Research funded by the National Institutes of Health (NIH) has resulted in saving lives as well as increasing longevity and quality of life for people in the United States and around the world. There are numerous success stories including The Framingham Heart Study, development of childhood vaccines, and the rapid decrease in morbidity and mortality from human immunodeficiency virus. In each case, concerted and dedicated funding from the NIH on disease-specific initiatives resulted in important advances in science which translated into measurable improvements in health outcomes.1 Dedicated research agendas and funding also have been shown to cultivate scientists, and several recent reports have documented the association between NIH funding and academic productivity in various specialties.2–11
While trauma affects people of all ages, unintentional injury is consistently the leading cause of deaths in Americans ages 1 year to 44 years, and homicide and suicide also fall into the top five causes of death in Americans ages 1 year to 44 years and 10 years to 54 years, respectively.12 Beyond the direct health care burden to the individual, the societal impact of trauma is enormous. In 2013, the total lifetime medical expenditures and work losses secondary to injury was estimated to be US $671 billion, dwarfing heart disease (US $313 billion), diabetes (US $245 billion), and cancer (US $216 billion).12,13 Trauma is now being recognized as a chronic disease with an accelerated death rate among survivors of all ages.14–17 The 1-year treatment cost of adult major trauma is estimated to be up to US $27 billion; 42% of which were sustained following the acute care period.18 Since the National Academies' 1966 publication of “Accidental Death and Disability: The Neglected Disease of Modern Society,”19 and despite the 1994 release of NIH's “A Report of the Task Force on Trauma Research,”20 there continues to be a profound underappreciation of the impact of injury on our nation's health and with it a huge opportunity gap. Recently, The National Academies of Sciences Engineering and Medicine published a critical report on “A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury.” This report highlighted the superb improvements in trauma care in the United States while still noting the large number of preventable deaths and lifelong disabilities resulting from trauma. They recommend the development of a comprehensive trauma system whose overarching goals should be set by the White House in order to achieve the goal of “zero preventable deaths.”21
In the absence of an executive mandate, who will provide leadership to pursue this recommendation? The NIH is the primary federal agency that supports biomedical research. Injury is consistently listed among diseases with the highest burden, but with the lowest funding. Moses et al.22 highlight some reasons for this including the appeal of rare diseases, as well as established funding patterns like funding for cancer and human immunodeficiency virus/acquired immune deficiency syndrome which is consistently above the predicted level based on their burden of disease. In that report, “injuries” are listed as the last of 27 disease categories relative to the difference in percent of NIH funding relative to percent of the total burden of disease. Their analysis identified US $366 million of NIH funding for injury research in 2012. The use of administrative data in analyzing grant funding may be flawed as many trauma-related grants about topics, such as suicide, chronic pain, or post-traumatic seizures that may not include “injury” among their “NIH spending categorization” terms.
We hypothesized that the administrative search algorithm would overcount actual grant funding. Furthermore, we postulated that we would identify the diffusion of trauma-related research funding across the NIH which would be contrary to the goals set out in the National Academies' report on “Zero Preventable Deaths.” To rectify the potential flaws and imprecision in administrative data, we embarked on a more granular analysis of NIH funding for trauma research. By capturing all possible grants with any trauma association, and then manually reviewing the details, we aimed to truly identify and discern grants that may appear to be “trauma” related from those that actually address concepts related to the optimal care of traumatic injury. In short, our aim was to describe how much NIH funding is specifically addressing this important topic.
We searched the NIH Research Portfolio Online Reporting Tools Expenditures and Results (RePORTER) to identify all extramural grants from FY2016 that may have been trauma related.23 We developed an expansive search strategy building on existing resources and using both index terms and key words to capture all grants with any possible trauma association (Supplemental Digital Content 1, Appendix A, http://links.lww.com/TA/B471).24–26 We then identified terms for grants that would not be trauma related and included them in a list of excluded terms which we used for our search. In short, we attempted to capture all possible sources, spending categories, mechanisms of funding, award types, and activity codes that may be associated with trauma-related research funded by NIH.
Once we completed our initial query, we compiled data on grants into RedCAP (Research Electronic Data Capture hosted at Rutgers) with titles, abstracts, and project terms.27 An independent group of three reviewers then developed a subsequent search strategy to identify which of these grants were trauma related. The three independent reviewers initially evaluated 100 awards separating grants into “Trauma,” “Not Trauma,” or “Maybe Trauma” and used an iterative process to develop a list of criteria as we reviewed the first 100 grants (Supplemental Digital Content 2, Appendix B, http://links.lww.com/TA/B472). We then tested our criteria on a second set of 100 grants with all three reviewers. Reviewers were instructed to categorize any grant that could not be definitively included or excluded as trauma related as “Maybe Trauma” for further review by our expert panel. We found that among the second 100 awards the intra-class correlation was extremely good (r = 0.73). Where variation was observed, it was primarily among grants that were classified as “Maybe Trauma.” We therefore established validity for using a single reviewer to complete the remaining reviews. To assess that our search strategy was inclusive, we compared the results of our search strategy to the traditional approach of using the NIH spending categorization of “Injury (total) Accidents/Adverse Effects.” Our search strategy captured 979 of 1,147 of these awards. Of the 168 that we missed, 144 were clearly not trauma related (e.g., cellular injury from chemotherapy or neonatal hypoxic ischemic encephalopathy). Twenty-four were considered only tangentially trauma related (for example bone healing in patients who have rheumatoid arthritis and distal radius fractures). Therefore, we postulate that the in the extreme our search schema would have missed ≤2% of remaining grants.
A team of experts made up of experienced trauma surgeons then analyzed the grants in the “Maybe Trauma” category and definitively classified them as “Trauma” or “Not Trauma.” Once these reviews were complete and we had identified all trauma-related grants, we compared our results to denominator data from established NIH Reports on funding to highlight important patterns. We received a non-human subject research determination from the Rutgers institutional review board for this study.
In FY2016, NIH awarded 50,137 grants of which our search strategy identified 6,401 (13%) for further evaluation (Fig. 1). Upon detailed review, 1,888 (28%) were classified as trauma research. These grants represent 3.7% of all NIH extramural grants and came from 23 of the 27 NIH Centers and Institutes as well as from the Office of the Director (Table 1). The percent of an institute's funding for trauma ranged from 13% (1,308 grants) from the National Institute of Arthritis and Musculoskeletal and Skin Diseases to no grants from the National Human Genome Research Institute. Trauma is a leading cause of death and disability among children, yet only 167 (6.8%) of the 2,441 grant portfolio of the Eunice Kennedy Shriver National Institute of Child Health and Human Development went to pediatric trauma research. Evaluating the number of dollars spent on trauma research, the budgetary percentages are even lower. Of the total US $25 billion NIH extramural research budget, US $720 million (2.9%) was awarded for trauma research. With 3 institutes providing more than 5% of their respective funds for this topic—the National Institute of Arthritis and Musculoskeletal and Skin Diseases, the National Institute of Neurological Disorders and Stroke, and the National Institute of Mental Health.
For purposes of available denominator data, we further evaluated extramural grants that were categorized as Research Grants, Fellowships, or Training Grants to determine how they compared to the general distribution of NIH funding by grant type. Most trauma-related grants fell into these categories (1,715 projects with US $544 million of funding). There were relatively more grants and funding dollars for fellowships (7.5% of all grants), training grants (6.7%), research centers (5.1%), small business innovation research/small business technology transfer (5.0%), and career development awards (4.5%) over traditional investigator initiated research projects (e.g., R01) (3.6%) or other research grants (1.1%) (Table 2). Further examining research centers, 13% of P50 grants (30/231 accounting for 2.1% of funds) were trauma related. Evaluating training grants, 7.2% (27/374 accounting for 5.4% of funds) of T32 awards, were trauma related.
Analyzing research project grants to medical schools (certain DP, R, and U codes), we described how the distribution of trauma-related grants compared with the distribution of grants overall among different departments.28 The largest absolute number of trauma related (reported as trauma-related/total grants in that category according to a report from the NIH28) were awarded to Departments of Internal Medicine (110/1,119) although the percentage was less than 10%. The highest percentage of these awards for trauma versus all awards to that department type were among departments of orthopedics (100% or 29/29), physical medicine and rehabilitation (95% or 18/19), neurosurgery (85% or 50/59), emergency medicine (67% or 10/15), anesthesia (63% or 40/63), and surgery (45% or 55/123).
We report the first comprehensive and granular evaluation of NIH funding for trauma. These results document that NIH funding for trauma research is pitiful, representing only 2.9% of extramural NIH Funding with 3.7% of extramural awards going to trauma. Ironically and despite this tiny percentage, the distribution of awards spans nearly every NIH Institute, Center, and Office. It further demonstrates the scope of trauma's health care impact involving medical researchers of almost all specialties and broad interest by the entire scientific community on various aspects of trauma research. Despite this wide ranging engagement in research on trauma, funding is scattered throughout the agency without a single central focus on coordination, undermining the goal of “zero preventable deaths” and neglecting to provide a comprehensive framework for trauma research.
We noted that trauma was disproportionately represented in awards for training both at the institutional and individual levels. Of note, there was a relative increased percentage in institutions receiving research center grants (i.e., P50 grants) which support specialized centers providing a multidisciplinary approach to the research on trauma. This correlates with what we know about trauma—that it is a complex problem that requires a multidisciplinary approach to achieve impact.21,26,29–31 These data also suggest the need for better coordination of trauma research at the NIH. Of note, the number of NIH grants for trauma that are going to departments of surgery as opposed to other departments is low; this correlates with previous reports which have highlighted the low level of NIH funding for surgical departments. Even within surgical departments, disciplines, such as transplantation and surgical oncology, account for the majority of NIH awards.31–34
This report actually identified a higher percentage of NIH grants related to trauma than previous reports of “injury”-related funding,22 but levels of funding still do not begin to match the burden of disease and disability. There have been many reasons postulated for this lower than expected level of support, and it is likely multifactorial. The lack of national and public awareness of trauma as a true disease clearly shapes and influences national policy. The multidisciplinary nature of trauma both from the perspective of number of medical specialties that are involved to the myriad of research questions (e.g., immunology, traumatic brain injury, respiratory failure, wound healing) which span the gamut of biomedical researchers results in their applying for funds wherever they exist. Simply put, the lack of a dedicated trauma institute means that trauma researchers scramble for funds wherever they can find them. The lack of a singular funding entity providing a more focused and unified approach to trauma research would allow synergy across the medical research community that could both prevent the burden of the disease, as well as improve treatments and outcomes. Such an approach could have a huge impact to improve the clinical and translational research being conducted in this field.35
Historically, surgical research receives less funding from the NIH than their non-surgical counterparts.31,34 In 2016, despite an increase in the NIH budget to US $32.3 billion, surgeons were only funded US $292 million for research. From 2006-2016 the NIH budget has been increasing at a rate of US $213 million per year, however the funding for surgeons decreased at a rate of US $3 million per year.34,36 Trauma research is multidisciplinary in nature, and trauma surgery represents only one of its many facets. In short, in the 27 institutes and centers at NIH, there is no entity specifically dedicated to research on trauma, which ranks as one of the top 10 causes of death and disability among Americans.
Previous reports estimated that NIH funding for injuries was low, with approximately 2% of the total NIH budget going to trauma research.21,22,31,37,38 These data rely on the presence of the key term “injury” within the NIH spending categorization, and the use of administrative data that may not accurately reflect the specific grant at hand. Trauma care covers a broad spectrum of conditions (blunt trauma, penetrating wounds, unintentional injuries, homicide, suicide, etc.); provision of care by many specialties in medicine, nursing and health care, and types of research (clinical outcomes, translational, behavioral, and outcomes research). We feared that the categorization previously used may not capture the full breadth of trauma-related funding because of the large variety of topics that may not include the key term “injury” for their “NIH spending categorization.” This might include grants that have no NIH categories listed or topics like suicide, chronic pain, or posttraumatic seizures.
This study has several limitations inherent in its design. We chose to only evaluate NIH funding because its data are easily accessible and account for the majority of biomedical research funding. Federally funding for research on trauma also include the Department of Defense (DOD), the Department of Transportation and the Centers for Disease Control and Prevention. The DOD continues to fund important trauma-related research, but by its very nature, the agenda and focus is set by the military which excludes trauma-related research that is not of interest or relatable to the DOD mission. The amount of dollars within the DOD budget going for research is also just a fraction of the NIH budget. Professional organizations like the American College of Surgeons, the American Association for the Surgery of Trauma (AAST), industry, universities, and foundations also fund trauma research, although the dollars are dwarfed by federal research dollars. This study attempted to capture all trauma-related grants from NIH and exclude grants that were deemed unrelated. To achieve the granularity, we felt that it is necessary that we established and tested clear search criteria and a screening methodology which gave consistent results. The intra-class correlation was good, but could still have resulted in inconsistencies. That said, because these inconsistencies tended to put more grants in the “maybe trauma” category, we had another opportunity to assess those grants using expert determination. Because of the methodology and our goal to be inclusive, we were more likely to be biased by overestimating the number of grants and the amount of research funding. A previous study by the Society of Critical Care Medicine used a similar methodology to identify grants associated with another broad topic that encompasses some of trauma, “critical care.”25
Our results extend and fully justify the recommendations of The National Academies of Sciences, Engineering and Medicine report that argues for an increase in dedicated funding for research on trauma, as well as establishment of an institute or center with a clear focus on the topic. This center would have the singular goal of reducing the burden of trauma-related death and disability through research to prevent serious injury, accidental or self-inflicted, while improving care of the trauma patient. Establishing a National Institute of Trauma should be a national priority. Such an Institute could marshal the resources necessary to improve trauma care and outcomes throughout the United States and around the globe.
D.H.L., S.L.B., and N.E.G. conceived of the study and contributed to the data analysis, article execution and review. J.R. and N.I.F. participated in study design, did the data collection, literature review, analysis, and critical article editing.
The authors declare no funding or conflicts of interest.
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WILLIAM G. CIOFFI, M.D. (Providence, Rhode Island): President Croce, Recorder Reilly, members and guests, I want to congratulate the authors on clearly documenting a problem which has vexed all trauma surgeons and researchers for decades, and that is the paltry extramural NIH funding committed to trauma-related topics and the lack of a true home at the NIH for trauma research.
Given both the considerable loss of life and extended disability, in combination with the total lifetime cost, which dwarf heart disease, diabetes, and cancer, this problem persists, despite multiple National Academy reports, the first in 1966 and the last just three years ago.
The fact is, we are dead last in funding given the burden of disease, with only 3.7 percent of total NIH grants and only 2.9 percent of funding.
I have a few questions, which are really only quibbling given your findings.
You divide up the grants by fellowship, training grants, traditional research grants, et cetera, but do you have more granular detail in terms of clinical versus basic science questions, as well as what topics were being funded.
Where were we successful? You point out that musculoskeletal disease and traumatic brain injury are better funded, but what about other topics?
More disturbing to me, however, is that the Departments of Medicine had the largest number of "trauma" grants. Were you correct in how you identified them, and if so, what were the topics that they were studying? Your critics will claim that your methods missed and misclassified grants. How did you validate your search methods, as well as your expert panel, who were trauma surgeons, and obviously biased?
Most important, however, is what are we going to do about this? We must share some of the responsibility. Is the NIH the correct place for this, or should we be looking elsewhere?
Five years ago, the AAST, in conjunction with EAST, West, and the NTI founded the Coalition for National Trauma Research or CNTR. We've had some success, but mostly with DOD funding. Recently we strengthened our relationship with the ACS and Committee on Trauma, and our most important grant to date is NTRAP, or the National Trauma Research Action Plan, with Eileen Bulger as the PI. This is an advertisement. If you're one of those participating, please complete your role in this modified Delphi approach, which will outline what the next decade of trauma research should look like.
In addition, we formed a new research committee led by Rosemary Kozar that will leverage the vast amount of data contained in TQIP and like databases.
However, if we are to be successful in obtaining, an NIH institute for trauma research, we must act together in terms of advocacy. A concerted, joint, collaborative effort, putting aside our individual goals, will be required if we are to be successful.
Again, thank you for documenting this continued failure of our national agencies, such as the NIH, to pay attention to one of the most important national healthcare issues, that is trauma.
EILEEN M. BULGER, M.D. (Seattle, Washington): Dr. Bulger from Seattle. I, too, rise to applaud the authors on this very important study.
After the 2016 report NASEM was published, the American College of Surgeons hosted meetings at the NIH to address this issue, and we were told, "We do study it; you just don't know it, and it's spread across all our institutes," so I think this is a critically important study to highlight that it is spread across all the institutes, but at a very low rate, so I thank you for doing this work.
I do have a couple of questions for you that which I think will be important as we are challenged by those who believe this research is funded and just don’t recognize it. First, can you tell me how you defined trauma? Did you include burns? Did you include all basic science of the inflammatory response to injury? Did you include sepsis or other critical care topics that may impact the injured patient? I think it's really important that we're very clear on the definition.
My second question is, what time period did you look at specifically, because I think it's important to be able to compare your data to the data from the MOSES study from 2015. Thank you very much.
ERNEST E. MOORE, M.D. (Denver, Colorado): This a very timely issue, and I am proud to say Nina completed her TACS fellowship with us in Denver. I have two observations for your consideration, and a proposal.
First, the horizon looks even more bleak for NIH supported fundamental research. The long-standing NIGMS P50 Research Centers in Injury and Peri-operative Sciences has been sun-downed despite vigorous appeals from academic trauma surgeons. The P50 Program has been the foundation for NIH supported basic research for trauma since 1974. A major component of this Program was a clinical core to translate observations from the bedside to the bench, and to test findings from the bench in the injured patient. The NIGMS replacement is the RM1, which precludes clinical investigation. Thus, it will be much more difficult for trauma surgeons to compete in this arena.
Second, as I have stated in previous AAST meetings, the research dilemma for trauma surgeons is a two-way issue. To designate a new trauma division within the NIH will literally take an act of Congress. The research productivity of surgeons has declined progressively over the past decade, and trauma surgeons rank at the bottom. We need to demonstrate our capabilities in research to policy-makers, and our current TACS fellowship does not emphasize research training or productivity. We marvel at the success of our colleagues in medicine, but virtually all medicine fellowships in academic medical centers ensure dedicated research time, and many expect the fellows to acquire NIH K99 training grants.
I submit we need to offer flexibility in our TACS fellowship to develop the next generation of trauma surgical scientists. For example, I believe we should permit fellows an option to complete a two-year T32 basic research fellowship after their first year of critical care training, instead of their second year of EGS training.
In sum, we all agree the societal toll of trauma warrants a dedicated NIH division, but this will not occur unless we demonstrate our ability to capitalize on this tax-based resource.
MITCHELL J. COHEN, M.D. (Denver, Colorado): Mitch Cohen from Denver. Really outstanding study, and I think extremely important as we advocate for more research, so I would corroborate what Dr. Bulger has said.
I do have a question, because I think that some of this becomes a self-fulfilling prophecy for us. I was extremely lucky to have very good mentors who pushed me and guided me into basic fundamental research.
And now as we complain about a lack of funding, we also say, well, it's too hard, and we don't have enough time, so I very much wonder what the submission rate is, and what the failure rate is.
How many people are really trying to do research who can't get funded, rather than the perception that there's just no money out there, so it's not worth trying?
That data may be available for the NIH, but it also might be something that would be good to survey the membership across these broad categories and find out, are people really trying to do this, and what are the barriers to doing research, other than outside funding? Otherwise, I applaud you on a very nice paper.
HOWARD R. CHAMPION, M.D. (Annapolis, Maryland): Champion, semi-retired in Annapolis, but I ran a trauma center in Washington, D.C., in the 70's, 80's, and 90's, and became a pain in the neck on Capitol Hill. Senator Kennedy used to say, "Here comes that trauma doc again."
In the '90s, I co-chaired a Congressionally-mandated committee on trauma research for NIH. With the cognoscente of trauma in the world at that time, some of whom are still alive, I wrote a 90-page report which I co-authored with the Deputy Director of NIH in Building One.
That went to every Department of Surgery and all over Congress and, as usual with these reports, as has been elaborated on in this presentation, nothing happened. So I really appreciate this update. I would love to compare the methodology.
We extensively discussed a National Trauma Institute at that time, and there was a lot of people in favor of it. There were two problems, and the reason why it didn't happen was one, Congressman Dingell who was the gatekeeper on NIH authorizations, said, "I am not going to create another institute, period." He was pretty firm on that.
The second problem was NIH. As you correctly indicate, NIH has 32-odd billion dollars a year funding. It is spread through multiple fiefdoms of institutes and centers.
They individually decide how to disburse that largely relative to the investigator-instigated research proposals. So trying to claw money out of some of these big institutes with $3 or $4 billion dollar a year budgets and plunk it into a new institute was not acceptable, even though it had some support in Building One.
My basic questions are:
- I'd love to see the methodology to compare it with our methodology, because your numbers showed that the amount of money, or the percentage of money directed to trauma research has doubled since we did that study and published it in the ‘90s;
- Have the problems have been solved with Congress? to Is there support for a new institute there now; and
- Who has vetted this whole idea with the heavy-duty institutes at NIH. They are a stop-go, even if you could get legislation passed through Congress to support this?
Finally, I would say NIH is investigator-initiated research. It's unlike the military, and so, pointing the finger at NIH is not going to solve the problem.
We should look in the mirror, and say why are not trauma proposals acceptable to the various institutes. And the answer to that, for many of them is, THEY ARE NOT UP TO STANDARD. Thank you.
NINA E. GLASS, M.D. (Newark, New Jersey): Thank you, Dr. Cioffi, for your discussion, and thanks to everybody for your informative comments and insightful questions. I will try to address each in turn.
Dr. Cioffi, for your questions: We had more granular data about what types of research—basic science, clinical, et cetera, from the NIH Spending Categorization data that I mentioned, based on 233 reported categories of disease, condition, or research area. However, the drawback of using these data is that nearly half of the grants have no NIH Spending Category listed and the others each have several. About the specific topics of grants that were successful, that would require further qualitative evaluation, and we attempted to avoid putting more subjectivity into our evaluation.
You ask why Departments of Medicine received the highest number of grants related to trauma and if this signified a problem with our search strategy? Just as Dr. Moore mentioned, Departments of Medicine receive the most grants funded from NIH – over a thousand – nearly ten times as many as go to Departments of Surgery, so while only 10 percent of Departments of Medicine grants that were trauma-related, that added up to the highest absolute number.
To Dr. Bulger's comments, I would like to refer you to the appendices of our manuscript where our search strategies are spelled out; for the most part we attempted to included topics like burns, critical care, sepsis, only when they were also somehow trauma-related. About timing, we evaluated fiscal year 2016. The Moses paper evaluated NIH funding category estimates from 2012 and disease burden data from 2010.
I appreciate Drs. Moore and Cohen’s comments about how submissions for trauma related research are much lower than for other topics and from other specialties and acknowledge that this may be a barrier to getting more funded research for trauma. While we did not look at the success rates of applications and only focused on funded grants, I acknowledge we should take some responsibility for this lack of funding and emphasize the importance of actually applying for research funding. However, it is also true that researchers go where the money is. When there is a concerted effort and a specific call for research proposals, there is more funding for that specific topic, and therefore more minds focusing on that topic. A trauma institute, by its very nature would create those calls for research and focus investigator’s attention in that arena. That said, success breeds success, and I think that a concerted effort on our part in emphasizing the importance of research as a part of fellowship training could certainly begin a develop a larger cadre of researchers.
Thank you, Dr. Champion, for all your comments and your foundational work on this topic. As you mentioned, there are several barriers to creating another institute at the NIH including the Congressional mandate that there be only 27 institutes and centers, so under current rules, there has to be one that closes to make room for another institute. Obviously this is problematic on many levels. However, we're here this week talking about the disease burden of trauma — I think focusing on that should redirect the conversation to make it an obvious next step that funding must be improved. As trauma surgeons, we know that there are a lot of important topics that need to be funded, and having a National Institute of Trauma could really help to coordinate those efforts in terms of prevention, acute care, and then post-injury survival. I have high hopes that ongoing research will continue to chip away at addressing the problems we see in our everyday practice and improving the care of trauma patients — this includes having trauma surgeons apply for more funding — to make the case that trauma deserves more funding and to support the idea that a focus on emphasizing trauma research by large funding bodies like the NIH will benefit the health of our country.