Suggested Comments from PHSSR
on Initial Topics for PCORI's Tier 1 Pilot Projects

Consider submitting your input on PCORI’s first eight research topics that will be funded this fall. PCORI is asking for public comments on the Initial Topics for PCORI's Tier 1 Pilot Projects by Aug. 31. These topics are to help them define the future PCORI research agenda and priorities.

Created through the ACA, PCORI is a quaisi-governmental research program that will develop evidence “to help patients and their health care providers make more informed decisions.” PCORI’s mission includes prevention and treatment options and comparative delivery system innovations, in addition to studying patient care and clinical interventions. PHSSR-oriented studies have a role in these areas, perhaps even studies that directly compare the health impact of public health prevention vs. clinical treatment strategies.

It is important for PCORI to hear from the PHSSR community about the importance of studying the comparative effectiveness of public health interventions and delivery systems – not just “sick care” strategies. The recent JAMA commentary by noted public health scholar and LA County Dept. of Public Health staffer Steve Teutsch discusses federal policy directing comparative effectiveness research. His article points out how inclusion of public health systems research in PCORI’s agenda would identify effective interventions with the greatest potential, specifically addressing the underlying determinants of health.

Our comments below stress how public health contributes to patients’ health and supports medical providers, and how PHSSR benefits patients’ health through optimal delivery and financing of public health services.

1.  Developing, testing, and/or evaluating novel methods and approaches that can inform the process of establishing and updating national priorities for patient centered outcomes research (PCOR).

PHSSR Comments: An expanded research agenda for Public Health Services and Systems Research (PHSSR) has been developed this year to consider the combined challenges facing public health agencies of funding reductions and the changes to health care through health reform legislation.  Given that clinical care consumes 95% of health spending, preserving the reach of public health’s prevention services is more critical than ever because the clinical care system is unable to provide these services.

 The public health research agenda-setting process was guided by the Centers for Disease Control and Prevention, the Robert Wood Johnson Foundation, the National Coordinating Center for PHSSR and facilitated by the Altarum Institute, and integrated input from researchers, practitioners and policymakers across the U.S.

Based on previous agenda-setting processes, the updated agenda focuses on four main areas for public health services and systems research:

• Defining the competencies for and training the workforce
• Public health systems organization, characteristics, performance management and outcomes
• Public health systems financing mechanisms, costs, performance and outcomes
• Technology, data and methods used in systems, including performance and outcomes specification

As the listing above indicates, clearly-defined reasonable patient-centered research outcomes are essential for the eventual adoption of patient-centered care processes, both in medical care and public health systems. For example, the HEDIS measures to inform patients and employers on the efficacy of health plans’ medical care quality provides lessons in how important outcome specification and adoption are to providers of health care and public health services. In addition, the context of out-of-control health care costs requires that outcomes are valued for cost as well as benefit, and that research evaluate comparative health delivery system innovations alongside traditional clinical interventions. 

To improve the potential for research findings to be translated into improved patient care, new research should expand the existing evidence base on community and clinical preventive services, to synergize the value of integrating medical care and public health services and improve patient outcomes.

From a public health perspective, national priorities for PCOR must consider the environment in which patients live and receive care as well as the medical treatments and services provided to patients. Patient-centered outcomes must be considered through evaluation of medical treatment as well as systems that address the social determinants of health through public health prevention and education services.

Given the variety of evaluations on quality of care underway throughout the country and the availability of natural experiments due to changing economic conditions and insurance market changes, novel methods and approaches can serve to extract relevant findings from many of these efforts.

2.  Developing, testing, and/or evaluating methods for bringing together patients, caregivers, clinicians and non-traditional partners in all stages of a multi-stakeholder research process, from the generation and prioritization of research questions to the conduct and analysis of a study to dissemination of study results.

PHSSR Comments: The expanded research agenda for Public Health Services and Systems Research (PHSSR) developed this year was based on an intensive process to collect the research priorities from federal and state agencies as well as researchers, practitioners and policymakers across the U.S.  As this agenda illustrates, which is also the case for many other federal and practitioner research agendas, the implications of building an evidence base and widely integrating it into practice have costly financial and workforce implications for practitioners.

The new research questions should be developed to integrate with the other agenda setting efforts and identify approaches that will most quickly lead to adoption of new evidence in the diverse practice communities within health care and public health.

3.  Developing, testing, and/or evaluating novel processes for translating research findings into changes in health care practices.

• What is the optimal structure and organization of health care and public health services for successful innovation?
• What is the cost-benefit of new models of health care and public health services?
• What are the licensing and regulatory changes needed to encourage adoption of new models, and are there any medical liability concerns? Will there be a need to change education standards for medical and public health professions?
• What organizational conditions are needed for successful translation, such as partnerships involved, financing, and community environment?
• What is the role of leadership in the translation and what are effective accountability and governance mechanisms to assure adoption?
• How can new models be implemented through natural experiments based on changing conditions?
• What examples of effective diffusion exist, and how can these attributes be maximized?

4.  Developing, testing, and/or evaluating approaches that could systematically, without bias, identify gaps in evidence that most affect low-income populations; minorities; children; elderly; women; people with disabilities, multiple medical conditions, rare conditions, and other vulnerable populations.

• What skill sets are needed by practitioners serving vulnerable populations to apply research evidence to practice?
• What environmental conditions should be documented in the research so that applicability to other communities can be evaluated?
• What short term and long term patient outcomes should be measured, and at what cost?
• What are the roles of public health, medical care and other relevant sectors (housing, public safety, transportation) in addressing the needs of vulnerable populations?
• How can technology and information systems be used to identify gaps and facilitate building the evidence?
• How can comparative studies through natural experiments occurring in health care and public health services be used to identify gaps and facilitate building the evidence?

5.  Identifying, testing, and evaluating novel predictive outcomes instruments of interest to patients.

• Which metrics based on currently available data should be used to measure outcomes?
• What methodological tools from other fields can be applied to assess outcomes?
• What surveillance and quality improvement system should be developed to monitor and further develop outcome measures?

6.  Identifying, testing, and evaluating novel methods for researching behaviors, lifestyles, and choices within patient control that may influence their outcomes.

• Which metrics based on currently available data should be used to measure outcomes?
• What methodological tools from other fields can be applied to assess outcomes?
• What surveillance and quality improvement system should be developed to monitor and further develop outcome measures?

7.  Identifying, testing, and evaluating novel methods for studying the patient-clinician interaction in situations where multiple options for prevention, diagnosis or treatment exist.

• What are the implications for new health care and public health workforce competencies?
• How can information and communication technology, including electronic medical records, be used and what is the effect on patient outcomes?
• What conditions of in the patient-clinician environment are important to applicability of methods in other patient care and public health environments?

8.  Identifying, testing, and evaluating methods to assess strategies that respect patient autonomy and promote informed decision-making, incorporating the best healthcare knowledge into the application of care.

• What are the implications for new health care and public health workforce competencies?
• What short term and long term patient outcomes should be measured, and at what cost?
• How can information and communication technology, including electronic medical records, be used and what is the effect on patient outcomes?