Frequently Asked Questions

Because Health Services Research (HSR) can be conducted in many different settings (e.g.: academia, government, business), it has been defined in many different ways.

Our laboratory is aligned with the definition posted by the Agency for Healthcare Research and Quality: Health services research examines how people get access to health care, how much care costs, and what happens to patients as a result of this care. The main goals of health services research are to identify the most effective ways to organize, manage, finance, and deliver high quality care; reduce medical errors; and improve patient safety.”

Academically, it is the far end of the continuum of health-related research. It is concerned to learn ways to close the gap between what we know and what we do and to disseminate sustainable practices in health-care.

  • Flook, E.E. and Sanazaro, P.J. Chapter 1. Health Services Research: Origins and Milestones. In: E.E. Flook and P.J. Sanzaro, eds. Health Services Research and R&D in Perspective. Ann Arbor, MI: Health Administration Press, 1993.
  • Institute of Medicine. Health Services Research. Washington, D.C.: National Academy of Sciences, 1979.
  • Eisenberg, JM. 1998. “Health services research in a market-oriented health care system.” Health Affairs (Project Hope) 17 (1): 98-108.

Value in health-care should be defined by each patient and for each condition. We believe that we provide valued care only when we meet the patient’s needs.

According to Michael Porter, PhD, it “is what matters for patients and unites the interests of all actors in the system…If value improves, patients, payers, providers, and suppliers can all benefit while the economic sustainability of the health care system increases.”

Value is also defined as the health outcomes achieved per dollar spent. Accurate estimations of value are important because the ratio of cost to quality of care, or value, is critical to new payment models and systems of care.

  • Porter ME. What is value in health-care. N Engl J Med 2010; 363:2477-2481
  • Porter ME, Teisberg EO. Redefining health . care: creating value-based competition on results. Boston: Harvard Business School Press, 2006.
  • Porter ME. A strategy for health care reform–toward a value-based system. N Engl J Med. 2009 Jul 9;361(2):109-12. doi: 10.1056/NEJMp0904131. Epub 2009 Jun 3.
  • Brook RH, McGlynn EA, Cleary PD. Quality of Health Care. Part 2: Measuring Quality of Care. N Engl J Med. 1996; 335: 966-70.
  • Donabedian, A. 2005. “Evaluating the quality of medical care.” The Milbank quarterly 83 (4): 691-729.
  • Blumenthal D. Part 1: Quality of Care – What is it? N Engl J Med. 1996; 335: 891-4.
  • Allison, J.J., T.C. Wall, C.M. Spettell, J. Calhoun, C.A. Fargason Jr, R.W. Kobylinski, R. Farmer, and C. Kiefe. 2000. “The art and science of chart review.” The Joint Commission journal on quality improvement. 26 (3): 115-36.

Processes in healthcare refer to the development, performance or implementation of certain measures. For instance, the processes across the spectrum of epilepsy care include documentation of seizure type and frequency, etiology or epilepsy syndrome, review of EEG and neuroimaging, the assessment of antiepileptic drug side effects and counseling about safety, impact on reproduction and alternatives when seizures are drug resistant.

A process evaluation would check if doctors have prescribed folic acid to woman of childbearing potential with the assumption that this would be associated with better outcomes (e.g.: decreased prevalence of serious birth defects).

  • Mant J. Process versus outcome indicators in the assessment of quality of health care. Int J Qual Health Care. 2001; 13(6): 475-480.
  • Donabedian A. Quality of care, how can it be assessed? JAMA. 1988;260:1743-8.
  • Brook RH, McGlynn EA, Cleary PD. Quality of Health Care. Part 2: Measuring Quality of Care. N Engl J Med. 1996; 335: 966-70.
  • Mant J. Process versus outcome indicators in the assessment of quality of health care. Int J Qual Health Care. 2001; 13(6): 475-480.
  • Park RE, Fink A, Brook RH, Chassin MR, et al. Physician ratings of appropriate indications for six medical and surgical procedures. Am J Pub Health 1986; 76(7): 766-772.
  • Stulberg JJ, Delaney CP, Veuhauser DV, Aron DC, Fu P, Koroukian SM. Adherence to Surgical Care Improvement Project measures and the association with postoperative infections. JAMA. 2010;303:2479-85.

Outcomes in healthcare are the changes (or health status) that have occurred as a result of a medical intervention, counseling, etc.

These should be multidimensional and centered in the patients and what they value. Examples include degree of health or recovery achieved, the time needed for recovery, the discomfort of care, and the sustainability of recovery.

Taking the example given in “What are processes of care”, an outcome evaluation would tell us how many of those counseled women achieved the desired outcome (e.g.: decreased prevalence of serious birth defects).

  • Mant J. Process versus outcome indicators in the assessment of quality of health care. Int J Qual Health Care. 2001; 13(6): 475-480.
  • Donabedian A. Quality of care, how can it be assessed? JAMA. 1988;260:1743-8.
  • Brook RH, McGlynn EA, Cleary PD. Quality of Health Care. Part 2: Measuring Quality of Care. N Engl J Med. 1996; 335: 966-70.
  • Mant J. Process versus outcome indicators in the assessment of quality of health care. Int J Qual Health Care. 2001; 13(6): 475-480.
  • Park RE, Fink A, Brook RH, Chassin MR, et al. Physician ratings of appropriate indications for six medical and surgical procedures. Am J Pub Health 1986; 76(7): 766-772.
  • Stulberg JJ, Delaney CP, Veuhauser DV, Aron DC, Fu P, Koroukian SM. Adherence to Surgical Care Improvement Project measures and the association with postoperative infections. JAMA. 2010;303:2479-85.

Process and outcome measurement are the fundamental tool in quality of care research.

When caring for a patient, the provider should always focus on achieving the desired outcome or result – which is usually an improvement in a health status (e.g.: cure, comfort, maintenance or re-establishment of a function, wellbeing).

Certain outcomes can be easily and reliably measured (e.g.: number of deaths). Other outcomes are much trickier to measure (e.g.: mood changes, rate of progression of a disease, level of attention). And measuring outcomes in large scale can be unfeasible due to high costs and complexity. That is why researchers and regulatory agencies so frequently chose to use processes of care as their measurement unit.

Much attention should be given to the distinction between those measures. Process measures are not ‘‘quality’’ in and of themselves. They should be considered as tools or surrogates of good outcomes. Each process measure should be continuously validated and questioned.

We suggested here some references that illustrate the complex relationship between processes and outcomes and how misinterpretations can be harmful to patients.

  • Mant J. Process versus outcome indicators in the assessment of quality of health care. Int J Qual Health Care. 2001; 13(6): 475-480.
  • Donabedian A. Quality of care, how can it be assessed? JAMA. 1988;260:1743-8.
  • Brook RH, McGlynn EA, Cleary PD. Quality of Health Care. Part 2: Measuring Quality of Care. N Engl J Med. 1996; 335: 966-70.
  • Mant J. Process versus outcome indicators in the assessment of quality of health care. Int J Qual Health Care. 2001; 13(6): 475-480.
  • Park RE, Fink A, Brook RH, Chassin MR, et al. Physician ratings of appropriate indications for six medical and surgical procedures. Am J Pub Health 1986; 76(7): 766-772.
  • Stulberg JJ, Delaney CP, Veuhauser DV, Aron DC, Fu P, Koroukian SM. Adherence to Surgical Care Improvement Project measures and the association with postoperative infections. JAMA. 2010;303:2479-85.

 Appropriateness of care refers to the combination of the appropriateness of the service and the appropriateness of the setting in which the care is provided.

Adequately measuring both criteria objectively requires the analysis of the usual protocols taken in health care and comparing them to a strict set of standards that are used as the prerequisites of appropriate care.

It is critical to ensure that the guidelines outlining appropriate care have a justifiable foundation before beginning to study the appropriateness of the care itself.

We suggested here some references to give you an introduction about appropriateness of care.

  • Park RE, Fink A, Brook RH, Chassin MR, et al. Physician ratings of appropriate indications for six medical and surgical procedures. Am J Pub Health 1986; 76(7): 766-772.
  • Shekelle PG, Kahan JP, Bernstein SJ, Leape LL, Kamberg CJ, Park RE: The reproducibility of a method to identify the overuse and underuse of medical procedures. N Engl J Med 1998; 338(26): 1888-1895.
  • Phelps CE. The methodologic foundations of studies of the appropriateness of medical care. N Engl J Med 1993; 329: 1241-1245.

 When choosing between alternative courses of action in health care it is imperative to select the route with the best possible outcomes. In order to decide which approach would yield the most successful results, it is important to utilize one of the following analytical techniques: cost-effectiveness, cost-benefit, or cost-utility. However, not all three techniques can be applied to the same health care dilemma, because each method has its own criteria for calculating the best course of action.

Cost-effectiveness analysis (CEA) compares two or more health care treatments and selects the one that will yield the best results for the lowest cost. It is important to note however, that in this form of analysis the lowest financial cost is not what is being looked for. Instead, it examines the outcomes of health care treatments that cannot be measured in money such as living a longer life.

However, cost-benefit analysis (CBA) focuses on the monetary and health outcomes of the possible treatments by looking for a treatment with the best benefits, at the lowest costs. This method would be more useful for example in determining whether it is more effective to either vaccinate people against a disease or not vaccinate at all and treat the people who acquire the disease.

Finally, cost-utility analysis (CUA) is considered a specialized form of CEA, but in the case of CUA, health care outcomes are also valued in terms of utility, value or quality. For example, a CUA will differentiate between the utility of avoiding a case of melanoma or a case of poliomyelitis.

These differences in utility are measured with the use of quality-adjusted life year (QALY), which is a health measure that combines the duration of life and the health-related quality of life after treatment, and disability-adjusted life year (DALY), which measures the burden brought to the patient through the disease in terms of the number of years lost due poor-health, disability, or early death.

It is vital for researchers to carefully examine each of these three analytical methods and work alongside with physicians and other health care practitioners to establish a not only successful treatment, but a treatment that will bring about the most benefits to its patient at the lowest cost, whether it is a monetary cost or a quality cost.

We suggested here some references where you will find the distinction between cost-effectiveness, cost-benefit and cost-utility.

  • Weinstein MC, Stason WB. Foundations of cost-effectiveness analysis for health and medical practices. N Engl J Med 1977; 296(13): 716-721.
  • Meltzer MI. Introduction to Health Economics for Physicians: Health Economics Quintet. The Lancet. 2001; 358: 993-998.

Value = health outcomes that matter to patients / costs of delivering the outcomes

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