Emergency Medicine Research and the Stimulus Bill: Researchers Scramble to Claim Piece of the Pie

Article Outline

• Lateral Thinking
• Poor Fit
• Looking Forward

If you happened to step into an emergency department (ED) between March and April this year, and stopped and listened closely, then beneath the crying kids, the shouting drunks and the barked orders, you might have heard an unfamiliar sound: frantic typing.

It was the sound of thousands of fingers hammering out grant applications.

The massive economic stimulus bill passed by both houses of Congress on February 13 and signed into law 4 days later, formally known as the American Recovery and Reinvestment Act of 2009, gave $29.02 billion to the Department of Health and Human Services, with $10.4 billion going just to the National Institutes of Health (NIH). Out of that $10 billion, NIH freed up $200 million in Challenge Grants. The grants offered one-time, 2-year allotments of up to $1 million each, with one substantial catch: They were announced on March 4, and applications were due 8 weeks later, on April 27.

The grants looked like manna in the midst of a research funding famine. Institutions across the US threw so many personnel into pursuit of them that the online magazine Slate joked that most researchers had stopped doing research to pursue the Gold Rush bonanza of potential new money, and science blogs gossiped about the double digit numbers that various universities were rumored to be filing. Despite widespread suspicion that the process favored established big university labs that could exploit existing NIH connections, there were plenty of EDs among them.

“We are all constantly looking for new funding opportunities as they arise,” said Thomas E. Terndrup, MD, professor and chair of emergency medicine and associate dean for clinical research at Penn State University College of Medicine in Hershey, PA. He called the grants a “new and important opportunity… whether that would be in a field that we traditionally think of as our domain, or a related field.”

The “related field” reference comes from the reality that, among the 15 categories of challenge grants, none specifically addresses emergency medicine. Instead, they cover areas that NIH deems “high priority topics,” including prevention, bioethics, disparities, genomics, comparative effectiveness and health information technology. But creative investigators found ways to tweak the categories toward emergency medicine, though most contacted by Annals declined to discuss their applications.

Stephen H. Thomas, MD, MPH, George Kaiser Family Foundation professor and first chair of the new department of emergency medicine at the University of Oklahoma School of Community Medicine in Tulsa, OK, said before the grant deadline that his faculty would be looking for ways to nudge the grants' “behavior, behavioral change and prevention” category toward that perennial prairie concern, tornadoes. “We don't actually know a lot about the disease and injury burden from tornadoes, whether that is during a tornado or after, from water supply disruption or from putting your hand through broken glass during clean-up,” he said. Because of Oklahoma's socioeconomic status and because the new department is seeking to build relationships with rural communities, there might also be opportunities under the rubric of health disparities, he said.

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Lateral Thinking 

That sort of sideways thinking, looking at current research interests to fit them to the challenge grant categories, has been necessary for any emergency medicine researchers seeking to take advantage of the NIH opportunity, Dr. Terndrup said. “It's great when you are already working in an area and it takes only a slight shift to line up your existing interests with application funding opportunities,” he said. “But if you are an emergency physician who is already active in research, very likely when you looked through this list, you saw categories that could accommodate your interests.”

The Challenge Grants were so alluring to emergency medicine investigators at least in part because the specialty has been so starved for research money. As noted in the 2006 Institute of Medicine report, “Hospital-Based Emergency Care: At the Breaking Point,” academic emergency medicine has historically been the lowest-funded of any specialty, receiving only 0.05% of the NIH training grants awarded to medical schools.¹ Up to this point, emergency medicine has been its own chief funder through the Society for Academic Emergency Medicine and the Emergency Medicine Foundation of the American College of Emergency Physicians.

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Poor Fit 

That is at least in part because emergency medicine as a discipline does not fit the prevailing mode of NIH-driven research, which tends to be system-specific. “NIH is really set up around diseases and organs — that's why the institutes have names like National Heart, Lung and Blood Institute, or National Institute of Neurological Disorders and Stroke,” said Charles B. Cairns, MD, professor and chair of emergency medicine at the University of North Carolina. “It's starting to ramp up now, but there clearly was a long lag between the founding of the specialty and any significant awarding of federally funded research.”

Emergency medicine has been struggling with this poor fit for more than a decade, ever since the 1995 Josiah R. Macy Foundation report, “The Role of Emergency Medicine in the Future of American Medical Care,” stressed how much the specialty needed to develop its own research agenda. The 2006 IOM reports emphasized the critical lack of not only funding but also investigators, and called for the development of research networks as well as fresh attention from federal funders.

But when emergency physician researchers including Dr. Cairns tried to stimulate that process, meeting 6 months after the reports' publication with then-NIH Director Elias Zerhouni, MD, they were stymied by his request that they state emergency medicine research's fundamental hypothesis. In the 12 years since the Macy report called for one, no underlying hypothesis — the first step in any research enterprise, as those researchers understood — had ever been reached.

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Dr. Zerhouni's question triggered a process of self-scrutiny within the specialty, culminating in the statement of a hypothesis in a 2007 paper in Annals by Robert W. Neumar, MD, PhD, of the University of Pennsylvania: “Rapid diagnosis and early intervention in acute illness or acutely decompensated chronic illness improves patient outcomes.” But it also prompted NIH to examine how little emergency medicine research had been funded — and to confront that understanding the unique nature of emergency medicine would be a prerequisite for any reviewers evaluating grant applications in emergency research.

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Looking Forward 

The result, Dr. Cairns said, was an internal NIH review, the formation of a Task Force on Research in the Emergency Setting and a commitment to holding 3 round table discussions aimed at educating the NIH institutes and centers. The round tables, on neurological and behavioral emergencies, medical and surgical emergencies, and trauma, are scheduled to be completed by the end of June 2009.

“The plan at the end is to distribute the results internally to NIH and externally to the public,” Dr. Cairns said, “to develop prioritization of what studies can be done now, what studies need to be done in the future and which areas need further scientific exploration and research before they can be adequately addressed in clinical studies.”

That painstaking stepwise process leaves emergency medicine still without a formal commitment of support from NIH to the specialty, let alone any sense of where among its 27 institutes and centers emergency medicine research is more likely to find a home. But though that seems to leave emergency medicine research temporarily still a stepchild, Dr. Cairns said it actually has been beneficial, because it advanced emergency medicine's research needs on NIH's agenda at a key moment.

“The results of these interactions over the past couple of years have definitely resulted in some emphasis on emergency care within the Challenge Grant program,” he said. “It is a focus within at least 5 of the Challenge Grant topics. And I think it speaks not only to the evolution of the field, but the increased recognition NIH has of the importance of emergency medical research.”