Author + information
- Received March 12, 2012
- Revision received April 26, 2012
- Accepted April 30, 2012
- Published online January 22, 2013.
- Tuan V. Mai, MD⁎,
- Donna L. Agan, EdD⁎,
- Paul Clopton, MS†,
- Glenn Collins, BS‡ and
- Anthony N. DeMaria, MD§,⁎ ()
- ↵⁎Reprint requests and correspondence:
Dr. Anthony DeMaria, Division of Cardiology, University of California–San Diego, 200 West Arbor Drive, San Diego, California 92103-9000
Objectives The aim of this study was to determine the extent, type (e.g., staff, equipment), and sources of funding for published cardiovascular research.
Background Important cardiovascular research is often performed without direct financial support. The degree to which medical research is conducted on an unfunded basis remains uncertain.
Methods We sent an electronic survey (Survey Monkey) to 938 corresponding authors who published papers in the Journal of the American College of Cardiology from 2007 through 2009. The data sought included the authors' characteristics (e.g., age, institution, type of research), funding, sources of funding, and types of support for their research.
Results The response rate was 41% (388 of 938). The percentage of authors who were fully funded was 26%, 44.1% were partially funded, and those without any direct funding amounted to 30%. Most funding came from government (41.8%) and industry (35.1%), whereas institutional, foundation, association, philanthropy, and other grants contributed the remaining 23.1%. Funded authors received supplies (43.6%), staff (41.5%), and salary (39.7%) to a greater extent than equipment (27.3%) or administrative (24.7%) support. Significantly fewer authors 40 years of age or younger (24.3%) were partially funded relative to authors older than 40 years of age (≥47%) (p = 0.001). Significantly fewer authors from a community hospital (0%), from Europe (16.7%), or conducting interventional (7.3%) or heart rhythm (11.5%) studies were fully funded (all p < 0.05). Although only a trend, clinical investigators were more likely to be unfunded (35.7%) relative to basic/basic and clinical investigators (19.1%) (p = 0.001). Those significantly more likely to be fully funded were authors from the United States (35.3%) relative to non-American authors (≤28.6%) (p = 0.006). In addition, authors received more funding working in a government or VA hospital (45.9%) than nongovernment hospitals (≤27.1%) (p = 0.001). The authors who were 50 years of age or older, from the United States, had PhD degrees, doing basic as well as clinical research, or studying genetics/genomics had significantly more sources of funding and types of support (all p < 0.05).
Conclusions Considerable published cardiovascular research is currently being conducted without direct financial support. This is particularly true for young clinical investigators. The inability to accommodate this investigation in the medical enterprise might substantially diminish the amount of new knowledge coming forth.
It has generally been accepted that adequate funding is necessary to create major advances in biomedical research. However, important cardiovascular research is often performed without direct financial support, especially clinical research from academic institutions (1). Drawing on discretionary time sequestered from clinical assignments, equipment and personnel used to provide medical services, and data derived in the course of clinical care, investigators have generated important insights into the mechanism, diagnosis, and treatment of cardiovascular disease. Similarly, basic scientists have used the facilities and personnel from other studies to conduct unfunded experiments in their spare time (2). However, the degree to which medical research is performed on an unfunded basis remains uncertain. Therefore, the current study was conducted to assess the prevalence, sources, and type of funding used by authors who published in the Journal of American College of Cardiology (JACC).
We surveyed the 938 corresponding authors whose manuscripts were accepted for publication between 2007 and 2009. In November 2010, an e-mailed invitation and link to an electronic survey was sent to the authors explaining the purpose of the research and requesting them to voluntarily complete the survey. A follow-up e-mail reminder was sent 9 weeks later. The survey contained 11 questions about the authors' name, age, institution, location, highest degree (MD, PhD, MD/PhD, other), highest degree of senior author if not the corresponding author, type of research, topic of research, and funding. If their research was either partially funded (<100%) or fully funded (100%), they were asked to list all the sources and types of support. The survey instrument appears in the Online Appendix.
The experimental unit of this study is the author rather than the article. None of the corresponding authors who responded to the survey published more than 1 study in JACC within the 3-year study period. In addition, the survey was set so that no more than 1 response from the computer with the same Internet Protocol address was allowed, but 34 authors did respond a second time using a different computer when the e-mail reminder was sent. For these authors, only the first response was accepted.
Analyses were conducted using SPSS version 12.0 (SPSS Inc., Chicago, Illinois). Twenty-one chi-square tests were used to find significant relationships between the corresponding authors' 7 baseline characteristics (age, institution, location, highest degree of senior authors, highest degree of corresponding authors, type of research, and topic of research) and the categories of funding, sources of funding, and types of support separately. Each significant chi-square test was followed by examination of standardized residuals to indicate where the statistical significance lay and absolute values >1.96 were declared significant at p < 0.05.
Descriptive statistics regarding the authors' characteristics in Table 1 included the corresponding authors (n = 7) and senior authors (n = 7) whose highest degrees are chosen as “other degrees.” However, these small numbers of individuals were excluded from the analysis presented in Table 2 for simplicity.
In addition, a 2-sample test of proportion was used to compare the proportion of unfunded original scientific research reported by the authors in our study to all published authors in 2011 to determine whether the proportions were significantly different from each other.
Characteristics of the authors
The final response rate was 41% (388 of 938). Table 1 shows that most authors were in the 41- to 50-year age group, worked in a university hospital setting, and were either from the United States (U.S.) or Europe. A majority of authors and senior authors had an MD degree, although more than one-third had a PhD degree, and most were clinical rather than basic investigators. The subject matter of research was spread broadly among many cardiovascular topics reflecting the general nature of the journal.
More than 70% of authors received at least some financial support for their research, although in the majority of cases, it was only partial funding. However, nearly one-third of published papers were unfunded (Fig. 1). There was no statistically significant difference between the proportion of unfunded publications (93 of 375, 24.8%) in 2011 and the one reported in this e-mail survey (116 of 388, 29.9%) (z = 1.579, p = 0.114).
Funding in our study varied significantly based on the characteristics of the authors (Table 2). Age had a significant relationship with funding; authors who were 40 years of age or younger were less likely to receive partial funding and more likely to be unfunded (p = 0.001). The type of institution also had a significant association with funding. No authors from community hospitals were fully funded, and a greater percentage had no funding than authors in other settings (p = 0.001). By contrast, authors from Veteran Affairs or government hospitals were more likely to be fully funded (p = 0.001). The likelihood of support also varied by location. The U.S. had a larger percentage of fully funded authors (36.3%) than other areas, whereas Europe had a lower percentage (16.7%) (both p < 0.05). In terms of the type of research performed, authors who did basic or combined basic and clinical research were unlikely to be without any support (80.9%) (p = 0.001). Although not significant, the data showed a trend for authors who did clinical research to be more likely unfunded. The subject matter of research was also associated with funding: a smaller percentage of authors who studied coronary artery disease, heart failure, or genetics and/or genomics were without any support, whereas those who did interventional research were more likely to be unfunded (all p < 0.05). Additionally, full funding was less available for interventional and heart rhythm investigation (both p < 0.05).
Sources of funding
Government and industry were the primary basis of support in this study, accounting for 65% of funding, while the remainder was provided by the five other potential sources (Fig. 2). Analysis further revealed that sources of funding were distributed differently for authors with certain characteristics (Table 2). There was a significant relationship between age and industry grants; authors 40 years of age or younger had a lower likelihood of acquiring such support (10.3%), whereas those 51 to 60 years old had a higher likelihood (35.9%) (both p < 0.001), relative to authors 41 to 50 years of age (21.5%). A smaller proportion (11.1%) of authors from community hospitals received government grants relative to other institutions (≥29.2%) (p = 0.007). The highest degree attained by the corresponding authors was significantly associated with the sources of funding. Whereas authors with MD degrees received more industry contracts (16.1%), those with MD/PhD degrees received less (4.6%) (both p = 0.005). Furthermore, funding sources significantly supported different types of research. Unlike industry contracts (5.9%), government (58.1%), foundation (25.7%), and association grants (17.6%) significantly favored basic or combined basic and clinical research (all p < 0.05). In contrast, government and association grants did not favor clinical research. As regards the subject matter of research, authors who did interventional research received fewer government grants (17.1%) (p = 0.003) relative to those who did genetics and/or genomics research (76.9%) (p < 0.05).
Type of support
In general, published authors received more supply, staff, and salary support than equipment or administrative support (Fig. 3). In addition, the distribution of each type of support varied based on the authors' characteristics (Table 2). Age had a significant relationship with type of support; authors 40 years of age or younger had less support for supplies (p = 0.013) and staff (p = 0.009), whereas those 61 years of age or older had more administrative support (p = 0.011). Compared with all other locations, authors from the United States had more salary support (53.9%) and those from Asia had less (8.0%) (both p < 0.001). Although not significant, the data suggested that authors from community hospitals received less salary support (11.1%) relative to authors from other institutions (≥37.5%) (p > 0.05). Authors with PhDs had more salary (p < 0.001) and equipment (p = 0.008) support compared with all others, and those manuscripts whose senior authors were PhDs had a higher frequency of salary support (73.3%) (p = 0.017). Equipment and supply support was more prevalent for studies involving basic research (Table 2). Last, for the topic of research, significant associations were seen with supply, salary, and equipment support (Table 2). Of interest, authors who did interventional research were less likely to have salary support (p < 0.001).
Few data exist regarding the sources, recipients, and type of funding for medical research in general or specifically cardiovascular investigation. To address this question, we surveyed corresponding authors who have published original research articles in JACC from 2007 to 2009. Nearly one-third of published papers received no funding whatsoever. In general, investigators 40 years of age or younger were less likely to receive financial support, and clinical research was less likely to receive funding than investigation involving basic research. Although financial support was particularly infrequent for interventional cardiology papers, >40% of studies in heart rhythm, cardiac imaging, and congenital heart disease were also without funding.
These data point to the importance of cardiovascular investigation performed in discretionary time using supplies and equipment, which are available for activities other than research. One assumes that much of this research involved data acquired and time expended in the course of clinical duties. These findings testify to the importance of cardiovascular research performed in this setting and indicate the consequences that would occur if the demands for patient care eliminated these opportunities. It is often difficult to rationalize the present cost versus the future benefit from research. It is likely that academic and not-for-profit institutions are more inclined to support research endeavors that do not generate immediate revenues because their mission is community service and the advancement of health care. As the current model of health care shifts toward pay-for-performance, it may be increasingly difficult for health care organizations to justify the cost of research.
The lack of funding may be due to a decreased supply of grants. For example, spending for research by the National Institutes of Health decreased by 8.6% from 2003 to 2007 (p < 0.001) (3). Similarly, the growth rate of research spending by industry has decreased (4), and there are indications of a decline in foundation support and charity donors (5).
Our study, which categorized sources of funding by the percentage of authors who received it, should not be compared with other studies that categorized funding sources by monetary amount. Although given less frequently, the total monetary grant contribution from industry may be more than government; however, this was not assessed in this survey. In addition, our sample may be biased because authors with fewer ties to industry may be deemed more favorably for publication in JACC.
Distribution of funding, sources, and types of support based on the authors' characteristics
Authors 40 years of age or younger were more likely to receive only partial funding or no funding. This is consistent with the finding of Zinner and Campbell that junior faculty members were twice as likely to have unsponsored research compared with full professors (6,7). Despite having less experience, the young authors in this study published in a competitive journal, which attests to the value of their investigation. Failure to obtain research funding may end the promising careers of some young investigators.
Authors from Veteran Affairs and government hospitals were more likely to be fully funded. In 2009 alone, the Department of VA Research and Development budget in the United States was $884 million (8). Conversely, authors from community hospitals were less likely to receive funding, especially from government grants. They likely had difficulties conducting clinical trials due to limited access to well-characterized populations, necessary information technology tools, and qualified research staff (9).
More authors in the U.S. were fully funded and had higher rates of staff, salary, and administrative support than those in the rest of the world. In 2003, the U.S. spent 5.6% of its total health care spending on biomedical research, whereas no other country approached this amount in relative or absolute terms (6). In the past few years, there have been major efforts to stimulate research funds for investigators in Europe since the establishment of the European Research Council (10).
Type of Degree
The proportion of investigators with MD degrees who obtained funding was not significantly different from that of those with PhD or MD/PhD degrees. However, the authors with PhD degrees in our study were more likely to have support for salary and equipment. This result is consistent with a previous study showing that nonclinical researchers (often PhDs) depended on their current project fund for income (11). Industry contracts were significantly more often given to those with MD degrees, likely reflecting the clinical orientation of the research that they sponsored.
Type and Topic of Research
Authors who did basic or basic and clinical research, especially in coronary artery disease, heart failure, and genetics and/or genomics, were less likely to be unfunded. These findings concur with those of the Williams et al. study showing that patient-oriented research had a significantly lower rate of funding than laboratory-oriented research (12). With regard to specific sources of grants, unlike industry contracts, government, association, and foundation grants significantly favored basic or combined basic and clinical research. For cardiovascular disease research in the U.S. from 1996 to 2006, 40.1% of articles examining basic science questions received National Institutes of Health support, which is more than clinical trials or any other type of research (13). As clinical trials increasingly move toward less wealthy countries, these findings portend challenges to obtain financial support for clinical researchers in industrialized countries (14).
Several factors were capable of influencing our findings. Some data were recategorized to have a valid chi-square analysis based on the small number of data points in certain categories. Although the response to our survey was 41%, this percentage compares favorably with the response rates to other e-mail surveys (mean response rate of 24%) (15). In addition, the respondents to this survey were authors who have published in JACC as opposed to other cardiology publications and general journals that publish on cardiac biology and medicine; therefore, the results may not be applicable to the overall status of funding for cardiovascular research. More than 80% of articles in JACC are devoted to clinical topics.
Another limitation of this study is the lack of a comparison between the authors who responded to the survey with those who did not. Although JACC authors are supposed to acknowledge funding, details of funding, and author characteristics (e.g., full vs. partial funding, salary support, staff support, age) are not provided. In addition, it is not clear from reading the manuscript whether their sources of funding were specifically for the published study or for other studies. The purpose of the survey was to directly ask the corresponding authors specific information about funding beyond the scope of a typical disclosure for publication purposes. However, we confirmed that the proportions of unfunded authors in our study were not statistically different from all authors in 2011.
There is a long tradition of piggybacking clinical investigation on the delivery of clinical care. Supplies and equipment used for patient care are often exploited to gather research data. Evenings, weekends, and whatever discretionary time is available are frequently devoted to the analysis of data and preparation of manuscripts. Some of the most important medical discoveries for cardiovascular patients have been developed without specific grant funding: for example, Edler and Hertz for echocardiography, Favaloro for coronary bypass surgery, and Gruentzig for angioplasty. That this trend continues is evidenced by the findings of our survey. Nearly 1 of 3 manuscripts published in JACC does not have financial support, and these are more often clinical studies done by young investigators. These data are almost certainly a reflection of the difficulty in obtaining grant support from the National Institutes of Health, industry, and other sources. The increasing demand to generate patient care dollars to support academic institutions and faculty represents a clear danger to this important source of medical knowledge because it limits the ability to gather ancillary data and to find time to analyze and write. This stress is accentuated by declining rates of reimbursement for medical services. The data in this study signal the importance of preserving this important avenue of medical advancement and argue for greater research funding and the protection of the capacity to generate clinical research on the back of clinical care.
The authors thank Joel Plotkin for his contributions to the database of the authors' contact information.
For the survey, please see the online version of this article.
Mr. Collins is an employee of the American College of Cardiology. Dr. DeMaria is the Editor-in-Chief of the Journal of American College of Cardiology. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Michael Lauer, MD, served as the Guest Editor for this paper.
- Abbreviations and Acronyms
- Journal of American College of Cardiology
- United States
- Received March 12, 2012.
- Revision received April 26, 2012.
- Accepted April 30, 2012.
- American College of Cardiology Foundation
- Bassand J.P.,
- Martin J.,
- Ryden L.,
- Simoons M.
- Zerhouni E.A.
- European Research Council
- Sheehan K.