Future Directions in Primary Care Research

Special Issues for Nurses

Nursing research information, grant process guidance, career development opportunities, nursing agenda, and staff nurse contacts at the Agency for Healthcare Research and Quality.

The information presented in this article was originally published in Policy, Politics, and Nursing Practice (Volume 2, Number 2, May 2001).

Contents

Overview
Reauthorization
Quality of Care
Nurse Staffing
Primary Care
Practice-Based Research
Nurse Scholar
Nurse Grant Applicants
References

Overview

How treatments work in practice rather than in basic and clinical research studies is the domain of the Agency for Healthcare Research and Quality (AHRQ). The Agency conducts and funds research into health services research, especially the effectiveness of treatments—including patient outcomes, treatment costs, and accessibility. AHRQ also is concerned with the quality of care, including major initiatives in patient safety and medical errors. The article outlines the role of the Agency in primary care research, and particularly its role in nursing research. The authors note the role of the Agency in developing a research agenda for nurse staffing research and outline initiatives and programs of interest to nursing researchers.

Although new treatments are studied under controlled conditions—typically with support from the National Institutes of Health (NIH)—to determine their efficacy, how these treatments work in the real world of primary care is more difficult to assess. For example, a controlled trial may show that a particular antibiotic is effective in reducing the inflammation associated with childhood otitis media, but determination of whether antibiotic treatment improves patient outcomes requires a different set of research designs, generally with support from the Agency for Healthcare Research and Quality (AHRQ).

The assessment of the effectiveness of patient outcomes and of treatment cost and accessibility—as opposed to the assessment of treatment efficacy alone—is not a new field of research. Its modern roots go back at least to 1968, when the National Center for Health Services Research was established within what was then the U.S. Department of Health, Education, and Welfare. In 1989, this center became the Agency for Health Care Policy and Research, which was reauthorized by Congress in 1999 as AHRQ. The reauthorization affirms the Agency's existing goals and research priorities:

  • Support improvement in health outcomes.
  • Strengthen quality measurement and improvement.
  • Identify strategies to improve access, foster appropriate use, and reduce unnecessary expenditures.

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Reauthorization

The Center for Primary Care Research (CPCR) at AHRQ was named in a statute as part of the 1999 reauthorization process. CPCR was codified as the major Federal source of funding for primary care practice research in the Department of Health and Human Services and the focal point of research on access, quality, and cost of primary care services, as well as patient-provider communication, generalist-specialist issues, and workforce issues in primary care.

The legislation also codified the Medical Expenditure Panel Survey (MEPS) and the U.S. Preventive Services Task Force (USPSTF). It directed the Agency to advance the use of information technology for coordinating patient care and for undertaking quality and outcomes research. The legislation also directed the Agency to address the needs of specific priority populations:

  • Residents of inner-city, rural, and frontier areas.
  • People with low incomes.
  • Elderly, children, women, and minorities.
  • People with special health care needs, including disabilities, chronic care, and end-of-life health care.

At the end of last year, Congress passed the fiscal year 2001 appropriations bill for the departments of Labor, Health and Human Services, Education, and related agencies, which the President subsequently signed. The bill recommended $270 million for AHRQ in fiscal year (FY) 2001, which is approximately $70 million above the FY 2000 level and $20 million above the president's request. The increase includes $50 million to conduct and support research to enhance patient safety, initiatives that are expected to involve the nursing community. The increase also provides $10 million to support research related to health care workers and the quality of health care, especially to examine the relationship between the health care workplace and its impact on medical errors and the quality of care provided to patients. The remaining increase will go to activities such as the National Quality Report, research on disparities in care, training, and early career development, and other extramural research initiatives.

In many ways, AHRQ seeks to answer a question put by Rep. John Porter (R-IL), retiring chairman of the House Appropriations Subcommittee on Labor, Health and Human Services (HHS), and Education. "What we really want to get at [in health care research] is not how many reports have been done, but how many people's lives are being bettered by what has been accomplished. In other words, is it being used, is it being followed, is it actually being given to patients—... [W]hat effect is it having on people—" The Agency seeks to assist the health care pipeline, increasing resources for new research on priority health issues to develop tools and talent for a new century, and to translate research into practice. The goals of these activities are improved outcomes for patients, better quality of care, greater access to care, and delivery of care with appropriate cost and use.

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Quality of Care

In addition, a growing focus of the Agency is on reducing medical errors and improving patient safety. Although actively supporting research into these fields, the Agency also serves as part of the Quality Interagency Task Force (QuIC), a group that brings together Federal agencies working on patient safety and other quality issues. In response to an Institute of Medicine (IOM) report, To Err Is Human (IOM, 1999), the QuIC issued Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact (QuIC, 2000). This report, including more than 100 errors-related activities to be taken by various Federal agencies, was released by former President Clinton in February 2000. Fulfilling one of the promised actions, AHRQ organized a "National Summit on Medical Errors and Patient Safety Research," held in September 2000. Bringing together a panel of 14 Federal agency and private sector funders to develop a national research agenda, the meeting drew submissions from a variety of organizations and individuals, including nursing organizations, on research needs in this field.

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Nurse Staffing

Increasingly, nurse staffing is becoming an issue of concern to both the nursing community and the broader community of providers, patients, and policymakers. For example, an October 2000 meeting on working conditions, jointly sponsored by the National Institute of Occupational Safety and Health and AHRQ, included nurse staffing as an issue on the agenda. As cost containment efforts over the past 18 years have led to more selective use of hospital services, hospital organizations have sought to reduce financial concerns by changing nursing services. Because of the financial issues and changes in health care technology, research into the impact of nurse staffing on health outcomes has become of greater importance. Addressing this concern, the Agency has supported research on this topic and has been a cosponsor of a research contract supported by the Health Resources and Services Administration's Division of Nursing, "Nurse Staffing and Quality of Care in Inpatient Units in Acute Care Hospitals." In response to an IOM report on nurse staffing (Wunderlich, Sloan, & Davis, 1996), AHRQ, the American Nurses Association, and the American Association of Nurse Executives sponsored a meeting held by the American Academy of Nursing (AAN) on "Outcome Measures and Care Delivery Systems." The results of that conference was a research agenda (AHRQ, 1997) published in the November 13, 1996, Federal Register and revised in response to public comment. A key need to come out of the meeting was that of refining and standardizing conceptual and operational definitions of such factors as nursing staff level and nursing skill mix. An upcoming solicitation for research grants and conferences will support research on the impact of working conditions on the safety and quality of care.

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Primary Care

A number of research projects related to primary care nursing issues are supported by CPCR, the only one of the AHRQ's six centers and four offices that focuses on understanding the quality effectiveness, cost, and outcomes of primary care; other types of nursing research are considered by the Agency's remaining centers. CPCR investigates issues surrounding:

  • Patient-provider communication.
  • The relationship between medical generalists and specialists.
  • The health care workforce.
  • Access to care, including racial and ethnic disparities.

All of these are issues of strong interest to the nursing community.

The center is also playing a lead role within AHRQ on initiatives concerning ambulatory patient safety. In cooperation with the Health Care Financing Administration (HCFA), AHRQ has begun working toward understanding patient safety and medical errors in the outpatient setting. A recent conference sponsored by AHRQ and HCFA addressed the epidemiology of medical errors in the ambulatory setting and began to develop a research agenda and demonstration programs to address this issue. In particular, researchers need to understand how primary care providers can help to reduce the high-risk errors, such as medication errors and missed followup of laboratory and radiology tests.

CPCR has been designated as the lead for the Agency on clinical informatics. As part of our reauthorization, AHRQ was directed to support the use of information technology (IT) to improve patient coordination, quality of care, and patient outcomes. AHRQ's unique role in IT will focus primarily on those applications that can improve care and patient safety. An upcoming grant solicitation will support work in this area.

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Practice-Based Research

Recently, AHRQ awarded planning grants to 19 primary care Practice-Based Research Networks (PBRNs), a program administered by the center. These networks are groups of practices—devoted principally to the care of patients—that have affiliated with each other (and often with an academic or professional organization) to investigate questions related to community-based practice. Nurses will be an important component of these networks, which are expected to be ongoing structures designed to function over more than a single study. Together, the PBRNs will be able to engage in research with more than 5,000 primary care practice settings and almost 7 million patients across the United States. One of the networks, directed by Margaret Grey, Ph.D., B.S.N., at Yale, will focus on nurse-practitioner practice.

For FY 2000, the selected PBRNs recently received $75,000 in planning grants. During this fiscal year, the networks will be expected to:

  • Implement the computer-based collection of research data from the participating practices.
  • Expand the scope of the networks and include larger numbers of minority or underserved patients.
  • Plan how to translate new research findings into clinical practice.

AHRQ, in partnership with other Federal funding agencies and foundations, will also provide funds to conduct research in the context of the primary care PBRNs. These directed funds will likely support work in the area of patient safety, working conditions, mental health, and health care disparities.

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Nurse Scholar

Of direct interest to the nursing community, AHRQ and the AAN have joined forces since 1995 to put a senior nurse scholar in place at the Agency to help AHRQ develop areas of investigation that integrate clinical nursing care questions with critical issues of quality, effectiveness, cost, and access to health care.

The first senior nurse scholar was Christine Kovner, Ph.D., R.N., F.A.A.N., of the New York University Division of Nursing, selected in 1995. While at AHRQ, Dr. Kovner focused on the impact of nurse staffing on quality of care. She was succeeded in 1997 by Lorraine Tulman, D.N.Sc., R.N., F.A.A.N., of the University of Pennsylvania School of Nursing. During her stay at AHRQ, Dr. Tulman looked at the literature on controlled clinical trials in women that use functional status as an outcome measure. Subsequently, Linda Moody, Ph.D., F.A.A.N., of the University of South Florida served as the senior nurse scholar. While at AHRQ, she focused on avoidable adverse outcomes in cognitively impaired nursing home residents. Our most recent senior nurse scholar, Sally Lusk, Ph.D., R.N., F.A.A.N., of the University of Michigan, focused on issues related to primary care services and occupational health, particularly the prevention of noise-induced hearing loss. She also worked closely with the USPSTF and helped to develop a research agenda on worker health.

In addition, nursing is represented on the Agency's National Advisory Council by Marita Titler, Ph.D., R.N., F.A.A.N., Mary Katherine Wakefield, R.N., Ph.D., F.A.A.N., and Colleen Conway-Welch, Ph.D., C.N.M, F.A.A.N. To help improve the communications between AHRQ and the nursing community, the Agency is developing a nursing page for its Web site ().

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Nurse Grant Applicants

The Agency is actively encouraging more grant applications from nurses as principal investigators. Since 1994, nurse principal investigators have accounted for 4 percent to 7 percent of the total pool of AHRQ research grant applicants, and 2 percent to 9 percent of all funded grants during this period. Many of AHRQ's priority areas are especially relevant to nurse researchers—disease prevention, health promotion, primary care, quality of care delivery, and service delivery—and the opportunities for nurse principal investigators are good. However, although the Agency's funding has been increasing the past several years, much of the increase has been in specific program areas designated by Congress, such as medical errors and patient safety; in consequence, the amount of funds available for general investigator-initiated grants has been limited. 

Despite this, there has been an approximately 27 percent funding rate for grant applications from nursing principal investigators in recent years (select Figure 1, 28 KB). This suggests that it is the low rate of nursing applicants, rather than the funding level, that has produced the paucity of nursing research projects at AHRQ. To combat this, we need more nurse investigators applying to the Agency for support. Details of funding opportunities with the Agency are available at the AHRQ Web site (http://rxdev.ahrq.gov/funding/research/announcements/index.html), including both program announcements (PAs) and requests for applications (RFAs).

AHRQ's slogan is "quality research for quality healthcare." To accurately assess health care cost, access, and quality, it is imperative that we increase the voice of major providers of care in the United States—nurses—in research in these critical areas. With growing nurse-specific concerns, including the worsening nursing shortage and concern regarding the relationship between nurse staffing and quality of care, it is imperative that we increase the role of nurse investigators in health care research.

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References

Agency for Health Care Policy and Research (1997, August 25). Nurse Staffing and Quality of Care in Health Care Organizations Research Agenda.

Institute of Medicine (1999). To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press. Available online: http://books.nap.edu/books/0309068371/html/index.html

Quality Interagency Task Force (2000). Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact. Rockville, MD: Quality Interagency Task Force. Available online: http://www.quic.gov/report/

Wunderlich GS, Sloan FA, and Davis, CK (1996). Nursing Staff in Hospitals and Nursing Homes: Is It Adequate? Washington, DC: National Academy Press. Available online: http://www.nap.edu/books/0309053986/html/index.html

Page last reviewed September 2001
Internet Citation: Future Directions in Primary Care Research: Special Issues for Nurses. September 2001. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/clinicians-providers/resources/nursing/resources/future/index.html