Public advocacy and allocation of federal funds for biomedical research

Cross-disease spillover from research funding: Evidence from four diseases

There is widespread appreciation for the role of research in addressing health problems. However, there is limited evidence on the extent to which research can be targeted to specific diseases. Analyses highlighting a concentration of research funding towards certain diseases have prompted growing scrutiny over the allocation of research funding. In this paper, we show that research funding targeted to a disease often results in publications relating to other diseases. Using data from the world's largest biomedical research funders, we estimated the frequency and direction of this cross-disease spillover by examining 337,573 grant-publication pairs for four diseases. We found the majority of our grant-publication pairs were cross-disease spillovers. We also found some variation between "rich" and "poor" diseases, in terms of the frequency and direction of cross-disease spillover. These differences are likely to be related to characteristics of the diseases themselves, as well as features of the research environment. One implication of frequent cross-disease spillover is that although more investment in areas of research such as neglected diseases is necessary, it may not be sufficient to improve the alignment between research funding and health needs.

Impact of Orthopaedic Surgeons on National Institutes of Health Funding for Hip and Knee Arthroplasty Research

BACKGROUND

The National Institutes of Health (NIH) remains one of the predominant sources of biomedical research funding in the United States, yet its impact on total hip and knee arthroplasty research is poorly understood. This study defines the portfolio of NIH funding for total joint arthroplasty (TJA) and the impact of orthopaedic surgeons on this portfolio.

METHODS

The Research Portfolio Online Reporting Tools Expenditures and Results (RePORTER) database was queried for NIH grants that had been awarded for total hip and knee arthroplasty and total NIH funding from 2010 to 2020. Compound annual growth rates (CAGRs) were calculated. Funding totals were compared with those from 20 other clinical areas. The principal investigators (PIs) and grants were characterized, and comparisons were made with use of the Student t test.

RESULTS

A total of 489 grants were awarded, totaling $181 million (CAGR of 10.3%). This was >3 times the growth rate for the total NIH budget (CAGR of 2.9%), which increased from $31.2 to $41.7 billion over the 11-year period. When compared with 20 other clinical areas, TJA received the least amount of NIH funding over that period. Alzheimer disease received the most funding ($12.1 billion, CAGR of 19.5%), and cerebral palsy received the penultimate amount of funding ($284 million, CAGR of 6.3%). The R01 grant mechanism was the predominant source (63.1%), and the Mayo Clinic (Rochester, Minnesota) received the most funding (9.7%). Departments of orthopaedic surgery were awarded the most funding (23.5%), yet only 20 orthopaedic surgeons were identified as PIs (16.0%). There were no significant differences in NIH funding totals by PI demographic and academic characteristics (p > 0.05), yet orthopaedic surgeons had among the highest Hirsch indices (h-indices) (p < 0.001). Funding supported clinical (63.5%), translational (19.3%), basic science (7.1%), and other types (10.1%) of research. The top areas with funding were postoperative complications (44.4%), postoperative pain management (17.6%), rehabilitation (15.1%), and implant design (12.4%).

CONCLUSIONS

There is a paucity of orthopaedic surgeon representation among NIH grants awarded for TJA. Opportunities may exist for orthopaedic surgeons to collaborate in identified areas of clinical interest. Additional research is needed to understand the obstacles to obtaining NIH grant funding for orthopaedic surgeon PIs.

CLINICAL RELEVANCE

Increasing the levels of funding from the NIH is a strategic priority for departments of orthopaedic surgery. Understanding levels of funding for clinical areas in total joint arthroplasty is critical to foster research and discovery support from the NIH.

Bioethics, (Funding) Priorities, and the Perpetuation of Injustice

If funding allocation is an indicator of a field's priorities, then the priorities of the field of bioethics are misaligned because they perpetuate injustice. Social justice mandates priority for the factors that drive systematic disadvantage, which tend not to be the areas supported by funding within academic bioethics. Current funding priorities violate social justice by overemphasizing technologies that aim to enhance the human condition without addressing underlying structural inequalities grounded in racism, and by deemphasizing areas of inquiry most frequently pursued by Scholars of Color. This lack of attention to upstream determinants of health in bioethics research perpetuates a gap in the resources needed to understand the experiences of communities disproportionately experiencing poor health, which is itself a form of epistemic injustice. Both social and epistemic injustices are apparent in the impact of these funding priorities on people of color, both in the public and in the bioethics community.

Can mass media be an obstacle to rationing decisions? A case report from Portugal

Purpose

Continuous introduction of advanced health technologies coupled with limited resources force governments to adopt rationing measures in all types of health systems. The mass media can influence the application of these measures by rising people and patients' expectations and demands for new forms of healing. This article intends to find evidence of this influence by reporting two recent cases which occurred in Portugal involving two innovative drugs, one for the treatment of hepatitis C and another for type I spinal muscular atrophy. The new drugs were not publicly funded despite promising excellent overall health outcomes because of their high cost and exaggerated burden on national health system (NHS).

Design/methodology/approach

A qualitative research was used to collect information conveyed by the conventional media and social networks.

Findings

After a strong dissemination through conventional and social media of the nonapproved treatments, the drugs swiftly garnered support among the public and triggered remarkable and relentless advocacy efforts. The findings of this paper suggest that society opinions and, by extension, the decision of policy-makers are very susceptible to the influence of the mass media.

Practical implications

New ways of sharing information are changing health research and public health.

Social implications

These stories raise complex tensions and important questions about resource-allocation decisions involving scientific research or innovative medicine. Societal preferences seem very vulnerable to information conveyed by the mass media.

Originality/value

This study is the first attempt to awaken attention to the influence that Portuguese mass media may exercise on future healthcare rationing decisions.

"Media, politics and science policy: MS and evidence from the CCSVI Trenches"

BACKGROUND

In 2009, Dr. Paolo Zamboni proposed chronic cerebrospinal venous insufficiency (CCSVI) as a possible cause of multiple sclerosis (MS). Although his theory and the associated treatment ("liberation therapy") received little more than passing interest in the international scientific and medical communities, his ideas became the source of tremendous public and political tension in Canada. The story moved rapidly from mainstream media to social networking sites. CCSVI and liberation therapy swiftly garnered support among patients and triggered remarkable and relentless advocacy efforts. Policy makers have responded in a variety of ways to the public's call for action.

DISCUSSION

We present three different perspectives on this evolving story, that of a health journalist who played a key role in the media coverage of this issue, that of a health law and policy scholar who has closely observed the unfolding public policy developments across the country, and that of a medical ethicist who sits on an expert panel convened by the MS Society of Canada and the Canadian Institutes of Health Research to assess the evidence as it emerges.

SUMMARY

This story raises important questions about resource allocation and priority setting in scientific research and science policy. The growing power of social media represents a new level of citizen engagement and advocacy, and emphasizes the importance of open debate about the basis on which such policy choices are made. It also highlights the different ways evidence may be understood, valued and utilized by various stakeholders and further emphasizes calls to improve science communication so as to support balanced and informed decision-making.

Rare disease patient groups as clinical researchers

In the face of inadequate treatments, rare disease patients have begun acting like scientists and studying themselves. Through online networks, patient groups transform disease experiences into novel research data: exchanging therapeutic anecdotes, willingly self-testing treatments and compiling outcomes into preliminary research hypotheses which are subsequently relayed to professionals. Through such efforts, rare disease patient groups have helped evaluate and validate several new therapeutic modalities. This article specifically explores the process of patient-driven research while considering broader implications of the trend. While issues regarding methodological quality and patient safety must not be overlooked, through future partnerships with academia and the pharmaceutical industry, patient groups could function as a powerful resource in rare disease research.

Burden of disease and economic evaluation of healthcare interventions: are we investigating what really matters?

Background

The allocation of limited available healthcare resources demands an agreed rational allocation principle and the consequent priority setting. We assessed the association between economic evaluations of healthcare interventions published in Spain (1983-2008) and the disease burden in the population.

Methods

Electronic databases (e.g., PubMed/MEDLINE, SCOPUS, ISI Web of Knowledge, CRD, IME, IBECS) and reports from health technology assessment agencies were systematically reviewed. For each article, multiple variables were recorded such as: year and journal of publication, type of study, health intervention targetted, perspective of analysis, type of costs and sources of information, first author's affiliation, explicit recommendations aimed at decision-making, and the main disease cause to which the intervention was addressed. The following disease burden measures were calculated: years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life years (DALYs), and mortality by cause. Correlation and linear regression models were fitted.

Results

Four hundred and seventy-seven economic evaluations were identified. Cardiovascular diseases (15.7%), infectious diseases (15.3%), malignant neoplasms (13.2%), and neuropsychiatric diseases (9.6%) were the conditions most commonly addressed. Accidents and injuries, congenital anomalies, oral conditions, nutritional deficiencies and other neoplasms were the categories with a lowest number of studies (0.6% for each of them). For the main disease categories (n = 20), a correlation was seen with: mortality 0.67 (p = 0.001), DALYs 0.63 (p = 0.003), YLLs 0.54 (p = 0.014), and YLDs 0.51 (p = 0.018). By disease sub-categories (n = 51), the correlations were generally low and non statistically significant.

Conclusions

Examining discrepancies between economic evaluations in particular diseases and the overall burden of disease helps shed light on whether there are potentially over- and under-investigated areas. The approach taken could help policy-makers understand whether resources for economic evaluation are being allocated by using summary measures of population health.

Identifying research priorities for health care priority setting: a collaborative effort between managers and researchers

Background

To date there has been relatively little published about how research priorities are set, and even less about methods by which decision-makers can be engaged in defining a relevant and appropriate research agenda. We report on a recent effort in British Columbia to have researchers and decision-makers jointly establish an agenda for future research into questions of resource allocation.

Methods

The researchers enlisted decision-maker partners from each of British Columbia's six health authorities. Three forums were held, at which researchers and decision-makers from various levels in the health authorities considered possible research areas related to three key focus areas: (1) generation and use of decision criteria and measurement of 'benefit' against such criteria; (2) identification of so-called 'disinvestment' opportunities; and (3) evaluation of the effectiveness of priority setting procedures. Detailed notes were taken from each forum and synthesized into a set of qualitative themes.

Results

Forum participants suggested that future research into healthcare priority setting would benefit from studies that were longitudinal, comparative, and/or interdisciplinary. As well, participants identified two broad theme areas in which specific research projects were deemed desirable. First, future research might usefully consider how formal priority setting and resource allocation projects are situated within a larger organizational and political context. Second, additional research efforts should be devoted to better understanding and improving the actual implementation of priority setting frameworks, particularly with respect to issues of change management and the resolution of impediments to action on recommendations for resource allocation.

Conclusion

We were able to validate the importance of initial areas posed to the group and observed emergence of additional concerns and directions of critical importance to these decision-makers at this time. It is likely that the results are broadly applicable to other healthcare contexts. The implementation of this research agenda in British Columbia will depend upon the ability of the researchers and decision-makers to develop particular projects that fit within the constraints of existing funding opportunities. The process of engagement itself had benefits in terms of connecting decision-makers with their peers and sparking increased interest in the use and refinement of priority setting frameworks.

Patient participation in collective healthcare decision making: the Dutch model

OBJECTIVE

To study whether the Dutch participation model is a good model of participation.

BACKGROUND

Patient participation is on the agenda, both on the individual and the collective level. In this study, we focus on the latter by looking at the Dutch model in which patient organizations are involved in many formal decision-making processes. This model can be described as neo-corporatist.

DESIGN

We did 52 interviews with actors in the healthcare field, 35 of which were interviews with representatives of patient organizations and 17 with actors that involved patient organizations in their decision making.

RESULTS

Dutch patient organizations have many opportunities to participate in formal healthcare decision making and, as a result, have become institutionalized. Although there were several examples identified in which patient organizations were able to influence decision making, patient organizations remain in a dependent position, which they try to overcome through professionalization.

DISCUSSION

Although this model of participation gives patient organizations many opportunities to participate, it also causes important tensions. Many organizations cannot cope with all the participation possibilities attributed to them. This participation abundance can therefore cause redistribution effects. Furthermore, their dependent position leads to the danger of being put to instrumental use. Moreover, professionalization causes tensions concerning empowerment possibilities and representativeness. Conclusion Although the Dutch model tries to make patient organizations an equal party in healthcare decision making, this goal is not reached in practice. It is therefore important to study more closely which subjects patients can and should contribute to, and in what way.

Advocacy groups as research organizations: the PXE International example

Advocacy organizations for genetic diseases are increasingly becoming involved in biomedical research, particularly translational research, in order to meet the needs of the individuals that they serve. PXE International, an advocacy organization for the disease pseudoxanthoma elasticum, provides an example of how research can be accelerated by these groups. It has adopted methods that were pioneered by other advocacy organizations, and has integrated these along with new approaches into franchizable elements. The model has been followed for other conditions and has led to the establishment of a common infrastructure to enable advocacy groups to initiate, conduct and accelerate research.

Dollars, disease, and democracy: Has the Director's Council of Public Representatives improved the National Institutes of Health?

The National Institutes of Health (NIH) Director's Council of Public Representatives (COPR) was established in 1998 as an advisory council to the NIH director and NIH's only wholly "public" advisory group. COPR's stated objective was, and remains, to strengthen and formalize public input into funding-allocation decisions for biomedical research by the NIH, the single largest sponsor of such research. Yet, to date, COPR's work and effectiveness have not been carefully explored. In beginning to fill this void, my goal is to contribute to the understanding of public involvement in the distribution of health research dollars. More specifically, I show that COPR has failed to promote public participation in the apportionment of biomedical research funds, but that it has been beneficially effective in some respects and likely could -- and arguably should -- be made more effective. The essay draws on interviews I conducted with former COPR members and discussions I initiated with executive branch employees familiar with COPR's mission, opportunities, impediments, and performance.

Did A Rising Tide Lift All Boats? The NIH Budget And Pediatric Research Portfolio

This paper examines National Institutes of Health (NIH) pediatric research spending in absolute terms and relative to the doubling of the NIH overall budget between fiscal years 1998 and 2003. Pediatric spending increased by an average annual rate of 12.8 percent during the doubling period (almost on par with the NIH average annual growth rate of 14.7 percent). However, the proportion of the total NIH budget devoted to the pediatric portfolio declined from 12.3 to 11.3 percent. We offer recommendations for implementing existing commitments to strengthen the pediatric research portfolio and to protect the gains of the doubling period.

Congress, health care, and congressional caucuses: an examination of the Diabetes Caucus

Caucuses have become a critical feature of the congressional landscape, yet are neglected in the literature on health-policy making in Congress. The principal goal of the article is to use the Diabetes Caucus as a case study to highlight this significant yet underappreciated political actor in the health-policy realm in Congress. The exploration, which draws on information gathered from thirty-two interviews with members of the Diabetes Caucus and their staff, will contribute to an increased understanding of both Congress's operations in the health area and the potential impact of caucuses on health-policy making. The article emphasizes particular characteristics relating to the membership and objectives of the Diabetes Caucus. In addition, the study stresses that the group had the requisite political momentum to achieve legislative successes when a policy window opened in the 105th Congress because it served much like, in the terminology of John Kingdon, a "policy entrepreneur".

National policy on CAM: the White House Commission Report

In March 2000, President William Clinton signed Executive Order 13,147, establishing the White House Commission on Complementary and Alternative Medicine, to develop public policy proposals geared toward maximizing “the benefits to Americans of complementary and alternative medicine.” Disconcertingly, the Commission's charge presumed the safety and efficacy of complementary and alternative medicine (CAM). In so doing, it placed the proverbial cart before the horse by setting the Commission on a mission to “address education and training of health care practitioners in CAM; [coordinate] research to increase knowledge about CAM products; [provide] reliable and useful information on CAM to health care professions, and [provide] guidance on the appropriate access to and delivery of CAM.”

The Commission's final report (“Commission Report”), issued in March 2002, similarly skirts the fundamental question of whether evidence exists that CAM interventions are safe or offer sufficient benefit to justify their proliferation.

Emergency medicine and public health: new steps in old directions

Emergency medicine and public health have opportunities to interact in at least 4 areas: surveillance of diseases, injuries, and health risks; monitoring health care access; delivering clinical preventive services; and developing policies to protect and improve the public's health. Recent, cross-cutting initiatives and innovations in these 4 areas follow pathways first explored more than a generation ago and provide an important impetus for future work. An analysis of recent contributions also points to various obstacles and challenges that must be addressed to take full advantage of existing and rapidly developing ties between emergency medicine and public health. The connections between these 2 fields will continue to create important partnership opportunities and the strong possibility of achieving new benefits for patients, the public, and the professionals who serve them.

Clinical trials in the 21st century: the case for participant-centered research

Informed consumers of the 21st century increasingly will be hesitant to enroll in randomized clinical trials (RCTs) because they will be unwilling to (a) submit to random assignment; (b) complete assessments that are too lengthy, intrusive, or irrelevant; or (c) comply with protocols that do not meet their needs. Research centered on the needs and interests of participants is likely to engender greater participation and commitment than are traditional RCTs. Recommendations for making clinical trials more participant centered include: (a) expanding our conceptualizations of study validity, (b) involving consumers as advisers in the development and execution of clinical trials, and (c) offering participants reasonable alternatives to random assignment.