Preventing cigarette smoking with youth

A repeated measures, control group design compared skills-building with attitude modification approaches to prevent cigarette smoking of 234 sixth graders. Subjects in a skills-building condition, more than those in an attitude modification condition or in a control condition, had better posttest scores on cognitive and interpersonal precursors of nonsmoking. Greater pretest to posttest changes in cigarette use were reported for attitude modification condition subjects than for skills-building and control condition subjects. Compared with attitude modification and control condition subjects, skills-building condition subjects had lower reported increases in cigarette use from posttest to 6 months and from 6 to 12 months.The authors thank Cheryl Kelso, Thomas Glynn, Catherine Bell, Lois Holt, Virginia Senechal, Deborah Lodish, Janet Bobo, William Snow, and David Finke. Funding was provided by Division of Cancer Prevention and Control Grant, CA 29640: from the National Cancer Institute, National Institutes of Health, United States Public Health Service, Department of Health and Human Services.Steven Paul Schinke is Chairman, and Lewayne D. Gilchrist is Research Scientist, Social Work Research, Child Development and Mental Retardation Center, University of Washington, Seattle, Washington 98195.     

The report to Congress on the appropriate federal role in assuring access by medical students,residents, and practicing physicians to adequate training in nutrition.

The Congress has had a long-time concern about the adequacy of nutrition education provided medical students and physicians during their training. Attempts over three decades to address this deficiency have been largely ineffective. Yet, recent changes in the delivery of health care from inpatient to outpatient services require physicians be competent in both applied nutrition and patient counseling. The importance of patient counseling is underscored by the surveys of the National Center for Health Statistics which reveal that overweight for the U.S. population has increased between the early 60s and the late 80s. These findings suggest that the Healthy People 2000 objective of reducing the prevalence of overweight may not be met. Congress evidenced its concern about the nutrition education in the medical curriculum in Section 302 of the National Nutrition Monitoring and Related Research Act of 1990 that required a report on the subject from the Secretary of Health and Human Services. The Division of Medicine in the Health Resources and Services Administration, an agency of the Public Health Service, responded by compiling the report. The report to Congress focuses on two issues--why it has been so difficult to increase the nutrition content of medical school curriculums and, if the Federal Government intervenes, what strategies might be effective.     

Adverse drug reactions in a disadvantaged population

Adverse drug reactions represent an area of concern in the delivery of medical care; most recognized negative indices of health can result from the untoward effects of drug therapy. Current data indicating the nature and extent of the problem are considered to be inadequate for making policy decisions. This study contributes new information about drug reactions in a disadvantaged population, by (1) identifying the nature and the extent of the adverse effects of drugs and (2) estimating the costs for the treatment of these adverse effects.The findings showed that oral contraceptives accounted for almost 26% of the medical care contacts and almost 33% of the estimated costs for treating adverse effects. An incidence rate of approximately 2.3 and a prevalence rate of approximately 2.2 suggest that relatively few persons were treated for the adverse effects of drugs. Costs directly attributable to their treatment, including hospitalization but excluding outpatient drug costs, were estimated to be 44 cents per person per year.Although the adverse effects of drugs did not appear to be a major problem in terms of their occurrence and potential severity for a disadvantaged population and in terms of their economic impact upon a medical care system, more information is needed if strategies for dealing with them are to be efficient and effective.Dr. Campbell is Associate Professor and Chairman, Department of Pharmacy Practice, School of Pharmacy BG-20, University of Washington, Seattle, Washington 98195. The other authors are with the Health Services Research Center, Kaiser Foundation Hospitals, 4610 S.E. Belmont Street, Portland, Oregon 97215, where Dr. Johnson is Senior Investigator, Dr. Senft is Research Consultant, and Mr. Azevedo is Projects Administrator, for Drug Systems Research. This work was supported in part by Public Health Service grant 1 R 18 HS-01561-01. The authors wish to acknowledge the contribution of Marilyn W. Drichas, Health Services Research Center, in the preparation of the data.     

School Health Nursing Services Progress Review: Report of 1996 National Meeting

ABSTRACT: This is a report of the outcomes of an invitational meeting convened in 1996 by the Division of Adolescent and School Health at the Centers for Disease Control and Prevention (DASH/CDC) and the National Center for School Health Nursing, American Nurses Association. Participants reviewed progress made on seven critical needs identified in 1994 at the School Health Nursing Services: Exploring National Issues conference. Priority actions were updated, consensus was reached for specific strategies to move towards achievement of goals and organizations and agencies were suggested to assume leadership. Participants and current membership of the National Nursing Coalition for School Health are listed as well as examples of related activities occurring in the interim. Collaborative partnerships are encouraged to assist school nurses in meeting the school-related health needs of all students.     

The content of care provided by Family Nurse Practitioners

The content of care provided by 30 graduates of the UCLA Primex (Family Nurse Practitioner) program was examined. An encounter form similar to that used in the National Ambulatory Medical Care Survey was employed to code patients' complaints. These practitioners had been specifically trained to provide care for ambulatory patients. Data were collected one year after the completion of the university didactic phase of the program. We found that Primex practitioners spent more time with patients, more often employed traditional nursing functions, and more often used medical investigative procedures, such as x-rays and laboratory tests than did the physicians in the NAMC survey. Although the types of problems seen varied according to the organizational setting, these nurse practitioners were more often assigned routine health examinations and less often saw certain kinds of acute health care problems than had been anticipated in their training; 116 different types of symptoms or problems were presented, with a total of 1,170 encounters.The authors are with the UCLA Primex Program; Dr. Lewis is Professor of Medicine and Dr. Linn is Associate Researcher in the Department of Medicine, University of California at Los Angeles, Los Angeles, California 90024. This work was supported by grant HS-00985 from the National Center for Health Services Research.     

A baseline evaluation of family support programs

This paper presents a baseline evaluation of four demonstration family support programs located in communities identified as having a disproportionate number of families at risk for malfunctioning. In this baseline evaluation, a one year cohort of 422 family support participants were assessed along key dimensions of parenting known to contribute to child well-being and potentially to the incidence of child abuse or child neglect. These dimensions include parents' attitudes toward child rearing, knowledge of child development, level of perceived social support, and level of depression.Black participants and teenage parents had more punitive attitudes toward child rearing, less knowledge of child development, and less perceived social support than white or older parents. Overall, attitudes, knowledge, level of perceived social support and depression are inter-related in accordance with previous clinical observations and developmental theory, e.g., depressed parents are less knowledgeable, more punitive and have less support than nondepressed parents. The results of the baseline evaluation suggest that the demonstration projects are successful in reaching some subgroups of families at risk for parenting problems.Janet Reis, Ph.D. is Assistant Professor, Center for Health Services and Policy Research, 629 Noyes Street, Northwestern University, Evanston, Illinois 60201. Linda Barbera-Stein, Ph.D. is Assistant Research Professor, Center for Health Services and Policy Research, Northwestern University. Elicia Herz, Ph.D. is Assistant Research Professor, Center for Health Services and Policy Research, Northwestern University. John Orme, Ph.D. is Assistant Professor, School of Social Work, Louisiana State University. Susan Bennett, M.A. is Research Associate, Center for Urban Affairs and Policy Research, Northwestern University.This work was supported in part by a contract from the Illinois Department of Children and Family Services and the Pittway Charitable Fund to the Center for Health Services and Policy Research, Northwestern University. Special thanks are given to Dr. Edward Zigler for his early guidance on this project. An earlier version of this work was presented at the American Public Health Association, Washington, D.C., November 1985.     

Federal primary health care projects in texas

The rural health strategy of the Bureau of Community Health Services has focused on the integrative mechanism of the Rural Health Initiative (RHI) to combine resources in the best manner to meet local community health needs. An essential component is the National Health Service Corps which provides physicians and other health service personnel both to the RHIs and to free-standing sites.Whether this strategy succeeds or not depends in large measure on the location of the limited health care resources available. In this study, the researchers examined the Bureau's efforts in Texas, a rural conservative state, to place RHIs, NHSC personnel, and other health care projects in areas by priority of need. The basic underlying hypothesis in examining the availability of primary health care services is that the projects would go predominantly into areas with at least three of four need designations defined by the Bureau under positive programming. The baseline used was 1975, just prior to the initiation of the RHI, and 1980 a period sufficiently later to assess progress of the program.The data show the number of federal primary health care projects increased in Texas and the number of projects in areas of highest need also increased. Further, analysis of the data by rural versus urban setting showed the rural areas had increased both in numbers of projects and as a percentage of the total number of projects in the State, suggesting the effectiveness of positive programming.Accessibility to primary health care and physicians for the rural population of more than 2,000,000 people in Texas declined for many years. More recently, however, a number of programs were established to reverse this trend. One of the most important of these, the Rural Health Initiative (RHI), was established by the Bureau of Community Health Services in 1975 to assist in developing the primary health care capacity of underserved rural areas. This article describes the RHI in Texas. It compares the placement of primary health care projects in 1975 and 1980, highlights the growth of selected RHIs, and considers the effect of the private sector of medicine in increasing the number of physicians for rural practice.Research support provided under Personal Service Contract from the Director of the Bureau of Community Health Services, Department of Health and Human Services, 1980.     

Balancing statistical data and clinician judgments in the diagnosis of patient educational needs

Survey content is necessarily limited by the investigators' foresight and by prior research on their subject of inquiry. Clinical data must supplement statistical data whenever the prior research is insufficient to delineate exactly what problems to expect. The differing perspectives on needs of patients sometimes set up competing demands. This calls for strategies based on a programmatic or population perspective that identifies the commonalities in patient educational needs from the statistical profiles, while at the same time allowing for the development of interventions that provide for as much tailoring of the educational experience based on clinical judgments as possible. By combining the community health education perspective with a clinical perspective, we were able to design interventions that responded to the educational needs of a population of low-income, black hypertensive patients. A needs assessment process that combined these perspectives began with a historical and community assessment of the problem in its most general terms. A second phase focused on the most important behavioral and organizational points for intervention. A third phase required formal assessment of predisposing, enabling, and reinforcing factors that may be determining the priority behaviors of health care organizational problems. Finally, clinical and administrative judgment sharpened and supplemented the educational interventions that were suggested by statistical data from formal surveys. Behavioral science theory was applied usefully in all these phases.At the time this study was conducted, the authors were all with the Health Services Research and Development Center and Division of Health Education, The Johns Hopkins Medical Institutions, Baltimore, Maryland 21205. Dr. Green is now Director of the Office of Health Promotion, DHEW. Dr. Lewis is currently with the Department of Community Health Care Systems, School of Nursing, University of Washington, Seattle. Correspondence and reprint requests should be addressed to Lawrence W. Green, Office of Health Promotion, Office of the Assistant Secretary for Health, U.S. Department of Health, Education, and Welfare, Room 721B, Hubert Humphrey Building, 300 Independence Avenue, S.W., Washington, D.C. 20201.Parts of this paper were presented at the Second Annual Needs Assessment Conference, March 28–31, 1978, in Louisville, Kentucky; the National Conference on High Blood Pressure Control, Los Angeles, April 3, 1978; and Endocrinology Rounds at the Indiana University Diabetes Research and Training Institute, Indianapolis, January 29, 1979. This research was supported by Grant Nos. 1R25 HL 17016-03 and IT32-H10710 from the National Heart, Lung, and Blood Institute. The authors would like to acknowledge the support and consultation of Drs. Carol Johns and R. Patterson Russell of the Johns Hopkins Hospital and of Robert Bertera, Michael Bowler, A. Judith Chwalow, Sigrid Deeds, Marion Field Fass, Brian Flynn, Michael Gross, Donald Morisky, Patricia Mullen, and Sam Shapiro of the Health Services Research and Development Center and the School of Hygiene and Public Health, Johns Hopkins University.     

Assessing technical performance at diverse ambulatory care sites

The purpose of the large study reported here was to develop and test methods for assessing the quality of health care that would be broadly applicable to diverse ambulatory care organizations for periodic comparative review. Methodological features included the use of an age-sex stratified random sampling scheme, dependence on medical records as the source of data, a fixed study period year, use of Kessner's tracer methodology (including not only acute and chronic diseases but also screening and immunization rates as indicators), and a fixed tracer matrix at all test sites. This combination of methods proved more efficacious in estimating certain parameters for the total patient populations at each site (including utilization patterns, screening, and immunization rates) and the process of care for acute conditions than it did in examining the process of care for the selected chronic condition.It was found that the actual process of care at all three sites for the three acute conditions (streptococcal pharyngitis, urinary tract infection, and iron deficiency anemia) often differed from the expected process in terms of both diagnostic procedures and treatment. For hypertension, the chronic disease tracer, medical records were frequently a deficient data source from which to draw conclusions about the adequacy of treatment. Several aspects of the study methodology were found to be detrimental to between-site comparisons of the process of care for chronic disease management. The use of an age-sex stratified random sampling scheme resulted in the identification of too few cases of hypertension at some sites for analytic purposes, thereby necessitating supplementary sampling by diagnosis. The use of a fixed study period year resulted in an arbitrary starting point in the course of the disease. Furthermore, in light of the diverse sociodemographic characteristics of the patient populations, the use of a fixed matrix of tracer conditions for all test sites is questionable. The discussion centers on these and other problems encountered in attempting to compare technical performance within diverse ambulatory care organizations and provides some guidelines as to the utility of alternative methods for assessing the quality of health care.Dr. Osterweis is Assistant Professor in the Department of Community & Family Medicine, Georgetown University School of Medicine, Washington, D.C. 20007. Mr. Bryant is Biostatistician at the Biometric Research Institute, Washington, D.C. 20007. The project on which this paper is based was supported by grant HS-01040 from the National Center for Health Services Research, DHEW.     

An empirical definition of “primary care”

An operational definition of primary care, useful to a wide variety of professionals, has eluded researchers since the term first gained popularity. This paper presents an activity-based definition of primary care derived from ratings of 59 representative health care activities by a group of state health administrators, a group of local health department directors, and a random sample of primary care physicians practicing in North Carolina. Thirty-one activities received ratings indicating they were considered core primary care services. Examination of differences in ratings among the three groups surveyed suggests that health department directors differ from the other two groups. Consideration of the variances of activity ratings within the groups emphasizes the unique response of the health department directors and identifies activities characterized by considerable disagreement.The study includes information necessary for researchers and practitioners to form an activity-based definition of varying scope. Definitions constructed from this information should be useful in planning the evaluation efforts that involve different groups of providers, since activities provide an objective basis for agreement. Repeating the approach outlined in the paper with other provider groups in other areas of the country should lead to better understanding of intergroup and regional differences in the concept of primary care.Dr. Farrow is Clinical Associate Professor, Dr. Harrison is Postdoctoral Fellow, Dr. Kaluzny is Professor, and Ms. Newsome is Research Assistant, all with the Department of Health Administration, School of Public Health, and the Health Services Research Center, University of North Carolina at Chapel Hill, 27514. This work was supported in part by grant number HS 01971 to the Health Services Research Center of the University of North Carolina at Chapel Hill from the National Center for Health Services Research, Department of Health, Education, and Welfare. Correspondence and reprint requests should be addressed to Arnold Kaluzny, Department of Health Administration, School of Public Health, University of North Carolina, Chapel Hill, NC 27514.     

Curing and caring—A proposed method for self-assessment in primary care organizations

Key research in the area of quality assessment is reviewed and a method for periodic assessment in primary care organizations is proposed. The suggested approach is designed for administrative, rather than research, purposes. Therefore, it focuses on indicators that are both practical and realistic for use in periodic monitoring.The proposed method is two-staged and includes both technical performance (curing) and satisfaction (caring). At the first level of evaluation, general areas of performance are examined; these are key performance indicators in prevention, diagnosis, and management of illness, and questionnaires dealing with the accessibility and acceptability of care, coupled with objective measures of satisfaction. Those areas of performance that are not up to management standards are then examined in greater detail at the second level of evaluation. Using this approach, organizations can build a longitudinal picture of performance and chart their progress annually.Ms. Howell, formerly an instructor in the Department of Community Medicine and International Health, Georgetown University School of Medicine, is now attending the John F. Kennedy School of Government, Harvard University. Dr. Osterweis is Assistant Professor, Department of Community Medicine and International Health, Georgetown University School of Medicine, Washington, D.C. 20007. Dr. Huntley is Professor and Chairman of that department. Reprint requests should be addressed to Dr. Osterweis. This work was supported in part by grant R18-HS-01040 from the National Center for Health Services Research.     

Factors which influence use of prenatal care in low-income racialethnic women in Los Angeles county

There is very limited information on ethnic differences in use of prenatal care services. The purpose of this study was to examine the effect of sociodemographic, health behaviors, medical risk, and psychosocial risk factors on the timing of prenatal care among Black-American, Mexican-American, and recent Mexican immigrant women in Los Angeles. A sample of 107 primiparous women were interviewed using a structured questionnaire. Information obtained included socioeconomic indicators, relationship with baby's father, timing of prenatal care, psychosocial factors, and substance use before pregnancy. Ethnic patterns of timing of prenatal care revealed no significant differences. The relationship with the baby's father was associated with early timing of prenatal care and more prenatal care visits. Substance use before pregnancy was significantly related to total number of visits for this pregnancy.Ruth E. Zambrana is Associate Professor of Social Welfare; Christine Dunkel-Schetter is Associate Professor of Psychology; Susan Scrimshaw is Professor of Public Health and Anthropology; all at University of California, Los Angeles, 405 Hilgard Avenue, Los Angeles, California 90024.This study was supported by the following funding agencies: UCLA Center for the Study of Women, UCLA Biomedical Faculty Research Support Grant, UC Mexus Development (Grant DG87-123) and Agency for Health Care Policy and Research (formerly known as National Center for Health Services Research and Technology Assessment (HS/HD #05518-01A 1).     

Primary care and local health departments: The initiation of a state-sponsored grant program

This study examines factors that differentiate health service organizations that were successful applicants for a grant program to initiate primary-care services from a matched sample of organizations that did not apply for the program. Factors that were different between the two sets of organizations include the attitudes and behaviors of physicians in the local community, previous success of the organization in obtaining grant support, and employee perceptions of selected organizational and grant program characteristics. These findings suggest that factors both internal and external to the organization are influential in decisions to initiate activities sponsored through grant programs. Implications of these findings for the design of state block grant programs are discussed.Dr. Hernandez is with the School of Community and Allied Health, University of Alabama in Birmingham, Birmingham, Alabama 35294.Dr. Kaluzny is with the School of Public Health, University of North Carolina, Chapel Hill, North Carolina 27514.This project was supported in part by Grant No. HS 01971 to the Health Services Research Center at the University of North Carolina at Chapel Hill from the National Center for Health Services Research, Department of Health and Human Services, and funds from the Division of Health Services, North Carolina Department of Human Services.     

Structuring HIV prevention service delivery systems on the basis of social science theory

In order to identify the optimal configuration of HIV prevention programs, it is necessary to examine different theoretical models of behavior change. Cognitive/decision-making theories of human behavior change are compared to social learning theories vis-a-vis their influence on the structure of service delivery systems. Cognitive/decision-making theories ascribe behavior change to the provision of new information and favor the development of homogeneous interventions providing clients with information about risk behaviors. These interventions are easily standardized across delivery sites and various target populations. Social learning theories view behavior change as a series of stages and recognize the influence of sociocultural variables. They favor multiple heterogeneous interventions in a variety of settings, with the provision of skills training as well as information. Ongoing HIV prevention research indicates that social learning theories provide a more accurate paradigm of human behavior change for the complex behaviors related to HIV risk. Public health agencies must therefore continue to strengthen organizational and referral relationships with community-based organizations that can provide the specialized prevention interventions called for by social learning theory. This will require ongoing collaboration and technical assistance.Ronald O. Valdiserri is Deputy Director (HIV) of the National Center for Prevention Services; Gary R. West is Assistant Deputy Director (HIV) of the National Center for Prevention Services; Melinda Moore is Deputy Director of the International Health Program Office; William W. Darrow is Chief of the Behavioral and Prevention Research Branch, Division of Sexually Transmitted Diseases/HIV Prevention, National Center for Prevention Services; and Alan R. Hinman is Director of the National Center for Prevention Services, all at the U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, Atlanta, Georgia.This paper was presented, by poster, at the VII International Conference on AIDS in Florence, Italy, June 16–21, 1991.The authors would like to thank Lynn Erickson for her secretarial assistance and Mary Willingham for her bibliographic assistance.     

Toward understanding elders' health service utilization

Providing appropriate health services to the elderly is emerging as one of the major challenges of this decade. Using the theoretical framework developed by Andersen and Aday, this study attempts to improve our understanding of those factors which inhibit or facilitate elders' use of health services. The data come from a 1974 statewide random probability sample of 1,625 noninstitutionalized elders 65 years of age or older living in Massachusetts. Regression analysis is used to study the effects of predisposing, enabling, and need characteristics on the use of five health services: hospitals, physicians, dentists, home care, and ambulatory care. The model explains from 5% to 27% of the variance in health service utilization. Need characteristics, in general, account for most of the explained variance.Drs. Branch and Jette and Ms. Polansky are with the Department of Social Medicine and Health Policy, Division on Aging, Harvard Medical School, 643 Huntington Avenue, Boston, Massachusetts 02115; Dr. Jette is also with the Massachusetts General Hospital's Institute of Health Professions; Dr. Evashwick and Ms. Rowe are with the Department of Health Services and Long Term Care Gerontology Center, School of Public Health and Community Medicine, University of Washington; and Dr. Diehr is with the Department of Biostatistics, School of Public Health and Community Medicine, University of Washington. Work for this project was supported in part by a grant from the Massachusetts Department of Public Health while the first author was with the Center for Survey Research, a facility of the University of Massachusetts and the Joint Center for Urban Studies of M.I.T. and Harvard University; in part by Grant 90-A-1350/2 from the Administration on Aging of H.E.W. to the Harvard School of Public Health; and in part by Grant 90-AT-2159 from the Administration on Aging of H.E.W. to the Harvard Medical School.     

关于促进基本公共卫生服务逐步均等化的意见

国家基本公共卫生服务项目作为2009年医改的主要任务之一,实施已近十年,基层服务水平和能力得以提升,健康效益逐渐显现,逐步实现服务“均等化”,区域、城乡、人群间差距逐渐缩小。随着社会经济发展,基本公共卫生服务在实施过程中面临新机遇与新挑战。适时总结评估,对于完善项目实施有重要意义。本文通过系统梳理数据、研究文献及政策报告等,分析国家基本公共卫生服务项目实施进展与成效,尝试探讨实施的主要问题,并提出相应的政策建议。     

Ethical issues in primary health care: A survey of practitioners' perceptions

While most health care is provided at the primary care level, little research has been done to document the ethical issues of such care. A stratified random sample of 702 physicians, nurses, physical therapist, and physician assistants within one southeastern state was surveyed to determine the frequency of ethical issues in primary care. The most frequently occurring issue concerned moral decisions about the amount of time to spend with each patient. A comparison of physician and nonphysician professional groups revealed significant differences in frequencies of the issues. Age had a slight impact on the responses, while gender, religion, and region of practice had none. The study showed that the most frequently occurring issues are pragmatic, not dramatic, and center on patient self-determination, adequacy of care and professional responsibility, and distribution of resources.Helen M. Robillard, R.N.-C., M.S.N., is a doctoral student in Organizational Psychology at the University of Michigan, Ann Arbor. Dallas M. High, Ph.D., is Professor in the Department of Philosophy and Associate of the Sanders-Brown Center on Aging, University of Kentucky, Lexington. Juliann G. Sebastian, R.N., M.S.N., is Associate Professor, College of Nursing, University of Kentucky, Lexington. Janet I. Pisaneschi, Ph.D., is Associate Professor and Assistant Dean, College of Allied Health Professions, University of Kentucky, Lexington. Lea J. Perritt, Ph.D., is Assistant Professor, Allied Health Education and Research, College of Allied Health Professions, University of Kentucky, Lexington. D. Mark Mahler, M.D., is Assistant Clinical Professor, Indiana University School of Medicine, Indianapolis. Requests for reprints should be addressed to: Dallas M. High, Ph.D., Professor, Department of Philosophy, University of Kentucky, Lexington, KY, 40506.     

The psychologist's role in sexual rehabilitation of people with physical disabilities

Sexual rehabilitation of individuals with physical disabilities is a new and expanding field. Psychologists are contributing in the areas of direct counseling services to patients and families, consultation with other health professionals, education, advocacy and research. Their work is characterized by the philosophy and skills imparted by psychological training. Influential factors include knowledge of human learning theory and skill in implementing programs of behavioral change, a research orientation toward the identification of needs and provisions of services, training in personality theory and the complex process of adjustment, and highly developed interviewing skills.This work was supported in part by the Grant No. 16-P-56810/(5-17) from the Rehabilitation Services Administration, Department of Health, Education, and Welfare, Washington, D.C. for the University of Minnesota Medical Rehabilitation Research and Training Center.     

The legislative battle over health services research.

Budget reconciliation legislation in 1989 created the new Agency for Health Care Policy and Research (AHCPR), which folded in the National Center for Health Services Research and Health Care Technology Assessment, among the law's other provisions. The creation of the new agency represented a shift in priorities toward outcomes and effectiveness research in medical practice and made explicit the federal government's role in developing practice guidelines. The new agency was born in the midst of an extraordinary bipartisan budget negotiation process in late 1989; its becoming linked to the contentious issue of physician payment reform nearly killed the new agency before it appeared. The narrative of political wrangling that resulted in the creation of AHCPR spans Capitol Hill, the White House, the agencies of the Department of Health and Human Services, and renowed health services researchers on either coast and in Washington, D.C.