Emergency Medicine Advocacy Handbook

Ch. 33 - Health Services Research

Kirstin Woody Scott, MPhil, PhD; Anna Nabel, MD; Justine Seidenfeld, MD; Brandon Maughan, MD, MHS, MSHP, FACEP

Emergency departments provide care to patients across the full socioeconomic landscape and at all levels of acuity. On a daily basis, emergency physicians face system- and individual-level barriers that make it difficult to provide appropriate, effective, and timely care to our patients. Physicians, policymakers, and advocates alike are increasingly concerned about the rising costs of health care, the unmet primary care needs of socioeconomically disadvantaged populations, the lack of availability of mental health care services, and the ever-increasing number of diagnostic and therapeutic technologies.

In an era of increasing focus on health care value and efficiency, health services researchers in EM will help revolutionize the way health care is delivered.

Health services research (HSR) is a multidisciplinary field that addresses these gaps in practice by examining the delivery, quality, cost, and access to health care services. HSR may measure the effects of past policy interventions or describe the current state of affairs to help guide future policy design.

Emergency physicians, emergency medicine residents, and medical students are well-positioned to contribute to this emerging field. Shifting political landscapes have changed the delivery of emergency care over the past several years, creating a critical need for research to examine the ways that EDs ultimately impact public health across different communities and policy environments.

What Is HSR? How Does It Differ from Other Research?

Health services research examines a diverse set of topics that relate to the organization of health care systems, the financing of those systems, the ways in which they deliver care, individuals’ access to care, quality and safety of care, and the role of social factors, personal behaviors, and health technology in shaping health outcomes. It is a broad discipline that draws not only from applied sciences like public policy, epidemiology, engineering, and health administration,

but also from more traditional academic disciplines like psychology, sociology, economics, and biostatistics. Health services researchers can work in many sectors including academia, government, foundations and other nonprofit organizations, and private-sector organizations such as consulting firms or drug/device manufacturers.

They often utilize a number of research skills that differ from biomedical or clinical researchers, and they use a wide variety of both quantitative and qualitative study designs that are described below. They can work with a diverse field of stakeholders including payers, providers, pharmaceutical and drug/device companies, and patients, and the results of their research can directly influence decisions regarding clinical practice guidelines or policy implementation. HSR studies may examine a single emergency department, a hospital, or a regional or national health system.

Health services research often focuses on the real-world effectiveness, utilization, cost, and quality of different health care interventions or delivery tools at a system-wide level. In contrast, biomedical or clinical research often looks at the efficacy of interventions, meaning their effects in an ideal setting free from bias or confounding factors. HSR studies may consider provider biases, patient preferences, or barriers to access, and as a result the research may be more generalizable across different patient populations and policy environments.

What Topics and Study Designs Comprise HSR?

Health services research can encompass a broad range of topics and study designs.

• Reporting on the utilization and outcomes of health care services is a key component of HSR. For instance, Kocher and colleagues examined ED volumes across the United States and measured the association of volumes with mortality.¹ They found that patients admitted through high-volume EDs had lower rates of inpatient mortality, but the difference in mortality was substantially more significant for some conditions (eg, sepsis) than for others (eg, pneumonia).
• Another approach to examining ED utilization is to examine physician attitudes and practice patterns, such as through surveys. Lin and colleagues surveyed over 700 emergency physicians to assess their familiarity with the Choosing Wisely program and measure its impact on their delivery of care.²
• Health services research also examines patient access to care with various study designs. To examine the availability of primary care appointments, Rhodes and colleagues performed “simulated patient” studies in which they posed as real patients and called primary care practices in several different states to examine how quickly appointments would be available for new patients with different types of insurance.³
• Comparative effectiveness studies examine the real-world outcomes associated with two or more interventions. For example, Suzuki and colleagues published a 2016 comparative effectiveness analysis that examined outcomes associated with use of emergency thoracotomy versus closed chest compressions for critically ill blunt trauma patients.⁴ They found in a multivariable regression analysis that thoracotomy was associated with a statistically significantly lower survival rate.
• Cost-effectiveness analysis goes a step further to examine both the outcomes associated with different interventions, and the costs associated with them. For instance, Ward and colleagues examined the cost-effectiveness of adding a point-of-care lactate testing protocol to identify patients with suspected sepsis who could benefit from early resuscitation; they found that the protocol was effective at improving patient outcomes for a relatively small additional cost.⁵

Many other topics are often addressed by health services researchers, including (but not limited to) examining the impact of new technologies (eg, electronic health records or diagnostic tests) in the delivery of care, implementation sciences, examination of health programs on socioeconomically vulnerable populations, health care ethics, quality and safety of care, patient satisfaction, and issues facing the health services workforce (eg, workplace violence, physician burnout).

Key Tools for Conducting HSR

Data Sources

Systematic data collection in the ED can provide insight into what brings patients into the health system, how they are cared for in any given encounter, and can capture other valuable public health and societal trends in health care. As such, there are a number of large administrative databases and survey tools that capture data for the study of state, national, and global emergency care. The following highlights only a subset of the possible data tools that exist for researchers interested in EM HSR.⁶

In terms of federal resources, through the Centers for Medicare and Medicaid Services (CMS), HSR researchers can utilize claims data captured for administrative and billing purposes to study national ED utilization and trends. Further, the Centers for Disease Control and Prevention (CDC) conducts an annual survey of a sample of nonfederal hospital EDs and outpatient offices through National Hospital Ambulatory Medical Care Survey (NHAMCS); this broad survey includes data on patient demographics, type of ED care providers, vital signs, diagnostic tests, medications, and diagnoses. Though many more exist, additional examples of federal resources include the CDC’s National Health Interview Survey (NHIS) and pre-hospital data through the Office of Emergency Medical Services (EMS) National EMS Information System (NEMSIS). Other EM-focused databases exist through the AHRQ Healthcare Cost and Utilization Project, including the hospital-based, all-payer Nationwide Emergency Department Sample and the longitudinal State Emergency Department Databases.

A number of professional societies and organizations manage data sets that are useful for monitoring aspects of EM, including the American College of Surgeons’ National Trauma Data Bank, the hospital-level view of ED utilization and volume through the American Hospital Association’s annual survey and EMS. Further, ACEP has developed the Clinical Emergency Data Registry, which aims to serve many functions to meet requirements set forth by CMS to capture clinical and patient data for quality reporting in EM. As this registry matures, it is expected to be a rich data source for future HSR focused on improving the quality of emergency care.

Beyond these sources, health services researchers in EM can leverage the growth of provider EHRs and dynamic nature of health information technology (HIT) as useful data repositories. In addition, nonprofit organizations also play a major role in HSR and may collect data relevant for EM researchers. Examples of these organizations include Academy Health, the Robert Wood Johnson Foundation, the Commonwealth Fund, Institute for Health Metrics and
Evaluation, and the Kaiser Family Foundation.

Funding

There are a number of mechanisms to obtain funding for HSR in EM, including:

• Federal granting agencies
• Patient Centered Outcomes Research Institute
• National foundations (eg, Robert Wood Johnson Foundation, Commonwealth Fund)
• State-level foundations (eg, California Health Care Foundation)
• EM organizations (eg, Emergency Medicine Foundation, Society for Academic Emergency Medicine)
• Global health agencies (eg, Gates Foundation, Fogarty, Fulbright, MEPI)7

How Has HSR Contributed to EM Advocacy?

There are many examples in which HSR has informed advocacy efforts to strengthen the delivery of emergency care. For instance, health services research has played an important role in shaping local and federal policy responses to the opioid epidemic. In response to research showing increasing rates of opioid-related ED visits and overdose deaths, agencies took steps to improve access to treatment services and increase availability of naloxone. Several states passed legislation that require first responders such as police and firefighters to carry naloxone,8 and health services researchers have shown that communities with these naloxone program have lower rates of opioid-related deaths than non-participating communities.⁹

Health services research has also identified populations that suffer disproportionately high rates of morbidity and mortality from opioid abuse, such as pregnant women with substance use disorders who live in Appalachian states (which are already disproportionately affected by the opioid crisis). Patrick and colleagues conducted research which identified that providers in these states were less likely to treat or accept pregnant women and/or Medicaid patients.¹⁰ Identifying these gaps is care is the first step toward improving care for these at-risk populations.

Conclusion

Health services research will continue to guide the development, evaluation, and reform of health policy on state, federal, and international levels. With a wide variety of data and funding sources, researchers will have more tools to better analyze the relative costs, benefits, and risks associated with diagnostic and treatment decisions. In an era of increasing focus on health care value and efficiency, a generation of new health services researchers in emergency medicine will help revolutionize the way health care is delivered. Emergency physicians must be active participants in health services research to ensure the correct clinical questions are being identified and studied that benefit our patients and providers.

• Emergency physicians can use health sciences research to better understand issues related to access, delivery, quality, and cost of health care, and how it may affect their practice environment.
• Health services research can provide crucial data to support advocacy and improve delivery of care to the community.
• Physicians should advocate for funding for HSR. Without funding, we cannot generate the data needed to guide future policy decisions.