Not too long ago I was an eager general surgery resident seeking out research opportunities anywhere I could get them. A minority of residents around me sought basic science opportunities, but most of us picked the “easier” route, a.k.a. clinical research. This referred, at that time, to a sprinkling of case series, small to medium single-institution database mining and, the most sophisticated of all, the large administrative database. Over the past 6 years I have heard repeatedly that the problem with all of this type of work is that data can be made to say anything if you set the statistics up right. But the more I came to identify as a health services researcher I began to appreciate how much more there was to the science within this field. Health services research, which many think is clinical research with a longer and fancier name, seeks to answer a wide array of questions related to health care structure, process and outcomes. A far cry from torturing large data sets to produce the answer the researcher is looking for, the modern methodologies and novel fields described below seek to explore mechanisms underlying the complicated system of health care delivery and practice in which we all exist. While many of these methods are not new outside of our field, their implementation by surgeons has increased the rigor and established the value of health services research in improving the care we deliver to patients.
This is a heterogeneous collection of methods that may include focus groups, semi-structure interviews, discourse analysis or directed observational data collection. While it may see initially as an antithesis to the quantitative approaches more widely excepted in medical research, the current trend among experts in health services research often seek to combine techniques from both quantitative and qualitative research, with an understanding that each have unique strengths and weaknesses in answering the most compelling research questions. Qualitative research is particularly suited toward understanding workplace processes including operating room dynamics, barriers in health care decision making and the complex interplay between humans and health care delivery systems. Qualitative research is better suited than its quantitative counterpart to study human behavior, which has obvious and direct impact on clinical outcomes. Qualitative research is often termed ‘hypothesis generating’, suggesting that one of its unique contributions to health services research is in helping to inform and develop more thoughtful quantitative or mixed methods research questions. In each of the types of research below, qualitative methods often play an important role in performing these valuable investigations.
The major underlying concept in patient-reported outcomes (PRO) is a paradigm shift within quality research from hospital and provider defined outcomes (i.e. survival, complication rates) to more patient defined outcomes. PRO and the study of patient centered care focuses on both the input of the patient to the patient-provider relationship, including evaluation of their values and preferences but also measurable, patient centered outcomes. These might include functional outcomes, quality of life and satisfaction, just to name a few. Like the subsequent fields, the evaluation of PRO utilizes both qualitative and quantitative methods (e.g. surveys).
Implementation science is the study of the adoption of new research in to clinic practice. Implementation science may include highly quantitative evaluation about whether new evidence or guidelines have been adopted, but also often includes more subjective evaluation of institutional, provider and patient factors that may facilitate or impede the integration of new evidence in to clinical practice. Implementation science is often integrated into quality improvement as we look to better understand the challenges involved in incorporating change at the level of large institutions as well as at the level of individual providers, based on the most current evidence available.
Decision science is a diverse field of study and explores both patient and provider facets of decision-making. It includes establishing value and preference among both groups, development of decision aids and the use of decision analysis models to inform decision making for both patients and providers. Like the previously described fields of research, decision science employs a variety of different qualitative and quantitative methods to better understand decision-making and to ultimately introduce interventions designed to improve decision-making between patients, providers and health care systems.
These methodologies and frameworks are just a few of the exciting areas that health services researchers on a daily basis. Each contribute uniquely to the most important health care questions and problems that we, as a community, must address to understand and improve the health care system and delivery for generations to come.