Testimony on Comparative Effectiveness Research
Sean M. O'Neill, M.Phil.; Alec R. Levenson, Ph.D.; Jennifer L. Malin, M.D., Ph.D.
Delivered Via Electronic Mail
Please accept the following comments for consideration regarding the priorities for a national health services research agenda and AHRQ's portion of funds provided under the American Recovery and Reinvestment Act (ARRA) for comparative effectiveness research:
We strongly believe that a portion of ARRA funds should be used to fund research into organizational effectiveness and organizational behavior in health care delivery. ARRA provides for "the development and dissemination of research assessing the comparative effectiveness of health care treatments and strategies" (1). Understanding the effectiveness and behavior of health care delivery organizations certainly falls under this purview. Obtaining such an understanding is paramount for improving the actual delivery of care to Americans for three reasons.
First, current effectiveness studies comparing different healthcare delivery strategies do not adequately take into consideration the highly complex, multi-level nature of health care organizations (2, 3). Even with state-of-the-art research designs such as cluster-randomization (4-6), a deeper understanding of the organizational determinants (structure, culture, politics, resources) of safe and effective health care is lacking and necessary for understanding how to improve care (7).
Second, the clinical registries and other data-collection facilities funded by ARRA are sorely needed, but they alone are insufficient for improving health care (8). Understanding how health care organizations can most effectively utilize these tools to improve actual care is of the utmost importance if our substantial health IT investment is ultimately to be of any value to American patients. Data monitoring and feedback alone are insufficient for improving the quality of care because much of healthcare is delivered via complex organizational structures. Understanding how the varied medical professionals spanning a myriad of disciplines come together within complex organizational structures is essential to identifying critical factors that can impact patient care. A fundamental change in the way data monitoring and feedback are used and characterized within the culture of an organization is essential for producing improved results (9). We thus need to better understand the organizational barriers and facilitators for effective use of clinical data in real time if we are to fully capitalize on the opportunities ARRA affords. Organizational behavior research approaches are critical for obtaining this understanding.
Finally, although we are able to compare healthcare organizations on various sets of performance measures (the Premier Hospital Quality Incentive Demonstration (10) and HospitalCompare (11) are two hospital-based examples) and stratify them using those measures, we have virtually no systematic understanding of why the highest-decile groups end up as the highest-performers. Moreover, we have even less understanding of how to translate such stellar performance to the rest of the pack. Research has demonstrated that improved quality typically comes through an evolution of organizational culture that stresses a focus on quality improvement above other competing priorities (7, 12). If we want to make health care more effective in the United States, we need to better understand this evolution and the specific processes by which health care organizations can become high performers.
Organizational behavior and organizational effectiveness research approaches have been effectively applied in numerous industries including health care, with the research literature dating back over decades (13-22). The result has been deep insights into the factors that drive behavior in complex organizations, including behaviors that produce outcomes at odds with organizational and societal objectives. It is straightforward to apply these research approaches to study and understand processes that are overlooked by more traditional health services research programs. Yet funding for these types of projects is not currently prioritized by AHRQ. Given the deep influence organizations have on actual care delivery and the vast opportunity ARRA affords to expand and deepen our understanding of the relative merits of different health care delivery strategies, we strongly urge AHRQ to make studies of health care organizational effectiveness and behavior a priority in its use of ARRA funding.
Sean M. O'Neill, M.Phil
Doctoral Fellow, Pardee RAND Graduate School
Medical Student, Northwestern University, Feinberg School of Medicine
Alec R. Levenson, Ph.D.
Research Scientist, Center for Effective Organizations
University of Southern California, Marshall School of Business
Jennifer L. Malin, M.D., Ph.D
Associate Professor, David Geffen School of Medicine at UCLA
Attending Physician, VA Greater Los Angeles Healthcare System
Policy Analyst, RAND Corporation
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