Health Services Research Methods 3rd Edition by Leiyu Shi – Answer Key

 

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Sample Test

Chapter 3

Answer Key

 

1.   What are the major national-level sources for health services research? Describe the major features of these data sources.

The major national-level data sources commonly used for health services research include the following:

• The National Center for Health Statistics (NCHS)collects statistics through national representative surveys on illness and disability in the U.S. population; the impact of illness and disability in the population on the U.S. economy and on other aspects of the well-being of the U.S. population; environmental, social, and other health hazards; determinants of health; health resources; utilization of health care; health care costs and financing; and family formation, growth, and dissolution.
• The Area Resource Filepools data from various sources to facilitate health analysis both cross-sectionally and longitudinally. Each data series is available at the levels of county, state, and aggregate United States. The major unit of observation is the county, and the four major types of variables include demographics, health professions, health facilities, and health status.
• The Behavioral Risk Factor Surveillance System (BRFSS) has as its unit of observation the noninstitutionalized adult population. Data elements include weight control, hypertension, physical activity, obesity, mammography, alcohol consumption, seat belt use, tobacco use, HIV/AIDS, preventive health practices, and demographic information.
• The Medicare Current Beneficiary Survey (MCBS)targets a representative national sample of the Medicare population and collects data on expenditures and payments for health care services used by Medicare beneficiaries; the types of insurance held by Medicare beneficiaries; changes over time in beneficiaries’ health status, satisfaction with care, and usual source of care; and the impact of Medicare program changes on beneficiaries.
• The Survey of Mental Health Organizations (SMHO) contains information on types of mental health services; number of inpatient beds; number of inpatient, outpatient, and partial-care additions; average daily census; patient characteristics; staffing characteristics; expenditures; and revenue by sources. It provides valuable information on the sociodemographic, clinical, and treatment characteristics of patients served by mental health facilities.
• The National Ambulatory Medical Care Survey (NAMCS) obtains data through a national sample of office-based physicians and a systematic random sample of physician office visits during a seven-day period. The unit of observation is the patient visit as recorded in the patient record.These national estimates describe the provision and utilization of ambulatory medical care services in the United States and provide information on demographic characteristics of the patient, clinical aspects of the visit, and physician specialty and practice type. They offer indirect measures of health status via diagnostic information.
• The National Health Interview Survey (NHIS) is a cross-sectional interview survey that is conducted of households, with most of its data made publicly available. The units of observation are the household and the individual members of the household. The major categories of information include region of residence, reported health conditions, doctor visits, hospital stays (in the prior 12 months), household characteristics, and personal characteristics. Specific health conditions include acute and chronic conditions, restricted activity days, bed days, work- and school-loss days, doctor visits, hospital stays, and long-term limitations of activity.
• The National Health and Nutrition Examination Survey (NHANES) is a continuous survey with a changing focus on various health and nutrition measurements. The unit of observation is the individual person, and the surveys provide measures of prevalence of a variety of physical, physiological, and psychological diseases in the U.S. general population and nutrition status.
• The National Hospital Discharge Survey (NHDS) is a continuous survey of inpatient utilization of short-stay hospitals nationwide and allows for sampling at the census division level. The unit of observation is the patient’s medical records, and data elements include patient characteristics, expected payment sources, admission and discharge rates, discharge status and disposition, length of stay, hospital characteristics, patient diagnoses, surgical and nonsurgical procedures, dates of procedures, and residence zip code. A hospital may also be used as a unit of analysis.
• The Medical Expenditure Panel Survey (MEPS)consists of three related surveys: (1) the Household Component Survey, which collects medical expenditure data at the individual and household levels from the U.S. civilian noninstitutionalized population; (2) the Medical Provider Component Survey, which surveys medical providers and pharmacies identified by household respondents to verify and supplement information; and (3) the Insurance Component Survey, which collects data on private- and public-sector employer-sponsored health insurance plans. It provides information on expenditures for health care, use of health services, payment sources or insurance coverage, and individual health status.
• The National Nursing Home Survey (NNHS) has as its major units of observation nursing home residents and staff of nursing home facilities. Data are collected on four major areas: (1) nursing homes (size, ownership, license and Medicare and Medicaid certification status, number of beds, services offered, staffing patterns and characteristics, and costs); (2) residents (demographics, activities of daily living, status and living arrangements prior to admission, condition at admission and at interview, receipt of services, cognitive and emotional services, charges, sources of payment, history of nursing home utilization, and hospitalization during stay); (3) discharged residents (demographics, history of nursing home utilization, hospitalization during stay, status at discharge, condition at admission and discharge, and sources of payment); and (4) follow-up with the next of kin of the current or discharged residents (living arrangements, health, and functional status prior to admission; history of previous nursing home use; activities of daily living; and Medicaid spend-downs). The NNHS provides a series of national samples of nursing homes, residents, and staff.
• The Health and Retirement Study (HRS) is a national panel study on older adults in the United States. Information collected includes demographics, health status, housing, family, previous and current employment, disability, retirement plans, net worth, income, and health and life insurance coverage. It is also linked to employer information and administrative data, such as Social Security benefits, Medicare claims, and pension information. The unit of analysis is the individual, and several different cohorts of individuals are tracked and interviewed every two years from the time they enter the survey until death. Every six years, the HRS adds the birth cohort that is between 51 and 56 years old that year.
• The National Vital Statistics System (NVSS) obtains data from birth and death certificates provided by states, and the unit of observation is the individual. It is a national registration system for vital statistics, including natality, fetal death, mortality, and their contributing causes. The most relevant health status databases are the following mortality types: Mortality: Detail; Mortality: Local Area Summary; and Mortality: Cause of Death Summary. All databases include data on age, race, sex, and residence.

 

2.   Become familiar with the funding sources most likely to support the research topics of your interest. What are their requirements and restrictions?

Answers will vary based on the research topics of interest to each student. Responses may include examples of public funding sources such as NIH grants; R-series grants, including R01, R03, and R21 grants; CDC grants and cooperative agreements; AHRQ grants, contracts, and agreements; HRSA funding; and USAID grants. Responses may also include private funding sources, such as Kaiser Family Foundation grants, Robert Wood Johnson Foundation grants, Bill Gates Foundation grants, WHO Regional Office grants, and World Bank Group grants. The requirements and restrictions will vary. Examples include limiting funding to projects addressing specific medical conditions, providing funding only to individuals or certain types of institutions, providing funding for only a limited amount of time, limiting the amount of funding to a predetermined sum, and limiting funding only in specified geographic regions.

 

3.   Identify the major steps in a research proposal. As an exercise, compose a research proposal on a topic of interest to you.

The major steps in a research proposal include performing the preliminary work (reviewing the funding literature and examining information regarding the funder’s areas of interest and funding priorities, guidelines for proposal submission, possible restrictions, size of the grants, cost-share requirements, and review procedures), contacting the identified funding source prior to writing or submitting a formal proposal, preparing a preliminary proposal if required, preparing the research proposal, and submitting the proposal.

Students’ research proposals will vary, but should include the following elements (in this order):

• Title page
• Table of contents
• Abstract
• Project description
• Introduction
• Problem statement and significance
• Goals and objectives
• Methods and procedures
• Evaluation
• Dissemination
• References
• Budget and justification
• Human subjects
• Appendices

 

4.   What is the research review process of the National Institutes of Health?

When a grant proposal is submitted to the NIH, it is received by the Division of Research Grants, where it is assigned to a health scientist-administrator, who acts as the primary institute contact for the applicant. The application undergoes two levels of review. The first level of review is by an initial review group, often referred to as a study section, which judges the scientific merit of the application. The second level of review is by an advisory council, which judges the application based on program considerations including funding priorities and funding level.

 

In the first level of review, the study section provides the initial scientific review of the application, assigns a priority score based on scientific merit, and makes budget recommendations. The primary and secondary reviewers prepare written critiques that evaluate the proposal’s scientific and technical merit, originality, and methodology or research design; examine the qualifications and experience of the investigators; and assess the availability of resources, the appropriateness of the budget and timeline, and ethical issues. The reviewers present their critiques, and then after discussing the proposal, a recommendation is made by majority vote for approval, disapproval, or deferral for additional information. The budget is then discussed in terms of appropriateness.

 

For each approved proposal, all study section members then vote through a secret ballot using a numerical score from 1.0 (best) to 5.0 (worst). A recommendation for a site visit may be made by the primary reviewer or the executive secretary of the study section who recognizes the need for additional information that cannot be obtained by mail or telephone. After the study section meeting, the scores assigned by the individual members for each approved proposal are averaged and multiplied by 100 to yield a priority score. The executive secretary prepares a summary statement, often called the pink sheets, based on the primary and secondary reviewers’ reports and the discussion at the study section meeting. The summary statement is sent to the principal investigator, and the grant application is then forwarded to the advisory council for further review.

 

The second level of review is conducted by a national advisory council at each institute. The council reviews the summary statements of all approved applications from each study section, together with the proposals, and adds its own review based on scientific merit and relevance to the program goals of the institute. The executive secretary of a study section attends the council meeting when an application reviewed in his or her section is discussed. The council then makes recommendations on funding to the institute staff. It may concur with or modify actions in study sections on grant applications, or defer them for further review.

 

5.   What are the organizational and administrative issues related to research?

Researchers must determine the organization and management of research work before starting their research. The three main options for the organization of a research team include the hierarchically organized research team, the research team of formal equals, and the collaborative research team. Regardless of how a research team is formed, it should include people with substantive, methodological, and analytic knowledge and experience related to the research topic.

 

Problems can arise in the research team because people have different research styles, work habits, and ways of thinking. Clearly specifying the roles of the members of the research team helps reduce possible confusion, conflicts, and disputes during project implementation.

 

If funding needs to be sought, questions of access need to be resolved before a proposal is presented to a funding body. Obtaining access often depends on the presentation of a study design that is meaningful and interesting to those concerned. It is usually necessary to provide a separate, shorter outline of the study for this purpose, focusing on the issues and questions addressed and their relevancy to the collaborators.

 

Other practical details to be attended to prior to carrying out research include negotiating with the funding agency to work out a protocol; getting familiar with the research site; determining the level of staff support and services needed; reallocating the budget to fit with the actual situation of project implementation; finalizing the research plan with collaborators; recruiting personnel; identifying supplies and logistics; revising or updating the timetable or schedule of research activities; training staff for data collection, processing, and analysis; conducting a human subjects review; revising the data collection instrument; and pilot-testing the instrument.

 

 

Chapter 5

Answer Key

 

1.   What is the difference between secondary analysis and primary research?

Secondary analysis refers toanalysis of data or information collected by another researcher or organization, including the analysis of data sets collated from a variety of sources to create time-series or area-based data sets. It differs from primary research in that primary research involves the firsthand collection of data or information by the researchers or research team. The data are gathered through the research and did not exist prior to the study. By contrast, secondary analysis uses available data or information collected by others, for similar or different purposes, whether research-oriented or not. Secondary analysis can also be additional analysis of a data set collected by the researcher, but to answer questions other than the one initially studied. Not all secondary data analysis studies involve data from external entities. Since most secondary analysis does not require researchers to have contact with subjects, it is sometimes referred to as nonreactive or unobtrusive research.

 

2.   What are the major types of secondary analysis?

There are several ways to classify the types of secondary analysis. When considering the number of databases used, secondary analysis may be classified as a cross-sectional study or a longitudinal study. Cross-sectional studies capture one moment in time. Exploratory and descriptive studies are often cross-sectional. Longitudinal studies are designed to allow for observations over an extended period of time, and include trend studies, cohort studies, and panel studies. Trend studies investigate changes within a general population over time, cohort studies examine specific subpopulations over time, and panel studies are similar to trend or cohort studies, but investigate the same set of people each time.

 

Secondary analysis can also be classified by the sources of data. Research-oriented secondary data include all data sets collected by others for research rather than other purposes. Nonresearch-oriented secondary data include publicly available documents, official records, private documents and records, media, and physical nonverbal materials. The fundamental difference between research-oriented and nonresearch-oriented secondary data has to do with quality in terms of both data collection and documentation. Research-oriented data sets are generally collected according to strict procedures of sampling and measurement, while nonresearch-oriented data sets are comparatively less strict on both accounts.

 

Another way to classify the types of secondary analysis is by method. Content analysis is a research method appropriate for studying human communication and aspects of social behavior, and is typically used with archival records. The basic goal is to take a verbal, nonquantitative document and transform it into quantitative data. The units of analysis include words, paragraphs, books, pictures, advertisements, and television episodes, and contents can be manifest or latent. A second method is analyzing published statistics, which are aggregate information that cannot be traced to the individual level from which the aggregation is made. The unit of analysis is an aggregate element, such as a county, region, state, country, or city. The third method is historical analysis, which involves attempts to reconstruct past events and the use of historical evidence to generate and test theories. The basic evidence primarily consists of authentic documents, such as testimony and organizational records.

 

3.   What are the secondary data sources you can identify?

Answers will vary. Examples of research-oriented secondary data sources include the Area Resource File, National Ambulatory Medical Care Survey, National Health Interview Survey, National Hospital Discharge Survey, Medical Expenditure Panel Survey, HRSA Geospatial Data Warehouse, Uniform Data System (UDS), Pregnancy Risk Assessment Monitoring System (PRAMS), National Survey of Children with Special Health Care Needs, Medical Expenditure Panel Survey (MEPS), Healthcare Cost and Use Project (HCUP), Medicare Current Beneficiary Survey (MCBS), National Health Care Survey (NHCS), National Health Interview Survey (NHIS), Cardiovascular Health Study (CHS), National Sample Survey of Registered Nurses, and Medicaid Analytic eXtract.

 

Examples of nonresearch-oriented secondary data sources include:

• Public documents and official records, such as government agency proceedings, court records, state laws, city ordinances, directories, almanacs, and indexes such as the New York Times Article Archive and The Reader’s Guide to Periodical Literature
• Official statistics, such as vital statistics from birth, death, marriage, and divorce certificates, and census data
• Private documents and records, such as diaries, letters, notes, personnel and sales records, inventories, tax records, and patient records
• Media, such as the Internet, television, newspapers, radio, periodicals, and movies
• Physical nonverbal materials, such as works of art (paintings and pictures), artifacts, and collections

 

Responses identifying other secondary data sources are also acceptable.

 

4.   What are the strengths and weaknesses of secondary analysis as a scientific inquiry?

The principal strength of secondary analysis is economy, achieved through money, time, and personnel saved in data collection and management. The development of computer-based analyses has also made it relatively easy for health services researchers to share their data with one another. The multiple sources of secondary data enable researchers to conduct inquiries into many areas of interest. Because of the economy and availability of secondary data, secondary analysis is fast becoming one of the most popular methods of health services research.

 

In addition to savings on time, cost, and personnel, the use of available data may afford the opportunity to generate significantly larger samples than primary research, such as surveys and experiments. Secondary data may also be viewed as more objective and, therefore, more credible because the purpose of data collection is not research oriented, and personal biases are less likely to be introduced. Secondary analysis affords the opportunity to study trends and changes over a long period of time, and is also the preferred method for carrying out area-based research, particularly international comparative studies. Using secondary data can also strengthen primary research, as secondary data are helpful in designing subsequent primary research studies and can serve as a baseline for comparison with primary data collection results.

 

The principal weakness of secondary analysis is the extent of compatibility between the available data and the research question. Secondary data must be found rather than created to the researcher’s specifications, and searching for relevant data sources isn’t easy. Once identified, the value of available data will depend on the degree of match between the research questions to be addressed and the data that happen to be available. Often, available data are not well suited to the researcher’s intended purposes. Because of potential compatibility problems, the design of secondary studies may have to be started from back to front. One key disadvantage is that the scope and content of the studies are constrained by the nature of the data available. Even if relevant secondary data exist, they may not offer the information required to address the research question, including the definitions and classifications that the researcher wishes to use. Access to data may also pose a challenge. It may need to be negotiated, there may be constraints for confidentiality and ethical concerns, and laws may sometimes prohibit the release of certain government data.

 

Another limitation of secondary data, particularly administrative records that were not collected for research purposes, is that records are frequently incomplete or inaccurate. The process of examining secondary data can be time-consuming, and there are several ethical issues to consider regarding secondary data analysis. The researcher must obtain informed consent, and authorship and acknowledgment issues must be worked out between the researcher and the owner of the data. The researcher must also make clear his or her intentions for the use of the data at the start of the project, and must maintain the subjects’ confidentiality in the data throughout the project.

 

5.   Do the following exercise as a way to learn the process of conducting secondary analysis. Choose an available data set, either from published sources or other researchers, and study the measurements carefully. Based on the measurements available, try to conceptualize a research topic of interest to you. Describe, in detail, what measures you will use to study your topic. Describe any limitations you might encounter (e.g., missing variables or inaccurate approximates).

 

Answers will vary, but should identify a research topic and include a detailed description of the measures the student will use to study the topic, and any limitations the student is likely to encounter.