Statement of

John I. Kennedy, Jr., MD

On behalf of the
Alliance for Academic
Internal Medicine

Before the
Committee on Veterans' Affairs
United States Senate

VA Research: Investing Today to Guide Tomorrow's Treatment

Washington, DC

April 27, 2006
 
Good morning Mr. Chairman and members of the committee.  My name is John Kennedy, and I am a Professor of Internal Medicine and Residency Site Director at the University of Alabama at Birmingham.  I spend the majority of my professional time at the Birmingham VA Medical Center where I hold the positions of Associate Chief of Staff for Acute and Subspecialty Care and Chief of the Medical Service.  I am testifying today, however, in my role as a leader of the Association of Program Directors in Internal Medicine and on behalf of the Alliance for Academic Internal Medicine. 

Thank you for providing me the opportunity to testify about the successes of and challenges to the VA medical and prosthetics research program.  Internists represent roughly 50 percent of all VA researchers and conduct bench research, clinical research, and health services research in all the specialties of internal medicine.  These specialties range from the primary care field of general internal medicine to rheumatology, gastroenterology, and cardiac electrophysiology?as well as my own field of pulmonary and critical care medicine?to name a few.  Internists have also been at the forefront of providing excellent leadership to the VA research program, and I must take this opportunity to thank my fellow internists here today, Drs. Feussner, Perlin, and Kupersmith, for their vision and management of the program.

I am here today to tell you that the VA research program works but faces challenges.  My examples of this success will come from my local experience, but the nation is replete with similar stories.

My first example of the success of the program is VA's Birmingham/Atlanta Geriatrics Research, Education, and Clinical Center, or GRECC.  The GRECC employes 22 core VA personnel at the two VA medical centers.  In their research, the GRECC investigators focus on genitourinary disorders, mobility, and palliative care, studying such topics ranging from sarcopenia, or loss of muscle, to driving issues among older veterans.  Among the results reported by investigators from the GRECC in 2005 were studies showing that daytime exercise and bladder control strategies were more effective than medication in controlling the need to urinate at night and studies documenting the important aspects of team functioning that yielded functional improvements for stroke patients.

Of course, the GRECC investigators are also clinicians and educators in the two facilities.  Notable among their clinical accomplishments has been the development of a palliative care program at the facility in Birmingham, well-recognized among the best in the nation if not the world.  Approximately 25 percent of all patients hospitalized at the Birmingham VA Medical Center are seen by palliative care consultants who address their needs for relief of suffering of all types and assist with development and implementation of directives for future care and at the end of life.  This work has ultimately led to the opening of a new 10-bed inpatient palliative care unit in our medical center where veterans nearing the end of life can receive compassionate care from a multidisciplinary team trained to address their particular needs and those of their families. 

On the education front, GRECC educators have been successful in raising over $2 million in the last year alone to improve the training medical practitioners receive in caring for elderly patients, a critical area for education given America's aging population.  The GRECC has also reached out to the community with its VA Teacher Ambassador Training Program, a VISN recognized effort to honor veterans.

In addition to these programmatic accomplishments, VA research support has worked in this case by leveraging funds from other sources.  In FY 2005, the GRECC had a total of more than $35 million in research funding.  Of this total, $9.9 million came from VA while $25.8 million came from outside funding sources.  This group of researchers has proven to be highly productive and able to successfully compete for funding in every sphere.  However, without VA's investment in the GRECC, it is hard to see how any of these results would have materialized.

The Deep South Center on Effectiveness at the Birmingham VA Medical Center is another excellent example of VA's research successes.  The Center is funded as a VA Research Enhancement Award Program, or REAP.  The Center's mission is to improve healthcare for veterans and the nation through partnerships in effectiveness research.  The Center develops strategies to change provider practice patterns using evidence-based interventions to improve the quality of care for veterans, and it uses VA's extensive databases to promote improved care by establishing links between direct patient care and population-based analyses.  The Center includes 35 investigators and 14 FTE support staff.

One of the reasons this Center is a success for VA research is because it has forged strong liaisons with the University of Alabama at Birmingham.  In one linkage, the Center has undertaken a research project to assess the effectiveness of bioterrorism preparedness education among health care practitioners.  This project directly ties in with the work of the UAB Center for Biodefense and Emerging Infections.  Through the affiliation with UAB, several VA researchers also participate in major national research initiatives such as Coronary Artery Risk Development in Young Adults, or CARDIA.  Utilizing the CARDIA database, these VA researchers recently published their important new findings identifying a link between second-hand smoke exposure and glucose intolerance, a precursor of diabetes.  This function of the academic affiliation strengthens both the VA and UAB, improving their research efforts and the care provided to veterans and other patients.

The Center is also a success in that it is a platform for research efforts with possible effects on both the nation's current veteran population as well as the veterans returning from Afghanistan and Iraq.  For instance, the Center is planning a study of atypical antipsychotic medications in post-traumatic stress disorder, while at the same time studying best practices for hernia repair and improving intermediate outcomes in veterans with diabetes. 

Finally, the Center is a success in utilizing VA as an excellent laboratory for projects that aim to improve care for veterans.  The Center's recently funded VA MI+ study seeks to understand and increase provider adherence to clinical practice guidelines for post-heart attack patients.  The study integrates the VA electronic health record system and its community based outpatient clinics, or CBOCs, to achieve this goal.  No other health system in the United States could serve as well as VA as a setting for this study.

Despite the successes of the VA research program, AAIM has concerns for its future.

The lack of growth in program funding, particularly the administration's long standing reluctance to incorporate increases for the program in its budget proposal, is particularly troubling.  A flat budget sends messages to young clinician-scientists, as well as established investigators, that hard times are ahead and that research may not be the career for them.  Over the past four years, during which overall research funding to our VA medical center has remained relatively flat, the number of funded investigators has decreased by 30 percent and the entry of new investigators has dropped dramatically.  Mid-level and senior researchers with a prior history of sustained funding, and active funding from NIH and other sources, have found it increasingly difficult to obtain research funding in VA.  Several of our physician-investigators have had to resubmit grant proposals up to four times before obtaining funding.  During such gaps in support, the momentum of the research effort is seriously eroded.  One investigator working in HIV reported that 60 percent of the lab's personnel departed during such a gap.  Faced with these ongoing problems, physicians from our medical center in the specialties of nephrology, gastroenterology, and pulmonary diseases have abandoned efforts to obtain future research funding from VA.  As a result, our ability to recruit and retain the highly skilled specialists needed to care for our complex patient population is compromised.

AAIM thanks the Committee for its support of the program in your views and estimates letters.  The Alliance also thanks Senator Craig and Senator Akaka for their sponsorship of the Dear Colleague letter to appropriators.  As a member of the Friends of VA Medical Care and Health Research coalition, or FOVA, AAIM supports a $460 million appropriation for the VA research program in fiscal year 2007.  I cannot overstate how important growth to the program will be given the likely difficulties in increasing overall federal support for research in the coming year, despite your best efforts.

AAIM's second specific concern for the future of the program is VA's research infrastructure.  Modern scientists need modern facilities in which to conduct research.  I have heard countless stories from AAIM members across the country about difficulties in upgrading ventilation and electrical systems.  These basic needs are critical.  The precision equipment required for modern research programs, such as genomics, will require precise control of the laboratory environment.  The advanced computer systems and high-tech equipment that will support this work will absolutely demand consistent, uninterrupted supply of electrical power.  More investment in core facilities to house essential research tools, such as mass and NMR spectrometers, advanced microscopy, robotics and computer equipment, will be required for VA to move into the future of research where it most deservedly belongs.  AAIM encourages you to consider the development of a designated authority for funding VA research infrastructure.

The alliance's final concern pertains to the distribution of VA's scarce research resources.  The successes outlined in my statement inherently result from the intramural structure of the research program.  In most cases, VA funded investigators must have at least a 5/8ths appointment.  This structure assures these same investigators are available as clinicians and educators in the VA, vital roles for caring for the veteran population.  The other inherent element of the program is peer review, the process through which the best research can be identified and prioritized for funding.  AAIM encourages this committee to lead efforts to retain these valuable aspects of the program and strengthen VA research as it serves today's and tomorrow's veterans.

Again, thank you for the opportunity to appear today.  I look forward to your questions.