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Why Health Services Research Fails to Deliver: Complexity and Context

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Complex Systems in Medicine

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Abstract

There have been many critiques of health services research. Sometimes it has been called ‘academic,’ meaning not of practical relevance or of only theoretical interest. Another criticism that I have heard (and made) that health services researchers prove the obvious. There are several articles that provide so called ‘lessons learned’ or prove the importance of one factor or another and these have been published in “high impact journals.” Some of the factors associated with implementation success have been known for millennia, e.g., leadership, (see Book of Exodus) and the leader’s vision (see Proverbs 29:18). Health services researchers would be more useful if they looked at how to implement something in the face of poor leadership or how to accomplish things when space is a constraint, i.e., we need to examine more carefully and productively the intervention by context interaction. My perspective about health services research concerning interventions is that it must be closely linked to clinical operations; linking research and system improvement would be a good strategy to both provide the answers and improve quality simultaneously, though it doesn’t always work out that way.

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Notes

  1. 1.

    Ceteris paribus if it is acknowledged that the prediction, although usually accurate in expected conditions, can fail or the relation can be abolished by intervening factors. https://en.wikipedia.org/wiki/Ceteris_paribus

  2. 2.

    See also: Deuteronomy 5:11–14. Observe the sabbath day, to keep it holy, as the LORD thy God commanded thee. Six days shalt thou labour, and do all thy work; but the seventh day is a sabbath unto the LORD thy God, in it thou shalt not do any manner of work, thou, nor thy son, nor thy daughter, nor thy man-servant, nor thy maid-servant, nor thine ox, nor thine ass, nor any of thy cattle, nor thy stranger that is within thy gates; that thy man-servant and thy maid-servant may rest as well as thou. And thou shalt remember that thou wast a servant in the land of Egypt, and the LORD thy God brought thee out thence by a mighty hand and by an outstretched arm; therefore the LORD thy God commanded thee to keep the sabbath day. Interestingly, the idea of a day of rest for the working class was an innovation and by no means the usual practice. The Jewish Sabbath was criticized by first Century Roman Seneca the Younger who was quoted by Augustine in City of God: ‘Seneca, among the other superstitions of civil theology, also found fault with the sacred things of the Jews, and especially the Sabbaths, affirming that they act uselessly in keeping those seventh days, whereby they lose through idleness about the seventh part of their life, and also many things which demand immediate attention are damaged. (De Civitate Dei. 6:11) Nevertheless the concept caught on.

  3. 3.

    https://en.wikipedia.org/wiki/Contract_bridge. 2 July 18.

  4. 4.

    One of the criteria for human subjects research is that it be intended to be generalizable, although no good operational definition (i.e., one that distinguishes research from quality improvement or just thoughtful life) has been provided by OHRP or anyone else for that matter.

  5. 5.

    Don’t you just love this term? It is a measure of the rate of filled pauses (“uh,” “er,” and “um”) during classroom lectures for undergraduate courses (a negative indicator suggesting some imprecision in basic disciplinary concepts at least according to [50]).

  6. 6.

    If you want truly to understand something, try to change it. Attributed to Kurt Lewin in: Charles W. Tolman (1996) Problems of Theoretical Psychology – ISTP 1995. p. 31. https://en.wikiquote.org/wiki/Kurt_Lewin

  7. 7.

    There’s that word again.

  8. 8.

    The fact that research was at the heart of this is evident both in its name and in the financing of QUERI. It was clear that there needed to be an increase in the budget of HSR&D. However, the VA’s research budget is a separate line item in the legislation and the likelihood of increasing it was low. It was possible to re-allocate money within the research budget from basic and clinical research to HSR&D, but that was viewed as a non-starter. At the time of QUERI’s launch, the availability of VA research funds in basic and clinical research was an important recruitment tool for specialists who could get higher salaries in the private sector. To move money from the medical care budget to research was not allowed. Therefore, a workaround was needed. It was possible to use medical care dollars for quality improvement so that QUERI was designated a quality improvement initiative. This was done with the agreement of the network directors from whom the money would be taken. They wanted help in improving care too.

  9. 9.

    I was a clinical coordinator of the diabetes QUERI along with my best friend leonard pogach. Although we had clinical experience as endocrinologists, we were really researchers as were the research coordinator and implementation coordinator. Later, I was replaced as clinical coordinator with an actual clinician, i.e., someone who spent most of her time in the clinic. I then became a member of the executive committee of the diabetes QUERI.

  10. 10.

    I thought that researchers should be directly involved in quality improvement. In fact, I felt that there was no fundamental distinction between research and QI. Nevertheless, QI was not what got academic researchers promotions. Publications in research journals did and those journals have not liked to publish QI projects. Many of them are not done with the kind of rigor necessary to be able to draw conclusions. Moreover, the context is usually not described with sufficient detail to allow someone to make inferences to their own context.

  11. 11.

    QUERI began with the noblest intentions, but at its heart it was also a workaround. The problem being faced was that the budget for VA research is a line item separate from the rest of the budget and is voted on by Congress separately. There was little likelihood of an increase to support a bigger HSR&D group that was felt to be necessary for VA’s transformation. Moreover, shifting resources within ORD was considered to be too disruptive and possibly counterproductive; the ability to get VA research funding is an incentive in recruiting subspecialists and was particularly important when the disparity between VA and private sector physician incomes was huge. It still exists particularly in some sub-specialties, e.g., orthopedic surgery, but it is less of an issue today. Although the amount of money for QUERI was relatively small and just a tiny proportion of the overall medical care budget, shifting medical care dollars to research was not allowed. The solution was to integrate research and operations and view this as a quality initiative that could be supported by medical care dollars. Particularly considering the results, some might consider this a scam, but I think the term workaround fits better. Certainly, there was no financial payback to the project’s originators.

  12. 12.

    I moved to New York City and begin junior high school (seventh grade). I remember being ushered into the auditorium early on and getting a lecture on sets and Venn diagrams. I had never heard of such things. I am not sure that the teachers had either. Another session was on using alternatives to the usual base 10. Of course, we didn’t think about it as base 10, it was just the way we counted and used numbers. These alternatives included everything from base 2 through base 12. This was the “New Math.” This was a short-lived but dramatic change in the way mathematics was taught. Apparently, it was part of the response to the challenge presented by the Soviet launch of Sputnik in 1957. We needed to be better prepared to compete with the Soviets, i.e., godless communists.

    For a highly amusing satire, I recommend a song by Tom Lehrer – New Math. https:// www.youtube.com/watch?v=Vetg7vWitTU

  13. 13.

    The population at high risk for hypoglycemia (hence overtreatment) included patients taking a diabetes drug known to have a relatively high frequency of hypoglycemia (insulin and/or sulfonylurea agents) plus having at least one of the following additional criteria: age 75 years or older, chronic kidney disease (defined as last serum creatinine measurement in a year greater than 2.0 mg/dL; to convert to micromoles per liter, multiply by 88.4), or an ICD-9-CM diagnosis of cognitive impairment or dementia in ambulatory care.

References

  1. Ecclesiastes 1:9-11 (Jewish Publication Society 1917). http://www.mechon-mamre.org/p/pt/pt0.htm. 30 Nov 15.

  2. http://archive.ahrq.gov/news/newsletters/research-activities/apr10/0410RA.pdf

  3. Bible translations and numbering from the JPS 1917 Edition. http://www.mechon-mamre.org/p/pt/pt0.htm. 30 Nov 15.

  4. Cohen NJ. Moses and the journey to leadership: timeless lessons of effective management from the Bible and today’s leaders. Woodstock: Jewish Lights Publishing; 2008.

    Google Scholar 

  5. Chang ET, Rose DE, Yano EM, Wells KB, Metzger ME, Post EP, Lee ML, Rubenstein LV. Determinants of readiness for primary care-mental health integration (PC-MHI) in the VA health care system. J Gen Intern Med. 2013;28(3):353–62.

    Article  Google Scholar 

  6. https://en.wikipedia.org/wiki/Contract_bridge. 2 July 18.

  7. Simonton DK. Psychology’s status as a scientific discipline: its empirical placement within an implicit hierarchy of the sciences. Rev Gen Psychol. 2004;8:59–67.

    Article  Google Scholar 

  8. Feinstein AR. Basic biomedical science and the destruction of the pathophysiologic bridge from bench to bedside. Am J Med. 1999;107(5):461–7.

    Article  CAS  Google Scholar 

  9. Flyvbjerg B. Making social science matter: why social inquiry fails and how it can succeed again. Oxford/New York: Cambridge University Press; 2001.

    Book  Google Scholar 

  10. Vepsäläinen K, Spence JR. Generalization in ecology and evolutionary biology: from hypothesis to paradigm. Biol Philos. 2000;15(2):211–38.

    Article  Google Scholar 

  11. Gorovitz S, MacIntyre A. Toward a theory of medical fallibility. J Med Philos. 1976;1(1):51–71.

    Article  Google Scholar 

  12. de Vries MJ. Engineering science as a “discipline of the particular”? Types of generalization in engineering sciences. In: Van de Poel I, Goldberg DE, editors. Philosophy and engineering: An Emerging Agenda. Dordrecht: Springer; 2009. p. 83–93.

    Google Scholar 

  13. Institute of Medicine. To err is human: building a safer health system. Washington, DC: National Academy Press; 1999.

    Google Scholar 

  14. Institute of Medicine. Crossing the quality chasm: a new health care system for the 21st century. Washington, DC: National Academy Press; 2001.

    Google Scholar 

  15. Demakis JG, McQueen L, Kizer KW, Feussner JR. Quality Enhancement Research Initiative (QUERI): a collaboration between research and clinical practice. Med Care. 2000;38(6 Suppl 1):I17–25.

    CAS  PubMed  Google Scholar 

  16. Kizer KW, Demakis JG, Feussner JR. Reinventing VA health care: systematizing quality improvement and quality innovation. Med Care. 2000;38(6 Suppl 1):I7–16.

    CAS  PubMed  Google Scholar 

  17. McQueen L, Mittman BS, Demakis JG. Overview of the Veterans Health Administration (VHA) Quality Enhancement Research Initiative (QUERI). J Am Med Inform Assoc. 2004;11(5):339–43.

    Article  Google Scholar 

  18. Feussner JR, Kizer KW, Demakis JG. The Quality Enhancement Research Initiative (QUERI): from evidence to action. Med Care. 2000;38(6 Suppl 1):I1–6.

    CAS  PubMed  Google Scholar 

  19. Milat AJ, Li B. Narrative review of frameworks for translating research evidence into policy and practice. Public Health Res Pract. 2017;27(1):e2711704.

    Article  Google Scholar 

  20. Trochim W, Kane C, Graham MJ, Pincus HA. Evaluating translational research: a process marker model. Clin Transl Sci. 2011;4(3):153–62.

    Article  Google Scholar 

  21. Cooksey D. A review of UK health research funding. London: The Stationery Office; 2006.

    Google Scholar 

  22. Papp K, Aron DC. Reflections on ‘Academic Duty’. Med Teach. 2000;22:406–11.

    Article  Google Scholar 

  23. Mittman BS. The quest for success in health care quality improvement: knowledge, will and ability. Washington DC. 13 Dec 2002.

    Google Scholar 

  24. Van De Ven A, Johnson P. Knowledge for theory and practice. Acad Manag Rev. 2006;31:802–21.

    Article  Google Scholar 

  25. Horner RD, Russ-Sellers R, Youkey JR. Rethinking health services research. Med Care. 2013;51(12):1031–3.

    Article  Google Scholar 

  26. Russ-Sellers R, Youkey JR, Horner RD. Reinventing the health services researcher. Med Care. 2014;52(7):573–5.

    Article  Google Scholar 

  27. Thompson DS, Fazio X, Kustra E, Patrick L, Stanley D. Scoping review of complexity theory in health services research. BMC Health Serv Res. 2016;16:87.

    Article  Google Scholar 

  28. Davidoff F, Batalden P, Stevens D, Ogrinc G, Mooney S, SQUIRE Development Group. Publication guidelines for improvement studies in health care: evolution of the SQUIRE Project. Ann Intern Med. 2008;149(9):670–6.

    Article  Google Scholar 

  29. Howell V, Schwartz AE, O’Leary JD, Mc Donnell C. The effect of the SQUIRE (Standards of QUality Improvement Reporting Excellence) guidelines on reporting standards in the quality improvement literature: a before-and-after study. BMJ Qual Saf. 2015;24(6):400–6.

    Article  Google Scholar 

  30. Goodman D, Ogrinc G, Davies L, Baker GR, Barnsteiner J, Foster TC, Gali K, Hilden J, Horwitz L, Kaplan HC, Leis J, Matulis JC, Michie S, Miltner R, Neily J, Nelson WA, Niedner M, Oliver B, Rutman L, Thomson R, Thor J. Explanation and elaboration of the SQUIRE (Standards for Quality Improvement Reporting Excellence) Guidelines, V.2.0: examples of SQUIRE elements in the healthcare improvement literature. BMJ Qual Saf. 2016;25(12):e7.

    Article  Google Scholar 

  31. Mosher H, Ogrinc G. Between the guidelines: SQUIRE 2.0 and advances in healthcare improvement practice and reporting. BMJ Qual Saf. 2016;25(8):559–61.

    Article  Google Scholar 

  32. Ragin CC. Using qualitative comparative analysis to study causal complexity. Health Serv Res. 1999;34(5 Pt 2):1225–39.

    CAS  PubMed  PubMed Central  Google Scholar 

  33. Ragin CC, Shulman D, Weinberg A, Gran B. Complexity, generality, and qualitative comparative analysis. Field Methods. 2003;15:323–40.

    Article  Google Scholar 

  34. Richardson KA. Methodological implications of complex systems approaches to sociality: Some further remarks. J Artif Soc Soc Simul. 2002;5(2):1–1.

    Google Scholar 

  35. Kapsali M. Equifinality in project management exploring causal complexity in projects. Syst Res Behav Sci. 2013;30:2–14.

    Article  Google Scholar 

  36. Gresov C, Drazin R. Equifinality: functional equivalence in organization design. Acad Manag Rev. 1997;22(2):403–28.

    Article  Google Scholar 

  37. Kahwati LC, Lewis MA, Kane H, et al. Best practices in the Veterans health administration’s MOVE! Weight management program. Am J Prev Med. 2011;41(5):457–64.

    Article  Google Scholar 

  38. Marsh DR, Schroeder DG, Dearden KA, Sternin J, Sternin M. The power of positive deviance. BMJ. 2004;329:1177–9.

    Article  Google Scholar 

  39. Sternin J. Practice positive deviance for extraordinary social and organizational change. In: Carter L, Cooperrider DL, et al., editors. The change champion’s field guide: strategies and tools for leading change in your organization. San Francisco: Wiley; 2013. p. 20–37.

    Google Scholar 

  40. Pascale R, Sternin J, Sternin M. The power of positive deviance: how unlikely innovators solve the world’s toughest problems. Boston: Harvard Business Press; 2010.

    Google Scholar 

  41. Mainemelis C. Stealing fire: creative deviance in the evolution of new ideas. Acad Manag Rev. 2010;35:558–78.

    Google Scholar 

  42. Spreitzer G, Sonenshein S. Toward the construct definition of positive deviance. Am Behav Sci. 2004;47:828–47.

    Article  Google Scholar 

  43. Vadera A, Pratt M, Mishra P. Constructive deviance in organizations: integrating and moving forward. J Manag. 2013;39:1221–76.

    Google Scholar 

  44. Baxter R, Kellar I, Taylor N, Lawton R. How is the positive deviance approach applied within healthcare organizations? A systematic review of methods used. BMC Health Serv Res. 2014;14(Suppl 2):7.

    Article  Google Scholar 

  45. Aron DC, Lowery J, Tseng C-L, Conlin P, Kahwati L. De-implementation of inappropriately tight control (of hypoglycemia) for health: protocol with an example of a research grant application. Implement Sci 2014;9:58. (May 19). http://www.implementationscience.com/content/9/1/58.

  46. Wilson B, Tseng CL, Soroka O, Pogach LM, Aron DC. Identification of outliers and positive deviants for healthcare improvement: looking for high performers in hypoglycemia safety in patients with diabetes. BMC Health Serv Res. 2017;17(1):738.

    Article  Google Scholar 

  47. Aron DC, Wilson B, Tseng CL, Soroka O, Pogach LM. Positive deviance in health care: beware of pseudo-equifinality. In: Sturmberg JP, editor. Putting systems and complexity sciences into practice. Cham: Springer; 2018. p. 189–98.

    Chapter  Google Scholar 

  48. Lindberg C, Clancy TR. Positive deviance: an elegant solution to a complex problem. J Nurs Adm. 2010;40:150–3.

    Article  Google Scholar 

  49. Spindler M, Wagenheim G. Positive deviance: sparks that ignite systems change. Chall Organ Soc. 2015;4:647–9.

    Google Scholar 

  50. Schachter S, Christenfeld N, Ravina B, Bilous F. Speech disfluency and the structure of knowledge. J Pers Soc Psychol. 1991;60(3):362.

    Article  Google Scholar 

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  1. School of Medicine and Weatherhead School of Management, Case Western Reserve University and Cleveland Veterans Affairs Medical Center, Cleveland, OH, USA

    David C. Aron

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Aron, D.C. (2020). Why Health Services Research Fails to Deliver: Complexity and Context. In: Complex Systems in Medicine. Springer, Cham. https://doi.org/10.1007/978-3-030-24593-1_11

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