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Keywords:

  • federal funding;
  • public health;
  • emergency medicine;
  • emergency departments

Abstract

  1. Top of page
  2. Abstract
  3. EM and Public Health
  4. Federal Agencies that Fund EM Surveillance and Other Public Health Activities
  5. Conclusions
  6. Acknowledgments
  7. References

The emergency department (ED) visit provides an opportunity to impact the health of the public throughout the entire spectrum of care, from prevention to treatment. As the federal government has a vested interest in funding research and providing programmatic opportunities that promote the health of the public, emergency medicine (EM) is prime to develop a research agenda to advance the field. EM researchers need to be aware of federal funding opportunities, which entails an understanding of the organizational structure of the federal agencies that fund medical research, and the rules and regulations governing applications for grants. Additionally, there are numerous funding streams outside of the National Institutes of Health (NIH; the primary federal health research agency). EM researchers should seek funding from agencies according to each agency’s mission and aims. Finally, while funds from the Department of Health and Human Services (HHS) are an important source of support for EM research, we need to look beyond traditional sources and appeal to other agencies with a vested interest in promoting public health in EDs. EM requires a broad skill set from a multitude of medical disciplines, and conducting research in the field will require looking for funding opportunities in a variety of traditional and not so traditional places within and without the federal government. The following is the discussion of a moderated session at the 2009 Academic Emergency Medicine consensus conference that included panel discussants from the National Institutes of Mental Health, Drug Abuse, and Alcoholism and Alcohol Abuse and the Centers for Disease Control and Prevention (CDC). Further information is also provided to discuss those agencies and centers not represented.

The Institute of Medicine’s (IOM) seminal report on the Future of Emergency Care in the United States Health Care System1 was the culmination of an extensive investigation into the status of emergency medicine (EM) and services. Hospital emergency departments (EDs) were described as broken systems, overcrowded, inefficient, and ineffective because the demand for care far exceeds the capacity in EDs. The IOM emergency care committee chair testified before Congress and described the need to enhance emergency care research.2 The committee determined that public health was negatively affected by the current state of emergency care. Specifically, the panel of EM experts recommended that federal agencies target additional research funding for prehospital emergency care services and for needs and gaps in emergency care.2

Not only are EM providers availing themselves of federal research funds in acute critical care, but also EM researchers have increasing opportunities to ameliorate a host of other health issues that directly or indirectly affect public health. To this end, both funding and sustaining EM public health research were the foci of a session at the 2009 Academic Emergency Medicine (AEM) consensus conference. As part of this larger meeting, representatives from the National Institutes of Health (NIH), including the National Institute of Mental Health (NIMH), the National Institute on Drug Abuse (NIDA), and the National Institute of Alcoholism and Alcohol Abuse (NIAAA), and the Centers for Disease Control and Prevention (CDC) participated in a discussion related to federal agencies and organizations that fund EM public health research, providing examples of federally funded EM public health initiatives and offering suggestions to sustain public health research, programs, and surveillance in the ED.

The purpose of this article is to describe the nature of federal funding for EM public health research, programs, and surveillance; to highlight the opportunities afforded emergency physicians (EPs) to improve the public health; to explain the differences among the major federal agencies that fund EM public health efforts; and finally, to delineate specific EM research foci according to the missions of various federal agencies.

EM and Public Health

  1. Top of page
  2. Abstract
  3. EM and Public Health
  4. Federal Agencies that Fund EM Surveillance and Other Public Health Activities
  5. Conclusions
  6. Acknowledgments
  7. References

As “…all the health problems and many of the social problems of society come to rest on the doorstep”3 of EDs, EM providers have ample opportunity to improve public health. However, embracing a public health approach to health care would require a shift in thinking for staff in EDs.

A “public health approach” is typically characterized by defining the scope and consequences of the problem, identifying risk and protective factors, designing, implementing, and evaluating interventions to ameliorate the problem and translating research into practice by implementing interventions on a wider basis to prevent others from becoming sick or injured. This may differ from the typical view of EM as only consisting of intervention with and treatment of persons who are already ill or critically injured.4 For example, screening for HIV, addressing obesity, or providing a brief intervention for substance abuse when a patient presents to the ED for an unrelated injury allows the EM professionals to provide acute care while simultaneously addressing other public health concerns with far-reaching consequences.

Ultimately, EM and public health professionals both aim to improve and preserve the health of the communities they serve.5 Therefore, the nature of EM research in the future can reflect a public health approach without abandoning its focus on caring for the acute needs of patients. The field of EM is evolving to embrace such an approach, and federally funded research opportunities exist for the development of effective prevention and intervention strategies, with real potential for improving public health.

There are a number of areas where EM and public health overlap, which can serve to facilitate the evolution of EM to comprise preventive care. Both EM and public health are interdisciplinary in nature. Whereas public health practitioners include epidemiologists, biostatisticians, and social scientists (to name a few), EM research is conducted by basic and clinical scientists, providers (physicians, nurses, and social workers), and many researchers in the same disciplines found in public health. Potential areas of collaboration between EM and public health personnel that make use of commonalities of experience and interest include surveillance of disease, injuries, and health risks; delivery of preventive services; monitoring access to care; and development of health policy.6

The 2009 AEM consensus conference included a panel discussion focusing on collaboration between EM and public health for population-based surveillance, screening, and intervention. This paper describes the opportunities presented by the primary federal agencies that fund EM public health research, surveillance, and programmatic activities.

Federal Agencies that Fund EM Surveillance and Other Public Health Activities

  1. Top of page
  2. Abstract
  3. EM and Public Health
  4. Federal Agencies that Fund EM Surveillance and Other Public Health Activities
  5. Conclusions
  6. Acknowledgments
  7. References

A basic understanding of the organizational structure of federal funding agencies is essential for researchers to be able to identify funding streams relevant to EM.7 Notably, there are federal research agencies that independently conduct research as well as to fund university research—like the NIH within the U.S. Department of Health and Human Services (HHS) or the National Institute of Justice (NIJ) within the U.S. Department of Justice. However, there are also other less widely known federal agencies with mechanisms and opportunities for funding EM public health research and collaboration.

Critical to EM researchers developing a diverse portfolio of funded public health research is an understanding of the mission of particular federal agencies and the knowledge that more than one agency may fund the same research topic. “Elder abuse,” for example, is a research focus that demonstrates how funding may be secured from multiple sources. The National Institute on Aging at NIH, the National Center for Injury Prevention and Control at the CDC, NIJ, and the Centers for Medicare and Medicaid Services at HHS all fund research on elder abuse.

A number of other federal agencies outside of HHS also fund research of direct relevance to EM investigators. For example, the U.S. Department of Agriculture (USDA) is concerned with preventing obesity and prevention and treatment of diabetes, both of which are concerns of EM professionals. Recently, the USDA provided a grant to the Montefiore Medical Center’s ED in New York City to promote healthy eating among its community residents.8

The Department of Commerce was the first federal agency to fund health information technology initiatives such as electronic immunization records. As an example of research funded by the Department of Commerce, the National Institute of Standards and Technology recently announced a cooperative agreement funding opportunity of up to $20 million to develop and implement a measurement science and engineering fellowship program.9 Among the eligible grantees are U.S. institutions of higher education and hospitals, the latter including academic departments of EM.

The Departments of Defense and Veterans Affairs each fund a variety of ED research initiatives. For instance, the Section of Emergency Medicine at The University of Chicago Division of Biologic Sciences is exploring proteomic changes during hemorrhagic shock, which is supported by a 5-year grant.10 As an example of EM research funded by the Department of Veterans Affairs, applications are about to be accepted for research on predicting which trauma survivors will develop enduring symptoms and posttraumatic stress disorder (PTSD).11

The Department of Homeland Security distributes funds for emergency response, a domain of EM. For example, Johns Hopkins University houses the Center for the Study of Preparedness and Catastrophic Event Response, a Homeland Security Center of Excellence that studies decision-making, infrastructure integrity, surge capacity, and other issues.12

The Department of Justice and its various offices and institutes fund research in a number of areas of interest to many ED researchers (e.g., injury and violence prevention research). For example, a team of EPs recently published research findings regarding the safety and injury profile of conducted electrical weapons (such as the Taser) used by law enforcement against criminal suspects.13 A number of research initiatives regarding detection and prevention of domestic violence have also been funded by NIJ, such as the examination by Rhodes and colleagues14 of the effect of victim participation on prosecution of violent partners, measured both within the civil and criminal justice systems and within the health care system (using ED services).

Another federal agency that funds EM activities is the National Highway Traffic Safety Administration (NHTSA), Department of Transportation. NHTSA has a history of sponsoring EM conferences (e.g., “Crossing Barriers in Emergency Care of Alcohol-Impaired Patients” [2003]) and even has its own emergency medical services (EMS) research agenda.15

The federal agency that funds most EM public health research is HHS (see Figure 1). When funding is available and an HHS agency is seeking applications on a particular topic, the agency will issue an official notice, known as a Funding Opportunity Announcement (FOA; available on Grants.gov). The FOA provides an overview on the research area of interest, guidance on how to receive an application kit, and instructions on how to apply. Investigators may also initiate ideas that are submitted under parent FOAs (e.g., Parent R01). Below, we describe the mission and funding priorities of some of the HHS agencies that issue FOAs relevant to EM public health research, as well as their associated research centers.

image

Figure 1.  Major federal funding agencies that report to the secretary of Health and Human Services (HHS).

Download figure to PowerPoint

National Institutes of Health

The mission of the NIH is to conduct science in pursuit of fundamental knowledge about the nature and behavior of living systems and the application of that knowledge to extend healthy life and reduce the burdens of illness and disability. Most of the research institutes within NIH fund EM public health research. The list below includes many of the NIH institutes and centers16 that have a record of supporting EM-related research:

  • • 
    National Institute on Aging
  • • 
    National Heart, Lung, and Blood Institute
  • • 
    National Institute on Alcohol Abuse and Alcoholism
  • • 
    National Institute of Allergy and Infectious Diseases
  • • 
    National Institute of Biomedical Imaging and Bioengineering
  • • 
    National Institute of Child Health and Human Development
  • • 
    National Institute of Diabetes and Digestive and Kidney Diseases
  • • 
    National Institute on Drug Abuse
  • • 
    National Institute of Mental Health
  • • 
    National Institute of Neurological Disorders and Stroke
  • • 
    Fogarty International Center
  • • 
    National Center on Minority Health and Health Disparities
  • • 
    Center for Information Technology

Some NIH institutes and centers focus on organ systems and their associated diseases. EM professionals can study both acute manifestations of these conditions, such as myocardial infarction, stroke, and suicide, and their underlying causes, such as diabetes, obesity, depression, smoking, and substance use.

National Institute on Alcohol Abuse and Alcoholism.  Of particular interest to many EPs is NIH’s NIAAA, whose mission is to provide leadership in the national effort to reduce alcohol-related problems by conducting and supporting research in a wide range of scientific areas; coordinating and collaborating with other research institutes and federal programs on alcohol-related issues; collaborating with international, national, state, and local institutions, organization, agencies, and programs engaged in alcohol-related work; and translating and disseminating research findings to health care providers, researchers, policy-makers, and the public.

According to one of the authors (RH, in the panel discussion at the AEM consensus conference), alcohol screening and brief intervention are part of NIAAA’s EM research portfolio, citing a number of encouraging findings from brief alcohol interventions in EM settings.17–19 A comprehensive review of the literature can be found in this issue.20 Challenges regarding research in screening and brief intervention that need further research include determination of the exact message and dose of the intervention and whether tailoring to subsets of patients may be of benefit.

NIAAA has an interest in exploring whether expanding screening and brief intervention in a variety of settings in communities increases reduction in alcohol misuse and related problems, beyond the demonstrated effects of community environmental interventions to reduce alcohol availability and driving after drinking.

National Institute on Drug Abuse.  The mission of NIDA is to reduce drug abuse and addiction by conducting and supporting research across a broad range of disciplines and disseminating research findings to improve prevention, treatment, and policy as it relates to drug abuse and addiction. One of the authors (RD) presented on NIDA’s EM public health research portfolio at the 2009 AEM consensus conference, noting that screening, brief intervention, and referral for treatment (SBIRT) has been shown to be effective in reducing use of alcohol and tobacco;21,22 while evidence of its effectiveness in reducing drug use is accumulating, it is not yet to the point sufficient enough to make a U.S. Preventive Services Task Force recommendation.23–25

The National Institute on Drug Abuse has numerous initiatives under way to obtain evidence for the effectiveness of SBIRT in reducing drug use, including funding five grantees to test the effectiveness of various SBIRT models in general medical settings, including EDs (RFA-DA-08-021 (R01)). NIDA’s other SBIRT priorities include funding research to 1) develop and validate brief screening questionnaires to detect (and interventions for) prescription drug abuse that can be applied in general medical settings; 2) test new technologies for implementing screening and brief intervention (internet, tablet, smart phones, etc.; the “SBI” of SBIRT); 3) develop models for referral and/or direct treatment in general medical settings (the “RT” of SBIRT); and 4) link results of SBIRT interventions to important morbidity and mortality outcomes.

National Institute of Mental Health.  The mission of NIMH is to transform the understanding and treatment of mental illness through basic and clinical research by promoting discovery in the brain and behavioral sciences to fuel research on the causes of mental disorders; charting mental illness trajectories to determine when, where, and how to intervene; developing new and better interventions that incorporate the diverse needs and circumstances of people with mental illness; and strengthening the public health impact of NIMH-supported research.

In addition to the diagnosis and referral of ED patients with depressive disorders, EPs treat patients presenting with suicide attempts and/or suicidal ideation. Intervention, referral, and follow-up with such patients by EPs can result in significant reductions of ED visits and a better quality of life. NIMH has targeted EDs for funding multiple interventions.26–28 For example, NIMH is currently part of a multiagency program FOA to conduct research designed to improve EMS for children.29 According to one of the authors (ABG, as presented at the AEM conference), examples of NIMH interests and areas of public health need include mental health crisis response and management, mental health services research, mental health consequences of exposure to potentially traumatic events, and suicide prevention.

In spring 2009, NIMH released two Requests for Applications (RFAs) related to suicide: RFA-MH-09-150, “Suicide Prevention in Emergency Medicine Departments (U01),” and RFA-MH-09-140, “Collaborative Study of Suicidality and Mental Health in the U.S. Army (U01).” The purpose of the former is to fund research that develops and tests practical interventions that demonstrate improved care of suicidal individuals seen in EDs (ABG, in the panel discussion). While not an exhaustive list, examples of additional relevant FOAs include RFA-09-060, “Network(s) for Developing PTSD Risk Assessment Tools (R21)”; PA-07-312, “Mental Health Consequences of Violence and Trauma (R01)”; PA-07-079, “Research on the Reduction and Prevention of Suicidality (R01)”; PAR-07-157, “Mechanism for Time-Sensitive Research Opportunities (R01)”; and PAR-06-252, “Rapid Assessment Post-Impact of Disaster (R21).”

Substance Abuse and Mental Health Services Administration

The mission of the Substance Abuse and Mental Health Services Administration (SAMHSA) is to improve the delivery and effectiveness of substance abuse and mental health services to the American public. A SAMHSA research center that funds EM public health research is the Center for Substance Abuse Treatment (CSAT). CSAT’s mission is to improve the lives of individuals and families affected by alcohol and drug abuse by ensuring access to clinically sound, cost-effective addiction treatment that reduces the health and social costs to our communities and the nation. In addition, SAMHSA has funded 11 universities across the country to teach and integrate SBIRT into residency programs, including many EM residency programs.30

Centers for Disease Control and Prevention

The mission of the CDC is to collaborate to create the expertise, information, and tools that people and communities need to protect their health—through health promotion; prevention of disease, injury, and disability; and preparedness for new health threats. Similar to NIH, CDC has several institutes and centers that fund EM public health research. The most relevant centers for such activity include the National Center for Injury Control and Prevention; the National Center for Chronic Disease Prevention and Health Promotion; the National Center for Immunization and Respiratory Diseases; the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention; and the National Center for Preparedness, Detection, and Control of Infectious Diseases. Three major ED functions are especially relevant to the CDC’s EM funding agenda: testing for HIV and sexually transmitted infections (STIs), surveillance for infectious diseases, and surveillance and research related to violence and injury.

Because the persons with the most acute and severe injuries and illnesses present to EDs,31 EDs are ideal sites for syndromic surveillance for detection and control of community outbreaks. In addition, EDs collect outbreak data in real time, making them an excellent site for active surveillance systems.32 For example, the CDC funded the Olive View UCLA Department of Emergency Medicine in 1995 to develop an emerging infections network. The 11-site EmergIDNet has resulted in significant advances in surveillance of infectious diseases.33–36

Unfortunately, ED visits are the only regular encounter with health care providers for some individuals.37–39 The ED is an important setting for testing for HIV and STIs as it may be the best, and possibly only, setting for identifying, treating, and controlling these infections, and this may be critically important for reducing morbidity, mortality, and further transmission. Testing for HIV and STIs in EDs also provides an opportunity to link persons identified with these infections to ongoing care. During 2002–2004, the CDC funded several EDs and other health care settings to evaluate the effectiveness of efforts for identifying HIV-infected patients and linking them to care (presented by JDH at the panel presentation). The CDC went on to fund HIV testing in a variety of medical settings, including several EDs between 2004–2007, to evaluate patient acceptance and the feasibility of making rapid HIV testing a routine part of health care offered in EDs. Approximately 15,000 tests were conducted in three EDs during the period, resulting in 1,087 (1.1%) new HIV diagnoses among persons tested (JDH at the panel presentation). The CDC provided funds to two large, urban EDs to conduct a clinical trial evaluating methods for HIV screening. These studies will continue through 2009. In addition, the CDC is currently providing funding for an HIV testing initiative in health care settings, and much of the testing is being conducted in EDs. Funded sites have been encouraged to integrate activities to prevent HIV, STIs, tuberculosis, and viral hepatitis.

Agency for Healthcare Research and Quality

The mission of the Agency for Healthcare Research and Quality (AHRQ) is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. Thus, funding opportunities are focused on improving health care, with a special emphasis on comparative effectiveness and cost–benefit studies. As cited in the IOM’s report on crowding in U.S. EDs, the AHRQ has funded some innovative research that addresses input, output, and throughput factors.40–43 Another example of research in EDs funded by AHRQ is in the burgeoning field of simulation research. Simulation in health care creates a safe learning environment that allows researchers and practitioners to test new clinical processes and to enhance individual and team skills before encountering patients. Many simulation applications involve artificial “patients” that can show symptoms and respond to simulated treatment, analogous to flight simulators used by pilots. Simulations result in fewer adverse events for patients, lower health care costs, and increased skills for ED physicians.44 [Editor’s note: the science of simulation was the topic of the 2008 AEM consensus conference; proceedings are available in the November 2008 issue of the journal, available at http://www3.interscience.wiley.com/journal/121498292/issue.] AHRQ has funded the National Emergency Department Safety Study that identifies factors associated with making mistakes in clinical practice.45 Three AHRQ Centers that fund EM research are as follows:

The Center for Financing, Access, and Cost Trends conducts, supports, and manages studies of the cost and financing of health care, access to health care services, and related trends. This center also develops data sets to support policy and behavioral research and analyses. The Center for Outcomes and Evidence conducts and supports research and assessment of health care practices, technologies, processes, and systems. The Center for Quality Improvement and Patient Safety works to improve the quality and safety of the health care system through research and implementation of evidence-based strategies.

Health Resources and Services Administration

The mission of the Health Resources and Services Administration (HRSA) is to provide national leadership, program resources, and services to improve access to culturally competent, quality health care, with a focus on uninsured, underserved, and special needs populations. For example, HRSA provided one-half billion dollars for states to develop surge capacity to deal with mass casualty events.46 This included developing the capacity to isolate infectious patients, identifying additional health care personnel, and providing mental health services, trauma, and burn care, communications, and personal protective equipment. Another example of HRSA-funded EM activity is the recently awarded planning grant to strengthen the North Dakota Quality Network for critical access hospitals across the state that provide essential help through emergency medical care.47

Conclusions

  1. Top of page
  2. Abstract
  3. EM and Public Health
  4. Federal Agencies that Fund EM Surveillance and Other Public Health Activities
  5. Conclusions
  6. Acknowledgments
  7. References

Many federal funding agencies support EM public health research and collaboration. Federal agencies have funded and will continue to fund EM public health research. EM researchers need to understand the organizational structure of the federal government, recognize that there are a variety of agencies that offer funding opportunities, and align their research interests and funding applications with the missions of particular agencies.

Given the recent publication of IOM’s sentinel report on emergency care, and increased awareness of the link between EM and public health, EM researchers will find numerous opportunities to obtain federal funding for research, surveillance, and other activities related to public health in EDs.

Acknowledgments

  1. Top of page
  2. Abstract
  3. EM and Public Health
  4. Federal Agencies that Fund EM Surveillance and Other Public Health Activities
  5. Conclusions
  6. Acknowledgments
  7. References

The authors thank the Society for Academic Emergency Medicine for providing the forum for this presentation. In addition, we thank the many agencies, institutes, and centers for funding this conference, specifically the Agency for Healthcare Research and Quality, the National Institute of Mental Health, the National Institute of Drug Abuse, the National Institute of Alcoholism and Alcohol Abuse, and the Substance Abuse and Mental Health Administration Services. Finally, the authors thank Brian Biroscak for his help in the preparation of the manuscript. The views expressed in this article are the opinions of the authors and do not necessarily represent the views of the Department of Health and Human Services or the United States government.

References

  1. Top of page
  2. Abstract
  3. EM and Public Health
  4. Federal Agencies that Fund EM Surveillance and Other Public Health Activities
  5. Conclusions
  6. Acknowledgments
  7. References
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