Creative Health Services Research

In 2003, a rather unique article appeared in the American Journal of Medicine that concluded there was a 10- to 12-year time horizon from the discovery of a molecule with therapeutic potential to a potential drug being tested in clinical trials.1 Do we see the same glacial pace of translation into practice of new health care policies or practices with a promise to improve health care delivery and population health? Indeed we do; a similar time horizon is reported for moving from an idea to its integration into public health practice.2 These reports are not alone; there are quite a few additional reports on the time lag from concept to practice with some authors having seemingly taken the estimation process to new heights of precision.3 Given the consistency of the evidence, it doesn’t take much thought to conclude that if it takes more than a decade to translate an idea into practice, there is a problem with the current research enterprise. How are we to solve this problem? Insights into a possible solution may be gained by considering a few more observations on the T1 to T4 translation process. We know that if industry is involved, promising biomedical discoveries are 8 times more likely to move into clinical trials.4–6 We also know that providers at participating study sites are no more likely to adopt the new therapy or technology than those not so involved.7,8 For me, these observations suggest the need for an intervention that aligns research with the realities of health care delivery. Fortuitously, a pathway forward, or perhaps the pathway forward, was proposed in the editorial accompanying the 2003 American Journal of Medicine article mentioned above. The editorialist argues that to shorten the time horizon from discovery to implementation, it is necessary to change scientific thinking to promote research that will have a more direct and immediate impact on policy or practice.9 If I may rephrase and focus on that point, health services researchers need to be more expansive in their scientific thinking, conducting studies with an eye toward the more pragmatic end goal of improving the functioning of the health care system in the near term. Preferably, this would be done in partnership, that is, through conversations with practicing clinicians and health systems’ leadership to understand the needs of these end-users.10–14 Such conversations are essential to formulating effective and sustainable near-term solutions to problems encountered in delivering health care. As many of us know anecdotally, a common drawback of academically driven interventions is that they are often too complex or too costly to implement in the real world of health care delivery. Please note that I am not suggesting a greater embrace of Implementation Science. That discipline focuses on the methods and means of getting health care systems, for example, to adopt “proven-effective” or “evidence-based” interventions. Rather, I am referring to being creative in identifying the interventions to test in the first place. Based on my experience as a Deputy Editor for Medical Care, we have a long way to go to achieve more creative health services research. I adjudicate 40–50 manuscripts a year and have done so since 1997. I have received far too many manuscripts that report on what I consider to be poorly targeted science. Among the most worrisome to me are the reports that are merely descriptive of a problem in health care delivery for which the limited focus of the work is justified by stating that no one has previously described the issue. It seems there is no recognition that simply because an issue or topic has not been investigated in whole or in part previously, that doing so now necessarily contributes to scientific knowledge and, especially, advances health care delivery. My fundamental question to the authors of these reports is this: “How does your work tell us where within the problem being described we should intervene or, better yet, what interventions we might employ to improve the situation?” As the late Dr Reuel Stallones noted years ago, a discipline cannot be creative; however, the practitioners of the discipline can be.15 Health services researchers are fully able to be creative in both their conceptualization of the root cause of a health care delivery issue and in applying their methods to solve the identified health or health care challenges. Thinking more creatively can be taught, at least to some degree. The importance, indeed, of the necessity of “creative thinking” has been well recognized and implemented in design and business schools for years, and increasingly by schools of medicine and public health. Guidance for how to train individuals in more imaginative thinking in the public health sciences, notably epidemiology, has been available for some time.16–18 So, what does creative health services research look like within the realities of this discipline? To make the argument more concrete, let us consider further the purely descriptive report of a health care delivery problem. I do not necessarily disagree with anyone seeking to publish on a previously unexplored or minimally explored topic: an insightful description of the problem is often the logical initial step. What I will suggest, though, is that in describing the problem the author(s) should include a discussion of (i) possible points of intervention and (ii) the most promising type(s) of intervention that could be employed at each point. This discussion should not be a shallow speculation on a wide range of possible etiologies and interventions, something that we see far too often in discussion sections. Rather, the manuscript should have, as an underlying framework, a pathway to solving the problem. This framework would guide the way the data are analyzed and the way the findings are presented and interpreted. A natural outcome of this approach will (or should) be a logical research agenda focused on the most promising interventions, those that have a higher likelihood of being a sustainable solution to the issue at hand and in the near term. Health services research is, and should be, a pragmatic discipline. Its mission is the improvement of the delivery of health care. How do you know if you are doing creative health services research? I have no satisfying answer but suggest that creative health services research is identifiable by its focus on correcting the lesion, not controlling the symptoms. I am confident, however, in stating that if our research focuses on solving real-world problems in ways that can be implemented and sustained, then the time horizon from findings to improved health care delivery will surely be shortened

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