What's New? What Needs to Change?

Michael Weitzman, M.D., Charles Homer, M.D., M.P.H.,
Charles Irwin, Jr., M.D., John Pestian, Ph.D.

Improving Children's Health Through Health Services Research was a special 1-day meeting held June 26, 1999, in Chicago. The state of the science in children's health services research was explored, including public and private funding opportunities, networks for conducting research, and uses of research in policy and practice. The meeting was co-sponsored by the National Association of Children's Hospitals and Related Institutions (NACHRI), with the Agency for Health Care Policy and Research (AHCPR), the American Academy of Pediatrics (AAP), the David and Lucille Packard Foundation, the Association for Health Services Research (AHSR), the Robert Wood Johnson Foundation, and Data Harbor, Inc.

Each of the speakers described the formal and informal child health services research (CHSR) training opportunities in their settings, and the roles they and others play in promoting child health services research opportunities for pediatricians, nurses, health services researchers without experience in child health, and others. They highlighted the contributions CHSR can make to both organizational and public policies.

Training in child health services research requires:

• A "critical mass" of trainees, role models, and teachers experienced in child health services research.
• Opportunities as part of a role, or as in a child health researcher position, for post-training careers.
• Sources of support for research during and after training.

Faculties for training programs need:

• Expertise and skill in the methods and techniques of child health services research.
• The ability to identify and guide the trainee in the development of appropriate and manageable research questions.
• A commitment and "passion" for child health services research.

The best training includes opportunities for multi-disciplinary and multi-institutional exposure, including community partners. Successful programs also have leadership and support from child health services researchers, as well as from other researchers, and administrators. In addition, a tradition of health services research, access to appropriate databases, and discretionary money for project start-ups are desirable.

The lack of a cadre of child health services researchers relates to the clinical practice focus of pediatrician, nurses, and other provider educational programs in child health. Even when health services research (HSR), such as studies of the relationship between structures and processes of care to outcomes, was being conducted, it was not often identified as such. Thus, the unique approaches of HSR may not have been utilized.

Reasons for this, discussed by Dr. Irwin, include:

• Many clinicians have little experience in evaluating their practice or in conducting research.
• Funding for CHSR was not, until recently, readily available, and few programs existed to train a future CHSR workforce.
• The numbers of graduating medical students with strong research career intent has declined in recent years, as has the number of funded grant applications at the National Institutes of Health (NIH) from physician researchers.

Horizontal versus vertical approaches to HSR training were discussed by Dr. Weitzman. The horizontal approach includes HSR training and fundamentals as part of the core curriculum through the use of national databases and research seminars. The vertical approach allows fellows to select HSR training as a core component of their research training.

Dr. Weitzman suggested that generalist training, with clinical skills learned prior to entering the HSR training component, allows for greater focus on the research training, and better integration into the fellowship training. For specialists, an HSR curriculum is not well developed or integrated into their training program, and there are few HSR models, as the research tradition of "bench science" remains.

A model for health services research is that of the Harvard community-based health services research-training curriculum, discussed by Dr. Homer. It includes components designed to train fellows in negotiation skills, in understanding the priorities of community organizations, and in listening and responding to community needs. The fellowship focuses on developing community relationships, so fellows can accomplish successful projects during the time frame of their program in HSR.

The panelists suggested a number of actions that should be taken to increase the cadre of child health services researchers:

• Identify talented young investigators.
• Develop and implement curricula for both horizontal and vertical approaches to HSR.
• Create a cohort of mid- and senior level mentors.
• Invest more in HSR training (at all levels).
• Increase participation in HSR by pediatric generalists and specialists and other providers, such as nurses, psychologists, and speech therapists, as all have unique contributions to make to the field.
• Maintain a database of CHSR.
• Explore new models and methods for multi-disciplinary and interdisciplinary education and research.
• Provide balance between independent projects and work on extant projects (similar to laboratory model).
• Cultivate partnerships with policymakers, community organizations and others who need the type of information CHSR can provide.

Internet Citation:

What's New, What Needs to Change? Presentation Summary, Improving Children's Health Through Health Services Research, Chicago, June 26, 1999. http://www.ahrq.gov/research/chsrtrng.htm