Where's the respect (and $$) for critical care research?

(image: Suburban Wino)

Craig Coopersmith of Emory is an amazing guy and a prolific investigator in critical care -- and it looks like he's fed up with having his grants rejected. After some epic bean-counting, his group concludes that critical care research gets short shrift in federal research funding, compared to the huge amounts spent on providing critical care in the U.S. (Editor's Note: The man in the photo to the left is not Dr. Coopersmith.)

Hannah Wunsch (Columbia), Mitchell Fink (UCLA), Clifford Deutschmann (U-Penn) et al co-author the paper in the April 2012 Critical Care Medicine.

Meanwhile, in an open letter from ATS in the AJRCCM (Blue Journal), Marc Peters-Golden (U-Michigan) et al argue that pulmonary disease in general is NIH's underfunded, unloved stepchild. They point out that only 2.5% of the NIH's $31 billion budget -- about $675 million annually -- goes to lung disease research, a figure far too low given the burden of lung disease in the U.S.

What They Did

Surprisingly, no one really knows the amount of funding spent on "critical care research," because there's no such category or department within the NIH's 27 disease-focused institutes and centers (heart disease, cancer, etc). Each of these centers dabbles in critical care research as part of its overall mission, but there's no unifying organization.

Investigators worked with the Society of Critical Care Medicine to create a list of 133 keywords and phrases that relate to critical care research. They then queried the NIH's grant database for all 19,257 grants funded in 2006 with a keyword match. This produced a list of 8,327 unique grants.

However, many of these grants had nothing to do with critical care. Some keywords (e.g., ARDS, shock, brain death, etc., etc.) were tightly linked to critical care, while many others (e.g., pneumonia, sepsis, toxicology) overlapped both critical care and non-critical care. Therefore, each grant title was individually reviewed by at least 2 of the authors to determine inclusion, which eliminated all but 1,212 grants as not related to critical care, with 93% concordance between reviewers.

What They Found

Using the conservative standard of both reviewers agreeing that a grant was critical care-focused further reduced the number of grants to 332 of the original 19,257. Using a liberal definition (one reviewer saying "at least possibly related to critical care") produced a list of 1,212 grants.

Ergo, between 332 to 1,212 grants (of 19,257) were related to critical care in 2006. Authors could calculate the percentage that were funded, and so could conclude that critical care research funding represents 1.7 to 6.3% of the federal research budget.

Using various estimation techniques (i.e., back-of-the-envelope figures based on the Premier database sample), they calculated U.S. critical care expenditures in 2006 to be $121-$263 billion. (No one knows what critical care really costs, either.) They divided this into the Centers for Medicare & Medicaid Services' total National Health Expenditure estimate of $2.3 trillion/year, to conclude that critical care services represent 17 to 38% of total hospital costs, and 5.2% to 11.2% of total U.S. healthcare spending.

They conclude that (most likely), critical care research is under-funded relative to the amount of money we spend on it as a nation. By comparison, cancer and cardiovascular disease (using the same estimation methods) are funded at multiples (2-11 times) of critical care's share.

It wasn't that critical care grants were treated unfavorably by NIH -- authors found that roughly the same proportion of grants related to critical care were funded as those unrelated to critical care.

They don't presume to explain why this is the case or what should be done about it; they spend most of the discussion marveling at the impossibility of precisely quantifying these costs and expenditures, and the questionable wisdom of such a fragmented allocation and tracking system, for something that is so important to our society and economy.

Coopersmith CM et al. A comparison of critical care research funding and the financial burden of critical illness in the U.S. Crit Care Med 2012;40:1072-1079. 

Peters-Golden M et al. The Case for Increased Funding for Research in Pulmonary and Critical Care. Am J Respir Crit Care Med; ePub May 10, 2012.