history, there are innumerable examples of efforts to identify best practices and improve the delivery of health care. For example, in 1789, the Public Health Service was established as a strategy to ensure appropriate care was given to ailing or injured merchant seamen in the United States.3 In 1837, William Farr collected statistical data regarding mortality, morbidity, and disability. Florence Nightingale furthered this work in 1858 with Farr, developing a uniform reporting system of health care practices and outcomes for London Hospitals.4

In the United States, HSR formalized during the mid-twentieth century following medical and technological advances from World War I and World War II.5 Before this, medical care was relatively accessible and inexpensive in the United States. However, effective treatments were lacking for many conditions, such as common infections or pregnancy complications. Military conflict spurred the development of numerous advances in medical and surgical diagnosis and treatment, such as blood transfusions, antisepsis, radiographs, electrocardiograms, and triage systems.4 This explosion of innovation was correlated with not only a rapid decline in morbidity and mortality but also a sharp increase in expenditures, prompting a closer examination of health care delivery.

The term “health services research” was formally coined in 1966.3 At that time, the federal government established a specific study section for grant proposals that were health services oriented.3 In 1968, the National Center for Health Services Research and Development was established under the leadership of Dr Kerr White, a pioneer in HSR in the mid-twentieth century. The National Center for Health Services Research, known today as the Agency for Healthcare Research and Quality (AHRQ), represents one of the first federally funded programs charged with systematically examining health care delivery and quality in the United States. HSR gained further momentum with the appropriation of research funds specific to the purpose of advancing the field of HSR, spearheaded by Dr Paul Sanazaro.5 Today, AHRQ is the primary federal agency focused on the delivery of health care in the United States and funds most of the HSR in the United States. With an annual operating budget of approximately 400 million dollars, more than 80% is directed toward HSR-related grants and contacts and more than 12,000 active health services researchers in the United States.6

What is health services research?

HSR has been broadly defined as the study of health care access, cost, and effectiveness, with the purpose of developing successful strategies to organize, manage, finance, and deliver high-quality medical care.5,7 HSR has expanded dramatically to become a multidisciplinary field in which investigators study health care delivery. Collaborators include specialists from clinical medicine, economics, psychology, statistics, education, and policy. With rapid advances in measurement technique, study design, and information technology, HSR has profoundly shaped health care delivery in the United States in the twentieth and twenty-first centuries.

Aspects of health services research

In general, HSR involves the examination of the effect of specific aspects of the health care system on endpoints, such as clinical outcomes (eg, mortality), quality of life (eg, pain), or cost. Fig. 1 describes a thematic overview of HSR. Nearly all HSR endeavors examine topics in 1 of 3 broad categories—access to care, quality of care, or cost of care—and seek to affect change in the following avenues: outcomes, policy, or system delivery. HSR uses a variety of study methods to accomplish these goals, which are outlined in Table 1. Although not an absolutely inclusive or comprehensive list, HSR studies generally include methodology, access to care, efficacy, quality, cost, or evaluation of effectiveness.