Health Care Research. This is the large and important area of primary care research focused on direct investigation of the primary care function itself. Questions directed toward improving the quality and effectiveness of primary care practices fit in this category. Although health care research has historically emphasized the analysis of large data sets, primary care research often employs both qualitative and quantitative methods to examine relatively small numbers of individual physicians and practices to determine which methods seem to work best.
Clinical Research. Studies in this category are focused directly on the effects of the primary care function on patients. It includes research on the factors that determine why patients become ill and seek medical attention, the meanings of presenting symptoms and signs in a primary care setting, the most effective and efficient diagnostic and treatment strategies, and the natural histories of health problems with and without intervention. The outcome measures used are often those that are directly meaningful to patients, such as quality of life, mortality, health of the family unit, and cost and convenience of care (outcomes research).
Health Systems Research. This category extends the first 3 to the larger systems level. It encompasses educational research, research on dissemination and adoption of new discoveries, implementation of quality improvement systems into primary care settings, and health policy.
Three examples
Night Sweats. Many diseases and health states are thought to beassociated with night sweats (eg, tuberculosis, menopause, nocturnal hypoglycemia in people with diabetes, autoimmune diseases, malignancies, and medications). However, for the primary care physician who is faced with an undiagnosed patient with night sweats, the following questions arise that currently lack answers: (1) What are the incidence and prevalence of night sweats in a primary care patient population? How often does this symptom go unreported? (clinical); (2) What are the most likely causes of night sweats in a patient presenting in a primary care setting? (clinical); (3) What is the most effective and efficient path to the correct diagnosis? (clinical); (4) What is the natural history of idiopathic night sweats in otherwise healthy patients? (clinical); (5) How much of an impact do night sweats have on the quality of life of patients and their bed partners? (clinical); (6) If common and significant but underrecognized, how can clinicians reorganize their assessment methods to systematically screen patients for night sweats? (health care); and (7) If night sweats are an important symptom of potentially serious disease, how can the population be educated to pay attention to and report them? (health systems).
Cognitive Impairment. Cognitive impairment is a prevalent and serious problem for older people. Early diagnosis and treatment are becoming more important as effective treatment strategies have become available. To provide optimal care for these patients, primary care physicians need answers to the following questions:11 (1) Is systematic formal screening for cognitive impairment necessary in primary care settings in which patients and their families are well known by their physicians and staff and are seen frequently? (clinical); (2) Does earlier detection result in better outcomes? (clinical); (3) What are the outcomes of greatest importance, and how can they best be measured? (theoretical/methodologic); (4) What would it cost to screen all patients [over] older than a specified age? (health systems); (5) Should we train primary care physicians to complete the evaluation and direct treatment, or should patients who screen positive be seen by a neurologist, geriatrician, or psychiatrist or psychologist? (health care); and (6) How can caregiver education programs, which have been shown to delay institutionalization and save money, be organized and funded? (health systems).
Laboratory Test Results
Another set of questions involves laboratory test results. What is the best way to manage (tracking, notification, documentation, follow-up) laboratory test results in a primary care setting? Before this health care question can be answered, several others must be addressed: (1) What is meant by “best”? How should patient preference, physician preference, cost efficiency, and legal requirements be balanced? (theoretical/methodologic); (2) How would we answer such a question even if “best” could be adequately defined? (theoretical/methodologic); and (3) Assuming that an answer can be found, what is the most efficient way to help clinicians incorporate the method into their practices? (health systems).
Education for the future
Primary care research is directed toward the better understanding and practice of the primary care function. It is further distinguished from other types of research by an emphasis on effectiveness rather than efficacy. It is often immediately applicable to primary care practice and widely generalizable.
The science base of medicine, including primary care, has improved significantly during the 20th century. Overall, however, primary care has been neglected because it was not seen as requiring an intellectual engine. The mismatch between the focus of research efforts to date and the need for research in primary care can be understood to derive from an unbalanced effort focused on understanding specific diseases and molecular mechanisms. To improve primary care, a more robust enterprise embracing the full scope of research in this setting is required. We hope that our attempt to define and describe the scope of primary care research will help its advocates educate those who are able to make this happen.