Understanding Context: Learning How Organizations Affect Healthcare Delivery
By Sarah Kobrin, PhD, MPH, Branch Chief of HDRP
Healthcare delivery settings influence every step of how care is given, yet far more work is needed to effectively describe characteristics of these settings; to link those characteristics to outcomes; and to develop setting-changing interventions to improve care quality. NCI and others are working separately and together to build this area of research and welcome collaboration to improve cancer prevention and control.
The Context of Healthcare Delivery
Cancer prevention and control takes place in many settings – community centers, at home, churches, barber shops, and, of course, a wide variety of healthcare settings. For decades, behavior change interventions were creatively tested in settings where people talk and influence each other’s views of smoking, exercise, cancer screening, vaccination, diet, and so on. Academic Public Health understood that interventions to change individual behavior could be more effective in settings where participants felt more comfortable, such as at home; or where a leader’s endorsement could be influential, such as at church; or where peers’ approbation could be heard and followed, such as a barber shop or other social gathering spot. Meanwhile, health services research focused primarily on describing processes of care and measuring patient outcomes. Tremendous advances were made in teasing apart the many processes that constitute “health care” and in measuring impacts of processes on outcomes – as reported by doctors and by patients. However, the two areas of work, even when conducted from the same academic setting, had little influence on each other.
Recently, and increasingly, these two perspectives – behavioral interventions and observations of healthcare processes – are being asked to merge. The context in which interventions are tested can be understood and measured with much more detail than simply capitalizing on an opinion leader or comfortable setting. Observational health services, in turn, can describe processes of care with a finer focus on modifiable characteristics that suggest points of intervention. Models developed to support Implementation Science highlight how the complexity of healthcare contexts affects success in uptake of evidence-based interventions (e.g., Consolidated Framework for Implementation Research, CFIR, Damschroder et al., 2009). We have high hopes that increasing the sophistication with which we conceptualize, measure, and intervene on the interplay across characteristics of healthcare settings, the more successful will be our interventions to improve cancer prevention and control.
Current Efforts to Describe Healthcare Context
Efforts to conceptualize and measure health systems have begun in several places. NCI, other Federal funders, and cancer researchers are focusing on developing the needed conceptual models, measurement tools, and public resources to allow innovative observational and interventional resource.
The Agency for Healthcare Research and Quality (AHRQ) has long funded studies that look at the impact of organizational factors in health systems affect patient outcomes. Recently, they have supported a collection of projects seeking to describe characteristics of high performing health care systems; The Comparative Health Systems Performance Initiative (CHSP) assembled measures available from administrative sources (Cohen et al., 2017) and created the first U.S. Compendium of Health Systems. Following analysis of administrative data, recent qualitative research is identifying organizational characteristics through which health systems influence practice (Ridgely et al., 2019).
NCI’s Healthcare Delivery Research Program (HDRP) is conducting several projects, internally and with extramural investigators, to advance this understanding of healthcare context. The Population-based Research to Optimize the Screening Process (PROSPR) initiative, led by Paul Doria-Rose, Chief of the Healthcare Assessment Research Branch (HARB), was recently funded for a second phase to study cancer screening processes, and to 1. Conceptualize and measure characteristics of all participating healthcare organizations; and 2. Conduct pilot tests of interventions to improve screening by changing one or more characteristics. This work has been underway for 18 months and began by discovering the complexity of attempting to characterize many settings with common terms. For example, PROSPR wanted to test a long-standing hypothesis that cancer screening guidelines and local policies affect what tests are recommended, ordered, carried out, etc. But the working group found no immediately obvious way to measure either the local policies – not written down, the level at which policies are set (per clinic? Per physician? Per insurer?), or even the existence of any enforcement of those policies (e.g., limited options in EHR, normative expectations around test ordering). The early conceptual work is completed and being prepared for publication (Beaber, Rendle, Kobrin et al., in progress).
NCI’s Health Systems and Interventions Research Branch (HSIRB) is directly focused on the merged area of context description and intervention. HSIRB is currently prioritizing how information technology and care teams affect quality of cancer care and outcomes. A key addition is that we are also supporting and conducting research regarding the interplay across these and other components. For example, an intervention that seeks to improve doctor/patient communication by lengthening appointments will affect not only the intended communication outcome but will also affect workflow in the clinic. If we, as researchers, do not measure those workflow changes, we are not fully understanding how our interventions affect our outcomes.
An important assumption in HSIRB’s work is that healthcare setting characteristics need, first, to be understood independent of a particular care process, behavior, or health outcome. This assumption is based on viewing healthcare delivery in the US as so complex that no characteristic will exclusively enable or inhibit quality care. A characteristic, for example, staffing ratio, will enable quality care from the perspective of some stakeholders, but may inhibit quality from the viewpoint of others. That is, the staffing ratio that appeals to management for decreasing costs is likely to be off-putting to patients who may find appointments shorter and provider accessibility decreased. Therefore, we need to develop measures of “staffing ratio” and other characteristics in ways that allow us to measure bivalent impact, depending on the outcome of interest. Several current projects in HSIRB are focused on an evidence gap limiting the progress of research on how context affect outcomes – that is, how do we describe healthcare organizations themselves? The work by AHRQ has shown that administrative data, easily collected, may not describe the characteristics that most influence healthcare processes. In fact, we do not yet know what parts of the organizations will turn out be influential on which downstream actions and ultimately health outcomes.
Initiatives in HSIRB are directed at answering this question; they include a workshop, led by Erica Breslau and held last October at Shady Grove, on Organizational Research in Healthcare, to bring together scientific leaders in health services research, practicing clinicians, and researchers; training on multilevel methods and interventions, developed by Erica Breslau and Brian Mittman; and an upcoming modified Delphi process, involving researchers and practitioners, to generate consensus regarding interpersonal and organizational-level measures that are feasible to collect, have practical relevance, and can be sustainably linked with existing IT systems.
Opportunities for Involvement
Collaborators are welcome from outside and inside NCI as we move this work forward. Immediate opportunities include participation in the Delphi survey, a faculty or student role in the multilevel training, consultation with staff in HSIRB about future directions, and, of course, talking with us about organizationally-focused research proposals. Feel free to contact us; learn about HSIRB here.
Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4:50. doi:10.1186/1748-5908-4-50 .
Cohen GR, Jones DJ, Heeringa J, et al. Leveraging diverse data sources to identify and describe U.S. healthcare delivery systems. EGEMS (Washington, DC). 2017;5(3):9. Published online December 15, 2017. doi:10.5334/egems.200 .
Ridgely MS, Duffy E, Wolf L, et al. Understanding U.S. health systems: using mixed methods to unpack organizational complexity. EGEMS (Washington, DC). 2019;7(1):39. doi:10.5334/egems.302 .
Dr. Sarah Kobrin currently Chief of the Health Systems & Interventions Research Branch at the National Cancer Institute, a position she has held for more than three years. Read More »