This report is a descriptive review based on seminal publications, targeted literature searches, project documents, federal databases, and a limited number of key informant interviews. The primary purpose is to describe AHRQ's investments in primary care research between 1990 and 2020; it is not intended as a comprehensive catalog of the Agency's entire portfolio or a systematic evaluation of impact. The report uses the following definitions:
- Primary Care—the provision of integrated, accessible healthcare services by clinicians who are accountable for addressing a large majority of personal healthcare needs, developing a sustained partnership with patients, and practicing in the context of family and community.1
- Primary Care Research—research conducted for the purpose of better understanding or improving primary care; more specifically, (a) research that is conducted in a primary care setting, (b) by or about primary care clinicians, or (c) on a topic that is integral to primary care.
- Agency—refers to the Agency for Healthcare Policy and Research (AHCPR) or the Agency for Healthcare Research and Quality (AHRQ).
Categorization of Research Investments
The first step in this review was to identify a set of thematic categories for organizing AHRQ investments in primary care research, 1990–2020. The purpose of the categories is to describe AHRQ's contributions to primary care research to date rather than as a definitive description of primary care research or the field of primary care as a whole. Furthermore, it was recognized that many if not most AHRQ work cuts across categories. Therefore, projects are described under the theme that seemed most appropriate and may appear in more than one section of this paper. These thematic categories were developed based on a targeted review of seminal primary care research publications, key internal AHRQ program documents and reports (including an unpublished 2019 portfolio review of primary care grants—see Appendix A for a description of the analytic approach), and dialogue with the National Center for Excellence in Primary Care Research (NCEPCR) team at AHRQ. Based on this review, AHRQ investments were grouped into three areas of primary care research capacity development and seven topics of primary care research (Figure 2).
Figure 2. Thematic Categories in AHRQ's Primary Care Research Investments (1990-2020): Topics for Primary Care Research and Areas for Capacity Development
The three areas of primary care research capacity development included: (1) research infrastructure, (2) research methods, and (3) primary care data. The seven topics included: (1) organization of care, (2) quality, (3) safety, (4) primary care workforce, (5) financing and cost of care, (6) digital healthcare, (7) prevention. Definitions of these can be found in Table 2.
Table 2. Definitions for Thematic Categories in AHRQ's Primary Care Research Investments (1990-2020): Topics for Primary Care Research and Capacity Development
| Theme | Definition |
|---|---|
| Developing Capacity for Primary Care Research | |
| Research Infrastructure | Investments to build or improve the capacity to carry out primary care research, including training researchers and developing and supporting programs and institutions designed to encourage and support primary care research. |
| Research Methods | Investments to develop, improve, and disseminate methodology, strategies, processes, and techniques used to conduct primary care research. |
| Primary Care Data | Data and analytics that describe primary care or that are used in primary care research and practice. |
| Topics in Primary Care Research | |
| Organization of Care | Research focused on the organization, structure, or routines of primary care service delivery, including Care Coordination (both team-based care and care management), the Patient Centered Medical Home (PCMH), integration of behavioral health and primary care, and management of Multiple Chronic Conditions (MCC). |
| Quality | Research to assess the equitability, effectiveness, accessibility, and person-centeredness of primary care, including the outcomes of primary care. |
| Safety | Research includes errors, potential harms, and unintended consequences experienced in primary care. |
| Primary Care Workforce | Research focused on primary care clinicians, including number and descriptive characteristics; training, recruitment, and retention; performance and morale; and experience and viewpoints. |
| Financing and Cost | Research to assess payment structure and mechanisms, costs and expenditures, and value as related to primary care service access and utilization. |
| Digital Healthcare | Research focused on the digital healthcare ecosystem and its relationship to primary care, including electronic health records (EHRs), the use of mobile devices, and telehealth. |
| Prevention | Research focused on preventing disease, maximizing health, and steps to conduct these functions in primary care. |
The second step was to develop an inventory of AHRQ's primary care grants, contracts, and intramural projects using the following strategies:
- Automated search of the National Institutes of Health (NIH) Office of Portfolio Analysis (OPA) QVR and iSearch databases for grants funded by AHRQ between FY 2008 and 2019 (the full date range for which this database was available), followed by an abstract review to determine alignment with the definition of primary care research (EK, AL) (Appendix A). Descriptive statistics were used for analysis.
- Examination of seminal primary care research publications and key AHRQ program documents and reports from 1990 to 2020, including a review of the NCEPCR website and NCEPCR program documents.
- Semi-structured interviews with 12 key informants (internal and external to AHRQ) purposefully selected to include individuals with unique knowledge of AHRQ's past or present contributions to primary care research.
Investments identified through these steps were compiled in a database and organized by thematic category and are described in the Results section. Because of time and space constraints, this report focuses on larger projects, although some investigator-initiated grants that had notable impact or addressed important topics are also included.
Research Impact
"[Health services research] impact is rarely immediate, nor does it necessarily unfold in a direct and linear fashion whereby one article leads quickly to one important change in health outcomes."5
John Eisenburg, MD, AHRQ Director (1997–2002)
Performing a rigorous evaluation or analysis of 30 years of investment in primary care research was beyond the scope, not to mention the timeframe and budget, of this report. Instead, we developed a functional rubric, based on a number of published frameworks for evaluating impact,5-12 and used it to identify examples of impact mentioned in the literature review and interviews.
AHRQ's investments in primary care research can be said to have impact if they led to:
- Knowledge that shaped thinking about the field and/or spurred further Research
- Tools, resources, or models for practice that led to changes or improvement in Programs and Clinical Practice
- Improvement in Health Outcomes
- Data or research conclusions that influenced Policy
Examples of project impacts were identified through review of key informant and stakeholder interview notes, research publications, and program documents. In addition, quotes from RAND's Health Services and Primary Care Research Study appear throughout the report. Peter Mendel, Senior Sociologist with the RAND Corporation, generously allowed AHRQ to access de-identified quotes obtained during RAND's work on the Health Services and Primary Care Research Study.9 however, any analysis, summary, or choice of quotes from those data in the report were conducted by AHRQ staff and do not reflect the opinions of RAND.
Limitations
As noted, the purpose of this report is to provide an overview of AHRQ's investments in primary care research over the past 30 years, highlighting notable programs and impacts. It is not intended to be a comprehensive list of AHRQ's work in the field of primary care research nor, due to time and resource constraints, is it a systematic evaluation. We hope this report will serve as a roadmap to AHRQ's role in primary care research over time, ground discussions on a new agenda for primary care research, and serve as a starting point for more rigorous assessment.
