Intro Health Services Research
Intro Health Services Research HAP 445
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Introduction to Health Services Research HAP 445 Section 001 Chapter 2 Conceptualiiimgm Chapter 3 Groundwork in Health Services Research Spring 2011 Vicky Debold RN PhD Week 2 Chapter 2 Conceptualizing Health Services Research Defining and Measuring the Determinants of Health Today s Agenda I Lecture on Chapter 2 and 3 I Winkleby presentation I Takehome assignment I Inclass exercise I Research proposal assignment Research Conceptualizing Stage I Six Key Steps Define each of the following I Research Purpose I Research Topic I Theories and Literature I Concepts and Variables I Development of a Conceptual Framework I Research Hypotheses or Questions Conceptualization The process of specifying and refining abstract concepts into concrete terms It begins with identifying the purpose of doing the research and ends with testable hypotheses or research questions HSR Research Purposes I Basic type of Research I Exploratory research to look at a new topic WHAT o It generates hypotheses that can be tested not usually representative of the group studied Typical for qualitative research case studies focus groups guided interviews I Descriptive research to explain describe and categorize HOW o It uses structured deliberate and numerical measures Health United States National Health Expenditures Data Survey methods I Explanatory research analyticcausal to establish answers WHY It uses advanced methods to formally test hypotheses RAND Health Insurance Experiment Experimental research designs multivariate analyses Differences in Types of HSR I Table 21 very helpful overview I Types of research varies according to Purpose Type of questions Position in the overall research process Rigor Use of theory Existing knowledge about the subject Research methods Sample size Number of variables Statistical tests Cost Representativeness HSR Research Topics I Must be able to be addressed empirically I Practical applied realworld problems I Potential to affect public policy I Can advance theory development I Investigator interests experiences skill I Availability of funding and data HSR Literature Review Process Identify all relevant literature on the topic narrow and refine topic Build off prior research Identify relevant theories Identify variables that need to be controlled to isolate the phenomenon of interest Identify successes and failures of previously used designs and procedures Honing The Topic I Figure 21 I Winkleby Y CV health X SES Z control factor Initial interests gt EgtY Idea X gt gtY Literature review X1 X2 X3 Z5 gt gtYS HSR Concepts and Variables I What concepts are of interest I Identify concept dimensions I Produce concept definitions I Nominal level most abstract Socioeconomic Status I Operational level less abstract Income occupation and education level The Field of HSR I Major Areas of Interest I Health Services Perspectives I Health Status I Environment I Lifestyles I Heredity I Medical Care Services Figwre 1 Blum39s quotFormField and We Being Paradim at Healthquot Eggu at ion suza distribution gromh rate gene pool Internal me 393 r Satvsfamonfgf hasa Discomfort Fetal physical aiural and 6n 2 man made ReamE lv39 HE A LTH quot Jlsablllfy suncioculluml 391 wallham yu r a icipa on Newman Cm Inzarpexsnnam m health care prewemmn econum Bahama 34 Gaye iC education psycmc 302157 x Healih Bewamor employmenl etc El u IEQIVEIEha Bewawor Life Styles ailitu ties behavmrs HSR Conceptual Frameworks I Links together concepts by specifying relationships between concepts l Direction of relationship strength shape linear or not I Developed by reviewing the literature I Guides research plan interpretation of findings HSR Hypotheses or Questions I Hypotheses I Specifies relationships between variables predicts the direction of relationships I Basic or theoretical research I Identify independent dependent variables I Questions I Focuses on current social problem I Direction of relationships usually unknown I Applied research Types of Hypotheses I Conditional I le then Y Continuous I Increases in X are associated with increases in Y continuous variables Difference I X is higher in Y1 than Y2 categorical Mathematical I Y fX1 X2 X3 Health Services Perspectives I Relevant Theories and Frameworks I Germ Theory infectious disease environmentfree I Lifestyle Chronic disease environmentsensitive I Environmental general health wellbeing environment dependent I Modern Theories Combine The Above I Starfield 1973 Determinants of Health Status I Blum 1981 Environment of Health Model Big HSR Concepts I Key Factors in Why People Have Different Health Outcomes l Baseline Health Status Factors I Environmental Factors I Lifestyle Choice Factors I Heredity Factors l Medical Care Service Factors Factor 1 Health Status Definitions I usually measured as poor health disease disability death I the needs and outcomes of health services for individuals and populations Overall I SF36 Quality of Life burden of illness Physical health measures I Symptoms mortality morbidity disability I Use of health services Mental health measures I Symptoms selfassessed psychological state General health perceptions Social health measures I Symptoms social wellbeing sraa Scales Measure thsical and Mental Components of illieal m G P hysisal Functiun e Role 4 Physical Badlin Pain Health 5 General Mental Health Hale Emotinna Sn cial Func on mu Imam muna 11311 Vitality ma mm mm mm mm International Classification of Functioning Disability and Health ICF Browser LanguageVersion 3 ICF Search Results El bBODY FUNCTIONS mo Gait pattern functions a in sBODY STRUCTURES d4 CHAPTERi MOBILITY ta ij dACTliITIES AND PARTlCIPATION d450 Walking g a e ENVIRONMENTAL FACifORS distill Walking short distances d4502 Walking on different surfaces d4503 Walking around obstacles d455 Moving around d480 Moving around in different locations d4602 Moving around outside the home and other buildings Assisiive products and technology for personal indoor and outdoor mobility and transportation ICFDH nominal definitions ICF Browser LanguageVersion ICF English 7 E iCF 1455 Moving around a 3 b BODY FUNCTIONS E E S BODY STRUCTURES Moving the whole body from one place to another by means other than walking such as climbing over a rock or running clown a street skipping scampering jumping 9 lg cl ACTIVITIES AND PARTICIPATION somersaultlng or running around obstacles in IQ 9 ENVIRONMENTAL FACTORS inclusions crawling climbing running jogging jumping and swimming Exciusions transferring oneself N420 walking d450 Search Fields Search Check the elds to be Included In the search IiiTitles gDescriptions glnclusions 39 Exclusions Basic ADL s l The basic activities of daily living consist of these self care tasks Bathing Dressing and undressing Ea ng Transferring from bed to chair and back Voluntarily control urinary and fecal discharge Using the toilet Walking not bedridden Instrumental ADLs l Instrumental activities of daily living are not necessary for fundamental functioning but enable the individual to live independently within a community Light housework Preparing meals Taking medications Shopping for groceries or clothes Using the telephone Money management Factor 2 The Environment I Definition events external to the individual that the individual has little or no control over I Physical Dimensions Pollution and toxic exposures UV radiation I Social Dimensions Income education occupational status Social support networks crowding isolation Demographics Factor 3 Lifestyle Choices I Behavioral Risk Activities I Cigarette smoking alcohol abuse lack of exercise driving habits diet I Leisure Activity Risks I Sexual behavior Egt STD s I Exercise Egt Obesity CV disease I Consumption Risks I Eating drinking drugs smoking I EmploymentOccupational Risks I Unsafe workplaces workrelated stress Factor 4 Heredity I Genetic Variation is associated with l Congenital and other heritable disorders Down Syndrome Huntington s Chorea I Patterns of maturation and aging Premature death and predisposition for certain categories of disease cancer diabetes CV I Physiological and biological characteristics Skeletal and muscular adverse reactions to drugs and vaccines Factor 5 Medical Care I Variations in Structure of Medical Care Table 24 I Health care organizations I Health care providers I Health care services I Government roles I Health care financing I Other critical issues Access to care ruralurban health minority health quality of care ethics Medical Care As a Commodity I Consumer demand for health translates into a demand for medical care services I Demand is not usually direct physicians are demand brokers Agency Relationship I Price and cost is incurred in atypical ways and varies depending on access to insurance I Demand is affected by social economic and cultural contexts I Debates are shaped by perspectives on Market vs Social Justice Table 23 Chapter 3 Groundwork in Health Services Research Data Sources Research Proposal Major Types of Data I Who collected it first I Primary I Secondary I What was collected I Crosssectional I Timeseries I Panel Major Data Resources I National Center for Health I National Health and Nutrition StatlstICS I Examination Survey I Area Resource Flle I National Hospital Discharge Behavioral Risk Factor Survey Surveillance System Med39cal E end39t re Panel I Medicare Current Beneficiary I I Xp lu Survey Survey I Survey of Mental Health 39 Nat39onal Nursmg Home Survey Organizations I National Ambulatory Medical I Health and Retirement Study Care Survey I National Vital Statistics Survey I National Health Interview Survey Data Sources I Lots of data on the Internet I Look at Blackboard resources I Examples to follow HEALTH SERVICES RESEARCH HER METHODS all Full Glamnu Lil new Tenn By and Data Soumas Bauhaus Ethics and Human Slbjects Policy and Legal Analysis Hiawatha Analysis mn ta va Analys Dmoepts and Madeis Keyword Search Glossary List Databases Adverse Event Reoortino Systems The Adverse Event Reporting System AERS is a computerized inf Administration39s FDA postmarketing safety suweiilanoe program t drug reaction reports are submitted by manufactures health care pr The FDA uses this system to matte reguia tory actions to improve pr product39s iebeliog information Reports are com piled by the Food an Research as wait as their Center for Biologics Evaluation and REESE Lexis Nexis A service that compiles legai opinions news articles and other schc areas There are over ve biliioo searchable documents from legai I through a paid subscription MedWatch MedWatch is the Food and Drug Administration39s voluntary reporting to detect safety hazard signals For medical and pharmaceutical prod product safety alerts or order product recalls withdrawals or iabelin coilects information on other FDA regulated products eg dietary 5 Voluntary reporting by healthcare professionals consumers and tea Reporting can be conducted oniine by phone or by submitting the t The National Fire incident Reportino System NFiRS39i The National Fire incident Reporting System NFJR S collects and n re departments across the Uniteoi States Authonized by the Federa Data Center in the United States Fire Administration USE391 helps E capability tor their own use and obtain data that can be used to ass and optional reports are completed by re departments for their res simple computerized database HEALTH SERVICES RESEARCH HSR METHODS w M View Full Elanay MI View Tennis By ul atebases and Data Soumes Bunny Dal Pollcy and Legal Analysis mlltative Analyse uenltteltiie Analyse Rehiltty and uhlldlly Conoeprte rid Models Keyword Seareh r Glossary List Survey Data The Communi Tracitin Stud CTS The Community Traciting Study CTSJ is a longitudinal study which tracks American oommunities The ITS was established in 1996 with sponsorshi conducted by the Center for Studying Health System Change iHSC The I randome selected communities The Household Survey Physician Survey under contract by private organizations but employ the same method of dz interviews of the same community The Current Population Survev The Current Population Survey CPS was established in 194039 as a house rate and earnings for ditterent population groups The March supplement 3 information and income The CPS is conducted monthlyr through oooperatlu Census Bureau Data is collected through telephone and lidperson intends The Health and Retirement Study tHRS The Health and Retirement Study HRS is oonduoted biennially through It information on the health employment family and retirement planning am over The HRS was that conducted in 1992 and currently includes a samplu Among the Oldest Old AHEAD study The Joint Canadai39United States Survey of Health The Joint Canadai39United States Survey of Health is a coliaborative project for Health Statistics NCHSJ of the US Center tor Disease Control and Pr November 4 2002 and ended March 31 2003 represents the ten Canadie Columbia The analytical report in this publication compares Canadians an inf lll tn l cel nnr ni39trnd hanlilh hrnnin r nnditinno flinnlinnnl Mali ic l39ifnoeli39 HEALTH SERVICES RESEARCH HSR METHODS View Full Glmary Lilt The National Survey of Children39s Health View Terms Ey Daiabaeee and Data Entrees The National Survey of Children s Health examines the physical and emotional health oi children age quotEmits and Human 3m Sponsored by the Maternal and Child Health Bureau of the Health Resources and Services Administr im vmm nn and mm Analysis from January of 2003 to July of 2004 Results are stored in an interactive public database housed by Human Senices called the Date Resource Center for Child and Adolescent Health The survey can i quotPam and Legalms for the NCHS State and Local Area integrated Telephone Survey SLAITSi Special emphasis is piac Qm39mm M95515 to wellbeing of children including medical issue family interactions parental health school and after Cluanllta ve Analysis neighborhoods Telephone interviews are conducted in all 50 states and the District of Columbia and Reliability and Validity without telephones iSottwate anti rarrtmin 5 PM 9 Further Reading Author Summary of Surveys and Data Systems AcademyHeaith 2004 Also see httpziiwwcdcpoy WWW m3 iNbHssiimeyuatnxpat Word Search Summary of Surveys and Data Systems National Center for Health Statistics June 2004 US DEPARTMENT OF HEALTH AND HUMAN SERVICES I Centers for Disease Control and Prevention I National Center for Hearth Statis cs Current NCHS Surveys and Data Systems Data Source Salaried Applications Plarrned RaceEH1ch Married of Data Produced Sartrpie art 55 1 oddty 0032007 Vital Statistics Coope39ative Program VS P National Health and u i i FEM Examinath Survey NHAN ES National Health lntenrrew Survey IS ier State vital registration Linked Blrthllnfant Death Program Matched multiple data sets Pe sonal interView Physrcaicxaminatim Laboratory tests Nut39rtrona assessment DNA reposrtory I Personal interviews isle expectancy All trirths Causes of death r million remd3 annually I Infant rrorta r Alldeaml Prenatal care and ol39t nwelgi39it Both rates Nonmantar births Pregnancy outcomes I Occupational mortally Teenage pregnancy I Method of dEWEW I M rates by brth and period cohots IM rate by txrthwerght J reterm dellvey I Multiple births eerinata mortalty Maternal smo eng about 24 39riilllon reco ds annually weeks grstatlo about 30000 annua ly I Counts of marriages and dvorces 39l39ota prevalence of disease or Co39ldlDOl39E including those unrecognized or undetected I Nutrition monitoring Heart disease I Diabetes Gsteoporosis Iron de ciency anemia and other nutritional disorders Entron39nentai exocsues monitoring Children s growth amp development Infectious disease monitonng Overwerglrtilrnyscai r tness I 3000 persons per year all a m I Oversample adolescents Olrersampie 60 Drersample B acks is Mexican Americans Pregnantwomen Annual data on Health status and limitations Utsllzauon or health care I In ur es Family YBMFCE Health Insurance Access to care Seleoted conditions Hoaim behaviors I 40000 houserolds I Dyersampie blacks and I Repoited fetal deaths of 20 n Fo births deaths and fetal deaths White Black 5 API groups American Indian 5 Hispanic groups I Education Births it deaths 10 AP group from 11 States I Marital status All Years Income a potwry llldEJt Education Occupation Type of living quaters I Sooai sewices Black White amp Mex Amer Hot to 1982 I White Black Other Birthgace 198 0MB categories Acculturation qluesuons re language usua ly spoken at home I 0MB categori Hispanic groups API groups I faintly amp indlvldual income Er poverty level Education Mecuoation sample pe scin only Type of illmg quarters Aoculturation quesuons re Annual Annual wrtn capability for longrtudna39 toliowup Annual hutsHunt Continue monthly annual data Fuly automate system to unite and reengineer the Engllathl39l Implement revised cet cates ree39rgineenng process inp emerrt new OMB race gold Eiazuate quality of new data he Implement new data access irlt Data coilectron for annual sans Data releases on 2yea39 cycres Surveys of other population grc or State am local geographlc a Community HANES are DEle considered Work to improve timeliness Provides sampling frame to the Expenditure Panel Survey I Supplements 2002 Complementary and at Healthy People 2010 Objective Chlldren39s mental ealth Healthy People 2010 Objectives 2005 Carter Control HSRR Health Services and Sciences Research Resources Data Sets Prepared for the National Information Center on Heatth Services Research and Health Care Technology NICHSR under the National Library of Medicine NLMII SOURCE TITLE NS Norsk Dental agent s Fond Caries Prevalence in Norwegian Children and Adolescents AcademyHealth formerly Association Directory of Traininq Proqrams in Hearth Services and Health for Health Services Research W 1991 Longitudinal Follow ug to the National Matemai and Infant Health Survey Adogtion and Foster Care Analysis and Reportinq System Emer en Tem ora Assistance for Nee Families Data Re rt System Federal Child Care Infonnation stem Head Start Pmram Information Regori National Child Abuse and N iect Data System Runaway and Homeless Youth Management information S ten39i Administration for Children and Universi Afflllated Pro rams National Information and Re ortin Families National Aging Programs Information System State Performance Administration on Ami m Adolescent and School Health nationa center for Chronic if 3353 School Health Policies and Procrrams Study Prevention and Health Promotion CDC Agency For Healthcare Research and Consumer Assessment of Hearth Plans Study Quality IAH RQI HIV Cost and Services Utiiization Study HIVnet Health Care Report Card Compendium ui nA 4 LI n L Department If Health and Human Services Centers for Disease Cuntroi and Preventinn National Efltf f fOI Sta stiCSMmui mfng we JUNE133 Hm i Publici a nns Pmcdmts Whath New gt Ambulatory Surgery lnfarmation Sheet El in the United States Pm 2006mdre AUQUStZ mG P F E mam I Summary cf Surveys and Data Systems b gt Fetal and Perinatal I Modality United I r V States 2005 more W 153 393 1 magma Page Content 5 WHO Ad pk w Vatat Statistics Ceogeraltive Program l v39SCP I Charactet iatics Of 39 Natlahall Health and Nutrition Examinatien Survey tNHANES Women and Men Naminnall Health interview Survey tNi il Who Have Adopted a National Hospital Dischame Survey NilI Di Childrenmmofe Netianall Ambulatory Medical Care Survey NAMCSU 1 25392 009139 National Hosgital Ambulatom Medical Care Surveg t NHAMCS Ann uncememts Maaanal Sumegef Familv Grewth NSFGl A Natuanall Immunization Survev I39NlSl tin earthershm Wrath CDCNIP gt w Netidna Survey of Children Iwith Special Health Care Needs gt Listsetws a Newlenall Survey ef Children s Health angering Infuma a o Nahienail Death Index NDII I National Nursmq Home Suwev NNHSi 3 W a National Nursihe Assistant Survev iNNASl gt Birth Death Natidnall Survey of Residential Care Facilities Marriage and Divorce o Natlanall Survey at Ambulatem Sum egg 1 NSASI Certi cates 1 Naltianall Survey of Adea39tive Parents iHSA Pl gt Gavernmem priminu National Survey ef Early Childhood Health Of ce Grder Form National Home and Husnice Care Survev iMHi lcg o Marianaquot Health ilrtlemiew Hurrvev rm inisahililu ifMHlSD39I Research Funding I Where does the money come from for research projects I Selffunded l Consultation payments I Public and private contracts I Public and private grants Research Proposal I How do you get money for research Submit a proposal I Preliminary work done before you write the proposal I Format use particular format required by the funder I Body of the proposal contains the following sections Title Page Table of Contents Abstract Project Description next slide References Budget and Justification Human Subjects Appendices Project Description Format I Introduction I Problem statement and significance I Goals and objectives I Methods and procedures I Evaluation I Dissemination Proposal Review Process I Can be lengthy I Involves teams of reviewers I Involves several layers of review including evaluation of the organization university submitting the proposal to ensure that the resources to conduct the work are adequate Introduction to Health Services Research Chapter 12 m Spring 2011 Vicky Debold RN PhD Week 11 Measurements in HSR I Definition I Levels of Measurement I Measurement Errors I Validity and Reliability of Measurement I Research Instrument Design Definition I Measurement I The process of specifying and operationalizing a given concept I Identify concept dimensions and indicators for dimensions eg Quality structure process outcome and satisfaction I Identify the questions and the response categories and assign codes eg gender male 1 female O I Context matters primarysecondary data research population Acute care quality v longterm care quality Definition I Measurement I Try to use established measures Reliability the ability to repeat research and replicate findings Validity the extent to which the measure assesses what it purports to measure I Collection methods Direct observation selfreports I Exhaustive measures The response categories are sufficiently broad I Mutually exclusive measures Responses can only be assigned to one category Levels of Measurement Nominal I Not rankordered cannot measure distance between categories Gender Ordinal I Rankordered o Satisfaction level strength of preference I Interval I Rankordered equal distance between categories zero is arbitrary temperature I Ratio I Rankordered equal distance nonarbitrary zero ANA HAAMA Anlllhnllinn nlnlt Measurement Errors I Deals with the observed differences between subjects I Refers to that portion of the difference that is NOT a true difference but is the result of how the differences were measured I Two types I Systematic serious threat related to validity Due to bias that affects measurement in a consistent way inaccurate concept operationalization social desirability issues low response rates high attrition I Nonsystematic less serious related to reliability Due to bias that affects measurement in a haphazard random way fluctuating interestmood differences in comprehension fatigue distractions improper interview methods interpersonal issues Validity and Reliability I Validity I Deals with accuracy Do get the right answer I The degree to which the important dimensions of a concept have been captured and operationalized appropriately I Reliability I Deals with reproduceability lfl do it more than once do get about the same answer I The degree to which consistent results are obtained when the measure is applied to similar elements I Valid measures should be reliable but a reliable Types of Validity I Facevalidity I Does it sound right I Constructvalidity l Does the measure capture all the important dimensions convergence and discriminant tests I Content validity I Do the response categories represent the concept s dimensions I Concurrent validity I Do instruments that measure similar concepts yield similar results I Predictive validity I Does the instrument accurately predict future results Types of Reliability I Testretest reliability I Does the measure applied to a group at two different times yield the same result Parallel forms of reliability I Does about the same test applied in close proximity yield the same result Internal consistency reliability I Does a test randomly split in half yield the same result lnterrater reliability I Do two different people administering the procedure yield the same result Improving Validity and Reliability I Use established measures I Insure confidentiality I Strengthen research instrument I Train research staff I Conduct pretest or pilot test I Validate instrument Research Instrument Design I Frame of reference I Understanding respondant characteristics ahead of time I Time frame I Past present future telescoping recall bias I Response format I Open or closeended respondent investigator burden contingency and skip patterns twoway and multiple choice questions forced ranking scales questions fixed sum questions agreement scale questions Likerttype scale questions semantic differential scale