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Fostering Evidence-Based Practice and Innovation
Improving the quality of American health care and enhancing Americans' health requires a commitment to delivering health care based on sound scientific evidence and continuously innovating new, effective health care practices and preventive approaches. The lack of evidence supporting effective health care practices contributes to the extensive levels of inappropriate care highlighted in Chapter One. Encouraging evidence-based practice, and thereby promoting appropriate, effective health care, requires a robust health care research enterprise, careful assessments of the effectiveness of health care technologies and practices, and approaches to encourage the widespread dissemination of effective health care.
Therefore, the Commission recommends bolstering public and private sector funding of basic, clinical, prevention, and health services research; strengthening the scientific evidence base for health care practices through further collaboration in technology assessment and research targeted to filling gaps in existing knowledge; and encouraging dissemination of innovations that have been demonstrated to be effective.
Federal funding for health care research, including basic, clinical, prevention, and health services research, should be increased and the necessary research infrastructure supported. Strong Federal funding and support for sustaining the network of research centers through the National Institutes of Health, the Agency for Health Care Policy and Research, the Centers for Disease Control and Prevention, and other agencies is the cornerstone of a robust health care research enterprise and, in turn, a high quality health care system.
Collaborative arrangements between researchers and public and private sector organizations supporting research should be developed to provide additional funding for research, make patients available for approved clinical trials, and provide training opportunities. Private sources, including pharmaceutical and health care supply manufacturers, health plans, and foundations are increasingly important for funding health care research. A summit meeting of key leaders in research, including academic health centers, government, health plans, health care professionals, pharmaceutical and equipment manufacturers, and not- for-profit foundations is a positive first step in furthering collaborative relationships. In addition, the NIH Clinical Research Panel's interim recommendations provide a strong starting point for enhancing training and career opportunities for researchers.
Research should be targeted to address areas where the greatest improvements in health and functional status of the population can occur and where gaps in knowledge exist. The establishment of national aims for improvement can provide guidance in setting an appropriate research agenda. Research should be focused on preventing, diagnosing, and treating conditions that are prevalent, costly, and where needed improvements are most likely to occur.
Public and private sector organizations should pursue greater collaboration in conducting health care technology assessments. The current pluralistic approach to technology assessment can be improved through developing an online directory of existing and ongoing technology assessments and developing a process for organizations relying on technology assessments to provide feedback to researchers regarding areas where additional research is needed to evaluate the effectiveness of health care practices.
More complete and rapid dissemination of effective health care practices should be supported by encouraging public and private organizations to collaboratively share knowledge of innovations, synthesize evidence on effective health care practices, develop practice protocols, disseminate this information, and provide technical assistance to practitioners. Synthesizing the existing clinical literature and developing practice guidelines are essential steps in support of evidence-based health care practices. To encourage their acceptance, practice guidelines should be developed by credible sources, allow for local adaptation, actively involve local clinical leaders, and enable practitioners to use clinical judgement in determining their applicability for particular patients. Because merely disseminating information has proven insufficient to ensure the widespread diffusion of effective health care practices, these efforts should be accompanied by technical assistance and implementation programs that encourage the adoption of effective health care practices.
A ROBUST RESEARCH ENTERPRISE
A robust health care research enterprise, including basic, clinical, health services, and prevention research, is critical to improving the quality of health care. Health care research has the potential to develop better treatments to improve health status and functional capacity; identify preventive approaches to avoid illness, injury, and disability; and evaluate effective, high quality approaches to delivering care. As the health care system undergoes dynamic changes, however, health care research faces a variety of challenges, including competitive pressures on the network of research centers, a shortage of trained investigators, and difficulty in enrolling patients in clinical trials. Resolving these concerns requires continued public commitment to supporting research and increased collaboration between researchers and public and private sector organizations that provide research funds.
A Wide Array of Research is Important
Health care research includes a broad range of types, is conducted by a diverse array of organizations, and is funded through a variety of sources. Each of these components within the broader research enterprise is essential for supporting an innovative environment that can improve American health care.
Continued expansion of basic and clinical research. Biomedical and other forms of clinical research have long been a hallmark of the American health care system that deserves a continued strong commitment to support the development of innovative health care interventions. The continuum of health care research ranges from basic research that focuses on issues of fundamental, scientific inquiry to applied research that is intended to translate directly into health care practice. Within this continuum exists other types of research, including translational research, focused on generating innovative approaches to the diagnosis, treatment, and prevention of disease.
Prevention and health services research also require increased support. Prevention research can identify effective approaches to prevent the onset of illness, injury, and disability. Public health and community-based research efforts, including surveillance and epidemiology, play a critical role in improving prevention efforts, providing evidence of disease trends, and identifying risk factors that contribute to poor health and functioning.
Major structural changes continue in health care, as most health care is now financed through a variety of managed care arrangements, the delivery of care increasingly occurs in outpatient settings, and health care organizations restructure to contain costs and provide quality patient care. Health services research can provide the rigorous evaluation necessary to assess the effects of these ongoing dynamic changes on costs, quality, and access. In addition, health services research is critical to the goal of evidence-based health care in its focus on assessing outcomes, cost-effectiveness, and appropriateness of new and existing health practices and developing new quality improvement approaches.
While there is significant overlap, there are differences in the locus and sources of funding of the different types of health care research. For example, academic health centers, health plan-based research centers, and other private research centers conduct a wide range of research activities, but each emphasizes research at different points on the continuum. Academic health centers generally focus on basic and translational research with an emphasis on clinical research, including clinical trials. Health plan-based research centers often focus on clinical and health services research that will have direct applicability to the care provided for conditions common among their enrollees. There is also an important role and need for increased emphasis for research conducted in primary care and ambulatory settings where an increasing share of health care is delivered. Federally-qualified health centers, including community health centers, migrant health clinics, and rural health centers, also provide an important venue for conducting public health research. Private research centers highlight applied research that supports the development of new commercial health care products. Publicly-sponsored funds are directed toward more basic health care research and prevention, whereas private funding sources, including major contributions from pharmaceutical and other manufacturers and subsidies from the clinical services provided within a research setting, are largely dedicated to applied research.
An innovative research enterprise requires a strong, sustained commitment of public funds for health care research, and Federal support of basic, clinical, prevention, and health services research should be increased. The National Institutes of Health (NIH), the largest source of public support of clinical research, received a 7 percent increase in funding to $13.6 billion in fiscal year 1998, and the President has proposed an increase of more than $1 billion for fiscal year 1999 and additional increases in subsequent years. The Agency for Health Care Policy and Research (AHCPR), the lead federal agency for health services research, endured sharp budget cuts in the mid-1990s and has a current budget ($146 million in fiscal year 1998) that is roughly only 1 percent of NIH's budget. The President's fiscal year 1999 budget proposal requests an increase of $25 million in AHCPR's budget, including $15 million in additional funds for research on quality of care, nearly doubling the fiscal year 1998 budget for this research.
In addition to investing in research aimed at developing and assessing effective health care practices, a similar commitment should be dedicated to research on preventing the onset of health care conditions. For example, the President has proposed $25 million in initial funding in fiscal year 1999 for Prevention Research Centers to bolster the $125 million that the Centers for Disease Control and Prevention (CDC) dedicated in fiscal year 1998 to prevention research activities. These Prevention Research Centers would develop a collaborative network of academic centers committed to research that benefits public health through enhancing prevention and focusing on behaviors that put Americans at risk for chronic health conditions.
Researchers increasingly have relied upon private sources and clinical revenues for funds. Funds for health research and development increased by 10.5 percent annually between 1984 and 1994 (Mechanic, 1996), but the source of research money has shifted from predominantly public sector (45 percent of funds in 1993 compared to 56 percent in 1983) to private sector sources (50 percent in 1993 compared to 39 percent in 1983) (NIH, 1996). The pharmaceutical industry, for example, invests $19 billion a year in research (Bello, 1997).
Research Infrastructure and Workforce.Expanded public and private funding of health care research needs to be accompanied by a robust research infrastructure and a workforce of highly qualified investigators. The highly competitive health care market poses challenges to academic health centers and may threaten the subsidies that clinical revenues provide for research and education (HHS, 1997). One study estimates that clinical services delivered by medical school faculty raised more than $800 million in 1993 that was used to subsidize clinical research -- an amount equal to about one-fifth of the funding medical schools received from NIH grants (AAMC, 1997). The costs that academic health centers incur due to their research and teaching functions, as well as the disproportionate share of uncompensated care that many provide, leads to charges that have been estimated to be as much as 15 percent to 35 percent higher than community hospitals, even after adjusting for case-mix differences (Skirboll, 1997; Blumenthal, 1996). These higher charges can make it difficult for academic health centers to compete with other health care delivery organizations.
In addition, academic health centers face increased competition from private research centers as a greater share of funding flows to these entities from industry sources. One analyst estimates that these contract research organizations currently manage one-half to three-quarters of Phase III and Phase IV clinical trials (Blumenthal, 1996). Although the portfolio of health care research conducted by academic health centers and private research centers often differs, traditional research institutions are facing increased competition not only in the funds available for research, but also in the increasing array of organizations available to provide research capability.
The supply of trained researchers poses another concern. A declining number of physicians and other health care professionals pursuing careers in health care research has led some analysts to refer to clinical investigators as an "endangered species" (Thompson, 1997). The high educational debt burden facing most medical school graduates -- often exceeding $100,000 -- makes it difficult for many to accept typically lower-paid research positions, and nurses and other health care professionals also face difficulties in pursuing careers in research. Furthermore, as the number of applications for NIH grants has increased and the average term of funding for approved grants has become longer, the share of new grant applications that successfully receive NIH funding has declined. As a result, young clinical investigators, in particular, may find it more difficult to receive grant funding that allows them to establish their careers in research (Pew, 1996). This has led some analysts to propose debt forgiveness programs for students pursuing research careers, additional training programs, and expanded career recognition for researchers. The NIH Clinical Research Panel's interim report recommends that NIH:
Established clinical researchers also face increasing pressure to expand their clinical practices, often at the expense of the time they are able to dedicate to their research (Mechanic, 1997). A case study of seven academic health centers found that "all were placing less emphasis on their teaching and research functions" (Blumenthal, 1996).
Enrollment in clinical trials and data availability
Researchers report concerns about maintaining access to patients for clinical research. The current ambiguity in payment responsibility between the patient's health plan and research sources is complicated by the difficulty in assessing whether marginal costs result from a research protocol or standard patient care. In addition, the willingness of third parties to make reimbursement may depend on whether a clinical trial is NIH-funded or approved, or has been reviewed by an external institutional review board. More clarity and consistency in the definition of investigational or experimental treatments may resolve some of the existing ambiguity in payment responsibility (Eisenberg, 1997).
The extent to which third-party payments are available for patients in clinical trials varies widely. Many health plans pay for the care either because they are unaware it is provided in a research context or they explicitly approve coverage of such care. Other health plans pay for standard care that would have been provided outside of research protocols, but exclude costs that they determine are associated with research. Some health plans choose to deny payment for care within clinical trials because of their experimental nature or due to lack of evidence of the safety, efficacy, or cost-effectiveness of the care. For example, it is Medicare's policy not to reimburse routine patient care costs for beneficiaries enrolled in a clinical trial. A survey of physicians participating in cancer clinical trials, however, suggests that Medicare reimbursement denials are rare (GAO, 1997). The President's fiscal year 1999 budget proposes a three-year demonstration that would provide Medicare coverage of patient care costs associated with NIH-sponsored cancer treatment clinical trials, but other clinical trials would remain ineligible for Medicare reimbursement.(1)
In addition, public health, prevention, and health services research efforts in particular require better availability of community and patient-level data. Assessing outcomes and evaluating the effectiveness of health care interventions, monitoring disease trends and the impact of prevention programs, and assessing the effects of dynamic changes in health care delivery systems depend on ready access to timely, comparable, and comprehensive data. The Federal government should continue to coordinate with private entities to enhance the public availability of such data for research and other purposes while maintaining rigorous standards of confidentiality to protect consumers (see also Chapter 14).
The trend toward most consumers being enrolled in health plans that require or encourage the use of a network of health care facilities and practitioners provides both opportunities and challenges for researchers seeking to establish enrollment in clinical trials and gain access to data. Managed care plans with large, integrated networks of enrollees can provide a fertile source of research opportunities, including a large base of patients for conducting research, the ability to track care across different settings and practitioners, and the availability of data to assess outcomes (Platt, 1997). But, to the extent that academic health centers and other research facilities are not represented in health plan networks, the flow of patients into clinical trials is curtailed. Similarly, the shift from inpatient to ambulatory care settings has complicated identifying and evaluating patients and obtaining comparable, accessible data for research purposes.
Collaborative Approaches Are Necessary
To ensure continued support for research and to establish better linkages between research and health care practice, continued productive collaboration needs to occur among academic health centers, government agencies that support research, health plans, pharmaceutical companies, and gateway.html foundations. Strong public funding remains the cornerstone of health care research efforts, but collaborative arrangements between researchers and private funding sources can greatly extend research capacity.
There are examples of existing collaborative arrangements between health plans and clinical researchers. A survey identified 20 HMO-based research centers with 1996 budgets of $93 million (Nelson, 1998). Such research centers include those sponsored by Group Health Cooperative of Puget Sound, Harvard Pilgrim Health Care, and Kaiser-Permanente. In exchange for funding, health plans are able to target research priorities to areas of particular concern to their enrollees and to have the research occur within the setting of their plan. Similarly, academic health centers increasingly are affiliating with managed care plans or developing their own integrated delivery networks to allow for continued support of clinical research. These trends provide the foundation for closer collaborative working relationships between health plans and researchers.
Other efforts also are being undertaken to encourage more fruitful collaborative arrangements between researchers and funding sources. NIH has initiated ongoing dialogues with managed care plans, the pharmaceutical industry, and philanthropic organizations seeking further collaborative efforts among these groups to support research (NIH, 1996). The American Association of Health Plans (AAHP) has endorsed a statement that supports patients having access to NIH-approved clinical trials and health plans establishing linkages with such trials, including, if plans choose to participate, covering associated routine patient care costs (AAHP, 1997). In addition, AHCPR and AAHP are collaborating to provide $7 million in support of evaluations of outcomes in the care of chronic disease in different care settings.
Finally, a recent proposal calls for convening a clinical research summit of key leaders in research, federal agencies, health plans, and manufacturers to (1) establish a process for setting broad national goals in research, (2) seek enhanced flexibility in using federal/state funding, (3) restructure clinical research training, and (4) annually report progress in achieving goals (Thompson and Moskowitz, 1997). The Association of American Medical Colleges and the American Medical Association have initiated planning for such a summit to be held in late 1998. While these discussions are good initial efforts, timeframes should be set for tangible agreements to be established and collaborative arrangements implemented in the near future (such as one year).
TECHNOLOGY ASSESSMENT NEEDED
A commitment to evidence-based health care requires that health care procedures, devices, pharmaceuticals, and other technologies be assessed for their clinical efficacy, cost-effectiveness, appropriateness, and outcomes. Because many new health care innovations and existing health care practices have only limited clinical evidence demonstrating their effectiveness, a key challenge is increasing the evidence base supporting the best approaches for improving the public's health. Developing this evidence base will require a long-term commitment to develop evaluations of the effectiveness of health care practices. Technology assessment -- broadly applied to include health care procedures and techniques as well as equipment and drugs -- is an important process that draws on evidence generated by all forms of health care research to evaluate the clinical and cost effectiveness of new innovations as well as existing health care practices. While much of the focus of technology assessment in the private sector has been on supporting health plans' coverage decisions, it also is a valuable tool for aiding the diffusion of effective health care practices through experimentation and adaptation of new innovations and providing physicians and other health practitioners with evidence regarding their effectiveness.
In general, technology assessments are conducted independently by health plans to make benefit coverage determinations, manufacturers to identify research needs and support marketing efforts, and health care delivery organizations to develop treatment protocols and make equipment purchasing decisions (Rettig, 1997). More than 50 public and private sector organizations conduct technology assessments, including Federal and state agencies, gateway.html organizations, health plans, professional societies, health industry manufacturers, and hospitals (Kamerow, 1997). Increased collaboration and cooperation would reduce unwarranted duplication, provide more consistency in health plans' coverage decisions and health care professionals' practices, and better target resources to assessing health care practices that have not yet been demonstrated to be effective. Furthermore, collaborative efforts among government, health plans, hospitals, and manufacturers would enable technology assessments to be undertaken that would be too expensive for a single entity to pursue (IOM, 1994; PPRC, 1994).
Several collaborative efforts have been developed. The Technology Evaluation Center, a collaborative effort of the Blue Cross and Blue Shield Association and Kaiser-Permanente, provides technology assessments to member plans that can use the information in making coverage decisions (Gleeson, 1997). Other health plans, such as Prudential and Aetna, also maintain programs to conduct technology assessments, and other independent centers provide these services for health plans and other organizations (Rettig, 1997). A new initiative of the Agency for Health Care Policy and Research, evidence-based practice centers, is intended to promote the development of syntheses of clinical research to provide information for public and private organizations to use in developing practice guidelines, performance measures, and other quality improvement approaches (AHCPR, 1997).
Further cooperation in performing technology assessment could be achieved by establishing an on-line directory of existing and ongoing assessments. This information would enable better public dissemination of evidence of the effectiveness of health care practices and prevent unnecessary duplication in performing technology assessments. In addition, better processes should be developed to allow feedback from organizations performing and relying on technology assessments to researchers to improve the scientific evidence that supports health care practices.
DISSEMINATING EFFECTIVE PRACTICES
Once effective health care innovations are identified, effective approaches to disseminate these practices need to be developed. This includes establishing guidelines for the use of effective health practices, disseminating this information, and providing technical assistance to aid health organizations and practitioners adopt effective health practices. Ultimately, however, the diffusion of effective health care practices depends on health organizations and practitioners changing established practices and adopting new innovations. This often requires health care organizations to change their culture to encourage innovation internally, collaboratively share knowledge of innovations, and to be receptive to incorporating and adapting innovations in their practices (see Chapter 12). The success of such voluntary collaborative efforts among health care professionals is demonstrated by efforts such as the Northern New England Cardiovascular Disease Study Group, Maine Medical Assessment Foundation, and Dartmouth Primary Care Cooperative Information Project (O'Connor, 1996; Conway, 1995; Wassen, 1995).
Diffusion Often Takes a Long Time
The need for effective dissemination is highlighted by the fact that, even when information regarding the effectiveness of a specific treatment is known, this knowledge may not be widely applied (such as the underuse of beta blockers for heart attack patients). Research in other industries has found that the diffusion of effective products and information can take years or even decades (Rogers, 1995; Van de Ven, 1997). The challenge, therefore, is to identify methods that accelerate the widespread adoption of effective technologies and methods and discontinued use of ineffective technologies and methods.
An "extension service" model, in which professionals with technical expertise regarding effective practices are available to provide a bridge in knowledge between researchers and practitioners, has been effective in other industries (such as agriculture) and health care (such as the use of academic detailing). The Agricultural Extension Service, developed to disseminate the research findings of agricultural colleges to farmers by way of county agents, has been cited as a model of effective diffusion of technical research to practitioners in the field. County agents provided technical assistance by translating technical research into practical methods and promoted these methods for farmers to adopt. Lessons learned from the Agricultural Extension Service model include:
Applying these lessons to health care suggests a need for closer collaboration between clinical researchers, health plans, and health care practitioners (as discussed above) and enhanced efforts to synthesize and translate clinical research innovations into practice protocols (discussed below).
Translating Evidence into Practice
An important step in the diffusion of new innovations from the laboratory to the bedside is to develop practice protocols that recommend appropriate methods for applying health care interventions. The development and dissemination of practice guidelines by the Federal government, professional associations, and health plans have accelerated during the 1990s. The benefits of practice guidelines include: developing an evidence-based consensus of the best practices for a particular condition; consolidating disparate sources of information regarding clinical effectiveness and outcomes; and preparing medical research into a usable format for practitioners.
The development and dissemination of practice guidelines based on evidence of clinical effectiveness, however, have not proven sufficient to lead to widespread change in health care professionals' behavior. Studies have found a significant lag between the publication of a clinical advance and its adoption into clinical practice. For example, a Florida study regarding the mandated dissemination of practice guidelines on cesarean sections concluded that "the mere dissemination of practice guidelines by a state agency may not achieve either the magnitude or the specificity of the results desired without an explicit and thorough guideline implementation program" (Studnicki, 1997). Similar findings elsewhere have led to a recognition of the need to ensure that information on effective health care practices is not merely disseminated, but that the information is distributed in a manner that encourages its adoption and includes follow-up programs and efforts targeted to individual providers.
Although many guidelines have been developed by highly credible organizations, the local adaptation of guidelines is an important factor in their adoption by health practitioners. Adapting guidelines allows local clinical input by practitioners who can in turn encourage the use of the guidelines, incorporates specific needs of the plan's enrolled population, validates the need for the guideline with local plan information that may be more credible to the health practitioners who will be called upon to adapt their practices, and counters a sense of threat posed by external mandates. This direct involvement of local clinical leaders in assessing the need for guidelines is particularly important because "physicians are more likely to alter divergent behavior if they are involved in the process of assessing their own practices" (Kassirer, 1993). Local adaptation of nationally developed guidelines, however, may in some cases compromise the integrity of the guideline or undermine the goal of minimizing variation in health care practices.
Encouraging Adoption of Effective Care
Ultimately, dissemination of effective health care practices depends on the efforts of health organizations to affect the adoption of desired practices. Many quality improvement methods, including decision support systems and provider profiling and feedback, are important tools in supporting the adoption of effective health care practices (and discontinuation of ineffective practices) once knowledge has been disseminated. Several organizational strategies appear to be key to encouraging innovation diffusion. These strategies include:
Further experimentation should focus on designing appropriate methods to encourage changes in clinicians' behaviors that reinforce effective health care practices. General examples of these approaches include education (e.g., academic detailing, continuing education programs, and practice guidelines); feedback (e.g., peer comparisons on outcomes and use); participation of health care professionals in improvement efforts (e.g., practice-based research networks); administrative interventions (e.g., computerized decision support systems); and financial incentives to reward quality performance (Greco and Eisenberg, 1993).
The collaborative sharing of knowledge regarding innovations in effective patient care should be encouraged among health care delivery organizations, health plans, and practitioners because maintaining proprietary knowledge of advances can stymie the diffusion of effective health care practices that would benefit patients. Current public and private sector efforts, such as the funding of evidence-based practice centers by the AHCPR and the reformed quality improvement organizations providing services to HCFA and other group purchasers, are positive steps furthering the dissemination of effective health care practices. Examples of ongoing public, private, and collaborative efforts to synthesize research on how to improve health care and disseminate these findings are summarized in Table 1.
Additional public and private sector efforts to provide technical assistance to support adoption of effective health care practices should be encouraged. For example, the Advisory Council for Health Care Quality should foster the development of approaches to provide collaborative technical assistance to health care organizations in support of national aims for improvement. Group purchasers can also play a role by facilitating the sharing of best practices among contracting health plans and providers. Similarly, health plans that share common networks of providers could collaborate on shared interests to identify and implement clinical quality management projects that would benefit a community.
Enhancing Dissemination Capabilities
The Internet and other computer-based technologies provide increased opportunities for effectively disseminating clinical research and effective health care practices. Traditional methods of disseminating information, including journals, continuing professional education, and peer recommendations, have been supplemented by the expansion of computerized databases sponsored by professional associations and public organizations. For example, the American Medical Association, American Association of Health Plans, and the Agency for Health Care Policy and Research have collaborated to develop a National Guideline Clearinghouse to catalog available practice guidelines and make them available via the Internet. Clinicians increasingly rely on computerized decision support systems that recommend practice alternatives based on the patient's diagnosis and health information. The increased use of telemedicine, allowing health practitioners in remote areas to access specialists and other resources with clinical expertise via video conferencing and electronic clinical data interchange systems, also provides an effective tool for disseminating information on effective care. Consumers also have gained access to extensive on-line data sources, including the ability to search citations to clinical literature through "Grateful Med" and general health information sponsored by private and public health organizations. While these new avenues of disseminating clinical information can be valuable, the ease with which information can be disseminated by the Internet without rigorous review raises concerns about the credibility of some information sources (Kassirer, 1995).
Table 1: Examples of Efforts to Better Disseminate Health Care Improvements
Agency for Health Care Policy and Research, "AHCPR Selection of Topics for Evidence-based Practice Centers," 1997.
American Association of Health Plans, "AAHP's Board Votes to Work with NIH to Advance Nation's Research Agenda" and "Health Plans' Role in Patient-Centered Clinical Research Expanding," June 1997.
Association of American Medical Colleges, Academic Medicine: Institutions, Programs, & Issues, Washington, D.C.: 1997.
Blumenthal, David and Gregg S Meyer, "Academic Health Centers in a Changing Environment," Health Affairs 1996:15(2);200-215.
Conway Ann C., Robert B. Keller, and David E. Wennberg, "Partnering with Physicians to Achieve Quality Improvement," Joint Commission Journal of Quality Improvement, 1995:21(11);619-626.
Durham, Mary, "Partnerships for Research Among Managed Care Organizations," Health Affairs, 1998:17(1); 111-122.
Eisenberg, John, Testimony before the Subcommittee on a Quality Improvement Environment, Advisory Commission on Consumer Protection and Quality in the Health Care Industry, November 18, 1997.
Gleeson, Susan, Testimony before the Subcommittee on a Quality Improvement Environment, Advisory Commission on Consumer Protection and Quality in the Health Care Industry, December 16, 1997.
Greco, Peter J. and John M. Eisenberg, The New England Journal of Medicine, 1993: 329(17), p. 1271.
Hadley, Jack, Testimony before the Subcommittee on a Quality Improvement Environment, Advisory Commission on Consumer Protection and Quality in the Health Care Industry, November 18, 1997.
Institute of Medicine, Medical Innovation at the Crossroads, Volume 4: Adopting New Medical Technology, National Academy Press, 1994.
Kamerow, Douglas, Testimony before the Subcommittee on a Quality Improvement Environment, Advisory Commission on Consumer Protection and Quality in the Health Care Industry, December 16, 1997.
Kassirer, Jerome P. and Marcia Angell, "The Internet and the Journal," The New England Journal of Medicine, 1995; 332(25): 1709-1710.
Kassirer, Jerome P., "The Quality of Care and the Quality of Measuring It," The New England Journal of Medicine, 1993; 329(17): 1263.
Mechanic, Robert E. and Allen Dobson, "The Impact of Managed Care On Clinical Research: A Preliminary Investigation," Health Affairs 1996:15(3); 72-89.
National Institutes of Health, "Interim Report of the NIH Director's Panel on Clinical Research," December, 1996.
Nelson, Andrew F. et al., "The State of Research Within Managed Care Plans: 1997 Survey," Health Affairs, 1998:17(1); 128-138.
O'Connor, Gerald T. et al., "A Regional Intervention to Improve the Hospital Mortality Associated wiht Coronary Artery Bypass Graft Surgery: The Northern New England Cardiovascular Disease Study Group," Journal of the American Medical Association 1996:275(11):841-846.
Pew Charitable Trusts, Trends in U.S. Funding for Biomedical Research, (Center for the Health Professions at the University of California, San Francisco; 1996).
Physician Payment Review Commission, "Coverage Decisions and Technology Assessment," Annual Report to Congress, 1994, 1994.
Platt, Richard, Testimony before Subcommittee on a Quality Improvement Environment, Advisory Commission on Consumer Protection and Quality in the Health Care Industry, November 18, 1997.
Rettig, Richard A., Testimony before Subcommittee on a Quality Improvement Environment, Advisory Commission on Consumer Protection and Quality in the Health Care Industry, December 16, 1998, and Health Care in Transition: Technology Assessment in the Private Sector, Santa Monica, CA; RAND, 1997.
Rogers, Everett M., Diffusion of Innovations. New York, The Free Press; 1995 (Fourth Edition).
Skirboll, Lana R., "The Impact of Managed Care on Research: The Changing Face of Medicine," Academic Medicine, 1997;72(9): 778-779.
Studnicki, James et al, "The Impact of Legislatively Imposed Practice Guidelines on Cesarean Section Rates: The Florida Experience," American Journal of Medical Quality, 1997; 12(1): 62- 68.
Thompson, James N. and Jay Moskowitz, "Preventing the Extinction of the Clinical Research Ecosystem," Journal of the American Medical Association, 1997;278(3): 241-245.
U.S. Department of Health and Human Services, Report by the Task Force for the Initiative on the Future of Academic Health Centers, October 7, 1997.
U.S. General Accounting Office, "Cancer Clinical Trials: Medicare Reimbursement Denials," GAO/HEHS-98-15R, October 14, 1997.
Van de Ven, Andrew H., Testimony before Subcommittee on a Quality Improvement Environment, Advisory Commission on Consumer Protection and Quality in the Health Care Industry, September 9, 1997.
Wasson, John H. et al, "Adolescent Health and Social Problems: A Method for Detection and Early Management," Archives of Family Medicine, 1995:4(1);51-56.
(1)In addition, the Health Care Financing Administration and NIH are collaborating to conduct a randomized clinical study of the effectiveness of lung volume reduction surgery, with Medicare paying the inpatient care costs for participating beneficiaries.
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