7. Conclusions and Recommendations | Agency for Healthcare Research and Quality

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href="/healthsystemsresearch/hspc-research-study/acknowledgments.html" data-drupal-link-system-path="node/232818">Acknowledgments</a> </li> <li class="dropdown-item sbf-level-three"> <a href="/healthsystemsresearch/hspc-research-study/abbreviations.html" data-drupal-link-system-path="node/232819">Abbreviations</a> </li> <li class="dropdown-item sbf-level-three"> <a href="/healthsystemsresearch/hspc-research-study/introduction.html" data-drupal-link-system-path="node/232830">Introduction</a> </li> <li class="dropdown-item sbf-level-three"> <a href="/healthsystemsresearch/hspc-research-study/study-methods.html" data-drupal-link-system-path="node/232832">Study Methods</a> </li> <li class="dropdown-item sbf-level-three"> <a href="/healthsystemsresearch/hspc-research-study/breadth-and-focus.html" data-drupal-link-system-path="node/232843">Breadth & Focus Areas</a> </li> <li class="dropdown-item sbf-level-three"> <a href="/healthsystemsresearch/hspc-research-study/impacts.html" data-drupal-link-system-path="node/232881">Impacts</a> </li> <li class="dropdown-item sbf-level-three"> <a href="/healthsystemsresearch/hspc-research-study/research-gaps.html" data-drupal-link-system-path="node/232883">Research Gaps & Prioritization</a> </li> <li class="dropdown-item active sbf-level-three"> <a href="/healthsystemsresearch/hspc-research-study/conclusions.html" class="active is-active" data-drupal-link-system-path="node/232882" aria-current="page">Conclusions & Recommendations</a> </li> <li class="dropdown-item sbf-level-three"> <a href="/healthsystemsresearch/hspc-research-study/overlap-and-coordination.html" data-drupal-link-system-path="node/232880">Overlap & Coordination</a> </li> <li class="dropdown-item sbf-level-three"> <a href="/healthsystemsresearch/hspc-research-study/appendix-a.html" data-drupal-link-system-path="node/232884">Appendix A</a> </li> <li class="dropdown-item sbf-level-three"> <a href="/healthsystemsresearch/hspc-research-study/appendix-b.html" data-drupal-link-system-path="node/232894">Appendix B</a> </li> <li class="dropdown-item sbf-level-three"> <a href="/healthsystemsresearch/hspc-research-study/appendix-c.html" data-drupal-link-system-path="node/232885">Appendix C</a> </li> <li class="dropdown-item sbf-level-three"> <a href="/healthsystemsresearch/hspc-research-study/appendix-d.html" data-drupal-link-system-path="node/232886">Appendix D</a> </li> <li class="dropdown-item sbf-level-three"> <a href="/healthsystemsresearch/hspc-research-study/references.html" data-drupal-link-system-path="node/232895">References</a> </li> </ul> </li> </ul> </li> <li class="nav-item sbf-level-one"> <a href="/healthsystemsresearch/virtual-roundtable-discussion/index.html" class="nav-link" data-drupal-link-system-path="node/240004">Measuring Climate Resiliency: A Virtual Roundtable Discussion</a> </li> <li class="nav-item menu-item--collapsed sbf-level-one"> <a href="/healthsystemsresearch/decarbonization/index.html" class="nav-link" data-drupal-link-system-path="node/238956">Primer: Reducing Healthcare Carbon Emissions</a> </li> </ul> </div> </div> <div class="subnav-2-cols col-sm-8 col-md-9"> <div id="main-content"></div> <article about="/healthsystemsresearch/hspc-research-study/conclusions.html" typeof="schema:WebPage" class="node node--type-page node--view-mode-full clearfix"> <div class="node__content clearfix"> <div class="main-content-no-sb2"> <h1 class="node__title"> <span property="schema:name" class="field field--name-title field--type-string field--label-hidden">7. Conclusions and Recommendations</span> </h1> <div class="pager-wrap"> </div> <div class="field field--name-field-description field--type-string-long field--label-hidden field__item">Health Services and Primary Care Research Study: Comprehensive Report</div> <div property="schema:text" class="clearfix text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><p>Since its emergence as an independent field of study in the 1960s, HSR has helped establish an evidence base to support decisionmaking and improvements in the quality, safety, effectiveness, and efficiency of health care in the United States. HSR findings have been used to improve the design of health care benefits, inform health care policy, and help providers and patients make better decisions about health care.</p> <p>PCR has emerged as a distinct field in its own right, addressing a central component of the health care system. The Council of Academic Family Medicine and other organizations have identified key characteristics of primary care, which highlight the importance of PCR, including its ability to touch the lives of all Americans, focus on the whole person, give attention to common conditions often not treated in hospitals or specialty clinics, and provide evidence that is critical for the delivery of high-quality primary care (<a href="/healthsystemsresearch/hspc-research-study/references.html#Wittenberg">Wittenberg, undated</a>).</p> <p>Consistent with this broad acknowledgment of the many meaningful contributions of HSR and PCR to improve health care, there has been growing recognition of the need to better understand the impact of HSR and PCR and to prioritize potential future directions of research among federal agencies and other stakeholders (<a href="/healthsystemsresearch/hspc-research-study/references.html#NAM">National Academies of Medicine, 2018</a>; <a href="/healthsystemsresearch/hspc-research-study/references.html#Simpson">Simpson et al., 2018</a>; <a href="/healthsystemsresearch/hspc-research-study/references.html#Meyers">Meyers and Clancy, 2009</a>).</p> <p>This report has documented the distinct focus areas of federal agency HSR and PCR portfolios, which have developed based on the agencies’ congressional authorizations, missions, and operational needs. It also has examined examples of how agencies have coordinated research funding on similar topics in complementary ways according to their distinct focus areas and expertise, as well as how federally funded HSR and PCR have had a wide range of impacts that are often cumulative across research portfolios. At the same time, the study has identified the need for federal agencies to more proactively recognize areas of potential overlap in research portfolios; to improve the communication, relevance, and timeliness of research results; and to prioritize the myriad of gaps in research in order to keep pace with and help guide the complex and rapidly changing U.S. health care system.</p> <p>In this chapter, we summarize these results and offer recommendations to improve the outcomes and value of federal HSR and PCR investments, including strategies for better coordination and potential realignment of research agendas. Each recommendation addresses a key gap or other important theme from the findings. Action steps included with each recommendation represent suggestions of study participants or the RAND study team based on the analysis, as specified below.</p> <h2>Summary of Key Results</h2> <h3><em>Federal Agency Portfolios in HSR and PCR Have Distinct Focus Areas Based on Their Individual Congressional Authorizations, Missions, and Operational Needs</em></h3> <p>HHS agencies and the VHA have developed research portfolios of HSR and PCR around focus areas that address the requirements of their individual congressional authorizations, missions, and operational needs. These portfolios differ in terms of scope, research objectives, and main audiences, which reflect agencies’ distinct focus areas in HSR and PCR. For example, study participants across the range of stakeholders noted AHRQ as the only agency that has statutory authorizations to generate HSR with a mission to do so across the U.S. healthcare system and to serve as the home for federal PCR. They further emphasized the unique focus of the agency's research portfolio on systems-based outcomes (e.g., making health care safer, higher-quality, more accessible, equitable, and affordable) and approaches to implementing improvement across health care settings and populations in the United States. NIH’s portfolio of HSR and PCR addresses a similarly broad scope of health care but tends to be organized around specific diseases, body systems, or populations. CDC’s portfolio of HSR and PCR is organized around diseases, health conditions, and injuries, but focuses on prevention and health promotion spanning community and health care settings. The portfolios of other agencies tend to focus on specific health care settings or other populations (e.g., CMS on Medicare and Medicaid beneficiaries, VHA on veterans’ health care and health, and ACL on community-living elderly and disabled individuals), or research audiences (e.g., ASPE on federal policymakers).</p> <p>Results of the environmental scan and portfolio analysis’s systematic enumeration of HSR and PCR projects confirmed a number of these distinct focus areas. At the same time, the scan results showed that other agency portfolios include projects in these areas, albeit to a lesser extent, as well as strong emphasis across agencies on the broad research domains of Quality of Care and Organization of Care. While the qualitative results from TEP and interview participants indicated that agencies would be expected to approach these topics differently, the broader categories of the scan analysis were not able to detect these distinctions. Thus, the study next examined the degree to which research funded by agencies in similar topic areas is complementary or redundant, and the extent and ways in which federal HSR and PCR funding is coordinated among agencies.</p> <h3><em>Agency-Funded HSR and PCR on Similar Topics Is Largely Complementary, but Potential Overlap in Portfolios Needs to Be Identified More Proactively</em></h3> <p>Study participants across various stakeholder groups emphasized the value of complementary overlap in agencies’ research portfolios, if the studies are sufficiently coordinated. They noted that agencies acted to address redundancy in research portfolios and worked to ensure that funding of research reflected the distinct roles and value-added of each agency once such redundancies have been recognized. Participants also observed federal agencies to be adept at utilizing appropriate and effective formal and informal mechanisms for coordination. Informal coordination mechanisms included interpersonal staff connections and networks and were considered critical facilitators of formal coordination.</p> <p>However, study participants commented on the lack of systematic processes for proactively identifying potential overlap in HSR and PCR portfolios across agencies. Individual study participants also suggested research areas they considered to lack sufficient coordination. Specific challenges to coordination of HSR and PCR portfolios noted by study participants included the breadth and volume of research activity across the federal HSR and PCR enterprise, differing time frames of research among agencies, and the lack of targeted funding for a lead agency to coordinate PCR in particular.</p> <h3><em>Federally Funded HSR and PCR Have Resulted in Wide-Ranging Impacts, Which Are Often Cumulative Across Agency Portfolios</em></h3> <p>Understanding how HSR and PCR can and have had impact on these systems is important for assessing the contributions of federally funded research and for informing the prioritization of research gaps. Based on existing frameworks of research impact as well as discussions with TEP and interview participants, we identified six categories of impact, which we illustrated with examples of federally funded HSR and PCR: (1) scientific impact, (2) professional knowledge and practice impact, (3) health care systems and services impact, (4) policy impact, (5) patient impact, and (6) societal impact. It is unlikely for single projects to generate impact across all categories, and the impacts of specific projects may not always occur in a linear order. However, the types of impacts identified represent a progression from interim research impacts (i.e., on scientific knowledge, professional practice, health care systems, and policy) to direct outcomes for patients and wider outcomes for society. As such, they represent a general guiding framework for assessing the accumulated impact of portfolios of research within an agency or that span agencies.</p> <p>In addition to identifying types of impact, study participants noted important challenges to <em>assessing</em> impact, including the difficulty of tracing the accumulation of impacts across specific projects or sets of projects within a portfolio, especially when research is funded by multiple agencies. Impact may take time to accumulate and be realized, which further complicates attribution to specific projects or sources of funding. Moreover, many types of impact are by their nature difficult to systematically measure. Study participants also called attention to challenges in <em>achieving</em> impact of HSR and PCR, including a lack of investment in high-risk studies and various disconnects between research and implementation.</p> <h3><em>The Variety of Gaps in HSR and PCR Reflect the Challenge of Improving U.S. Health Care, Which Requires New Research Approaches and Strategies for Prioritizing Research Needs</em></h3> <p>TEP and interview participants identified a wide range of research gaps in HSR and PCR, reflecting the complexity and rapidly evolving landscape of the U.S. health care system. Many of these gaps are related to specific “inputs” and “outputs” of health care services in the study’s research domain framework (Figure 2.1). However, many of the gaps also reflect the difficulty of understanding the linkages between health care inputs and outputs to produce important outcomes and the limitations of currently used research approaches to generate and disseminate evidence in ways that have a meaningful impact on real-world health care systems and practice. At the same time, these gaps represent opportunities to find new ways to use research to solve problems and improve the health care system, and ultimately the nation’s collective health.</p> <p>Our analysis highlighted key gaps, that is, research gaps that were raised by multiple study participants within one stakeholder perspective or across stakeholder perspectives. Study participants noted that many of these gaps have been the subject of research studies sponsored by federal agencies and other funders, but that further research is needed, or different research approaches are required to make positive impact on health care delivery and health outcomes.</p> <p>TEP participants and Federal Advisory Group members also emphasized the need to prioritize research gaps to effectively and efficiently allocate limited research funding. Study participants noted the importance of the prioritization process using transparent and explicit criteria, and engaging the range of relevant stakeholders including consumer groups. Possible criteria for prioritization mentioned include the potential for impact, the potential to address a gap in a poorly funded research area, the potential to address foundational areas of research, and the timeliness of the research. Federal Advisory Group members additionally noted that, within federal agencies, an important criterion for prioritization is the alignment of an issue with the mission of an agency and its comparative advantage and expertise in funding research on the topic.</p> <h2>Recommendations to Maximize the Outcomes and Value of Federally Funded HSR and PCR</h2> <p>Based on our review of the key study results and suggestions of study participants, we propose three sets of recommendations: cross-cutting recommendations on approaches to research, dissemination, and implementation of federally funded HSR and PCR (Table 7.1); recommendations to improve the impact of HSR (Table 7.2); and, recommendations to improve the impact of PCR (Table 7.3). In the discussion of each recommendation, we suggest the types of actions that are needed to implement the recommendation.</p> <h3><em>Cross-Cutting Recommendations in Approaches to Research, Dissemination, and Implementation</em></h3> <p>Our first set of recommendations to improve the impact of federally funded HSR and PCR addresses three key gaps in research approaches identified by study participants, specifically, the need to: (1) improve relevance and timeliness of research, (2) increase innovation in research, and (3) improve translation of research into practice. We suggest specific action steps for each recommendation.</p> <h3>Table 7.1. Cross-Cutting Recommendations on Approaches to Research, Dissemination, and Implementation</h3> <table border="1" cellpadding="3" cellspacing="1" style="width: 680px;"> <thead> <tr> <th scope="col">Recommendations</th> <th scope="col">Suggested Action Steps</th> </tr> </thead> <tbody> <tr> <td>Improve the relevance and timeliness of HSR and PCR</td> <td> <ul> <li>Create funding mechanisms that support more rapid, engaged research approaches, such as embedded research and learning health systems models, and dissemination of their results. </li> <li>Expand funding to refine mixed qualitative and quantitative methods suited to generating evidence on the implementation of change in complex health care systems.</li> </ul> </td> </tr> <tr> <td>Encourage innovation in HSR and PCR</td> <td> <ul> <li>Create funding mechanisms that support innovative high-risk, high-reward research.</li> </ul> </td> </tr> <tr> <td>Improve translation of HSR and PCR into practice</td> <td> <ul> <li>Train and assist researchers in effectively communicating results in formats actionable for health care delivery stakeholders.</li> <li>Fund research to identify the most effective channels to communicate research results for different users of HSR and PCR.</li> <li>Require researchers to consider implementation issues earlier in the study development and proposal process and explicitly apply theories of change to help connect disparate results.</li> <li>Expand funding for the synthesis of evidence across research studies on topics of interest to health care delivery and other users of HSR and PCR.</li> </ul> </td> </tr> </tbody> </table> <h4>Improve Relevance and Timeliness of HSR and PCR</h4> <p>The study identified the need to improve the relevance and timeliness of HSR and PCR for health care delivery stakeholders. Study participants noted that many federally funded HSR and PCR studies take a relatively long time to be approved and conducted compared to the pace of change in health care delivery systems. In addition, such research often occurs in highly controlled conditions or atypical settings that are difficult to generalize. These studies typically do not use research designs or methods suited to examining the complex dynamics of health delivery in ways to guide improvement. The action steps described below seek to improve both the relevance and timeliness of HSR and PCR.</p> <p><strong>Create funding mechanisms that support more rapid, engaged research approaches, such as embedded research and learning health systems models, and dissemination of their results.</strong> Embedded research models place health service researchers within health care settings to work closely with leaders and staff to develop and conduct research projects. Learning health systems offer another type of research model in which health care delivery systems seek to develop improvements in care based on rigorous analysis of their own storehouses of EHR and other care service data. Both types of models involve blurring the lines between traditional health care quality improvement activities and HSR in order to improve the relevance and timeliness of research and, ultimately, health care delivery.</p> <p>However, current federal funding mechanisms are not suited to funding projects that utilize these models, particularly due to the length of time it takes for typical federal extramural HSR and PCR projects to be awarded. A new delivery system intervention in the current rapid pace of health care systems may already be implemented or substantially evolved by the time a federal grant is funded for its study. Federal funding agencies also have an important role in ensuring that results and methods of embedded research and learning health system models are disseminated beyond the specific health delivery systems in which they are generated.</p> <p>AHRQ has supported studies of learning health systems and funded projects involving embedded research. The VHA has funded an embedded research initiative within the VHA system. Such efforts can provide a foundation for further support and funding of these models by federal agencies.</p> <p><strong>Expand funding to refine mixed qualitative and quantitative methods suited to generating evidence on the implementation of change in complex health care systems.</strong> Study participants pointed to the need to expand the use of qualitative methods, such as interviews, focus groups, and observational methods that more directly examine the context of health care delivery and the process of change in health care systems. In particular, emphasis was placed on the need to further develop and refine mixed designs that use both qualitative and quantitative methods. More regularly and effectively incorporating mixed qualitative and quantitative methods would help to link health care context and process with outcomes and produce richer and more relevant evidence for stakeholders on effective health care interventions and change. Included in these research methods would be hybrid study designs that take a dual focus on evaluating clinical effectiveness and implementation.</p> <h4>Encourage Innovation in Research</h4> <p>The study found that current funding mechanisms reward safe, but incremental research over innovative, but risky research. Study participants reported this bias for peer-reviewed grant mechanisms, which tend to gravitate to a traditional incremental approach to science, as well as CMMI’s demonstrations, given the size and investment in the payment and delivery models being tested. To address the need for innovative research with the potential to yield breakthroughs in health care system design and change, we recommend that individual funding agencies consider the following action step.</p> <p><strong>Create funding mechanisms that support innovative high-risk, high-reward research.</strong> One suggestion by study participants was to fund small-scale pilot studies to test innovative approaches, particularly for strategies to reduce health care costs and for new payment and incentive models, which tend to change rapidly in the current health care environment. Given the noted bias of conventional funding mechanisms, funding these, or other high-risk, high-reward studies, would likely require separate review processes, selection criteria, and funding streams. Study participants also mentioned lessons from past federal efforts, such as the need to not only fund health care innovations but also learn from them. Efforts by private foundation funders of HSR and PCR, who have launched initiatives to support innovative research, may also provide lessons for federal agencies.</p> <h4>Improve Translation of HSR and PCR Findings into Practice</h4> <p>The study identified a need to improve the translation of research into practice, which is hindered when HSR and PCR findings are not communicated in actionable ways to health care stakeholders. In addition, evidence related to topics of interest is often dispersed across studies and sources. To improve the translation of federally funded HSR and PCR into practice, we recommend that individual federal agencies consider the following action steps.</p> <p><strong>Train and assist researchers in effectively communicating results in formats actionable for health care delivery stakeholders.</strong> Health care delivery leaders and participants from other stakeholder groups, who use HSR and PCR results, highlighted the need to know not only what system changes or care interventions have been shown to be effective, but also how to implement and adapt innovations into service settings. This includes presenting key details that may affect implementation, as well as the key steps or “playbook” needed to implement and adapt the innovation for replication into new settings. In addition to lists of key steps, case studies or stories can be effective at communicating the dynamics of implementation. Such information can be communicated in research publications and packaged into toolkits with materials (e.g., checklists, training guides, and presentations) that facilitate implementation.</p> <p>Yet, the expertise to do so is not typically in the expected skill set of researchers. Training in such skills and strategies would allow researchers to better translate findings into actionable formats. This training could also be incorporated into current research training and career advancement grant programs. Resource centers operated by staff in federal agencies or other institutions with this expertise could provide training as well as translate or assist researchers in translating HSR and PCR findings into actionable formats.</p> <p>Researchers also do not typically receive funding to translate findings into actionable formats for implementation and further dissemination of evidence-based interventions. The VHA and AHRQ offer separate funding mechanisms for dissemination, and the VHA offers a mechanism for intervention studies to apply for additional funding to disseminate to other settings in the VHA system. Such funding mechanisms in these, and other agencies, should be expanded.</p> <p><strong>Fund research to identify effective channels to communicate research results for users of HSR and PCR. </strong>Federal agencies should also investigate the communication channels most frequently utilized by the range of stakeholder audiences for their funded HSR and PCR, which may include newer channels such as social media apps, online video platforms, and podcasts, in addition to conventional channels such as journal articles, written clinical guidelines, or research reports. The channels that are most effective for a chosen audience may also influence the format as well.</p> <p><strong>Require researchers to consider implementation issues earlier in the study development and proposal process and explicitly apply theories of change to help connect disparate results.</strong> Considering implementation issues earlier in the proposal and study design process could accelerate the translation and dissemination of findings into practice and ultimately address barriers to adoption and the use of research. Study participants also noted that applying and building theories, conceptual frameworks, and logic models of change are useful to help connect disparate HSR and PCR findings and advance knowledge on implementation of improvements in health care systems. For example, such change theories, frameworks, and logic models help indicate why certain interventions may be expected to work in certain settings, explain when they work or do not work, and generate implications for generalizing results to other health care settings.</p> <p>Similar to funders like the VHA, requirements could include guidelines for developing research projects as well as incentives built into scoring assessments for funding research proposals.</p> <p><strong>Expand funding for synthesis of evidence across research studies on topics of interest to health care delivery and other HSR and PCR stakeholders.</strong> Study participants appreciated synthesized research evidence on HSR and PCR topics, such as those generated through AHRQ’s evidence-based practice reports and other sources (e.g., online clearinghouses or research resources of various federal agencies). <a name="ImpactHSR"></a></p> <h3><em>Recommendations to Improve the Impact of Federally Funded HSR</em></h3> <p>Our second set of recommendations focus on improving the impact of federally funded HSR in particular, and addresses three key themes identified by study participants: (1) prioritization of the many ongoing and emergent research gaps in HSR, (2) coordination of federally funded HSR by proactively identifying potential overlap in agency research portfolios, and (3) maintaining alignment of federally funded HSR through continued support of AHRQ as an independent agency within HHS to serve as the funded hub of federal HSR.</p> <h3>Table 7.2. Recommendations to Improve Impact of HSR</h3> <table border="1" cellpadding="3" cellspacing="1" style="width: 680px;"> <thead> <tr> <th scope="col">Recommendations</th> <th scope="col">Suggested Action Steps</th> </tr> </thead> <tbody> <tr> <td>Identify HSR priorities for agencies to effectively allocate research funding</td> <td> <ul> <li>Initiate a strategic planning process across federal agencies to prioritize HSR areas for funding investments.</li> </ul> </td> </tr> <tr> <td>Proactively identify potential overlap in agency HSR portfolios</td> <td> <ul> <li>Establish a review process and data systems to proactively identify areas of potential HSR overlap across agencies.</li> </ul> </td> </tr> <tr> <td>Maintain a funded entity to address core HSR needs and coordinate federal HSR efforts</td> <td> <ul> <li>Maintain AHRQ as an independent agency within HHS to serve as the funded hub of federal HSR.</li> </ul> </td> </tr> </tbody> </table> <h4>Identify HSR Priorities for Agencies to Effectively Allocate Research Funding</h4> <p>The study found that federal agencies engage in internal strategic planning and research prioritization processes, frequently with input from other agencies. However, no overall prioritization of HSR agendas occurs across agencies, except on a limited number of topics. At the same time, health care delivery stakeholders encouraged federal agencies to have a single agenda for HSR to ensure that priority research areas are being addressed across federal research portfolios. We recommend that HHS and VHA departmental leadership authorize the following steps.</p> <p><strong>Initiate a strategic planning process across federal agencies to prioritize HSR areas for funding investments. </strong>A strategic planning process to prioritize HSR areas across federal agencies would facilitate consensus on research needs. It would also indicate how individual agencies’ priorities relate to an overall federal HSR agenda, and to priority areas not currently being addressed. Given the breadth of HSR topics and federal funding, separate but linked processes for prioritizing HSR within sub-fields would help to ensure that efforts are manageable and sufficiently fine grained to provide agendas that are useful for guiding research funding decisions. Ideally, this set of processes would also be linked to the individual strategic planning and research priority processes within agencies, as well as to existing prioritization efforts among health care stakeholders to provide opportunities for more fully aligned federal HSR priorities with the research agendas of private funders. AHRQ’s role as the federal agency with statutory authority for HSR would make it a natural lead agency for such a process, but as study participants noted, this effort would need authorization from departmental leadership.</p> <p>Study participants also emphasized that such a cross-agency process should use transparent criteria, and incorporate input and participation of health care stakeholders—including consumers. Focusing research on problems of importance to health care stakeholders—including health care administrators, clinical leaders, policymakers, purchasers and payers, patients, families, and caregivers—was expected by study participants to increase the likelihood and speed with which findings are adopted. TEP participants also suggested that longer-term issues (e.g., health care consolidation, resolution of health care disparities) and research methods (e.g., better integration of qualitative and quantitative methods in mixed study designs) be prioritized within their own areas or “buckets” to ensure that key needs in these areas are not continually overlooked compared to more immediate, high-visibility topics (e.g., the opioid epidemic).</p> <h4>Proactively Identify Potential Overlap in Agency HSR Portfolios</h4> <p>A strategic planning process across federal agencies would facilitate coordination of HSR agendas, but the study also identified the need to proactively identify potential overlap in agency HSR portfolios. Study participants from various stakeholder groups noted that federal agencies act to address redundancies in research portfolios and are generally adept at coordination once redundancies are recognized, but that identification of potential overlaps in portfolios occurs inconsistently. We recommend that HHS and VHA departmental leadership consider the following action steps.</p> <p><strong>Establish a review process and data systems to proactively identify areas of potential research overlap across agencies. </strong>Proactively identifying areas of potential research overlap would require: (1) systematic data on planned and current HSR projects across agencies to identify areas of general potential overlap, and (2) a process for staff from different agencies, with expert knowledge on federal HSR portfolios, to review the data to determine whether the overlap is complementary or redundant; and whether it affects research agendas of additional agencies.</p> <p>Systematic data on federally funded HSR grants are available through the NIH RePORTER database, which contains grant projects across HHS agencies and the VHA, as well as other grants databases used by federal agencies. However, based on our experiences cataloging HSR for this study, implementing this recommendation would require the creation of a federal-wide data system for contracted HSR projects. Data systems for federal contracts are neither designed nor well suited for identifying research projects, let alone HSR-related research. These contract databases also tend to provide less information about the content of research projects needed to distinguish domains and categories of research compared to the RePORTER and other grants databases. Without such a data system for contracted projects, HHS lacks ongoing visibility into the breadth and scope of a significant portion of federally funded HSR.</p> <h4>Maintain a Funded Entity to Address Core HSR Needs and Coordinate Federal HSR Efforts</h4> <p>This study documented the breadth and complexity of HSR, highlighting both the need for research in HSR beyond the capacity of any single agency, and different agencies to contribute to the federal HSR enterprise depending on their missions and operational requirements. At the same time, the study emphasized the critical role of a central entity or hub that is responsible for ensuring that core issues of HSR are funded, and that research conducted across agencies is bridged and coordinated.</p> <p>The study found consensus across all stakeholder groups on the unique and effective role AHRQ serves in HSR as the only agency focused on health care system outcomes and improvement of health services across health care settings and populations in the United States. It plays a key role in bridging disease-, population-, and setting-specific HSR funded by other agencies, as well as translating and promoting implementation of HSR evidence with health care delivery systems and stakeholders to effect change. This is also its current statutory mandate. Thus, we recommend the following step.</p> <p><strong>Maintain AHRQ as an independent agency within HHS to serve as the funding hub of federal HSR.</strong> This recommendation requires no additional action. We also note that some study participants suggested the possibility of relocating AHRQ from an independent agency in HHS to an institute within NIH. Potential advantages discussed by study participants included the possibility of more stable federal funding and increased status within the academic research community. Risks discussed by study participants included potential drift of AHRQ away from more impactful research for health services and primary care systems (i.e., toward more academic research) and a loss of focus on broader systems of care (i.e., toward more disease- and organ-specific emphases). Other study participants, including those within NIH, noted the difficulties smaller ICs within NIH would face coordinating with larger institutes, which would be a disadvantage compared to external agencies. We judge that the risks associated with moving AHRQ or its role as the funded hub of federal HSR into NIH outweigh the potential advantages. The risks are particularly concerning given they would affect the distinct role and capabilities of AHRQ in the federal HSR and PCR enterprise. We thus do not recommend that AHRQ or its role as the funded hub of federal HSR be located within NIH. <a name="ImpactPCR"></a></p> <h3><em>Recommendations to Improve the Impact of Federally Funded PCR</em></h3> <p>Our third set of recommendations focuses on improving the impact of federally funded PCR. These recommendations also address key themes identified by study participants related to prioritization, coordination, and the alignment of federal agency research portfolios , but attending to the distinct needs of PCR. First, a separate interagency prioritization process for PCR would ensure that core primary care research needs are attended to. It also would incorporate the specific sets of primary care stakeholders needed to inform prioritization, as well as span clinical research and HSR, both of which are part of the PCR field. Second, a process that proactively identifies potential overlap in federal agency PCR portfolios would focus on coordinating research efforts to maximize the limited federal funding available for PCR and rely on the expert staff of different agencies in federal PCR portfolios. Lastly, with respect to the alignment of federal PCR efforts, we recommend providing funding for a hub of federal PCR that includes targeted funding for both research on core functions of primary care and coordination of PCR across federal agency research portfolios.</p> <h3>Table 7.3. Recommendations to Improve Impact of PCR</h3> <table border="1" cellpadding="3" cellspacing="1" style="width: 680px;"> <thead> <tr> <th scope="col">Recommendations</th> <th scope="col">Suggested Action Steps</th> </tr> </thead> <tbody> <tr> <td>Identify PCR priorities for agencies to effectively allocate research funding</td> <td> <ul> <li>Initiate a strategic planning process across federal agencies specifically dedicated to prioritizing PCR areas for funding investments.</li> </ul> </td> </tr> <tr> <td>Proactively identify potential overlap in agency PCR portfolios</td> <td> <ul> <li>Establish a review process to proactively identify areas of potential PCR overlap across agencies.</li> </ul> </td> </tr> <tr> <td>Fund an entity to address core primary care research needs and coordinate federal PCR efforts</td> <td> <ul> <li>Provide targeted funding for a hub for federal PCR.</li> </ul> </td> </tr> </tbody> </table> <p> </p> <h4>Identify PCR Priorities for Agencies to Effectively Allocate Research Funding</h4> <p>The study found that research is lacking on key PCR priorities due to the fragmentation of PCR funding across agencies with missions and research focuses that do not include the core functions of primary care. This gap includes research on how effective primary care practices a holistic approach to addressing personal health care needs, and its role in the wider health care system. To ensure that the distinct needs for PCR are attended to, we recommend that HHS and VHA departmental leadership consider authorizing an effort to:</p> <p><strong>Initiate a strategic planning process across federal agencies specifically dedicated to prioritizing PCR areas for funding investments.</strong> A separate prioritization process would also incorporate other distinct features of the PCR field. These distinct features include the specific sets of stakeholders needed to inform prioritization, and the breadth of PCR spanning both clinical research on common health conditions found in primary care and health services research in primary care context. The latter would need to be linked with the federal HSR prioritization process described above. As with the HSR prioritization process, AHRQ’s statutory authority as the home for federal PCR and its current role in synthesizing and bridging PCR across agencies would make it a natural lead agency for such an initiative. However, there currently are no dedicated resources nor departmental authorization for such an interagency prioritization process, which study participants noted would be needed.</p> <h4>Proactively Identify Potential Overlap in Agency PCR Portfolios</h4> <p>There is also a need to proactively identify potential overlap in federal agency PCR portfolios. Study participants considered the risk of redundancy in agency PCR portfolios to be less than with HSR, given the relatively smaller amount of federal funding for PCR. However, early coordination of PCR efforts becomes even more important to maximize the impact of limited resources to address primary care research needs. Thus, we recommend that HHS and VHA departmental leadership consider authorizing an effort to:</p> <p><strong>Establish a review process to proactively identify areas of potential PCR overlap across agencies. </strong>The PCR review process could utilize the data systems developed for the HSR process to identify potential overlap but rely on staff from different agencies expert in federal PCR portfolios. The PCR review process for HSR topics in primary care contexts would need to be coordinated with the HSR review process described above. As with the prioritization process, departmental authorization would be needed for such an interagency initiative.</p> <h4>Fund an Entity to Address Core PCR Needs and Coordinate Federal PCR Efforts</h4> <p>The study found that the lack of a funded hub of federal PCR has created a critical research gap on the core functions and role of primary care within the U.S. health care system, and hampered coordination of federal PCR. AHRQ currently has a statutory mandate to serve as the federal home for PCR but does not receive targeted appropriations for this mission. This requires that the agency’s funding for PCR comes from, and is often tied to, portfolios of HSR within the agency (e.g., patient safety or HIT implementation). Likewise, funding for PCR in other agencies tends to become focused on their particular missions and priorities (e.g., managing specific diseases in primary care for certain populations or specialized federal delivery systems). We recommend the following step.</p> <p><strong>Provide targeted funding to create a hub for federal PCR.</strong> Study participants emphasized that the most expeditious way to create a funded hub to support research on core PCR needs and adequately coordinate federal PCR efforts would be to provide targeted funding for this mission to AHRQ, which already has the statutory authorization for this role. Despite not having received targeted funding for this mission, the agency has been able to sponsor key studies on primary care systems and innovation to help fill this gap. In addition, it operates the National Center for Excellence in Primary Care Research that has expertise in disseminating evidence, practical tools, and other resources to improve primary care.</p> <p>Study participants also discussed potential advantages to creating the funded hub of PCR as an independent agency or office within HHS. These include possibly greater ability to attract funding for PCR and autonomy to focus on a PCR agenda wider than typical HSR domains.</p> <p>In either case, the hub of federal PCR should include targeted funding for both research on core functions of primary care and coordination of PCR across federal agency research portfolios. This targeted funding could be supported through federal appropriations or a fee assessed on health care insurers or delivery systems, similar to the mechanism used for the Patient Centered Outcomes Research (PCOR) Trust Fund, with the rationale that PCR improvement likewise benefits patients across the U.S. health care system. Either option for funding a federal PCR hub would require legislative action by Congress.</p> <p>Some study participants suggested the possibility of creating the funded hub of PCR as an institute within NIH. We judge the risks associated with locating the funded hub of PCR within NIH to outweigh the advantages, for reasons similar to those mentioned above for AHRQ. Study participants also noted an additional risk. Other institutes and centers within NIH may reduce their funding for PCR if a funded hub for this field was established within the agency. We thus do not recommend that the funded hub of federal PCR be located within NIH.</p> <h2>Conclusions</h2> <p>This study has identified a number of important gaps in health services and primary care research, many of which are driven by the complexity and rapidly changing landscape of the U.S. health care system. As in the past, there is great opportunity for federally funded HSR and PCR to have a meaningful impact and guide understanding of new models of care delivery and payment. It can also inform health care stakeholders on best practices for implementing specific health care innovations and interventions and disseminating and promoting health system change. Study participants across a broad range of stakeholder groups attested to the unique and important role that AHRQ plays in generating HSR, synthesizing evidence, and scaling up dissemination to drive improvement of health services across the U.S. health care system. Participants also noted AHRQ’s central role in PCR promoting systems-based research, evidence and tools to improve primary care.</p> <p>However, the breadth and complexity of HSR and PCR, and the need for research in these fields, are beyond the capacity of any single agency. Other federal agencies contribute critical equities and functions in funding HSR and PCR depending on their congressional authorizations, missions, and operational needs. NIH plays a fundamental role in the development of biomedical and clinical treatments and in testing the efficacy and effectiveness of care interventions and strategies for specific diseases, body systems, and populations. ASPE plays a critical role in supporting and translating research to inform policy; CDC in research on prevention and the intersection between the health care system and public and community health efforts; CMS in evaluations of quality measurement systems as well as payment and delivery innovations for beneficiaries in Medicare, Medicaid, and other CMS programs; and the VHA in research on veterans’ health and the veterans’ health system. HRSA provides critical leadership in research on safety net services and the health care workforce, and ACL focuses on research to support community living of elderly and disabled individuals.</p> <p>The study also has identified opportunities to improve approaches to research funding and methods to ensure that federally funded HSR and PCR can keep pace with, and continue to guide, change in health care delivery systems. It additionally has offered separate recommendations for HSR and PCR to improve the outcomes and value of federal research investments, including strategies for better prioritizing, coordinating, and aligning agency research portfolios.</p> <p>Overall, the study has distinguished the strengths and contributions of the many HHS agencies and the VHA to the federal HSR and PCR enterprise, as well as offered insights on how to improve these research programs to serve the needs of the evolving U.S. health care system. The results of the study provide a balanced, evidence-based understanding of federally funded HSR and PCR that policymakers can use in shaping the future of the federal HSR and PCR enterprise.</p> <p><a href="/healthsystemsresearch/hspc-research-study/report.html">Return to Contents</a></p> </div> <div class="pager-wrap"> </div> </div> </div> </article> </div> </div> </div> <div class="row"> <div class="col-md-12 col-sm-12 text-right"> <section class="row region region-citation"> <div id="block-citation" class="block block-ahrq block-citation"> <div class="content"> <div id="created-reviewed-citation" class="pad-bottom-sections"> <div id="page-reviewed" class="body-copy-italic">Page last reviewed July 2021 </div> <div id="page-created" class="body-copy-italic">Page originally created June 2020</div> </div> <div id="citation"> <div class="twocolordiv"> <div class="twocolordiv-content"> <p> <span class="citation-hdr">Internet Citation:</span> 7. Conclusions and Recommendations. 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