Identifying and pursuing research priorities at the National Center for Complementary and Alternative Medicine

Neglected tropical diseases in Brazil: lack of correlation between disease burden, research funding and output

OBJECTIVES

To assess the correlation between the burden of seven priority neglected tropical diseases (NTDs) included in the Brazilian National Agenda of Priorities in Health Research - tuberculosis, Chagas disease, leprosy, malaria, leishmaniasis, dengue and schistosomiasis - and their respective research funding and output.

METHODS

This retrospective review obtained data on disease burden from the Global Burden of Disease Study and funding data from open access sources. Publications were retrieved from Scopus and SciELO, and characterised according to the type of research conducted. Correlation between funding, research output and burden was assessed by comparing the 'expected' and 'observed' values for funding and publications relative to the proportional burden for each disease.

RESULTS

There was an emphasis in basic biomedical research (average 30% of publications) and a shortage of health policy and systems (average 7%) and social sciences research (average 3%). Research output and funding were poorly correlated with disease burden. Tuberculosis, Chagas disease and schistosomiasis accounted for more than 75% of total NTD-related DALYs, but accounted for only 34% of publications. Leprosy, leishmaniasis and malaria, together, received 49% of NTD-related funding despite being responsible for only 9% of DALYs.

CONCLUSIONS

The analysis evidenced a lack of correlation between disease burden, research output and government funding for priority NTDs in Brazil. Our findings highlight the importance of monitoring health needs, research investments and outputs to inform policy and optimise the uptake of evidence for action, particularly in developing countries, where resources are scarce and the research capacity is limited. The results contribute to health policy by highlighting the need for improving coordination of scientific activities and public health needs for effective impact.

Using Health Care Utilization and Publication Patterns to Characterize the Research Portfolio and to Plan Future Research Investments

OBJECTIVE

Government funders of biomedical research are under increasing pressure to demonstrate societal benefits of their investments. A number of published studies attempted to correlate research funding levels with the societal burden for various diseases, with mixed results. We examined whether research funded by the Department of Veterans Affairs (VA) is well aligned with current and projected veterans' health needs. The organizational structure of the VA makes it a particularly suitable setting for examining these questions.

METHODS

We used the publication patterns and dollar expenditures of VA-funded researchers to characterize the VA research portfolio by disease. We used health care utilization data from the VA for the same diseases to define veterans' health needs. We then measured the level of correlation between the two and identified disease groups that were under- or over-represented in the research portfolio relative to disease expenditures. Finally, we used historic health care utilization trends combined with demographic projections to identify diseases and conditions that are increasing in costs and/or patient volume and consequently represent potential targets for future research investments.

RESULTS

We found a significant correlation between research volume/expenditures and health utilization. Some disease groups were slightly under- or over-represented, but these deviations were relatively small. Diseases and conditions with the increasing utilization trend at the VA included hypertension, hypercholesterolemia, diabetes, hearing loss, sleeping disorders, complications of pregnancy, and several mental disorders.

CONCLUSIONS

Research investments at the VA are well aligned with veteran health needs. The VA can continue to meet these needs by supporting research on the diseases and conditions with a growing number of patients, costs of care, or both. Our approach can be used by other funders of disease research to characterize their portfolios and to plan research investments.

Key issues in clinical and epidemiological research in complementary and alternative medicine--a systematic literature review

BACKGROUND

In the last 2 decades there has been a large increase in publications on complementary and alternative medicine (CAM). However, CAM research methodology was heterogeneous and often of low quality. The aim of this systematic review was to investigate scientific publications with regards to general issues, concepts and strategies. We also looked at research priorities and methods employed to evaluate the clinical and epidemiological research of CAM in the past to identify the basis for consensus-based research strategies.

METHODS

We performed a systematic literature search for papers published between 1990 and 2010 in 7 electronic databases (Medline, Web of Science, PsychArticles, PsycInfo, CINAHL, EMBASE and Cochrane Library) on December 16 and 17, 2010. In addition, experts were asked to nominate relevant papers. Inclusion criteria were publications dealing with research methodology, priorities or complexities in the scientific evaluation of CAM. All references were assessed in a multistage process to identify relevant papers.

RESULTS

From the 3,279 references derived from the search and 98 references contributed by CAM experts, 170 papers fulfilled the criteria and were included in the analysis. The following key issues were identified: difficulties in past CAM research (e.g., randomisation, blinding), utility of quantitative and qualitative research methods in CAM, priority setting in CAM research and specific issues regarding various CAM modalities.

CONCLUSIONS

Most authors vote for the use of commonly accepted research methods to evaluate CAM. There was broad consensus that a mixed methods approach is the most suitable for gathering conclusive knowledge about CAM.

Pain research in complementary and alternative medicine in Australia: a critical review

BACKGROUND

Sixty percent (60%) to 80% of patients who visit chiropractic, osteopathic, or Chinese medicine practitioners are seeking pain relief.

OBJECTIVES

This article aimed to identify the amount, quality, and type of complementary and alternative medicine (CAM) pain research in Australia by systematically and critically reviewing the literature.

METHODS

PubMed, Scopus, Australasian Medical Index, and Cochrane library were searched from their inception to July 2009. Australian and New Zealand Clinical Trial Registration and National Health and Medical Research Council databases were searched for human studies yet to be completed. Predefined search terms and selection criteria were used for data identification.

RESULTS

Of 204 studies selected, 54% were on chiropractic, 27% on Chinese medicine, 15% about multitherapy, and 4% on osteopathy. Chronic spinal pain was the most studied condition, with visceral pain being the least studied. Half of the articles in Chinese medicine or multitherapy were systematic reviews or randomized control trials. In comparison, only 5% of chiropractic and none of osteopathy studies were in these categories. Government funding was rare, and most studies were self-funded or internally funded. All chiropractic, osteopathic, and Chinese herbal medicine studies were conducted by the researchers of the professions. In contrast, half of the acupuncture studies and all t'ai chi studies were conducted by medical doctors or physiotherapists. Multidisciplinary collaboration was uncommon.

CONCLUSIONS

The quantity and the quality of CAM pain research in Australia are inconsistent with the high utilization of the relevant CAM therapies by Australians. A substantial increase in government funding is required. Collaborative research examining the multimodality or multidisciplinary approach is needed.

Development of a manualized protocol of massage therapy for clinical trials in osteoarthritis

BACKGROUND

Clinical trial design of manual therapies may be especially challenging as techniques are often individualized and practitioner-dependent. This paper describes our methods in creating a standardized Swedish massage protocol tailored to subjects with osteoarthritis of the knee while respectful of the individualized nature of massage therapy, as well as implementation of this protocol in two randomized clinical trials.

METHODS

The manualization process involved a collaborative process between methodologic and clinical experts, with the explicit goals of creating a reproducible semi-structured protocol for massage therapy, while allowing some latitude for therapists' clinical judgment and maintaining consistency with a prior pilot study.

RESULTS

The manualized protocol addressed identical specified body regions with distinct 30- and 60-min protocols, using standard Swedish strokes. Each protocol specifies the time allocated to each body region. The manualized 30- and 60-min protocols were implemented in a dual-site 24-week randomized dose-finding trial in patients with osteoarthritis of the knee, and is currently being implemented in a three-site 52-week efficacy trial of manualized Swedish massage therapy. In the dose-finding study, therapists adhered to the protocols and significant treatment effects were demonstrated.

CONCLUSIONS

The massage protocol was manualized, using standard techniques, and made flexible for individual practitioner and subject needs. The protocol has been applied in two randomized clinical trials. This manualized Swedish massage protocol has real-world utility and can be readily utilized both in the research and clinical settings.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00970008 (18 August 2009).

A comparison of cancer burden and research spending reveals discrepancies in the distribution of research funding

BACKGROUND

Ideally, the distribution of research funding for different types of cancer should be equitable with respect to the societal burden each type of cancer imposes. These burdens can be estimated in a variety of ways; "Years of Life Lost" (YLL) measures the severity of death in regard to the age it occurs, "Disability-Adjusted Life-Years" (DALY) estimates the effects of non-lethal disabilities incurred by disease and economic metrics focus on the losses to tax revenue, productivity or direct medical expenses. We compared research funding from the National Cancer Institute (NCI) to a variety of burden metrics for the most common types of cancer to identify mismatches between spending and societal burden.

METHODS

Research funding levels were obtained from the NCI website and information for societal health and economic burdens were collected from government databases and published reports. We calculated the funding levels per unit burden for a wide range of different cancers and burden metrics and compared these values to identify discrepancies.

RESULTS

Our analysis reveals a considerable mismatch between funding levels and burden. Some cancers are funded at levels far higher than their relative burden suggests (breast cancer, prostate cancer, and leukemia) while other cancers appear underfunded (bladder, esophageal, liver, oral, pancreatic, stomach, and uterine cancers).

CONCLUSIONS

These discrepancies indicate that an improved method of health care research funding allocation should be investigated to better match funding levels to societal burden.

Defining research priorities in complementary medicine in oncology

OBJECTIVES

The high usage of complementary and alternative medicines (CAM) by cancer patients is increasing, despite limited research available to support their use. Therefore identifying research priorities that can inform the evidence base for CAM treatment is relevant for many stakeholders, including funders, researchers and consumers.

DESIGN AND SETTING

Integrative medicine experts, oncologists with interest in CAM research, consumer representatives and CAM practitioners and researchers took part in a modified Delphi process conducted online over three rounds. In round 1 each participant recommended up to five CAM research priorities, which were collated and ranked in round 2 by their potential usefulness in cancer care, using a Likert scale. In round 3, participants ranked the remaining propositions by their ability to impact cancer care in Australia. The lowest ranking priorities were eliminated at the completion of each round.

RESULTS

From the 122 propositions originally submitted by the 27 participants, the highest scoring ones included: studying interactions between biologically based CAM and conventional cancer treatments, examining CAM effects on quality of life, identifying effective communication strategies around CAM, studying the role of physical activity in symptom relief and cancer prevention and exploring the role of acupuncture in cancer care.

CONCLUSION

This method of research prioritisation achieved consensus of opinion among a very diverse group of stakeholders, invited to collaborate around a highly polarising topic. Through a structured interaction, the group agreed on a priority research list acceptable to all stakeholders, which can serve as a blueprint for CAM research in oncology in Australia.

Use of complementary and alternative medicine among USA adults with functional limitations: for treatment or general use?

OBJECTIVES

This study compared the use of complementary and alternative medicine (CAM) to treat health conditions with CAM use for general wellness or disease prevention among USA adults with and without functional limitations.

DESIGN

This was a cross-sectional survey.

METHODS

Data were obtained from the 2007 U.S. National Health Interview Survey (n=20,710).

RESULTS

Overall use of CAM treatment was higher among adults with functional limitations than among those without (61.4% versus 41.8%; p<0.001). Adults with functional limitations were more likely to use 3 of 4 CAM groupings: biologically based therapies (BBT) (47.9% versus 29.5%, p<0.001), manipulative and body-based therapies (73.7% versus 54.1%, p<0.001), and mind-body therapies (MBT) (39.3% versus 17.4%, p<0.001). Use of alternative medical systems for treatment was highly prevalent among adults (86.9% versus 80.0%, p=0.06), regardless of functional status. Adults with functional limitations were as likely to use CAM to treat the condition underlying their functioning difficulty (48.7%) as they were to treat other conditions (51.3%). Massage therapy was used most often to treat conditions that limited functional ability (53.4%). Older age was a predictor of the use of BBT for treatment, whereas younger age was a predictor of the use of MBT.

CONCLUSIONS

The prevalence of CAM use for treatment of conditions is high. Public health strategies are needed to promote disclosure of CAM use to health care providers, promote increased screening for CAM use by health care providers, and promote health care interactions that facilitate communication about CAM safety and efficacy.

NIH disease funding levels and burden of disease

BACKGROUND

An analysis of NIH funding in 1996 found that the strongest predictor of funding, disability-adjusted life-years (DALYs), explained only 39% of the variance in funding. In 1998, Congress requested that the Institute of Medicine (IOM) evaluate priority-setting criteria for NIH funding; the IOM recommended greater consideration of disease burden. We examined whether the association between current burden and funding has changed since that time.

METHODS

We analyzed public data on 2006 NIH funding for 29 common conditions. Measures of US disease burden in 2004 were obtained from the World Health Organization's Global Burden of Disease study and national databases. We assessed the relationship between disease burden and NIH funding dollars in univariate and multivariable log-linear models that evaluated all measures of disease burden. Sensitivity analyses examined associations with future US burden, current and future measures of world disease burden, and a newly standardized NIH accounting method.

RESULTS

In univariate and multivariable analyses, disease-specific NIH funding levels increased with burden of disease measured in DALYs (p = 0.001), which accounted for 33% of funding level variation. No other factor predicted funding in multivariable models. Conditions receiving the most funding greater than expected based on disease burden were AIDS ($2474 M), diabetes mellitus ($390 M), and perinatal conditions ($297 M). Depression ($719 M), injuries ($691 M), and chronic obstructive pulmonary disease ($613 M) were the most underfunded. Results were similar using estimates of future US burden, current and future world disease burden, and alternate NIH accounting methods.

CONCLUSIONS

Current levels of NIH disease-specific research funding correlate modestly with US disease burden, and correlation has not improved in the last decade.