Abstract
Managerial epidemiology is a field that has yet to flourish. The topic became a required subject in health care management graduate programs many years ago, textbooks were written, and lectures were presented at national meetings. Academics and policy makers waxed enthusiastic about the potential benefits of applying the principles and methods of the field to the health care system.
Despite the fanfare, the field experienced a failure to launch. No national organization or professional society was formed to promote managerial epidemiology. Few people identified themselves as managerial epidemiologists. The term never came into use as a keyword, so searches for articles turn up very little information.
How could a field with so much promise experience almost no growth and development? Perhaps the problem was a fundamental flaw in its conceptual foundations. Most proponents saw the benefits of a population-based perspective when applied to health management and policy. Epidemiology, the study of disease distribution in populations, would enable the health care system to transition from episodic illness care to prevention and efficient allocation of resources that are devoted to disease treatment. Instead of planning for patients, we would plan for populations; instead of planning for treatment, we would plan for prevention. Instead of planning for disease, we would plan for health. The idealism of reform permeated the conceptual formulation of managerial epidemiology.
Analysis of large clinical data sets led to health policy studies that were epidemiological in design. But at the level of the health care delivery organization, the most direct relevance of population epidemiology was seen to be in system planning and perhaps market research. Efforts to apply epidemiology to quality management seem to have been supplanted by industrial engineering techniques. In the end, managers saw little relevance in epidemiology.
Despite repeated waves of health care reform, the health care system in the United States has never transitioned from treating patients to preventing disease in populations. Perhaps it is time that we jettison the old assumptions of managerial epidemiology. What will happen to the field if it draws from clinical epidemiology rather than population epidemiology? Patients, after all, form populations. Epidemiological methods can be and are used in the study of patient populations. One might argue that most of the studies testing different treatment approaches draw from clinical epidemiology.
Parenthetically, let me clarify the distinction between epidemiological methods and standard biostatistics; epidemiologists rely heavily on observational study designs, including case–control, cohort, and cross-sectional studies. The randomized experiment is more the domain of the biostatistician. Sooner or later, tests of treatment efficacy must be done using randomized designs. Treatment effectiveness studies in messy and uncontrolled field situations, however, are also needed. This is where clinical epidemiology has special strengths.
Managerial epidemiologists could stand with one foot in management and one foot in clinical epidemiology. Management concerns include quality management, cost control, and accessibility of services. Epidemiological designs, as stated above, include case–control, cohort, and cross-sectional studies. Including at least one clinical variable, such as diagnoses, medications, or test results, makes the study an example of managerial epidemiology.
The purpose of this special issue of the Journal of Primary Care & Community Health is to promote the field of managerial epidemiology. Very few of the authors who wrote the articles included here ever would have described their work as managerial epidemiology or themselves as managerial epidemiologists. I hope both the authors and readers of the journal will ask themselves if the shoe fits, why not wear it proudly?