Health Services Research in Improving the Delivery of Care for Patients with Cardiovascular Diseases: Moving From Observation to Innovation to Action.

Correspondence to: Thomas M. Maddox, MD, MSc, Cardiology Section 111B, VA Eastern Colorado Health Care System, 1055 Clermont St, Denver, CO 80210. E-mail thomas.maddox@ va.gov Thomas M. Maddox, MD, MSc P. Michael Ho, MD, PhD H ealth services research (HSR) is a multidisciplinary field of scientific inquiry that examines how people access health care, how that care is delivered, how much it costs and, ultimately, what happens to patients as a result of this care. Put simply, it asks what works, in whom, at what cost, and under what circumstances.1 Accordingly, HSR can provide important insights into the current delivery of health care, identify areas where current care falls short, and guide interventions for improvement in care delivery. HSR has a particularly valuable role in cardiovascular care. The prevalence, associated morbidity and mortality, and large financial costs incurred by cardiovascular disease make its impact on health and medical costs significant. As a result, HSR insights into improvement opportunities for cardiovascular care delivery can lead to large gains in healthcare value. For example, HSR insights into acute stroke care deficiencies led to the American Heart Association Get With the Guidelines Stroke quality improvement program. Over a 5-year period, the program significantly increased adherence to best acute stroke care practices.2 Another successful application of HSR methodologies in cardiovascular disease has been to ST-elevation myocardial infarction door-to-balloon times.3 HSR investigators identified significant barriers to achieving goal door-to-balloon times of ˂90 minutes, designed interventions to overcome these barriers, and systematically implemented and evaluated them. As a result, the majority of patients with ST-elevation myocardial infarction in the United States now receive guideline-concordant care, with an attendant improvement in clinical outcomes. However, these examples actually serve more as the exception than the rule in HSR efforts. One reason for this is the nature of academia, where HSR mainly lives. Academia’s reliance on grant funding for support and success measured by publication of peer-reviewed manuscripts provide important “checks” on the validity of HSR ideas and projects, but they often hinder the translation of HSR observations into meaningful action. For example, it is not uncommon for observational and interventional HSR studies to be conceived independently from those who oversee the delivery of care. Funding and publication decisions are often led by HSR investigators without insights or input from healthcare delivery operational partners. Accordingly, these operational leaders may not see the relevance of the research findings or have any incentives to implement their results into practice. Accordingly, its potential to optimally inform healthcare delivery is often undermined. For HSR to move from potential irrelevance to significant impact, innovation in how HSR ideas are generated, designed, executed, and incentivized is required. In his book How to Kill a Unicorn, innovation consultant Mark Payne4 describes how successful innovation requires equal parts “magic” and “money.” Magic refers to the creative idea at the heart of all innovations, and money to the practical reality of finding and deploying resources to support a specific innovation. To satisfy both parts, it is critical to design innovations with their users in mind. Thus, HSR projects that Health Services Research in Improving the Delivery of Care for Patients with Cardiovascular Diseases