Outcomes research

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Outcomes research is a branch of public health research which studies the end results (outcomes) of the structure and processes of the health care system on the health and well-being of patients and populations. According to one medical outcomes and guidelines source book - 1996, Outcomes research[ full citation needed ] includes health services research that focuses on identifying variations in medical procedures and associated health outcomes. Though listed as a synonym for the National Library of Medicine MeSH term "Outcome Assessment (Health Care)", [1] outcomes research may refer to both health services research and healthcare outcomes assessment, which aims at health technology assessment, decision making, and policy analysis through systematic evaluation of quality of care, access, and effectiveness. [2] [3]

Contents

Description

Outcomes research is applied to clinical and population based research that seeks to study and optimize the end results of healthcare in terms of benefits to the patient and society. The intent of this research is to identify shortfalls in practice and to develop strategies to improve care.

Like clinical trials, outcomes research seeks to provide evidence about which interventions work best for which types of patients and under what circumstances. However, the evaluation methodology of outcomes research may include both experimental and non-experimental designs: further, the "intervention" being evaluated is not limited to medications or new clinical procedures, but may also include the provision of particular services or resources, or even the enforcing of specific policies and regulations by legislative/financial bodies. Also, while traditional clinical trials focus primarily on therapeutic efficacy and safety, outcomes research may consider additional parameters such as cost, timeliness, convenience, geographical accessibility and patient preferences. Consequently, the field is more multi-disciplinary, involving, in addition to healthcare professionals and the manufacturers of medical devices or pharmaceuticals, medical economists, sociologists, and public health researchers.

The results of outcomes research are used to inform the decisions of legislative bodies that make decisions related to healthcare, as well as of financial bodies (governments, insurers, employers) who seek to minimize cost and waste while ensuring the provision of an acceptable level of care. Patients also have a significant stake in outcomes research because it facilitates their decision-making, both in deciding what intervention is best for them given their circumstances, and as members of the public who have ultimately to pay for medical services.

Origins

The c. 1847 work of Ignaz Semmelweis on the association between puerperal fever and the absence of aseptic procedures (specifically, doctors who failed to clean their hands before delivering babies) and the subsequent use of calcium hypochlorite to reduce risk, is an early example of outcomes research. Semmelweis' results were not accepted until after his death, when the germ theory of infection became established.[ citation needed ]

Although the exact origins of the term "outcomes research" is unclear, the methods associated with outcomes research first gained wide attention in the 1850s as a result of the work of Florence Nightingale during the Crimean War. Nightingale studied death as her primary outcome, recording the cause of death, including wounds, infections, and other causes. The intervention - a combination of effective nursing, hygiene, better nutrition, reduced crowding - reduced mortality significantly. After returning to England, Nightingale studied variation in childbirth practices at home and at institutions and their effect on maternal mortality. [4]

Both Semmelweis' and Nightingale's work were characterized by the continual gathering of detailed statistics.[ citation needed ]

Ernest Amory Codman, a Boston orthopedic surgeon, noted in 1914 that hospitals were reporting the number of patients treated but not how many patients benefited from treatment. At that point he argued that all hospitals should produce a report "showing nearly as possible what are the results of treatment obtained at different institutions." [5] However, Codman's advocacy of disclosure of institutional data by hospitals has yet to be universally adopted: such disclosure occurs only after being legally mandated.[ citation needed ]

Around the beginning of the twentieth century, professional organizations and hospital authorities began to adopt a standard form of medical record. In the UK, this was also adopted in primary care. Standardized data recording meant that for the first time medical records could be used as a moderately reliable data base for research.[ citation needed ]

During World War I, intense efforts to improve the outcomes of care for battle casualties, with careful attention to outcomes led to major advances in orthopedic surgery, plastic surgery, blood transfusion and the prevention of tetanus and gangrene. There were also major advances in the organization of care and in record keeping. During World War II, the UK centralized many medical services: the resulting infrastructure was used as the basis of a National Health Service in 1948. Centralization facilitated the establishment of national and local databases.

Avedis Donabedian's 1966 paper "Evaluating the Quality of Medical Care" first used the term "outcome" as part of the framework of quality assessment. [6] Archie Cochrane's 1971 Rock Carling Fellowship monograph Effectiveness and Efficiency: Random Reflections on Health Services clarified a number of key concepts in outcomes research and evidence-based medicine. John Wennberg's studies of variations of healthcare practice in the United States resulted in the publication of The Dartmouth Atlas of Health Care, [7] which reports on healthcare usage and distribution within the US. Wennberg described his methods in his book Tracking Medicine: A Researcher's Quest to Understand Health Care. [8]

Paul Ellwood's 1988 Shattuck Lecture coined the term "outcomes management" to describe a scenario where patient care would be driven by detailed analysis of how similar patients fared after alternative treatments. [9] Carolyn Clancy and John Eisenberg's 1998 Science paper emphasized the importance of considering patients' experiences, preferences and values in outcome evaluation, as well as the needs of those who provide, organize and pay for healthcare, including the public. [3]

Examples of health outcomes

A wide variety of outcomes are measured ranging from interventions such as acute clinical events like mortality to measuring the performance of a system. The goal of outcomes research, is to measure tangible events experienced by the patient such as mortality and morbidity. [2] Patient engagement in research presents opportunities to increase outcomes of both the studies themselves as well as the patients and their medical conditions. [10]

The common outcomes that are measured can be divided into broad categories of patient- and system-related. Patient outcomes are experienced by the patient and have a more proximal relationship with the healthcare intervention. System measures are more distal to the patient experience but are important for assessment of quality of care and influence the patient experience as well.

Common themes

Common themes of outcomes research are:

Safety
Effectiveness
Equity
Efficiency
Timeliness
System responsiveness
Patient-centeredness

Study designs used

Difficulties

Related Research Articles

Evidence-based medicine (EBM) is "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients." The aim of EBM is to integrate the experience of the clinician, the values of the patient, and the best available scientific information to guide decision-making about clinical management. The term was originally used to describe an approach to teaching the practice of medicine and improving decisions by individual physicians about individual patients.

<span class="mw-page-title-main">Health care</span> Prevention of disease and promotion of well-being

Health care, or healthcare, is the improvement of health via the prevention, diagnosis, treatment, amelioration or cure of disease, illness, injury, and other physical and mental impairments in people. Health care is delivered by health professionals and allied health fields. Medicine, dentistry, pharmacy, midwifery, nursing, optometry, audiology, psychology, occupational therapy, physical therapy, athletic training, and other health professions all constitute health care. The term includes work done in providing primary care, secondary care, and tertiary care, as well as in public health.

Evidence-based design (EBD) is the process of constructing a building or physical environment based on scientific research to achieve the best possible outcomes. Evidence-based design is especially important in evidence-based medicine, where research has shown that environment design can affect patient outcomes. It is also used in architecture, interior design, landscape architecture, facilities management, education, and urban planning. Evidence-based design is part of the larger movement towards evidence-based practices.

Clinical audit is a process that has been defined as a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change

In the healthcare industry, pay for performance (P4P), also known as "value-based purchasing", is a payment model that offers financial incentives to physicians, hospitals, medical groups, and other healthcare providers for meeting certain performance measures. Clinical outcomes, such as longer survival, are difficult to measure, so pay for performance systems usually evaluate process quality and efficiency, such as measuring blood pressure, lowering blood pressure, or counseling patients to stop smoking. This model also penalizes health care providers for poor outcomes, medical errors, or increased costs. Integrated delivery systems where insurers and providers share in the cost are intended to help align incentives for value-based care.

Health services research (HSR) became a burgeoning field in North America in the 1960s, when scientific information and policy deliberation began to coalesce. Sometimes also referred to as health systems research or health policy and systems research (HPSR), HSR is a multidisciplinary scientific field that examines how people get access to health care practitioners and health care services, how much care costs, and what happens to patients as a result of this care. HSR utilizes all qualitative and quantitative methods across the board to ask questions of the healthcare system. It focuses on performance, quality, effectiveness and efficiency of health care services as they relate to health problems of individuals and populations, as well as health care systems and addresses wide-ranging topics of structure, processes, and organization of health care services; their use and people's access to services; efficiency and effectiveness of health care services; the quality of healthcare services and its relationship to health status, and; the uses of medical knowledge.

Transitional care refers to the coordination and continuity of health care during a movement from one healthcare setting to either another or to home, called care transition, between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness. Older adults who suffer from a variety of health conditions often need health care services in different settings to meet their many needs. For young people the focus is on moving successfully from child to adult health services.

John E. "Jack" Wennberg was the pioneer and leading researcher of unwarranted variation in the healthcare industry. In four decades of work, Wennberg has documented the geographic variation in the healthcare that patients receive in the United States. In 1988, he founded the Center for the Evaluative Clinical Sciences at Dartmouth Medical School to address that unwarranted variation in healthcare.

Unwarranted variation in health care service delivery refers to medical practice pattern variation that cannot be explained by illness, medical need, or the dictates of evidence-based medicine. It is one of the causes of low value care often ignored by health systems.

<span class="mw-page-title-main">Ernest Amory Codman</span>

Ernest Amory Codman, M.D., was an American surgeon who made contributions to anaesthesiology, radiology, duodenal ulcer surgery, orthopaedic oncology, shoulder surgery, and the study of medical outcomes.

The Dartmouth Institute for Health Policy and Clinical Practice (TDI) has garnered significant accomplishments since its inception. Established in 1988 by John Wennberg as the Center for the Evaluative Clinical Sciences (CECS) and later reorganized in 2007 to its current form as TDI, the institute has made substantial strides in the realms of healthcare education, research, and policy

Comparative effectiveness research (CER) is the direct comparison of existing health care interventions to determine which work best for which patients and which pose the greatest benefits and harms. The core question of comparative effectiveness research is which treatment works best, for whom, and under what circumstances. Engaging various stakeholders in this process, while difficult, makes research more applicable through providing information that improves patient decision making.

<span class="mw-page-title-main">José María Valderas Martínez</span>

Professor José María Valderas Martínez is an Academic General Practitioner and health services researcher.

Clinical peer review, also known as medical peer review is the process by which health care professionals, including those in nursing and pharmacy, evaluate each other's clinical performance. A discipline-specific process may be referenced accordingly.

David M. Eddy is an American physician, mathematician, and healthcare analyst who has done seminal work in mathematical modeling of diseases, clinical practice guidelines, and evidence-based medicine. Four highlights of his career have been summarized by the Institute of Medicine of the National Academy of Sciences: "more than 25 years ago, Eddy wrote the seminal paper on the role of guidelines in medical decision-making, the first Markov model applied to clinical problems, and the original criteria for coverage decisions; he was the first to use and publish the term 'evidence-based'."

The Donabedian model is a conceptual model that provides a framework for examining health services and evaluating quality of health care. According to the model, information about quality of care can be drawn from three categories: “structure,” “process,” and “outcomes." Structure describes the context in which care is delivered, including hospital buildings, staff, financing, and equipment. Process denotes the transactions between patients and providers throughout the delivery of healthcare. Finally, outcomes refer to the effects of healthcare on the health status of patients and populations. Avedis Donabedian, a physician and health services researcher at the University of Michigan, developed the original model in 1966. While there are other quality of care frameworks, including the World Health Organization (WHO)-Recommended Quality of Care Framework and the Bamako Initiative, the Donabedian Model continues to be the dominant paradigm for assessing the quality of health care.

Health care quality is a level of value provided by any health care resource, as determined by some measurement. As with quality in other fields, it is an assessment of whether something is good enough and whether it is suitable for its purpose. The goal of health care is to provide medical resources of high quality to all who need them; that is, to ensure good quality of life, cure illnesses when possible, to extend life expectancy, and so on. Researchers use a variety of quality measures to attempt to determine health care quality, including counts of a therapy's reduction or lessening of diseases identified by medical diagnosis, a decrease in the number of risk factors which people have following preventive care, or a survey of health indicators in a population who are accessing certain kinds of care.

Harlan M. Krumholz, MD, SM is an American cardiologist, leading research scientist, and the Harold H. Hines, Jr. Professor of Medicine at Yale School of Medicine, where he has been on faculty since 1992. A pioneer in the development of the field of outcomes research, his groundbreaking contributions to science have directly led to improvements in healthcare outcomes for patients and populations. He is an international expert in the science to evaluate and improve the quality and efficiency of care, reduce disparities, improve integrity in medical research, promote better health policies and regulations, and promote patient-centeredness in research and clinical care. He is the founder and director of the Yale New Haven Hospital Center for Outcomes Research and Evaluation.

<span class="mw-page-title-main">Donald L. Patrick</span> American social scientist

Donald L. Patrick is a social scientist, academic, and an author. He is a Professor Emeritus of Health Systems and Population Health at the University of Washington, Director of Seattle Quality of Life Group, and Creator of the Biobehavioral Cancer Prevention and Control Training Program jointly with the Fred Hutchinson Cancer Center. He has served as the co-chair of the Cochrane Collaboration's Patient Reported Outcomes Methods Group. His research interests revolve around various aspects of public health which integrate the themes from fields such as psychological intervention, social stratification, public health, and quality of life. Much of his research works have focused on outcomes research on vulnerable populations, health disparities, and end-of-life-care.

References

  1. "Outcome Assessment Health Care". National Center for Biotechnology Information. MeSH. National Library of Medicine.
  2. 1 2 Lee, Stephanie J.; Earle, Craig C.; Weeks, Jane C. (February 2000). "Outcomes Research in Oncology: History, Conceptual Framework, and Trends in the Literature". Journal of the National Cancer Institute. 92 (3): 195–204. doi: 10.1093/jnci/92.3.195 . PMID   10655436.
  3. 1 2 Clancy, Carolyn M.; Eisenberg, John M. (October 1998). "Outcomes Research: Measuring the End Results of Health Care". Science . 282 (5387): 245–246. doi:10.1126/science.282.5387.245. PMID   9841388. S2CID   44738305.(subscription required)
  4. Nightingale, Florence (1871). Introductory Notes on Lying-In Institutions, Together With a Proposal for Organising an Institution for Training Midwives and Midwifery Nurses. London, England: Longmans Green & Co.
  5. Codman, Ernest Amory; Mayo WJ; Clark JG; Chipman WW (1913). "Standardization of Hospitals: Report of the Committee Appointed by the Clinical Congress of Surgeons in North America". Trans Clin Congress Surg N Am. 3-8. 4.
  6. Donabedian, Avedis (July 1966). "Evaluating the Quality of Medical Care". The Milbank Quarterly . 44 (3): Suppl:166–206. CiteSeerX   10.1.1.592.1258 . doi:10.2307/3348969. JSTOR   3348969. PMID   5338568. S2CID   2255444.
  7. "The Dartmouth Atlas of Health Care". The Dartmouth Institute for Health Policy and Clinical Practice.
  8. Wennberg, John (2010). Tracking Medicine: A Researcher's Quest to Understand Health Care. Oxford University Press. ISBN   978-0-19-973178-7. Archived from the original on 28 June 2013.
  9. Ellwood, Paul (9 June 1988). "Outcomes Management. A technology of patient experience". The New England Journal of Medicine . 318 (23): 1549–1556. doi:10.1056/NEJM198806093182329. PMID   3367968.
  10. Domecq, Juan Pablo; Prutsky, Gabriela; Elraiyah, Tarig; Wang, Zhen; Nabhan, Mohammed; Shippee, Nathan; Brito, Juan Pablo; Boehmer, Kasey; Hasan, Rim; Firwana, Belal; Erwin, Patricia (2014-02-26). "Patient engagement in research: a systematic review". BMC Health Services Research. 14 (1): 89. doi: 10.1186/1472-6963-14-89 . ISSN   1472-6963. PMC   3938901 . PMID   24568690.