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Research on medical liability issues (e.g., determinants of or alternative approaches to reduce medical liability) and,

Clinical practice-oriented primary care research.

We expect to fund up to 20 proposals during FY 1991 as a result of this small grant announcement.

There are other strategies that also would enhance the research base for issues in primary care for vulnerable and underserved populations. Our National Research Service Awards (NRSA) and dissertation grants program currently support approximately 24 institutional and individual awards in health services research and 25 dissertation grants per year. Research evolving from these training investments will, in part, make noteworthy contributions to the underserved issues.



Question. Dr. Clinton, since fiscal year 1990 over $100,000,000 has been made available to your agency for research on medical treatment effectiveness. How will the information gleaned from this research be translated into practice by physicians, policy makers and the American consumers?

Answer. The Medical Treatment Effectiveness Program (MEDTEP) emphasizes the dissemination of findings to potential users of the information including physicians, private and public decisionmakers, researchers, third-party payers, educators, legislators, allied health professionals, and consumers.

Multiple and detailed dissemination strategies for each medical practice guideline are now being developed, with emphasis on their adoption and use. They will be disseminated via a variety of means including print, direct mail, computer search systems, video tape, the press, exhibits, presentations, and other formats. Dissemination activities will involve professional groups, governmental agencies, consumer groups, educational organizations, libraries and targeted marketing efforts in selected communities. In order to ensure that we adequately address the critical issue of translating research into medical practice, we are holding a workshop with dissemination experts to thoroughly explore what is currently known about effective dissemination. The input from these experts will be used to guide the development of our dissemination strategies.

The National Library of Medicine (NLM) has expanded its information services to retrieve research findings and practice guidelines from computer-based medical information systems. The NLM and AHCPR are updating the medical subject headings to increase access to research findings and guidelines and will continue activities to increase dissemination of information. Further, we have an intra agency agreement with the NLM's National Technical Information Service to hold all of AHCPR's products. We

will be working with them to develop full text retrieval of these products beginning with the clinical guidelines.


Question. Dr. Clinton, is there a sufficient number of trained health services researchers to carry out this important line of research? How much is the federal government investing in training for researchers in this field? Is there a need to expand this effort in order to ensure an adequate pool of trained scientists for the future?

Answer. We are concerned about there being a sufficient cadre of health services researchers to keep pace with current and future research needs. This is a well recognized problem exacerbated by shrinking private investments in training health services research students. The AHCPR administers a National Research Service Award (NRSA) program directed at training pre and post doctoral health services research trainees through both institutional awards and individual fellowships. We are emphasizing areas in the field that are needed to support the medical effectiveness and outcomes research by encouraging applications in epidemiology, biostatistics, research methodology and behavioral research.

As mandated by the Public Health Service Act, the AHCPR receives 1/2 of 1% of the National Research Service Award monies appropriated to the National Institutes of Health (NIH) and the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA). Also, Medical Treatment Effectiveness Program (MEDTEP) funds were used to supplement the NRSA monies in FY 1990 ($ 1 million) and FY 1991 ($1.35 million). This resulted in $2.59 million being allocated for training of health services researchers in FY 1990 and $2.65 million in FY 1991 through these two programs.

Additionally, AHCPR's Health Services Dissertation Research Grants support doctoral research on the organization, delivery, financing, and of effectiveness of health care services. In FY 1990, 20 dissertation research grants were awarded totalling $395,000. Approximately 25 dissertation grants will be awarded in FY 1991 from the $500,000 earmarked for this activity.

Finally, the AHCPR has announced its intent to make administrative supplemental grant funds available to increase involvement of minority health professionals in ongoing health services research. Presently, racial and ethnic minority health professionals are not adequately represented throughout the spectrum of health services research. Their inclusion in prominent and significant roles is critical to a better understanding of problems encountered in delivering and ensuring health care in minority populations. The professional involvement of racial and ethnic minorities in the conduct of the grant can add immeasurably to the cultural sensitivity, appropriateness, and credibility of such research.

Effective enhancement of careers for minorities in health services research will require focused attention to the

fundamental and closely interdependent issues of training, recruitment, and research support. AHCPR will supplement grants to researchers who will make significant contributions to this critical priority in the Nation's health policy agenda. In order to increase the number and, capabilities of minority scientists in health services research sponsored by AHCPR, support will be provided to principal investigators to recruit, train, and employ minority investigators.


Question. Dr. Clinton, what do you see as the major issues in health over the next decade? What plans is the Agency making to gear its research to these issues?

Answer. We have identified three major sets of issues to be addressed over the course of the decade.

The first revolves around the interrelated problems of
health insurance, public sector health care expenditures,
and the costs of care to individuals. In particular, the
costs of care and access to care for vulnerable
populations--including minorities, those in rural areas, and
the poor will be increasingly serious health issues if the
costs of care continue to climb at present rates.

We must

The second relates to the quality of medical practice,
including impediments to effective practice.
identify better ways to ensure the quality of health
services and improve mechanisms to protect the public
against substandard health care.

The third set of issues relates to the need for innovation and improvement in primary care, again, focusing in particular on underserved and vulnerable populations, especially women and children in those populations.

AHCPR has developed a long-term strategy as well as some specific goals for addressing each of these sets of issues. Health Insurance. Health Expenditures, and the Cost of Care

The problems associated with the absence of health insurance coverage or under insurance are well known. One out of five Americans lacked health insurance at some point during all or part of 1987 and more than one in ten were without insurance for an entire year. These issues have been of special concern to the Deputy Secretary of DHHS and others in the administration and may be expected to persist and take on greater importance in future years. Up-to-date, detailed, reliable information on health care utilization, costs, and payment sources, including insurance coverage, will be essential for policy makers and program

1Short, P. (1990, September) Estimates of the Uninsured Population, Calendar Year 1987 (DHHS Publication No. (PHS) 90-3469). National Medical Expenditure Survey Data Summary, Agency for Health Care Policy and Research. Rockville, MD: Public Health Service.

administrators to understand the magnitude and determinants of the problem and consider policy options and their implications. Given current and projected budget constraints, it will become increasingly important to identify gaps in coverage for health care and to identify methods of paying for health services that promote the most efficient use of available resources.

The AHCPR's primary goal in the area of financing and coverage is to provide the information necessary to shape the debate regarding approaches to ensure that vulnerable populations--including the disadvantaged, minorities, and rural populations--have access to appropriate, quality health care. Both extramural and intramural research will contribute to expanding the knowledge base. A major vehicle for developing the information needed is the proposed National Medical Expenditure Survey (NMES) III. Planning and developmental activities are underway now to field NMES III by 1996, and to begin providing data to policy makers as early as 1997.

Enhancing Medical Practice

The legislation creating AHCPR was driven in large part by concerns about the effectiveness of much of current medical practice--particularly in light of evidence demonstrating dramatic variations in physician practice patterns. Our plan is to expand AHCPR's extensive program of medical effectiveness and outcomes research into the development of methods to use this knowledge, and to reduce barriers to its use. The goal is to improve medical practice. The major components of the Medical Treatment Effectiveness Program (MEDTEP)--effectiveness and outcomes research, the development of clinical practice guidelines, data base development, and information dissemination and liaison--will be continued and expanded. In addition, AHCPR's activities will include a broader program to examine the interrelated issues of quality assurance and medical liability.

Over the next 3 to 5 years medical effectiveness research and guidelines development will focus on a broader array of conditions affecting additional population groups; dissemination and use of this information will be emphasized; and a new research and demonstration effort in the related areas of medical liability and quality assurance will be expanded.

Primary Care

Careful attention to research in primary care is important for several reasons. First, most people receive the majority of their care in the primary care setting. When barriers exist to primary care, access to all care is severely limited. Second, the mechanisms or models for organizing primary care are rapidly changing. It is not clear which approaches are best at providing the acceptable, comprehensive, and coordinated services typically associated with good primary care-particularly as services are "unbundled" and free-standing providers proliferate, each rendering only a single or limited array of services. Third, in any effort at health care reform, the role of primary care providers is critical. The organizational, financial, and training arrangements for primary care in this country are

different from those found in Canada and most European countries and warrant careful analysis. Finally, the body of scientific knowledge upon which to base primary care has never been adequately developed. Wide variations abound among the disciplines that practice primary care and between primary care and specialty practitioners. Therefore, the primary care arena represents fertile ground for medical effectiveness and health systems research.

AHCPR's immediate goal is to begin to build the existing primary care research portfolio into a more comprehensive program focusing on ways to use available resources to efficiently and effectively serve the needs of underserved populations. This will include development of practice-based research laboratories in primary care, expanded research on managed care systems, and on improved integration of effectiveness research and information dissemination.

The AHCPR's long-term goal in this area is to a) increase the capacity for research in primary care and b) expand the knowledge base that supports the organization, practice, and evaluation of primary care programs and practices. While considerably broadening the scope of primary care research issues is encouraged, AHCPR will continue to stress health care services for underserved populations (including rural, minority and disadvantaged populations), infant mortality, HIV/AIDS, and delivery system issues (including comprehensive care and managed care).

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