[Senate Hearing 109-598]
[From the U.S. Government Publishing Office]
S. Hrg. 109-598
VA RESEARCH: INVESTING TODAY TO GUIDE TOMORROW'S TREATMENT
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HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED NINTH CONGRESS
SECOND SESSION
__________
APRIL 27, 2006
__________
Printed for the use of the Committee on Veterans' Affairs
Available via the World Wide Web: http://www.access.gpo.gov/congress/
senate
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COMMITTEE ON VETERANS' AFFAIRS
Larry Craig, Idaho, Chairman
Arlen Specter, Pennsylvania Daniel K. Akaka, Hawaii, Ranking
Kay Bailey Hutchison, Texas Member,
Lindsey O. Graham, South Carolina John D. Rockefeller IV, West
Richard Burr, North Carolina Virginia
John Ensign, Nevada James M. Jeffords, (I) Vermont
John Thune, South Dakota Patty Murray, Washington
Johnny Isakson, Georgia Barack Obama, Illinois
Ken Salazar, Colorado
Lupe Wissel, Majority Staff Director
D. Noelani Kalipi, Minority Staff Director
C O N T E N T S
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April 27, 2006
SENATORS
Page
Craig, Hon. Larry E., Chairman, U.S. Senator from Idaho.......... 1
Akaka, Hon. Daniel K., Ranking Member, U.S. Senator from Hawaii.. 3
Thune, Hon. John, U.S. Senator from South Dakota................. 4
Burr, Hon. Richard, U.S. Senator from North Carolina............. 4
Salazar, Hon. Ken, U.S. Senator from Colorado.................... 5
Jeffords, Hon. James M., U.S. Senator from Vermont............... 6
WITNESSES
Perlin, Jonathan B., M.D., Ph.D., Under Secretary for Health,
Department of Veterans Affairs; accompanied by Richard F. Weir,
Ph.D., Research Scientist, Prosthetics Research Laboratory,
Jesse Brown VA Medical Center, Chicago, Illinois, Department of
Veterans Affairs, and Joel Kupersmith, M.D., Chief Research and
Development Officer (CRADO), Department of Veterans Affairs.... 6
Prepared statement........................................... 8
Wright, Fred S., M.D., Associate Chief of Staff for Research, VA
Connecticut Healthcare System, Department of Veterans Affairs.. 24
Prepared statement........................................... 25
Stevens, Dennis L., M.D., Ph.D., Associate Chief of Staff for
Research, Veterans Affairs Medical Center, Boise, Idaho,
Department of Veterans Affairs................................. 26
Prepared statement........................................... 28
Feussner, John R., M.D., M.P.H., Professor and Chairman,
Department of Medicine, Birmingham, Alabama; Medical University
of South Carolina, Charleston, South Carolina.................. 28
Prepared statement........................................... 30
Responses to written questions submitted by Hon. Larry E.
Craig...................................................... 33
Kennedy, John I., Jr., M.D., Professor, Department of Medicine,
University of Alabama at Birmingham, Birmingham VA Medical
Center, Birmingham, Alabama; on behalf of The Alliance for
Academic Internal Medicine..................................... 34
Prepared statement........................................... 36
APPENDIX
Letter to Hon. Kay Bailey Hutchison and Hon. Dianne Feinstein
from the Department of Veterans Affairs Medical and Research
Prosthetics Research Program................................... 45
Friends of VA Medical Care and Health Research, prepared
statement...................................................... 46
VA RESEARCH: INVESTING TODAY TO GUIDE TOMORROW'S TREATMENT
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THURSDAY, APRIL 27, 2006
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 10 a.m., in room
SR-418, Russell Senate Office Building, Hon. Larry E. Craig,
Chairman of the Committee, presiding.
Present: Senators Craig, Burr, Thune, Isakson, Akaka,
Jeffords, Obama, and Salazar.
OPENING STATEMENT OF HON. LARRY E. CRAIG, CHAIRMAN, U.S.
SENATOR FROM IDAHO
Chairman Craig. Good morning, ladies and gentlemen. The
Committee on Veterans' Affairs will now be in order.
We have entitled this hearing today ``VA Research:
Investing Today to Guide Tomorrow's Treatment.'' Today's
hearing will focus on an aspect of the VA Health Administration
that often goes without the full measure of recognition that, I
believe and I think most who know about it believe it, is due.
The Medical and Prosthetic Research Program, VA's research
program, encompasses bench science, clinical research, health
service research, and rehabilitation research. Today these
research activities have vastly contributed to the scientific
knowledge base, led to the development of new technologies and
improved the delivery of health services at VA medical
facilities across the country.
VA research has played a major role in a number of historic
breakthroughs: the first successful liver transplant, the
development of the first cardiac pacemaker, and the technology
that led to the development of the CT scan, just to name a few.
Impressively, VA has accomplished all of this on a limited
budget. Each year, direct appropriations for VA R&D are
leveraged with the NIH grant funding and resources from VA-
affiliated nonprofits. Due in part to this maximization of
research funds, the roughly $400 million of annual
appropriations for VA research brings about improvements from a
$34 billion health system.
As you know, this year's budget proposed a $13 million
reduction in VA research funding. With servicemembers returning
from Iraq and Afghanistan with traumatic injuries and in need
of innovative medical care, now is not a time to cut research
funding. I would like to thank the Members of our Committee for
joining both with me and Senator Akaka, I believe some
additional Members joined, in writing a letter to the
appropriators urging them to overturn this reduction. We
proposed that VA research be funded at $432 million, a modest
increase over last year's budget, to keep pace with inflation
and ensure that critical initiatives involving traumatic brain
injury, spinal cord injury and prostheses are able to move
forward.
Beyond addressing this year's budget, we must look ahead to
the future of VA research. Many of the research facilities are
in great need of repair and modernization. Researchers carry
out their day-to-day activities while under serious space
constraints and in outdated buildings, many of which are
approaching a 100-year-old mark. For example, in one site that
is not fully equipped with modern air conditioning and
ventilation systems, researchers opt to work at night so that
extreme temperatures will not interfere with their results.
There are limits to how long we can rely on early 20th century
research facilities to yield cutting-edge 21st century research
discoveries.
However, there are also limits to the amount of funds the
Congress can provide. As part of our focus on the
infrastructure needs, it is important that we look for
innovative ways for VA to enhance its existing relationships
with universities. I am especially interested in exploring VA-
university collaboration in the form of jointly operating
research space. Modern facilities are not just about attractive
work space for academics.
One of the myriad ways that research benefits the VA health
care system is through recruitment of physician researchers. We
will hear from our witnesses here today about how the shortage
of modern research is hindering recruitment of new physicians.
I want to be clear that this hearing is not about pointing
out our shortcomings or our failures. It is about assessing our
challenges for the future. In fact, I commend VA for its
remarkable record of research accomplishments in spite of some
serious obstacles. This exciting work will be highlighted
during VA Research Week which will be held the second week of
May. As one of the outcomes of this hearing, I hope that
Members of this Committee will make a point of touring the
research bases when making visits to their local VA facilities.
We are joined today with VA Under Secretary of Health, Dr.
Jonathan Perlin, who happens to be an academically trained
researcher. He is accompanied by Dr. Joel Kupersmith, VA's
Chief Research and Development Officer, and Richard Weir, who
is a researcher at VA's Prosthetic Research Laboratory in
Chicago.
Following their testimony, we will hear from four
distinguished witnesses who are involved in VA research
throughout the country. Dr. Fred Wright comes to us from the
West Haven, Connecticut VA, and Dr. Dennis Stevens is from the
Boise, Idaho VA. We will also hear from Dr. Feussner, who is a
former head of VA Research and currently chairs the Department
of Medicine at the Medical University in South Carolina, and
Dr. John Kennedy, from the University of Alabama, in
Birmingham's School of Medicine, who will testify on behalf of
the Alliance for Academic Internal Medicine. So we have some
very distinguished and talented people before us.
Before we go further, let me turn to my colleague and
Ranking Member, Senator Akaka, for any opening comments he may
have.
Danny.
STATEMENT OF HON. DANIEL K. AKAKA, RANKING MEMBER, U.S. SENATOR
FROM HAWAII
Senator Akaka. Mr. Chairman, thank you so much. As always,
Mr. Chairman, I appreciate the work of Chairman Craig in
crystallizing the most pressing issues before the Committee,
and as always, I enjoy working with him and with the Committee
as well.
Today we will assess the tremendous value of VA's research
program, and I want to associate myself with the comments that
were made by the Chairman. I welcome our witnesses to the
hearing, including Dr. Perlin, good to see you again, and to
the other witnesses that were already introduced by the
Chairman.
I thank you all for being here today. We are all without
question immensely proud of VA research. The traditional
research model, which stems from the peer-review process, has
yielded an impressive list of accomplishments for the VA. VA's
research strengths have spanned large clinical trials and more
narrow looks into the fundamental parts of biology, what some
call bench research. However, the value of VA's research
enterprises do not lie solely in its results. The VA Medical
Research has been instrumental in allowing recruitment and
retention of physicians in the VA Health Care System.
Adequately funding VA research helps to ensure that VA remains
an attractive option to our best and brightest in medicine.
VA cannot compete with the nongovernmental health care
sector to attract highly paid physicians. But if VA can
continue to attract some of our Nation's best doctors, veterans
will receive the care they deserve, and I give some of this
credit to Dr. Perlin and what you are doing here. Some of VA's
researchers' greatest achievements have not been in the arena
of new treatments for war wounds or for service-connected
disabilities per se, but for illnesses affecting the populace.
It is my view that young or old, combat veteran or peacekeeper,
all of our Nation's veterans can and should be the recipients
of a vibrant VA research program.
Funding for the research program is obviously quite
critical as well. I am extremely grateful that we all came
together and agreed on the importance of fully funding VA
research. The $399 million proposed by the VA and the
Administration is simply not sufficient. I am confident that we
will more appropriately fund the research program and that we
will protect peer review research.
With that, Mr. Chairman, I look forward to this hearing.
Thank you very much for having it. Thank you very much.
Chairman Craig. Senator Akaka, thank you very much. Before
I turn to the rest of our colleagues on the Committee for any
opening statements, we do have a markup, that is when we get a
quorum of eight here.
We now have that magic number in front of us.
[Whereupon, at 10:10 a.m., the Committee proceeded to a
markup nominations hearing.]
[Whereupon, at 10:12 a.m., the Committee reconvened.]
Chairman Craig. Now let me move on to anyone who would wish
to make a comment before we move to our panelists. Senator
Isakson, you are here next in order.
Senator Isakson. I will yield to Senator Thune.
Chairman Craig. And that is the appropriate yield, because
that is the order involved.
John.
STATEMENT OF HON. JOHN THUNE, U.S. SENATOR FROM SOUTH DAKOTA
Senator Thune. Thank you, Mr. Chairman. I want to thank you
for holding this important hearing to examine the VA's Medical
and Prosthetic Research Program. I also would like to extend a
warm welcome to our panelists today. I am pleased to see Dr.
Perlin again testifying before the Committee.
The VA's researchers have the noble task of finding ways to
more effectively address the unique medical problems that our
veterans tend to suffer due to their service to our country. I
applaud the efforts of the researchers testifying today who
have dedicated their lives to improving the health conditions
of our veterans. You and the 3,000 VA researchers across the
country who work every day on behalf of our veterans are truly
great Americans, and I would like to thank you all for your
service to our country.
Mr. Chairman, I was pleased to join with you and with
Ranking Member Akaka, as well as with many other Members of the
Senate, to send a letter to the Appropriations Committee this
year expressing support for increased funding for the VA's
medical research programs. While the Administration's fiscal
year 2007 proposal for VA funding overall was quite generous,
medical research funding required some improvement. I am glad
to see that we are working in a bipartisan way to provide that
improvement by increasing funding for medical research by $20
million over last year's level.
As we continue with the process of developing the VA's
budget for fiscal year 2007, I am confident that we will
continue as well to find ways to improve funding for the VA
while not spending beyond our means. So, Mr. Chairman, I
applaud your efforts to increase funding for VA medical
research. I appreciate the opportunity to join you in that
effort, and again want to thank you for holding this hearing,
and thank our panelists for sharing their testimony. Thank you,
Mr. Chairman.
Chairman Craig. Senator Thune, thank you very much. Senator
Burr, do you have any opening comments you wish to add?
STATEMENT OF HON. RICHARD BURR, U.S. SENATOR
FROM NORTH CAROLINA
Senator Burr. I can ditto to what Senator Thune said, thank
you to you and the Ranking Member. More importantly, I cannot
think of a more important hearing for this Committee to have at
this what I think is a very pivotal time where the signal that
we send about the investment that we make and the tools that
the VA has should be very clear. I think this is a statement,
and I thank the Chair.
Chairman Craig. Senator Burr, thank you. Senator Salazar.
STATEMENT OF HON. KEN SALAZAR, U.S. SENATOR
FROM COLORADO
Senator Salazar. Thank you very much, Chairman Craig and
Senator Akaka, for your leadership on this Committee and on
veterans' issues, and thank you, Dr. Perlin, as well for your
leadership of the VA.
We all know how important the Veterans' Health
Administration is to all of our veterans in our country, but
something that I think we often overlook is how important VHA
is to our Nation's health care system as a whole. Our veterans'
health care system is often on the cutting edge of critical
advances in prevention, diagnosis and treatment, and VA's
medical research programs are a driving force behind its
ability to serve this important capacity for our veterans and
for our Nation. Because the core mission of the VHA is to
address the prevention and treatment needs of our Nation's
veterans, the services it provides and the research it conducts
are patient-oriented. Six out of every ten VA researchers treat
veterans. As a result, VA researchers do not operate in a
vacuum. They deal with the very real and very serious health
problems resulting from combat and from the sacrifices of our
men and women in uniform. For the 5 million veterans enrolled
in the VA health care system, they also have unique access to a
clinical setting in which to put the results of their research
into practice every day. For these reasons, VA medial research
has been responsible for significant breakthroughs in the
fields of prosthetics, diabetes, spinal cord injury, substance
abuse, mental illness, heart disease, and cancer, all of which
are prevalent among America's veteran population.
I understand today's hearing will focus on some of the
infrastructure challenges that VA's medical research programs
currently face. Challenges ranging from extremely old
facilities, to poor heating and ventilation, to outdated
equipment. There is no question we need to work to address
these needs if VA's research programs are to continue to be a
leader in health care innovations, and I look forward to the
testimony of today's panelists. However, we must be careful not
to overlook the need to provide adequate resources to the many
important research initiatives that are currently underway in
VA facilities across the Nation.
Despite the progress that research programs across the
country have made, this year's budget request proposed cutting
funding for research by $13 million. If anything, we should be
increasing funding for these important programs so that the VA
can continue to be a leader in innovation. I am proud to have
joined my colleagues including Senator Craig and Senator Akaka
in urging $432 million in funding for VA medical research.
Thank you again, Chairman Craig and Senator Akaka, for
holding today's hearing, and I look forward to hearing from the
witnesses.
Chairman Craig. Thank you very much, Senator Salazar.
Senator Jeffords.
STATEMENT OF HON. JAMES M. JEFFORDS, U.S. SENATOR
FROM VERMONT
Senator Jeffords. Mr. Chairman, thank you for holding this
hearing on the VA research funding. I think we all agree that
the cutting-edge research being conducted by the VA is one of
the most important functions of the Veterans Administration.
The VA is responsible for significant advances in medical
treatment, specialty care, prosthetics, and development in
outcomes research. The VA's research activities are one of the
big attractions for top-quality doctors who want to explore
advancements in medicine as they treat patients. I am concerned
by the proposal in the President's budget to cut $13 million
from the VA research budget. I joined many of my colleagues
here in signing a letter to the Appropriations Committee urging
the VA Subcommittee to increase the funding for VA research by
$33 million. I look forward to hearing from you, Dr. Perlin, on
this important topic.
Chairman Craig. Jim, thank you very much. Now we turn to
our panel. I have introduced them, but Dr. Perlin, once again
let me introduce you, the Under Secretary for Health, United
States Veterans Administration. So we welcome you and those who
you have brought with you not only to tell us what you are
doing, but to show us some of what you are doing. Welcome
before the Committee.
STATEMENT OF JONATHAN B. PERLIN, M.D., Ph.D., UNDER SECRETARY
FOR HEALTH, DEPARTMENT OF VETERANS
AFFAIRS; ACCOMPANIED BY RICHARD F. WEIR, Ph.D.,
RESEARCH SCIENTIST, PROSTHETICS RESEARCH LABORATORY, JESSE
BROWN VA MEDICAL CENTER, CHICAGO,
ILLINOIS, DEPARTMENT OF VETERANS AFFAIRS, AND JOEL KUPERSMITH,
M.D., CHIEF RESEARCH AND DEVELOPMENT OFFICER (CRADO),
DEPARTMENT OF VETERANS AFFAIRS
Dr. Perlin. Thank you very much, Chairman Craig, Ranking
Member Akaka, Members of the Committee, good morning. It is a
delight to be here with you, and we thank you for your support
of VA research and the recognition that VA research is indeed a
crown jewel among the Veterans Health Administration's
resources to serve our Nation's heroes. I am pleased to have
the opportunity to discuss our Medical and Prosthetics Research
Program with you today.
As mentioned, Dr. Joel Kupersmith is the Chief Research and
Development Officer, and I am also honored to be joined by Dr.
Richard Weir, a research scientist from the VA Chicago Health
Care System who, indeed, will demonstrate a cutting-edge
prosthetic device.
Mr. Chairman, our research program has a proud history of
accomplishments that have resulted in marked improvements in
the health not only of veterans, but of all Americans. VA
researchers developed the first effective therapies for
tuberculosis, the implantable cardiac pacemaker, the Seattle
Foot, and other prosthetic devices. Researchers made incredible
contributions to such things as the development of the CT scan
and the MRI, and just last year we announced the results of a
clinical trial finding that will make a new shingles prevention
vaccine the standard of care. Today, VA researchers are
developing artificial retinas, biohybrid limbs and other
futuristic prosthetic devices, including those designed for
high-performance athletes who ski, play basketball, and other
competitive sports.
We are also evaluating and improving the care that VA now
provides to veterans suffering from multiple injuries, or
polytrauma, and those who use prosthetic devices. This year we
are beginning a series of research projects on traumatic brain
injury and spinal cord injuries. These projects will directly
benefit veterans from Operations Enduring Freedom and Iraqi
Freedom, as well as all veterans of other eras.
Last week, Mr. Chairman, we established new collaboration
with the University of Texas Southwestern Medical Center to
launch a Center of Excellence for the research of Gulf War
illnesses. This collaboration will help expand our research
programs to help Gulf War veterans who continue to suffer from
unexplained illnesses.
We are collaborating with the Department of Defense and the
National Institute of Mental Health to look at the incidence of
PTSD among veterans of the Global War on Terror, and we will
also be looking at our ability to improve treatment of burn
injuries, long-term care issues involved with recovery from
traumatic brain injury as well.
Improving our ability to treat veterans is at the very core
of VA research. VA clinicians who treat veterans are also the
researchers who investigate the questions that they form at the
bedside. No other health system can match VA's strong
connection between clinical care and research, especially
coupled with our exceptional electronic health record.
Our unique position also enhances our ability to provide
long-term care and to use genomic medicines as a means to move
from preventive medicine to predictive medicine. In fact, we
recently established a Genomic Medicine Advisory Committee
composed of renowned scientists who will advise us on policy
and process, and their first meeting will be later this year.
For us to continue to build on the successes of both the
past and the present, there are four things that we need to do.
First, we need to continue our support to recruitment,
retention, and training programs for clinical investigators;
Career development awards bring tomorrow's stars to the care of
today's veterans. In particular, we must continue to nurture
our affiliations with medical schools which, as General Omar
Bradley recognized 60 years ago, were vital to providing
veterans with top-notch care.
Second, we must maintain a modern, safe, and appropriate
research infrastructure. This year we have already funded
approximately $2 million to provide new or replacement research
equipment and facility environment upgrades. We are currently
surveying facilities, identifying deficiencies and ensuring our
highly specialized needs are met. We will report the results of
the survey to Congress early next year.
Third, we must continue to lead the nationwide effort to
improve protection for human research subjects. VA is a
recognized leader in accrediting research facilities and
training staff. We are working with other Federal agencies,
medical school affiliates, and others to develop new
institutional review board structures. These structures will
allow us to maintain strict standards for subject protection,
yet provide flexibility to expedite the review process,
especially useful for smaller research facilities.
We are in the process of developing a Central Institutional
Review Board to facilitate consistent expertise and greater
efficiency, and this will particularly enfranchise and help our
smaller and rural research programs, allowing rural veterans
greater access to research protocols that may offer new
treatments for infections, heart disease, cancer, or other
illnesses under investigation.
Finally, we must support VA research. Appropriated funds
are VA researchers' core funding. We can leverage these funds
with money from industry, nonprofits and other Federal
agencies, as well as continue our partnerships and
collaborations, use our research programs to recruit and retain
investigators and clinicians who in fact treat patients and
help to find new solutions, treatments, devices, and
discoveries to benefit both veterans and our Nation.
Mr. Chairman, I thank you and all of the Senators who have
asked for additional funding for VA research. We are grateful
for your confidence in our program and in the work of our
researchers, in our basic science research to advance the
understanding of life and disease, who in our clinical research
and cooperative studies help to bring new medications, devices,
and treatments to the care of veterans and all Americans, who
in our rehabilitation research help make injured veterans
whole, and who in our Health Services Research Program in the
words of Dr. Jonathan Lomas in the British Medical Journal,
``Focus the light of health services research on our health
care delivery, helping make VA one of the leading health care
systems in the world.'' This concludes my statement, sir. Thank
you.
[The prepared statement of Dr. Perlin follows:]
Prepared Statement of Jonathan B. Perlin, M.D., Ph.D., Under Secretary
for Health, Department of Veterans Affairs
Mr. Chairman and Members of the Committee,
Thank you for the opportunity to appear before you today to discuss
the Department of Veterans Affairs (VA) medical and prosthetic research
program. I am pleased to have Dr. Joel Kupersmith, Chief, Research and
Development Officer (CRADO), accompany me today.
Also, Dr. Richard Weir, a VA Research Scientist from the VA Chicago
Healthcare System working in the Prosthetic Research Laboratory, is
here to describe the work he is doing. Dr. Weir will explain the
efforts to develop a new hand/wrist prosthetic. I am proud to say that
over three thousand researchers have the same commitment to their work
as Dr. Weir does.
introduction
The original design for the Veterans Health Administration (VHA)
Office of Research and Development (ORD) was clear: VA shall carry out
a program of medical research to provide health care more effectively
and contribute to the Nation's knowledge about disease and disability
with emphasis on injuries and illnesses particularly related to
service. We hold to that same purpose today.
A year ago in my confirmation hearing before you, I highlighted
several accomplishments of VA's research program. Today, I would like
to reiterate these and describe their importance to veterans and the
Nation as a whole.
VA pioneered the first effective therapies for
tuberculosis in the 1940s; veterans returning from the Pacific theater
and POW camps in World War II were some of the first to receive these
treatments.
From the 1940s to the present, VA researchers have led the
development of better fitting, lighter, more functional artificial
limbs. In the late 1970s and early 1980s the Veterans Administration,
as it was called then, supported research that led to the Seattle Foot,
a prosthetic device for lower limb amputees. This revolutionary device
has allowed thousands of amputees from the Vietnam War to return to an
active life and participate in activities like basketball, skiing, or
running, all of which were impossible with traditional artificial
limbs. By 1991, more than 70,000 Seattle feet were in use in the United
States. Later, I will describe the exciting work VA research is doing
today in the area of robotics and other cutting edge prosthetics.
VA was instrumental in the invention and use of the first
implantable cardiac pacemaker. William C. Chardack, chief of surgery at
Buffalo's Veterans Administration Hospital, collaborated with Wilson
Greatbatch in a partnership to develop the device and surgical
techniques that have helped millions of Americans, including our aging
veterans.
VA research contributed significantly to the development
of the CT scanner and MRI machine. VA's basic science research in 1960
and 1961 contributed to the development of the computerized axial
tomography (CAT scan) in the early 1970s and modern radioimmunoassay
diagnostic techniques in the mid-1980s. This illustrates that the
progress of discovery is not an overnight task. Sometimes, scientists
must work for decades to find solutions to complex problems. Today,
veterans and all of us benefit from the basics discovered by VA
investigators.
Smoking and military service have coincided for many
years, so VA has a longstanding history of investigating treatments for
nicotine dependence. VA's investigator, Jed Rose at the Durham VA
Medical Center (VAMC), worked with others to invent the nicotine patch.
Today, VA continues to support a strong portfolio of research about the
effects of nicotine and its relationship with substance abuse, a major
concern for many veterans.
But, the history of VA research extends well beyond what we
discussed last year:
In the 1950s and 1960s, the VA cooperative studies program
developed the essentials of the multi-site randomized controlled
clinical trial that is the standard for testing the safety and efficacy
of new treatments today. VA cooperative studies in the 1960s, 70s, and
80s proved the value of such widely used therapies as coronary artery
bypass, the use of lithium in bipolar disorders, and aspirin's ability
to ward off heart attacks. More recent VA clinical trials have led to
non-surgical treatments for gastro-esophageal reflux disease and
prostate enlargement, demonstrated the value of advanced cochlear
implants in veterans with profound hearing loss, and established
effective treatments for post-traumatic stress disorder (PTSD). Such
results have extended life and improved the quality of life for
veterans and non-veterans alike.
In the 1960s, the VA invented the radioimmunoassay, a
procedure that is now a mainstay of clinical laboratory testing through
the world for detecting biological markers associated with health and
disease such as prostate-specific antigen (PSA).
More recently in 2005, VA showed that an experimental
vaccine for shingles cuts its incidence in half and dramatically
reduces severity and complications in those that develop the disease.
Also, researchers from VHA, Stanford University, and Duke
University reported in the October 2005 New England Journal of Medicine
that the implantable cardioverter defibrillator, although a costly
device, is a relatively cost effective way to help prevent sudden
cardiac deaths for some high risk patients. This is a good example of
collaboration involving our academic partners with funding from another
Federal agency (the Agency for Healthcare Research and Quality) as well
as industry (Blue Cross Blue Shield Technology Evaluation Center).
But, past success is not enough. Research must be future oriented.
We must look at how we practice health care today and ask: how can we
do better? Our research program builds on its past by identifying and
confronting the important questions and challenges of today and then
doing the hard work to find solutions for the future.
va research as a unique laboratory
A special advantage of the VA research program is that it is nested
within a health care system that serves more than 5 million veterans.
This creates a unique national laboratory for the discovery and
application of new medical knowledge. Translating research into
clinical practice is talked about throughout the medical community, but
VA is one place where we apply research every day. VA research has made
direct contributions to current clinical practices for hypertension,
PTSD, diabetes, and other chronic diseases. VA clinicians who have
responsibility for providing care for patients and for training future
health care providers are the same scientists who initiate our research
projects; nurture the proposal through VA's rigorous scientific merit
review; identify and secure additional funding from other Federal
agencies, non-Federal sources, and industry; conduct the research;
publish the results in prestigious medical journals; and then complete
the circle back to the bedside. VA research truly brings scientific
discovery from bedside to bench and then back to the bedside.
In fact, the chance to conduct research has been a strong tool for
VA to recruit and retain high quality physicians and other clinicians.
Other health care systems rarely provide physicians and other
clinicians with the opportunity to research questions that are most
relevant to patient care. VA's healthcare system allows that we promote
the idea of research within our unique research setting with tools such
as the computerized patient record system and protected time for
research. Allowing researchers to identify or ``protect'' time within
their work week is part of VA's strong Career Development Program that
allows investigators to nurture a research career in the VA system.
The opportunity to conduct research has been one of our most
effective tools to improve the quality of our care, as well as to
recruit and retain top-notch clinicians. It also creates a culture of
continuous learning and innovation that helps us maintain our position
of leadership among health systems. Studies by the Institute of
Medicine, RAND, and others have highlighted the delays that occur from
the time of scientific discovery to the time an evidence-based practice
becomes routine--in US healthcare, on average, the likelihood of
receiving a treatment based on credible scientific evidence is only
about 50 percent. VA far exceeds that level of performance on virtually
every evidence-based indicator. Furthermore, VA has established a
unique program, the Quality Enhancement Research Initiative (QUERI),
whose mission is to bring researchers into partnership with health
system leaders and managers in order to ensure the care we provide to
veterans is based on the most current scientific evidence.
emerging priorities of va research
Although in any given year the bulk of VA's research budget is
committed to on-going investigation, each year we re-evaluate our
priorities based on the changing needs of the veterans we serve, and
attempt to fund high quality science that meets those priorities. I
would like to highlight our current areas of focus for VA research.
Operation Iraqi Freedom and Enduring Freedom (OIF/OEF). In order to
better serve military personnel injured during OIF/OEF, VA has
implemented a new research agenda which brings all parts of ORD
together to develop new treatments and tools for clinicians to use to
ease the physical and psychological pain of the men and women returning
from conflicts, to improve access to VHA services, and to accelerate
discoveries and applications, especially for PTSD diagnosis and
treatment, state-of-the art amputation and prosthetics methods, and
polytrauma.
Neurotrauma (including traumatic brain injury and spinal cord
injury). Traumatic Brain Injury (TBI) and Spinal Cord Injury (SCI)
account for almost 25 percent of combat casualties suffered in OIF/OEF
by US Forces. In November 2005, VA issued a program announcement to
stimulate research in the area of combat casualty neurotrauma. This
research initiative seeks to advance treatment and rehabilitation for
veterans who suffer multiple traumas from improvised explosive devices
and other blasts. Eighty-five letters of intent to submit a research
proposal were received, indicating a high level of interest among our
investigators, and we hope to fund as many high quality projects from
this initiative as our budget will allow.
Polytrauma and Blast-Related Injuries. Improvements in body armor
and battlefield medicine have resulted in higher survival among wounded
soldiers but also new combinations of critical injuries, including head
injuries, vision and hearing loss, nerve damage, infections, emotional
problems, and in some cases amputation or severed spinal cords. This is
a new challenge for VA, and we need to develop the knowledge base to
manage these conditions over the remaining lifetime of the veteran. VA
has devoted its newest QUERI center to polytrauma and blast-related
injuries with a focus on using the results of research to promote the
successful rehabilitation, psychological adjustment, and community
reintegration of these veterans. Other VA scientific studies are
currently underway to characterize these injuries and delineate their
outcomes and costs, and to identify geographic areas where the need for
rehabilitation is greatest. Such information is critically important in
helping VA redesign its care delivery system to meet the needs of these
veterans.
Amputation and Prosthetic Research. VHA ORD currently supports a
broad research portfolio pertaining to amputation and prosthetics, and
more research in this area is planned. Areas of interest include:
Nanofabrication, microelectronics and robotics to create
lighter, more functional prostheses. ORD is funding two new Prosthetics
Rehabilitation Engineering and Platform Technology Centers that are
national resources to develop computerized state-of-the art prosthetic
limbs with the goal of using the latest advances in orthopedic surgery,
tissue engineering, nanotechnology, and microelectronics to create
prosthetics that look, feel, and act more like one's own limb.
The Providence VA Medical Center, in collaboration with
Brown University and the Massachusetts Institute of Technology, is
working to develop a ``biohybrid'' limb that will use regenerated
tissue, lengthened bone, internal and external implants and sensors to
allow amputees to use brain signals and residual limb musculature to
have better control of their limbs and reduce the discomfort and
secondary complications associated with current prostheses. These
researchers are already publishing and presenting about their work.
The Advanced Platform Technology (APT) Center at the
Cleveland VA Medical Center focuses on sensory and implanted control of
prosthetic limbs, accelerated wound healing, and biological sensors for
the detection of health and function to accelerate the use of new
materials and innovative micro-mechanical or nanotechnologies to
provide more independence to veterans with disabilities.
ORD is starting a study to gather information about how
prosthetic devices are used, costs, amputee satisfaction, comparisons
selected prosthetic devices, and various prosthetic procurement
alternatives to help VA match technology to the needs of an individual
veteran.
ORD is partnering with the Department of Defense (DoD),
Walter Reed Army Medical Center, the Defense Advanced Research Projects
Agency and Brooks Army Medical Center to compare prosthetic designs;
define standards of function; evaluate psychological issues faced by
returning service personnel; determine psychosocial issues that
challenge successful reintegration; and initiate longitudinal studies
to study veterans care over time.
VA investigators are examining rehabilitation for the
visually impaired including artificial retinas, especially for
polytrauma victims; new treatments for burn victims; restoration of
hearing and maximizing function for those with hearing loss, especially
for polytrauma victims; and natural mechanisms of neural regeneration
to return function to paralyzed veterans and those with brain injuries.
VA investigators also plan to study advanced tissue engineering and the
manufacturing of artificial skin to accelerate wound healing.
Mental Health and PTSD Research. Studies about PTSD and other
mental health issues are an important part of the VHA ORD research
portfolio, and special attention is being paid to the circumstances of
the returning OIF/OEF veteran.
Interagency Collaboration regarding OIF/OEF Mental Health. VA, the
National Institutes of Health (NIH) and DoD jointly issued a Request
for Applications (RFA) in late 2005, to enhance and accelerate research
on the identification, prevention and treatment of combat related post-
traumatic psychopathology and similar adjustment problems. The goal is
to encourage studies involving active-duty or recently separated
National Guard and Reserve troops involved in current and recent
military operations (e.g., Iraq and Afghanistan). This RFA specifically
encouraged participation of clinicians and researchers who screen,
assess or provide direct care to at-risk, combat exposed troops, and
emphasized interventions focusing on building resilience for veterans
suffering from mental health problems, including PTSD, and developing
new modes of treatment that can be sustained in community-based
settings. Among the approaches being considered are novel
pharmacological, psychosocial and combination treatments as well as the
use of new technologies (e.g., World Wide Web, DVD, Virtual Reality,
Tele-health) to extend the reach of VA's health care delivery system.
Fifty-five proposals were received earlier this year in response to
this RFA, and those proposals deemed to have scientific merit and
relevance to veterans will start October 1, 2006.
Women and PTSD. Because of women's new roles in the military and
subsequent combat experiences, VA and DoD are studying the use of
psychotherapy for treatment of PTSD in female veterans and active duty
personnel. A randomized clinical trial, part of VA's Cooperative
Studies Program, has recently been completed and results are currently
being analyzed, with a report expected in 2007. Those results will
inform additional research and implementation activities across VHA.
Depression. Several approaches have been developed and tested by VA
investigators to improve the assessment and treatment of mental health
disorders. For example, implementation of an evidence-based
collaborative care model for depression called ``TIDES'' (or
Translating Initiatives in Depression into Effective Solutions) has
demonstrated significant improvements in depression symptomatology
among patients referred by their primary care providers. This study
plus two companion evaluations of the processes, outcomes, and costs of
implementation (called WAVES or Well-Being among Veterans Enhancement
Study and COVES or Cost and Value of Evidence-based Solutions for
Depression) are part of national VA strategic planning and rollout for
improving the quality of depression care. Future research projects are
planned to develop and test collaborative care models for PTSD and
other anxiety disorders.
Other projects. ORD is currently conducting and planning projects
that address the long-term care needs of veterans with TBI, and assess
(in collaboration with DoD) the long-term changes in health status
resulting from combat deployment. We are studying the role of smoking
and nicotine dependence among veterans with PTSD, and will begin this
fall a multi-site clinical trial to study the effects of risiperidone
on PTSD. ORD will continue to support other studies that test the
effectiveness of virtual reality therapy and other new treatments for
PTSD. It is important to note that this research will also have direct
applications for all veterans and not simply those involved in OIF/OEF.
Genomic Medicine Program. VHA, as a large healthcare system with an
integrated research network and an unrivaled electronic medical record
system, is uniquely positioned to develop a national Genomic Research
Program. The goal of this program is to expand VA's ongoing genomic
medicine effort. Research efforts will be developed to: understand the
role of genetics in the prevention and cause of disease; use genetic
information to improve how clinicians prescribe medications and to
prevent adverse reactions; develop computer systems to manage genetic
data and identify genetic predispositions; develop laboratory
capability to do genetic and pharmacogenomic profiling within VA; and
learn how to use genetic information effectively in everyday practice.
The ultimate goal of these efforts is to predict and prevent disease
and to treat more effectively and at lower costs through the
customization of clinical interventions.
In the March 22, 2006 Federal Register, VA announced the
establishment of the Genomic Medicine Program Advisory Board. The
Committee is composed of nationally renowned medical experts in genomic
research, bioethics, and disease management. The purpose of the
Committee is to provide advice to the Secretary of Veterans Affairs on
the scientific and ethical issues related to the establishment,
development, and operation of a genomic medicine program. Specifically,
the Committee will assess the potential impact of a VA genomic medicine
program on existing VA patient care services; recommend policies and
procedures for tissue collection, storage and analysis; and develop a
research agenda and approaches to incorporate research results into
routine medical care.
Gulf War Veterans' Illnesses. VA research places a high priority on
scientific research aimed at improving the quality of life for veterans
of the 1990-1991 Gulf War affected by chronic multisymptom illnesses
commonly referred to as Gulf War Veterans' Illnesses (GWVI). Some
veterans who participated in Operations Desert Shield and Desert Storm
have reported conditions and chronic symptoms such as fatigue,
weakness, gastrointestinal difficulties, cognitive dysfunction, sleep
disturbances, persistent headaches, skin rashes, respiratory problems,
and mood changes at rates that significantly exceed those reported by
comparison groups. VA research continues to expand its efforts to
understand and treat GWVI. The core objective is to improve the health
of ill Gulf War veterans. It is important to note that Gulf War
veterans with chronic unexplained symptoms are eligible for disability
benefits even when the cause of their illness cannot be determined.
VA has committed $15 Million in fiscal year 2006 for collaboration
with the University of Texas Southwestern Medical Center and has also
funded VHA ORD investigators for on-going projects. These ongoing
studies address areas of interest that include: chronic multisymptom
illnesses (CMI) affecting GW veterans; conditions and/or symptoms
frequently reported by GW veterans; long-term health effects of
potentially hazardous substances, alone and in combination, to which GW
veterans may have been exposed during deployment; and any of the 21
Research Topics forming the framework for the Annual Report to Congress
of federally Sponsored Research on GWVI.
Chronic Disease. According to a study of 1999 VA health care
expenditures, VA health care users have more chronic diseases than the
general population. This study also indicated that 72 percent of VA
patients had at least 1 of 29 chronic diseases such as diabetes,
Parkinson's disease, HIV/AIDS, Alzheimer's disease and substance abuse,
and the care for these veterans accounted for 96 percent of health care
expenditures provided at VA facilities. The following are examples of
efforts by VA researchers to discover how to prevent and treat chronic
disease.
Diabetes. According to the National Institute of Diabetes and
Digestive and Kidney Diseases at the National Institutes of Health,
20.8 million people--7 percent of the population--have diabetes. An
estimated 4.6 million people are diagnosed and 6.2 million people are
undiagnosed. In 2005, 1.5 million new cases of diabetes were diagnosed
in people aged 20 years or older. Diabetes affects nearly 20 percent of
veterans receiving health care from VA: 1 million veteran users. An
estimated 2 million veterans without diabetes have metabolic syndrome,
which places them at high risk for diabetes. The cost is tremendous: 30
percent of VA health care costs (in- and out-patient and pharmacy) are
attributable to patients with diabetes. This includes 1.7 million days
of hospital care. VA investigators have completed the first study to
compare the quality of diabetes care among patients in VA and
commercial managed care organizations. Quality of care measures were
compared for seven diabetes processes of care, three diabetes
intermediate outcomes, and four dimensions of satisfaction. Results
from this study showed that VA patients had better scores than
commercially managed care patients on all assessed quality of care
measures. VA patients also had better low-density lipoprotein control
and were slightly more satisfied with the overall quality of diabetes
care at VA.
Identifying the most effective treatment methods is crucial to
reducing the incidence of diabetes among veterans. Although more
patients are accessing medical information on the Internet, few studies
have examined the effects of web-based interventions that incorporate
an interactive component requiring feedback from patients. A VA study
tested diabetes care management using a web-based system for veterans
with poorly controlled diabetes. Results showed that web-based care
management improves poorly controlled diabetes in veterans. Veterans
participating in the web-based management program had significant
improvements in HbA1c over 1 year compared to usual care, and
persistent website users had even greater improvements compared to
intermittent users.
ORD has also initiated the VA Diabetes Trial to determine whether
intensive control of blood sugar, compared to standard methods, can
reduce other blood vessel damage and other complications. Smaller
trials to determine the value of the interventions will come first,
with more research to follow.
Obesity. Results from the 2003-2004 National Health and Nutrition
Examination Survey (NHANES) indicate that an estimated 66 percent of
U.S. adults are either overweight or obese. The problem is similar or
worse among VA's patient population, with 73 percent of veteran
patients overweight or obese. Obesity contributes to increased heart
disease, diabetes, and sleep apnea, and an estimated 300,000 Americans
die annually from illnesses related to overweight and obesity.
Findings from VA studies to assess the efficacy and safety of
weight loss medications, as well as the effectiveness and adverse
events associated with the surgical treatment of obesity, demonstrated
that surgical treatment is more effective than non-surgical treatment
for weight loss in severely obese patients; weight loss was maintained
for up to 10 years and longer and was accompanied by significant
improvements in several comorbid conditions.
Other examples of VA research include studies on traditional and
new approaches to prevent and treat obesity, such as a comparison of
lower extremity functional electrical stimulation on obesity and
associated co-morbidities in comparison to upper extremity aerobic
exercise for persons with paraplegia; an assessment of the impact of
walking aides on quality of life and physical activity in overweight
and obese veterans with osteoarthritis; and explorations of drug
therapies.
Alzheimer's Disease. Alzheimer's Disease (AD) and related dementias
affect 7.3 percent of veterans over age 65. VA research is helping to
discover new facts about AD and other diseases and conditions that
affect older veterans. For instance, researchers at the Bronx VA
medical center have reported that diet-induced insulin resistance, a
cause of type II diabetes, promoted beta-amyloid production concurrent
with decreased insulin-degrading enzyme (IDE) activity in an animal
model of AD. Beta-amyloid is the major component of amyloid plaques,
the hallmark of AD pathology. IDE has been proposed to be responsible
for the degradation and clearance of beta-amyloid in the brain. Such
research is needed to form the basis of future interventions to prevent
or reverse this devastating condition.
Influenza. VA health services researchers have been instrumental in
improving vaccination rates for veterans with chronic diseases that
place them at high risk for complications from influenza, as well as
enhancing vaccination among health care workers and veteran groups that
historically have had low vaccination rates, such as minorities,
smokers, and those with spinal cord injuries and disorders.
Pandemic influenza infection has the potential for causing
significant morbidity and mortality in the United States and elsewhere.
ORD is responding, along with other Federal agencies, to this
unprecedented public health threat by initiating studies that examine
optimal dosing strategies for the antiviral agent oseltamivir (Tamiflu)
in the event of an emerging pandemic of human infection with an avian
or other influenza strain for which an effective vaccine is lacking.
HIV/AIDS. AIDS (acquired immunodeficiency syndrome) is caused by
HIV (human immunodeficiency virus). The virus kills or damages the
body's immune system, which lowers the body's ability to fight
infections and certain cancers. According to the Centers for Disease
Control, at the end of 2003, an estimated one million persons in the
United States were living with HIV/AIDS, with 24-27 percent undiagnosed
and unaware of their HIV infection. VHA is the largest single provider
of HIV care in the US, with nearly 20,000 patients seen annually with
the disorder. Accordingly, ORD funds a full range of studies from bench
research aimed at elucidating the underlying mechanisms of HIV to
implementation projects that improve VHA's effectiveness in caring for
this population.
Researchers at the VA South Texas Health Care System and the
University of Texas Health Science Center recently showed that people
who have a below-average number of copies of a particular immune-
response gene have a greater likelihood of acquiring HIV and, once
infected, of progressing to full-blown AIDS. These findings, cited as
one of the top articles published in the eminent journal Science, have
important implications for the treatment and prevention strategies for
HIV/AIDS and possibly other infectious diseases as well.
Women's Health. According to information from the VA's Center for
Women Veterans, in 1973, women in the active duty military accounted
for 2.5 percent of the armed forces. By fiscal year 2001, however, the
number of women significantly increased making up 15 percent of the
armed forces and those numbers are expected to increase. To respond to
this demographic change and develop a more comprehensive VA women's
health research agenda, a VA Women's Health Research Planning Group
recently identified the needs of women veterans and a corresponding
research agenda. VA researchers currently are investigating optimal
strategies for conducting preventive health and disease screening
activities among women veterans (e.g., cervical cancer screening) and
developing and evaluating computerized, interactive educational
programs to enhance VA staff awareness of women veterans and their
health-care needs.
infrastructure
It is crucial that VA investigators have the equipment and
facilities necessary to conduct cutting-edge research in the twenty-
first century. To identify where improvements may be needed, ORD has
initiated a comprehensive review of VA's research facilities to
identify deficiencies and corrective actions. The objectives of the
Research Infrastructure Evaluation and Improvement Project are to
review the overall adequacy and utilization of research space and
infrastructure (including animal research facilities); to develop a
plan to update and maintain facilities; to ensure compliance with
biosafety and research laboratory security requirements; to enhance
collaborations between the local VA Medical Center and its academic
affiliate; and to ensure that the needs for highly specialized research
programs (e.g., Rehabilitation Research and Development (RR&D) and
Health Services R&D (HSR&D) Centers of Excellence) are met.
Survey teams including VA research administrators and scientists,
as well as other VA employees and engineering contractors, will review
documentation and visit facilities to evaluate the physical
infrastructure (including the animal facility, research laboratories
and common equipment rooms); operational infrastructure (capability to
conduct research while meeting requirements for compliance with safety,
animal welfare, and human subjects protection regulations); and
equipment (major items of equipment used for the conduct of research)
of VA facilities with active research programs. The data collected from
the surveys will be used to develop financial needs and an asset
management plan. We expect to have a report to Congress early in fiscal
year 2007.
In addition, ORD recently funded proposals as part of the Shared
Equipment Evaluation Program that is managed by the Biomedical
Laboratory and Clinical Science Research and Development Services. The
purpose of this program is to fund new or replacement research and
animal facility equipment. The program requires that facilities
identify dollar-for-dollar matches in order to leverage the VA
contributions. As a result of a December 2005 request for applications,
a total of $2,086,173 for facility projects and research equipment has
been funded for the following sites: Decatur, GA; Chicago, IL;
Cleveland, OH; Miami, FL; Loma Linda, CA; Memphis, TN; Nashville, TN;
New Orleans, LA; Omaha, NE; Palo Alto, CA; Philadelphia, PA; Portland,
OR; Richmond, VA; San Francisco, CA; Seattle, WA; San Diego, CA; San
Antonio, TX; and Los Angeles, CA.
Other proposals for research equipment are pending funding with
decisions expected later this fiscal year. This program was suspended
for a number of years, but plans are to begin funding proposals on an
annual basis after a review to determine merit and priorities.
conclusion
As an academically trained researcher, I understand the
complexities of the research process, and I am fascinated by the
results. I fully support this program and advocate to you that its
value, both to veterans as well as the Nation, far exceeds the costs.
The history of VA research is impressive, and the future promises even
more important advances. Can we prevent infections that hamper the use
of biohybrid limbs? Can we develop artificial retinas so that wounded
OIF/OEF soldiers and our aging veterans can regain their sight? Can we
use our computerized medical record system and genetic samples to
individualize drug and clinical treatments, or identify those veterans
who may have a predisposition for a particular disease and prevent the
onset of, rather than treat, the symptoms? Can we continue to examine
ourselves to find out how to deliver patient care more effectively? The
answers to these questions must be ``yes'', as no other health system
is better positioned than VHA to make these discoveries, and no other
group of patients is as deserving as America's veterans to receive the
benefit of such innovation.
Chairman Craig. Thank you very much, Dr. Perlin. You have
been accompanied by Dr. Joel Kupersmith, Chief Research and
Development Officer for the VA, and Dr. Richard Weir, VA
Prosthetics Research Laboratory, in Chicago. Before we get into
dialog and questions, obviously Dr. Weir has brought a unique
device along, and I think it is time our Committee Members see
it. I had the privilege of trying it on, fellow Senators,
before you arrived and before we convened the Committee, and so
I think it is important that we see some of this cutting-edge
technology firsthand, may I say? Dr. Weir, if you would,
please.
Dr. Perlin. Mr. Chairman, if I might introduce Dr. Weir as
he gets assembled there.
Chairman Craig. Please do.
Dr. Perlin. It is my privilege to introduce Dr. Richard F.
Weir, in fact, a former Career Development Awardee, and now a
research scientist, with the VA Prosthetics Research
Laboratory, at the Jesse Brown VA Medical Center in Chicago. As
with many, the Career Development Program nurtures the work of
young investigators so that they can mature in their career and
bring exciting new technology to the care of America's
veterans. Dr. Weir will demonstrate the work that the VA and
their partners are doing on hand and wrist prostheses. Too many
servicemembers who have served in the Global War on Terror or
in military careers experience trauma resulting in loss of
their hands, and Dr. Weir and his fellow scientists are doing
vital work that will significantly help these heroes. It is my
pleasure to introduce Dr. Weir, and one of the most futuristic
devices for restoring function to injured veterans.
Mr. Weir. Good morning, and thank you, Mr. Chairman. It is
an honor to be here today to have a chance to present on some
of the work that I have been doing for the VA.
We have been working on a new prosthetic for people who
have lost all fingers and the thumb.
Chairman Craig. Dr. Weir, we haven't made you sweat yet, so
as to your connection with your sensors, I'm sorry. Go ahead.
You need that moisture connection there.
Mr. Weir. I need some more moisture. It dried out in the
interval here.
This is a new prosthetic device for a particular level of
amputation that had not actually been addressed in the past,
and it was for those individuals who had lost all fingers and
thumb but still had a wrist. The wrist is a very important
joint to maintain if you want to give somebody some function if
you have lost all your fingers and thumb. So the challenge from
our perspective in this project was actually to be able to
develop a mechanism and a fitting technique that would allow
any residual motion in the wrist to be maintained, and to allow
an individual to regain as much function as possible.
From an engineering design point of view, the challenge is
where to put everything if you have only got the volume of the
fingers, because someone who has a wrist still has this portion
of their hand left, and then so the challenge is to get
everything into just the fingers and the thumb.
This was the little device that we came up with as an
armature. Then we have little sensors that sit in the
prosthetic socket it is called, or prosthetic interface, and
this pushes onto the residual limb and these sensors sit over
the residual muscles in the hand. The person will then think
about closing their hand to close the hand like this, and then
opening the hand to open the hand.
The other thing is to develop a prosthetic socket, though,
that keeps that motion going, and so this is the device we have
come up with. We are in the process of fitting this to some
patients at the moment, and we are in the process of developing
this prosthetic interface so that it can be freely suspended
without restricting wrist motion. Ironically enough or
unfortunately, this project was started before Operation Iraqi
Freedom just because the VA has a long-term view on prosthetics
and the development of orphaned products, and the problem is
that we are seeing injuries now coming from Operation Iraqi
Freedom where soldiers are incurring burns and some of these
burn injuries are resulting in amputation or loss of all digits
and thumb. So now this little mechanism has particular
relevance to fitting that level of amputation. That is pretty
much all I have to say.
Chairman Craig. Thank you very much, Dr. Weir, for that
demonstration. I think it is a phenomenal example of the kind
of work that is going on. Dr. Perlin, as you said, while the
work is going on at VA and collaboratively with university
settings, NIH and others, it is not exclusively for veterans.
Once this is done, it goes to the market, and that is what
becomes increasingly exciting, that the research going on for
veterans really gets spread across the world scene ultimately,
and that makes it all the more meaningful.
In your testimony you stated that VA has begun a
comprehensive review of its research infrastructure, and I am
glad to hear that. We look forward to that report, as you are
projecting its completion early next fiscal year?
Dr. Perlin. Yes, sir.
Chairman Craig. Meanwhile, can you elaborate, or possibly
Dr. Kupersmith could, on the kind of information you expect to
find from this report?
Dr. Perlin. Thank you, first, Mr. Chairman, Ranking Member
and Committee Members for your support of VA research. I think
what you have seen today is truly extraordinary.
Mr. Chairman, in particular you have really focused in on
an area that helps not only veterans, but all Americans, and
you have worked with us in grappling with serving veteran in an
infrastructure that is aging. Nationally, the CARES process
reviews some of the infrastructure, and the mean age of our
buildings is about 58 years. The research facilities are
equally aged. Let me ask Dr. Joel Kupersmith to describe some
of the findings that suggest that we need to invest to improve
and bring veterans and all Americans the sort of cutting-edge
research that you saw this morning.
Dr. Kupersmith.
Dr. Kupersmith. Thank you very much. I want to also echo my
thanks for your comments earlier. Much of the research space is
inadequate for very simple reasons, there is not enough space,
the ventilation in some places is not quite what it should be,
and the basic structure of the space is also not necessarily
easily adaptable to modern equipment. So I think those rather
simple factors are why it becomes difficult to work in some of
these areas.
Chairman Craig. I presume that a substantial portion of the
fiscal year 2007 research budget will be going toward projects
VA has already committed to fund. If Congress were to provide
additional funds for research above the President's request,
can you give Members of this Committee an idea of where the
additional funds would be allocated? And without asking you to
commit on any level of research funding for a particular area,
can you please explain if it would include research directly
related to OIF or OEF veterans at this time?
Dr. Perlin. Mr. Chairman, thank you for that question. Of
course, we have an obligation to do the sort of research that
helps assist our servicemembers in any injuries or illnesses
that they might experience, especially in combat, as that is
increasingly a focus, and the President's budget itself
increases the funding these areas of acute trauma, spinal cord
injury, brain injury, mental illness.
Of course, any additional funds that were to be provided
would be greatly appreciated and would be focused not only on
the issues of America's combat veterans, but the issue of
America's veterans broadly which, as you described, include not
only those things that occur as a result of service, but those
things that are part of the challenges of life, of aging,
ranging from heart disease to cancer, especially diabetes, a
challenge in our environment, and mental-illness research. Let
me ask Dr. Kupersmith to speak more, perhaps, on some of the
areas of strategic investment such as the Career Development
Awards that also bring new investigators, new clinician/
researchers, top-notch individuals, to the care of veterans.
Dr. Kupersmith. Yes, certainly I think Dr. Weir exemplifies
this because he is the product of a Research Career Development
Award as are many of the people who work in rehabilitation
medicine.
I think some of the programs that we are specifically doing
in regard to veterans of the Afghani and Iraqi Wars have to do
with neurotrauma, cervical spine injury, traumatic brain injury
which is very common, and looking at this at all levels, both
at the laboratory level as well as the clinical level, and how
to approach long-term care in a younger patient. So many of our
efforts in the past have been long-term care in the older
individual and there are different needs, obviously, as there
are different needs in prosthetics in younger and older
individuals. In addition, in the wide range of prosthetics
research, we are developing artificial retinas and some others.
But I think we do make an investment in people, and we have
an extensive Research Career Development Award program. That
is, I think, one of the best there is to create investigators
for the future. We like to keep all of these investigators, but
we do not. They go on to other things, and they go on to help
the country as a whole. Most of them stay with us and work in
these areas, and that is a very important investment we make.
The other important investment we make, as was mentioned,
is collaboration with the universities. Again, Dr. Weir's work
is an example of extensive collaboration on a number of
prostheses between Northwestern and the Research Institute of
Chicago and us. So these are the kinds of things we are doing.
Chairman Craig. Gentlemen, thank you. Let me turn to
Senator Akaka.
Danny.
Senator Akaka. Thank you very much, Mr. Chairman.
Dr. Perlin, in the fiscal year 2007 budget, I read funding
cuts are slated for research projects focusing on cancer, on
diabetes, and heart disease. We all understand the pressing
need and desire for the state of prosthetics and new treatments
for service-connected disabilities, but these projects should
not come, I believe, at the expense of peer-reviewed projects
which address all kinds of health care needs. Can you please
explain the rationale behind reducing funding for disease-
related research? Is there not enough room for all kinds of
research?
Dr. Perlin. Thank you, Senator Akaka, and thank you for the
support you have expressed for VA research in your introductory
comments and with the recognition that all of the areas of
research conducted are of significant value.
In the current environment with our troops deployed, we
felt the commitment to increase the focus on areas that are
related to injury or illness to which troops may be exposed, so
we did prioritize in that direction. We always do hope to
leverage and have had tremendous success in leveraging the
investment that you make in the direct appropriation through
recruiting additional grants in areas such as cancer or other
illnesses from other funding entities such as the National
Institutes of Health. In fact, the current support from the
National Institutes of Health and other Federal Agencies is
about $662 million, and so your investment in VA research is
significantly amplified. But you are correct that when we focus
on one area, it does push on project capacity in other areas
which is why we are particularly appreciative of the support
that you have endorsed.
Senator Akaka. As I am pointing out here, somehow we need
to continue the tradition of research that VA has in all of
these areas.
Dr. Perlin, the fiscal year 2008 construction list includes
a $7 million project for a research facility located at Tripler
Army Medical Center in Honolulu. This facility would be, as I
understand it, the first of its kind, a joint center of
cooperation and collaboration between VA and DOD. Do you see
this concept of joint research facilities as a future avenue
for success and innovation?
Dr. Perlin. Senator Akaka, let me endorse the general
concept of collaboration with our partners in the Department of
Defense. In fact, throughout the country there are over 450
separate sharing arrangements ranging from clinical activities,
to shared infrastructure, to shared capital equipment. So there
is no reason that should not extend to shared support of the
research environment. I would note that the sharing of a
physical space may have some unique aspects, and that is
certainly a part of the culture sharing in terms of research
activity.
In terms of mental-health care, mentioned in my opening
comments, there is collaboration with the Department of Defense
on mental health and PTSD which also includes a third partner,
the National Institute of Mental Health. We have collaborated
on physical illnesses research as well, and look forward to,
where we have the capacity to, be synergistic in sharing
physical infrastructure as well.
Senator Akaka. Dr. Perlin, I would like to ask you how much
VHA spends on the indirect costs for conducting NIH grants. I
ask that because NIH has refused to reimburse VA for the
indirect costs of conducting research grants, and, therefore,
those costs come out of health care dollars. Are you working
with NIH on this?
Dr. Perlin. Thank you, Senator. This has been an area of
ongoing discussion with the National Institutes of Health. When
NIH funds come directly to a VA medical center, they do not pay
an indirect research cost as would occur were those funds to be
conferred to any other institution. When funds come through a
university, the university actually receives the indirects, and
if there are space costs, some of those supports come through.
Certainly, when NIH funds through our not-for-profit research
corporations, the dollars come through. I would ask Dr. Joel
Kupersmith to elaborate on the actual dollar amounts or provide
for the record the complete figure.
Dr. Kupersmith. Our estimate in the budget submission for
2006 was $353 million coming from VERA dollars. The NIH issue
has been a subject of ongoing discussion for several years and
is pretty much in the same area. As Dr. Perlin mentioned, the
essential way that the overhead dollars can be recovered is
through the nonprofits. We have not been able to recover them
in other ways. And may I add only in certain places have they
been recovered. This is not uniform nationally by any means.
Senator Akaka. Thank you. Mr. Chairman, my time has
expired.
Chairman Craig. Danny, thank you very much. Senator Burr,
any questions of the panel?
Senator Burr. Thank you, Mr. Chairman. Again let me
reiterate my thanks to you and Senator Akaka for your
persistence on this.
Dr. Perlin, let me ask you, Durham, North Carolina, does a
sizable amount of research for the VA, and it is unique in its
location to Duke University, and the relationship that Duke
University has with the VA is an incredible one. Are you able
to work with academic institutions and with the private sector
often enough on the research directions to make sure that there
is little to no duplication in what our efforts are?
Dr. Perlin. Senator, first, thank you very much for your
question. Indeed, the relationship with Duke University and the
Durham VA is a terrific one that has produced very important
and cutting-edge research as, frankly, have many of the
relationships with other universities in the State of North
Carolina.
That said, nationally I would say whether it be VA or
elsewhere, there is not a program to effectively assure that
research activities are not reduplicated. I do know that
sometimes the advances are made in areas where there is
competition, as in industry as well, but in VA at least we try
to coordinate our portfolio to assure that we get the most
product for the investment. I don't know, Dr. Kupersmith, if
you would like to elaborate.
Dr. Kupersmith. There is no national strategic plan among
universities or for our collaboration with universities. I
would point out that there is a certain amount of duplication
that is appropriate because it is scientifically checking what
happens, and so a certain amount of that is appropriate.
I think that our collaborations, generally when grants are
applied for, one has to give the uniqueness of the grant
whether it is for us or NIH, and that guards against
duplication in many ways.
Senator Burr. The VA is faced with an increasing population
as is the rest of the country of type 2 diabetes. I think by
any historical standard, one might call this an epidemic, and
that I am not sure that we as a Nation yet have accepted like
we should. In North Carolina we are working on building a
public-private partnership that is a research institution
specifically focused on health science nutrition. You are aware
of this and we have talked. It is extremely close to the
Salisbury VA facility. It would probably be an ideal
partnership for ongoing research that the VA is currently
conducting in the area of diabetes.
Dr. Perlin, what do you see as the VA's role not only in
the North Carolina entity that we have talked about, but in
replicating something like that elsewhere in the country? I
just truly believe that public-private partnerships offer us an
opportunity to leverage Federal dollars in a way that produce
much more from the standpoint of the research bench and that
means the Government and the private sector have to find these
common points.
Dr. Perlin. Senator Burr, thank you for both parts of your
question, first, the public-private partnerships, and, second,
the epidemic of obesity, overweight, and diabetes.
I join the Secretary in being a fan of public-private
partnerships. In fact, this terrific demonstration that we saw
today has spawned a patent, and as Chairman Craig indicated,
will not only benefit the immediate and obvious needs for
veterans, but will benefit our country. It also will go into
the marketplace and help to provide an economic engine for
America's leadership in advanced biotechnology.
The areas of diabetes is, sadly, not only an American
epidemic, it is a worldwide epidemic. Our Secretary has
championed a program called HealthierUS Veterans. The toll of
overweight, obesity, and diabetes is affecting not only our
military personnel, a large population, but especially our VA
population, and this is one of the areas where if we can
partner strategically with the private sector to improve
exercise. In our HealthierUS Veterans program, you actually get
a prescription for health, a ``prescription for life,'' arming
veterans with pedometers now and new treatments. We offer care
for something that is, in the words of Surgeon General Carmona,
the number one threat to public health in the country, the
complications of obesity and diabetes, and that in the VA
population approaches nearly 1 in 4 veterans under our care.
Senator Burr. Thank you. Thank you, Mr. Chairman.
Chairman Craig. Senator Burr, thank you. Senator Jeffords,
questions?
Senator Jeffords. Dr. Perlin, the VA Medical Center at
White River Junction, Vermont, together with Dartmouth Medical
Center is doing a significant amount of cutting-edge research.
It is one of the programs that draws talented medical
professionals to our VA. A critical component of the medical
research is infrastructure and facilities, laboratories, and
access to patients. You mentioned that a study of the VA's
infrastructure needs is underway. Shouldn't we be funding some
of the needs that have already been identified?
Dr. Perlin. Thank you, Senator Jeffords, for your comments.
Indeed, the relationship of White River Junction and Dartmouth
is a terrific example of the academic affiliation. It produces
not only the basic science research that you have indicated,
but leading health services research, improving the quality of
health service delivery in many areas including to rural
Americans.
It is absolutely a necessity that we invest in our research
infrastructure. There has been a phased approach thus far.
There have been some issues related to improving the hardening
and security of research areas that was one of the first areas
of concentration and funding, and I would ask Dr. Kupersmith to
elaborate on some of the areas for infrastructural improvement
now and in the future, particularly as guided by the report
that will be forthcoming to Congress.
Dr. Kupersmith. As I said, I think the space issue is very
important, and in many areas there is a need for space. I think
some of these scientific appurtenances that older space have do
not come up to what the newer spaces have, so these are the
kinds of things that we are going to be interested in. This
survey is beginning, will be complete by the end of the fiscal
year and will be reported at the beginning of next year. We
will have very detailed information on each site and what it
needs, and I think it will incorporate all of these things.
Senator Jeffords. I am pleased to hear that. Your
demonstration of the hand was fascinating. Thank you for
bringing it, Dr. Weir. I note that you said that you began your
research work on this hand before the Iraq War. Dr. Perlin, has
the Iraq War demanded more from the VA? And how is the VA
redirecting its future research as a result of the war injuries
coming to the VA?
Dr. Perlin. Thank you, Senator Jeffords for the comment.
About 505,000 Americans have separated after having served in
combat, and in sheer numbers, the number of individuals who
have experienced amputation to date is about 424. But whatever
the number, our goal, our mission, is to restore function, and
this is in part the very central reason for VA. The promise of
doing what we can to make veterans whole, particularly, if they
have experienced a loss in service to our country is so core to
our mission that this really reminds us to refocus on the
rehabilitation. So both preceding the war, but certainly in the
context of combat, we are increasing our commitment to not only
prosthetic advances, but advances in brain injury, spinal cord
trauma such as occurs with the Improvised Explosive Devices, in
areas of amputation, of course, blindness, hearing loss, and of
course, the mental-health concerns that are important not only
in their own right, but also would accompany the physical loss
of function.
Dr. Kupersmith has put together a very exciting and
important portfolio for improving the care of injured veterans
ranging from combat casualty, neurotrauma, blast injury, a
program research on quality enhancement in care delivery, to
the long-term care management of complex injury, limb loss,
performance and an advanced platform technology development
program at Cleveland that produced such things as the
Functional Electrical Stimulator which actually gave
Christopher Reeve, Superman, the ability to breathe without a
ventilator, and artificial retina research. I believe in your
package you will find a picture of a device that can be
implanted in the back of the eye and work with a camera on a
pair of eyeglasses. In the same way that we now take for
granted that we can restore hearing with the cochlear implant,
we have the ability now and in the future to begin to restore
vision to veterans with physical injury, of trauma perhaps, or
macular degeneration, retinitis pigmentosa, or diabetes,
through these cutting-edge advances. Program projects with the
Department of Defense, NIH, and longitudinal studies just as
some examples.
Dr. Kupersmith.
Dr. Kupersmith. I just want to add that last study is a
deployment health study in which we are examining soldiers and
other military before they go to these wars, and then we will
be examining them after. It is the first study to look at the
genesis of PTSD and other mental difficulties in this way. I
think this will add a tremendous amount to our information in
gaining data on who is more likely to get PTSD and how it
happens.
Chairman Craig. Interesting.
Senator Jeffords. I have another question.
Chairman Craig. Please proceed.
Senator Jeffords. The aging of our veteran population
presents special challenges to the VA in treatment of veterans.
Can you discuss in more detail the specific research the VA is
doing to assist the Nation in understanding how to provide
better care to the elderly and better understand the unique
challenges of the diseases that disproportionately affect the
elderly?
Dr. Perlin. Again, Senator, a great question and a great
area. In VA's portfolio, there is work directed specifically at
improving the quality of life for aging veterans. Of course,
this will provide insight for the aging of all Americans.
In a sense, much of the disease-focused research that we
undertake has implications for aging. Cancer or heart disease,
stroke, as examples, are all areas where there are components
specifically directed at the disease of interest, but there is
another element of that that is focused on the complexity of
that disease in an aging population such as much of the veteran
population.
VA has been making particular focus on improving quality of
life at end of life as in palliative care. I recently came
across a statistic yesterday: Asking about pain at each visit
actually exceeds recording of any other vital sign, which is
really quite a testament. The usual four vital signs are pulse,
respiration, temperature, and blood pressure, and VA has a
program to record pain as the fifth vital sign, and it is now
the number one vital sign in VA. Improving the quality of
palliative care is particularly important not only in illness
in general, but at end of living in improving end-of-life care,
and hospice programs have been an area of focus and leadership
as well. Understanding the basis of dementia and Alzheimer's is
one example, but also vascular dementias that are caused by the
same sort of plaque buildup that lead to heart attacks is
another. These are not only of interest in terms of treatment,
but with our genomic medicine, it is very exciting, not only
about getting to good prevention, controlling the cholesterol
and the blood pressure, but getting to an era where we can
actually predict who is at risk, and even before the
cholesterol gets high, develop treatments and start treatments
that prevent things from deteriorating even before they would
be obvious to the clinician, and that is the promise of some of
the genomic medicine, the genetics-based therapy, that we hope
and the Secretary commits, to bring as the state-of-the-art
care for veterans. Dr. Kupersmith?
Dr. Kupersmith. I think the main point is that so much of
our research is relevant to the aging individual, and kidney
disease, lung disease, and particularly cancer, because as our
population ages, the incidence of cancer will rise. But the
other point is that many of our programs are related to
implementation of research and actually translation of research
to the beside have to do with aging individuals, and our so-
called QUERI program has a number of topics that are very
directly related to aging individuals so that we actually
assure that the care that the research is informing is provided
to the veteran.
Senator Jeffords. Thank you very much.
Chairman Craig. Jim, thank you. We could spend all day with
you, but we do not have all day, and neither do you. Thank you,
gentlemen, very much. Dr. Perlin, Dr. Kupersmith, Dr. Weir, the
work you are doing is going to make some people a good deal
more capable than they otherwise might be in the future because
of their injuries, and thank you for that work. Gentlemen,
thank you for your testimony.
Chairman Craig. We have a second panel, and we would like
you to come forward, please. If we could get our panelists
seated, we will proceed. Thank you. I guess the expression of
the next panel is where the rubber hits the road or where the
funding dollars make it to the bench or to the laboratory
facility. We are pleased to have with us Dr. Fred Wright,
Associate Chief of Staff, Research and Development, West Haven,
Connecticut, VA Medical Center; Dr. Dennis Stevens, Associate
Chief of Staff for Research Development, Boise, Idaho Medical
Center; Dr. John Feussner, Chairman, Department of Medicine,
Medical University of South Carolina. and Dr. John Kennedy,
Professor, Department of Medicine, University of Alabama, in
Birmingham, Alabama, VA Medical Center, representing the
Alliance for Academic Internal Medicine. Dr. Wright, we will
start with you.
STATEMENT OF FRED S. WRIGHT, M.D., ASSOCIATE CHIEF OF STAFF FOR
RESEARCH, VA CONNECTICUT HEALTHCARE SYSTEM, DEPARTMENT OF
VETERANS AFFAIRS
Dr. Wright. Mr. Chairman and Ranking Member, thank you for
the opportunity to discuss the importance of the VA research
program in general, and the research program and the facility
infrastructure at the VA Connecticut Healthcare System.
Our program has more than 350 active projects led by more
than 100 principal investigators. The majority of our
investigators are clinicians who also provide patient care in
internal medicine, surgery, mental health, or neurology. The
topics of VA Connecticut research include basic science
(including molecular biology, cell biology, and genetics) and
clinical research (clinical trials, health services,
epidemiology and rehabilitation). Approximately two-thirds of
the projects are clinical research studies involving human
subjects. Of the remainder, about half are investigations using
animal subjects, and the other half involve data analysis or
cell lines. Last year, the competitively awarded funding for
these projects exceeded $40 million. Most of this research
activity is concentrated at our West Haven campus.
The program centers on research to improve the health of
and the health care for veterans, including our newest
returning veterans. For example, our investigators at the
National Center for PTSD seek ways to improve treatment for
combat-related post-traumatic stress disorder and the
associated depression. A current project in that program, in
collaboration with the Department of Defense, is studying PTSD
in soldiers returning from Iraq to correlate specific genetic
information with response to a newly developed treatment.
Another group of investigators in our Neuroscience Research
Center is combining efforts in basic molecular biology,
clinical trials, and clinical rehabilitation to treat spinal
cord injury. Current work in that program is using tissue
transplant procedures to insert healthy myelin-producing cells
into damaged spinal cords in order to restore function.
Attracting, hiring, and retaining outstanding clinician
investigators is crucial to our ability to deliver high-quality
primary and specialty care to veterans. These clinicians are
individuals who are committed to academic medicine and are
attracted to work in VA by the combination of providing care to
veterans, teaching trainees, and conducting research in an
environment enhanced by the resources of the nearby medical
school. Without a robust research program, we would not be able
to recruit the nationally recognized clinician investigators
who also serve as attending physicians, clinical leaders, and
specialist consultants to whom our primary care physicians
refer patients.
Our affiliations with Connecticut's two medical schools are
also important to the success of VA Connecticut research.
Nearly all members of our medical staff have dual appointments,
as both VA physicians and medical school faculty members. Our
ability to recruit physicians to VA Connecticut medical staff
is greatly enhanced by the associated appointment to the Yale
facility, the opportunity to serve as a teacher for Yale
medical students and residents, and the expectation to carry
independent research in an environment enriched by the
proximity of the medical school.
Funding: Approximately one-third of the direct-cost funding
for VA Connecticut research comes from the VA research
appropriation, while nearly one-half of our funding is provided
by grants from the National Institutes of Health. VA research
funds provide the necessary core support for veteran-centric
research. However, we are able to supplement this funding by
competing successfully for funds from NIH and other non-VA
sources. This allows us to leverage what we are doing to
increase VA research.
Facilities: In the non-VA research world of public and
private universities and medical schools, facilities for
research, whether laboratories, offices, or patient care
settings, are maintained, replaced, or expanded by a
combination of funds from State governments, private
philanthropy, and Federal Agencies such as NIH. These sources
of funds are not generally available to VA medical centers, and
in my experience, have not been available at VA Connecticut to
support our needs for major infrastructure improvements. To
ensure that VA investigators are able to conduct cutting-edge
research in the 21st century, we will need appropriate
facilities and proper research infrastructure that will enable
us to attract clinician investigators to our medical staff.
Thank you again for this opportunity to describe our research
program at VA Connecticut.
[The prepared statement of Dr. Wright follows:]
Prepared Statement of Fred Wright, M.D., Associate Chief of Staff for
Research, VA Connecticut Healthcare System, Department of Veterans
Affairs
Thank you for the opportunity to discuss the importance of the VA
research program in general, the research program at VA Connecticut
Healthcare System (VACHS), and the facility infrastructure. Our program
has more than 350 active projects led by more than 100 principal
investigators. The majority of our investigators are clinicians who
also provide patient care in Internal Medicine, Surgery, Mental Health,
or Neurology. The topics of VACHS research include basic science
(including molecular biology, cell biology, and genetics) and clinical
research (clinical trials, health services, epidemiology, and
rehabilitation). Approximately two thirds of the projects are clinical
research studies involving human subjects. Of the remainder, about half
are investigations using animal subjects, and half involve data
analysis or cell lines. Last year the competitively awarded funding for
these projects exceeded $40 million. Most of this research activity is
concentrated at the West Haven campus.
The program centers on research to improve the health of and
healthcare for veterans, including our newest returning veterans from
Operation Iraqi Freedom and Operation Enduring Freedom (OIF/OEF). For
example, our investigators in the National Center for PTSD seek ways to
improve treatment for post-traumatic stress disorder and associated
depression. A current project, in collaboration with Department of
Defense, is studying PTSD in soldiers returning from Iraq to correlate
specific genetic information with response to a newly developed
treatment. Another group of investigators, in our Neuroscience Research
Center, are combining efforts in basic molecular biology, clinical
trials and clinical rehabilitation to treat spinal cord injury. Current
work is using tissue transplant procedures to insert healthy myelin
producing cells into damaged spinal cords in order to restore function.
Attracting, hiring, and retaining high quality clinical researchers
are crucial to advance the research agenda. These are individuals, who
are committed to academic medicine, and are attracted to work in VA by
the combination of providing care for veterans, teaching trainees, and
conducting research in an environment enhanced by the resources of the
nearby medical school. Without a robust research program, we would not
be able to recruit the nationally recognized clinician investigators
who also serve as attending physicians, clinical leaders, and
specialist-consultants to whom our primary care physicians refer
patients.
Our affiliations with Connecticut's two medical schools--the
Newington campus with the University of Connecticut Health Center and
the West Haven campus with the Yale University School of Medicine--are
also important to the success of VACHS research. Nearly all members of
the VACHS medical staff have dual appointments as both VA physicians
and medical school faculty members. In addition to their VA patient
care activities, VACHS physicians have responsibilities in teaching and
research. For example, the VA's West Haven campus is an important site
for clinical rotations by Yale medical students, residents, and fellows
in specialty training programs. They contribute to the care of VA
patients and are taught by Yale faculty who are based at the VA medical
center. VA's ability to recruit physicians to the VACHS medical staff
is greatly enhanced by the associated appointment to the Yale faculty,
the opportunity to serve as a teacher for Yale medical students and
residents, and the chance to carry out independent research in an
environment enriched by the proximity of the medical school.
Approximately one third of the direct cost funding for VACHS
research comes from the VA Research appropriation while nearly one-half
of our funding is provided by grants from the National Institutes of
Health (NIH). VA research funds provide the necessary core support for
veteran-centric research. However, we are able to supplement this
funding by competing successfully for funds from NIH and other non-VA
sources. This allows us to leverage what we are doing to increase VA
research.
In the non-VA research world of public and private universities and
medical schools, facilities for research (whether in laboratories,
offices, or patient care settings) are maintained, replaced or expanded
by a combination of funds from state governments, private philanthropy,
and Federal agencies such as the NIH. These sources of funds are not
generally available to VA medical centers.
To ensure that VA investigators have the equipment and facilities
necessary to conduct cutting-edge research in the twenty-first century,
the Office of Research and Development has initiated a review of VA's
research facilities. We believe that maintaining the proper research
infrastructure is necessary in facilitating cutting edge research, and
will enable us to attract outstanding clinician-investigators to our
medical staff.
Thank you again for the chance to describe our research program at
VACHS. I am ready to respond to any questions that you may have.
Chairman Craig. Doctor, not only did you do well, but your
timing was amazing.
Dr. Wright. Thank you.
Chairman Craig. Now we turn to Dr. Dennis Stevens.
Dr. Stevens.
STATEMENT OF DENNIS L. STEVENS, M.D., Ph.D., ASSOCIATE CHIEF OF
STAFF FOR RESEARCH, VETERANS AFFAIRS MEDICAL CENTER, BOISE,
IDAHO, DEPARTMENT OF VETERANS AFFAIRS
Dr. Stevens. Senator Craig, Members of the Senate Veterans'
Affairs Committee, and colleagues from the Department of
Veterans Affairs, it is with great pride that I come before you
as a veteran myself, and as Associate Chief of Staff for
Research at a small VA medical center in Boise, Idaho. As a
current member of the VA Career Development Review Board, and
as a science investigator who has enjoyed 26 years of funding
through the Department of Veterans Affairs Merit Review
Program, I want to say that at all VA medical centers of all
size, the important of research cannot be separated from the
quality of care that we provide for veterans.
Most VAs with research programs are affiliated with medical
schools. Having none in Idaho, we have had to be very creative
in establishing affiliations, both academic and research.
Specifically, we have a strong academic affiliation with the
University of Washington as part of the WAMI Program and have a
residency training program in collaboration with the University
of Washington in Boise.
While those relationships are very strong and have been
very productive in generating high-quality education, they
really have not improved the research capabilities of the Boise
VA. The topic that we have today is the infrastructure
mechanisms and costs, and clearly, building is one of those.
The space that we have I am not going to into in great detail,
but it is essentially one large room with two or three small
laboratories. We have a very excellent animal care facility,
and we have a very small clinical research unit.
At the local level of VA operations, most investigators in
small places wear many hats. We have about 30 percent of our
time, if we do have a merit review grant, to conduct research.
The rest of the time we are seeing patients, we are taking care
of Committees and various other things. So I think we have
special problems at small VAs just because of a lack of depth.
There are many things that we should talk about in terms of
VA infrastructure, but I think, clearly, buildings is one,
renovation projects is another. Equipment, and not only
equipment, but service contracts. Probably the VA's central
office could play a major role in addressing ways that we could
creatively reduce the cost of service contracts in dealing with
large corporations that make such equipment.
One of the major problems we have had at our small VA is
recruitment of new physician investigators, and that is
currently at an all-time low. I think the reasons for this are
multiple, but, first, the population of Boise has grown and
therefore the number of patients that we care for has
increased. For example, in 1995, we had 10,000 veterans that we
took care of, in 10 years this increased to 19,000. We have
conscientiously hired clinically oriented physicians to take
care of these patients to reduce the waiting list, but we
really have not actively recruited physician investigators, and
that is currently a high priority.
Lacking a medical school, it is also necessary to develop a
critical mass of researchers at the Boise VA, and that has
required very innovative relationships with the other
universities throughout the State. Specifically, I have been
able to develop collaborations with Boise State University,
Idaho State University, and the University of Idaho. I have met
with the research and development heads of all those
universities, and we have a plan together to develop a critical
mass of researchers at the Boise VA, and they are committed to
provide graduate student stipends, postdoctoral stipends, as
well as salaries for several faculty members, and I think this
is really going to help us. We have also coordinated these
efforts with the State legislature and the Governor's office
and so on.
The only thing that we really require is building space to
accomplish these goals, and we plan this fall to submit a small
research proposal for minor construction of a building for
research and education on the grounds of the Boise VA.
Thank you.
[The prepared statement of Dr. Stevens follows:]
Prepared Statement of Dennis L. Stevens, M.D., Ph.D., Associate Chief
of Staff for Research, Veterans Affairs Medical Center, Boise, Idaho,
Department of Veterans Affairs
Senator Craig, Members of the Senate Veterans Affairs Committee,
and Colleagues from the Department of Veterans Affairs.
It is with great pride that I come before you as a veteran, as
Associate Chief of Staff (ACOS) for Research at a VA Medical Center
(VAMC), a current member of the VA Career Development Review Board, and
as a basic science research investigator who has enjoyed 26 years of
continuous funding through the Department of Veterans Affairs (VA)
Merit Review Research Program.
Clinical investigators have successfully conducted basic science
research for more than 25 years at the VAMC in the areas of cardiology,
oncology, pharmacology, immunology and infectious diseases. Patient
related research has been conducted through outcomes research projects
involving clinical pharmacology, pulmonary medicine and the modern
mechanisms of clinical teaching. Investigators have also participated
or served as Principal Investigators in clinical trials involving
treatment of hepatitis C, HIV, pneumonia, bronchitis, skin and soft
tissue infections, septic shock, exacerbations of asthma and urinary
tract infections. These clinical studies have been in FDA phase II and
III clinical studies using novel new antibiotics and anti-viral agents.
All have been on the cutting edge of new clinical treatments. Boise
VAMC is currently participating in a clinical trial to compare
treatments for clinically localized prostate cancer. Prostate cancer
therapy is a topic of considerable discussion in the medical community,
and this study could provide significant value to that discussion.
At all VAMCs, the importance of research cannot be separated from
quality medical care for veterans. The VA's model of patient care,
teaching and research attracts the best, brightest and most hard
working of physicians. While translational research defined as ``from
the bench to the bedside'' has been newly discovered by other
healthcare systems, this is exactly what the VA Merit Review Program at
Boise VAMC and elsewhere has been doing for over 25 years.
Historically, within the VA system, we have learned to make clinical
observations, ask research questions, design experiments to answer
these questions and then move our results to clinical trials to improve
the care of veterans. As a consequence of the VA model for research,
there is currently a remarkable cadre of ``clinical investigators'' who
enjoy national and international acclaim. The title of this hearing,
``VA Research: Investing Today to Guide Tomorrow's Treatment'' is in
keeping with the historical theme of the VA Office of Research and
Development.
For example, a Boise researcher is currently studying how the heart
reacts when anthracyclines are used to treat cancer or infections.
Another researcher is working on what may be causing the increasing
number of streptococcal infections.
At small VA research operations, we must continuously identify
opportunities to improve our program, while balancing the
responsibilities and work loads of investigators and administrative
staff. As we develop plans to improve our program, it is also crucial
that we continue to identify funding sources to support our facility
infrastructure needs. Our goal is to improve patient care by finding
solutions through research projects that meet the needs of veterans in
Idaho as well as the Nation as a whole. Your support and interest in
our needs is appreciated.
Chairman Craig. Dr. Stevens, thank you very much. Now we
turn to John Feussner.
Dr. Feussner.
STATEMENT OF JOHN R. FEUSSNER, M.D., M.P.H., PROFESSOR AND
CHAIRMAN, DEPARTMENT OF MEDICINE, MEDICAL
UNIVERSITY OF SOUTH CAROLINA, CHARLESTON, SOUTH CAROLINA
Dr. Feussner. Mr. Chairman and Senator Akaka, good morning.
After listening to your opening statements, it appears to me
that the best my testimony can do is merely reinforce what you
already seem to know. Nonetheless, I appreciate the opportunity
to share my perspective on the importance and value of the
Veterans Affairs research program as it relates to academic
affiliations between VA and academic medical centers. In
addition to my role as professor and chairman of the Department
of Medicine at the Medical University in Charleston, South
Carolina, I also serve as a volunteer staff physician at the
Ralph H. Johnson VA Medical Center.
You already know about the extensive collaboration that
exists between the VA and the large majority of schools of
medicine and their academic centers. The affiliated VA Medical
Centers share key features in common with their academic
affiliates. The shared academic missions include superior
patient care, innovative and path-breaking medical research,
and broad-based medical education efforts. As a physician
researcher who has worked within university and VA medical
centers throughout my career, I provide a personal testimonial
to the importance and value of that affiliation, not just to
our Department of Medicine in Charleston, but for similar
affiliated Departments of Medicine throughout the country.
Clearly, the VA research program is superb in its own
right. You already know that. The presence of VA's research
activities coupled with excellent collaboration with academic
medical centers creates a culture of inquiry and innovation
that has the additional effect of attracting the best
practicing physicians. To be sure, the presence of the VA
Research Program raises the standard of medical care and
improves the quality of care delivered to our veteran patients.
Mr. Chairman, one of the key features of the growth and
success enjoyed by our two affiliated medical centers in
Charleston was the joint construction in 1996 of a new state-
of-the-art laboratory research facility named the Strom
Thurmond and Peter Gazes Biomedical Research Center. This
excellent research facility, now operating in its tenth year,
provides nearly 120,000 square feet of state-of-the-art
research space. The initial cost of this research building in
1996 was $31 million.
In addition, and historically, the VA has focused efforts
on training future physician researchers, and in this regard it
serves its clinical research and education missions
simultaneously. The VA's research career development program
provides excellent and stable support for new physician
researchers during the most vulnerable period of their careers,
the initial startup phase.
Given such a superb track record of achievement, the
current Administration budget recommendation is especially
disappointing in that it would result in an actual reduction of
$13 million in the VA research appropriation. Clearly, this
will have a deleterious effect for VA-supported physician
researchers and a loss of many new initiatives. And this
deleterious funding climate will also do harm to the VA/
academic affiliations, as opportunities will be reduced for
both. If the budget for research decreases, the competition for
grants of necessity will escalate, so meritorious proposals
will not be funded. And the newest physician researchers will
be especially disadvantaged and could be lost from the research
pool permanently.
Mr. Chairman, with regard to this Committee's activities, I
was gratified to note in your major views and estimates report
to the Budget Committee earlier this year that you recommended
VA research be augmented for fiscal year 2007 by an additional
$30 million. I believe Senator Akaka made a similar
recommendation. This type of bipartisan support by the Senate
Veterans' Affairs Committee for research is deeply appreciated,
sir, by those of us who are engaged in these pursuits. I know I
speak for the entire academic medical community in thanking you
and urging you to persuade the Senate and the House
appropriators to follow your lead.
Finally, Mr. Chairman, at some point in time--maybe this
point in time--somebody has to make the decision to make an
investment in the VA's future by repairing the VA's
deteriorating research infrastructure. VA, in conjunction with
its academic partners, operates dozens of substantial research
laboratories. It saddens me to say that most of them need major
renovations and some need complete replacement, as was the case
in Charleston nearly a decade ago.
Please remember that an investment in VA's research
program, whether in direct funding or infrastructure
improvement, preferably for both, counts twice in a way, as it
strengthens VA research and simultaneously enhances the half-
century of excellent affiliation and partnership between the VA
and some of the country's finest academic institutions.
Mr. Chairman, thank you. I am pleased to answer your
questions.
[The prepared statement of Dr. Feussner follows:]
Prepared Statement of John R. Feussner, M.D., M.P.H., Professor and
Chairman, Department of Medicine, Medical University of South Carolina,
Charleston, South Carolina
Mr. Chairman and Members of the Committee, good morning. I
appreciate the opportunity to share my perspective on the importance
and value of the Veterans Affairs research program as it relates to
academic affiliations between Department of Veterans Affairs Medical
Centers and Academic Medical Centers. My name is Jack Feussner, and I
am Professor and Chairman of the Department of Medicine at the Medical
University of South Carolina in Charleston. I am also a WOC (without
compensation, volunteer) staff physician at the Ralph H. Johnson VA
Medical Center. I have spent my entire academic career in a University-
based Academic Medical Center setting with a strong and effective
University and VA affiliation. I first became a funded VA physician
researcher in 1982, and I maintained that funding until I moved to VA
Central Office nearly 10 years ago to serve as the VA's Chief Research
Officer.
I am sure you already know about the extensive collaboration that
exists between the VA and the large majority of Schools of Medicine and
their Academic Medical Centers who are closely affiliated with the VA.
These affiliated Department of Veterans Affairs Medical Centers share
key features in common with their academic affiliates. The shared
academic missions include superior patient care, innovative and path
breaking medical research, and broad based medical education efforts.
As a Professor of Medicine, and as a physician researcher who has
worked within University and VA medical centers throughout my career, I
provide a personal testimonial to the importance and value of that
affiliation, not just to our Department of Medicine in Charleston, but
for similar affiliated Departments of Medicine throughout the country.
Clearly, the VA research program is superb in its own right. VA
research focuses on health issues that are common to or unique among
veteran patients. The VA research program is not just focused on
medical discoveries, or the generation of new medical knowledge,
treatment options, or diagnostic strategies. VA research focuses also
on translating this knowledge into improved patient care. The VA
Research Program is a potent enabler for VA and Academic Medical
Centers in facilitating recruitment of superior physician clinical
researchers. The VA Research Program, being completely intramural and
available only to VA employed staff, provides a special and incremental
source of funding that allows VA investigators additional options for
successful funding, especially in the current budgetary milieux, where
even non-VA research dollars are somewhat scarce. VA Research, in
collaboration with its academic affiliates, generates a halo effect
facilitating recruitment of outstanding physicians who themselves do
not do research. The presence of VA's superb research activities, and
excellent collaboration with Academic Medical Centers, creates a
culture of inquiry and innovation that has the additional effect of
attracting the best practicing physicians. With this academic
affiliation, VA is able to recruit scarce subspecialties to work in VA
Medical Centers, such as physicians who are expert in cardiology, GI
and liver disease, and medical oncology. Stability in VA research, and
until recently, reasonable annual growth in the VA Research Program
have also contributed to the retention of a cadre of superb VA
physicians and physician researchers. To be clear, the presence of VA's
research program raises the standard of medical care and improves the
quality of care delivered to our veteran patients.
In our own community, the Department of Medicine at MUSC and the
Charleston VA Medical Center collaboration has produced tremendous
success in acquiring NIH research funding, in addition to VA research
support, for illnesses important to veterans. Sustained funding in the
area of cardiovascular disease, kidney disease, diabetes, and
psychiatric illness has helped us address many medical problems that
are common in veterans and non-veterans alike. For example, in the area
of cardiovascular diseases, heart failure is one of the most frequent
causes of hospitalization and premature death among veterans. A VA/MUSC
based research program focused on understanding heart muscle
dysfunction and heart muscle disease was initially awarded to VA and
Medical University based investigators in 1993. This major NIH program
project grant has been continuously funded since then and will continue
through 2008. The grant is the second longest continuously funded major
heart research project funded by the National Heart Lung and Blood
Institute, and the principle researchers are faculty and staff at the
Medical University and VA, respectively. The research is conducted in a
shared VA MUSC state-of-the-art research facility. This research
opportunity has permitted the tripling of cardiology physicians, over
the grant period of time. While there is a national shortage of highly
qualified heart specialists, the Medical University and Charleston VA
Medical Center have not experienced such a shortage. The research
funding available to these collaborating investigators exceeds $3
million per year, and nearly $18 million in total funding over all
years of the current grant cycle. This collaborative research effort
between the Medical University and VA has led to significant research
success for a major clinical problem. The research has also facilitated
the recruitment, retention and stabilization of a group of medical
specialists that is currently in short supply nationally. As I said
earlier, the collaboration between the VA and the University, and the
availability of VA research funding, have permitted both institutions
to achieve success out of proportion to what either could have achieved
alone. In my opinion, the other key beneficiaries of such a successful
affiliation are veteran patients who receive excellent medical care
from superb doctors who care for their illnesses, and in addition,
these investigators conduct research that promises new therapies in the
future.
One of the key features of this growth and success between our two
affiliated medical centers was the joint construction in 1996 of new,
state-of-the-art clinical and laboratory research facilities, named the
Strom Thurmond and Peter Gazes Biomedical Research Center. This
excellent research facility, now in its tenth year, provides nearly
120,000 square feet of state-of-the-art research space. The initial
cost of this research building was $31 million with subsequent
renovations costing $12 million over the past decade. Because of the
close and productive affiliation between our state supported medical
school and the federally supported Department of Veterans Affairs
Medical Center, we were able to create a state and Federal partnership
which facilitated the building of modern research facilities, which
improved the infrastructure for both partners and greatly facilitated
additional high quality faculty recruitment. Unfortunately, few such
examples of successful partnering and planning between state and
Federal institutions exist, especially now when resources are scarce!
There are other examples of tremendous success within the context
of this one academic partnership between the Charleston VA and the
Medical University of South Carolina. Kidney disease, infectious
diseases, cancer, diabetes, and other medial illnesses benefit greatly
from the affiliation between an Academic Medical Center and a VA
Medical Center. The affiliation arrangement results in improved faculty
recruitment, improved research opportunities and infrastructure, and as
mentioned previously, improved retention of excellent physicians and
scarce specialists.
In addition, and historically, the VA has focused efforts on
training future physician researchers, and in this regard serves its
clinical, research and education missions simultaneously. The VA
research program offers a strong attractant for recruitment of young
physician researchers. The VA's research career development program
provides excellent and stable support for new physician researchers
during the most vulnerable period of their careers, the initial startup
phase. In the mean time, these VA Research Career Development awards
winners provide superb medical care to veterans, and often bring the
interest and expertise of their Academic/University mentors to an
engagement with other VA programs.
Given such a superb track record of achievement, and with all the
opportunities created by the affiliation between VA and the Academic
Health Centers, the current Administration budget recommendation is
especially disappointing in that it would result in an actual reduction
of $13 million in the VA research appropriation, from the current level
of $412 million to $399 million. This will have a deleterious effect
for VA supported physician researchers and a loss of many new
initiatives. And this deleterious funding climate will also do harm to
the VA/Academic affiliations, as opportunities will be reduced for
both! While the research infrastructure in Charleston, which culminates
in an excellent partnership between a state supported institution and a
Federal entity, is adequate now, such is not the case nationally. Much
like the VA's hospital facilities are aging and deteriorating, the same
applies for its research infrastructure. Furthermore, the difficulties
with the VA research infrastructure extend beyond buildings,
laboratories, and the customary bricks and mortar. VA needs resources
to update expensive research equipment. The VA also is suffering from a
lack of non-facility infrastructure. VA is having increasing difficulty
supporting its network of clinical trials centers, and may also have
difficulty supporting its outstanding centers in Outcomes (or Health
Services) and Rehabilitation Research. With a decrementing budget, the
VA will have difficulty sustaining its excellence in translational
research, which focuses on the transfer of research knowledge into
clinical practice to improve patient care. The current research budget
does not permit even secure support of ongoing studies. If the budget
for research decreases, the competition for grants will escalate, so
meritorious proposals will not be funded, and the newest physician
researchers will be especially disadvantaged and could be lost from the
research pool permanently. The research training that is so critical to
the VA and the academic community would also be diminished as VA loses
research resources--VA would lose the ability to fund research career
development awards.
The VA is an attractive partner with the academic community because
the missions of patient care, medical research and medical education
are shared and mutually supported. If VA must choose to retreat from
its commitment to excellence in research, decrement its training
opportunities, or continue to have its infrastructure deteriorate it
will become more problematic to achieve future success together. If VA
investment in these critical missions is diminished, another casualty
of that diminution in research resources will be the highly successful
Academic and VA affiliation.
Other groups such as the Friends of VA Medical Care and Health
Research (FOVA) have made recommendations for both research funding and
for separate funding for the VA research infrastructure. In the context
of the overall budget for the Department of Veterans Affairs,
additional funding for research seems like a necessary and valid
additional investment given the tremendous downstream returns, and
given VA's important role as a partner with Academic Medical Centers.
Mr. Chairman, with regard to this Committee's responsibilities, I was
gratified to note in your Majority Views and Estimates report to the
Budget Committee earlier this year that you recommended VA research be
augmented for fiscal year 2007 by an additional $30 million, bringing
its total to $429 million. Senator Akaka made a similar recommendation.
This bipartisan support by the Veterans' Affairs Committee for VA
research is deeply appreciated by those of us who are engaged in these
pursuits. I hope I can speak for the entire Academic/VA research
community in thanking you and urging you to persuade Senate and House
Appropriators to follow your lead.
Mr. Chairman, at some point, someone has to decide to make an
investment in the VA's future by repairing VA's deteriorating research
infrastructure. VA, in conjunction with its Academic partners, operates
dozens of substantial research laboratories. It saddens me to say that
most of them need major renovations and some need complete replacement.
But year in, year out these laboratories' needs do not draw any
significant funds from VA's major or minor construction accounts. Those
accounts are exclusively reserved for VA patient care and other
projects. To complicate matters further, since 1989 NIH has refused to
fund any facility-related costs in its VA-based grants. Some of the
VA's research and education foundations have supported the VA research
laboratories, but frankly, with very few exceptions, they do not have
the depth of funding resources to continue doing this in general.
Please remember that an investment in VA's research program, whether in
direct funding or infrastructure improvement, counts twice, in a way,
as it both strengthens VA research and also enhances the half-century
of excellent affiliation and partnership between the VA and some of the
country's finest academic institutions. While the dollars are
difficult, I am sure, and recognizing there are many competing needs,
this one is an especially good investment that the Congress can make in
support of veterans' health for today, and into the future.
Thank you, Mr. Chairman. I would be pleased to answer any questions
you or other Committee Members wish to ask.
______
Responses to Written Questions Submitted by Hon. Larry E. Craig
to John R. Feussner, M.D. M.P.H.
Question. ``As past director of the national VA research program,
what were the unmet needs in VA's laboratories, how did you try to
address them, and what is your assessment of those needs today? Do you
have any recommendations for the Committee in dealing with those
needs?''
Answer. The intramural research program in the Department of
Veterans Affairs is conducted in laboratories in VA Medical Centers
nationwide. These laboratories must be equipped and maintained to meet
standards for physical and operational infrastructure in order to
ensure the efficient operation of laboratories and animal facilities,
and to maximize the protection of personnel, experimental animals, the
public and the environment. Many VA Medical Centers do not provide
sufficient or appropriate space to investigators because of either a
shortage of laboratory space or deficiencies in the quality of space.
There is a serious risk that an aging and inadequately maintained
research infrastructure will become an impediment to recruitment of the
``best and brightest'' clinician scientists to VA facilities.
In 2001-2002 the VA research program compiled a list of thirty (30)
priority sites requiring research infrastructure improvements. These
needed improvements ranged from minor construction or renovation of
``wet'' laboratories, construction of new research structures and other
capital improvements. The list of thirty sites is contained in an
official VA report filed in the Office of Research and Development. An
important observation of this process was that research space in the
majority of the minority sites could be adequately renovated as ``minor
renovation,'' or for approximately $4 million/site. The VA's medical
research appropriation cannot be expended for capital improvements,
therefore available support from the research office alone has been
limited. VA has no other designated funding stream for improving,
renovating, or updating research facilities.
In addition to these construction costs, the second unmet need that
VA research has is a sustainable source of funding for equipment
purchases or modernization. Again, any funding for research equipment,
especially expensive, technologically sophisticated equipment must come
from the same funds that support individual research grants.
As there is no current mechanism for supporting research
infrastructure needs, I was unable to address the issue of remodeling
wet lab facilities or building new facilities. In the summer of 2001,
we initiated discussions with the House Veterans Affairs Committee and
had reached a mutual agreement that the only strategy for improving VA
research infrastructure, and addressing this problem systematically
through time, was to create a new line appropriation for research
construction similar to the line for construction of medical care
facilities in the medical care appropriation. The chairman of the House
Committee at the time was Congressman Christopher Smith, but our plans
and recommendations were hi-jacked by events occurring on September 11,
2001.
Fundamentally, the VA study that was done and discussed with the
House Veterans Affairs Committee was comprehensive and robust. This was
done with the intention that Congress might to address these serious
shortcomings on an incremental basis over a multi-year period. Our
initial request in 2001 was for approximately $40-45 million/year as a
new line item appropriation. As I reported in my congressional
testimony, ``at some point in time somebody has to make a decision to
make an investment in the VA's future by repairing the VA's
deteriorating research infrastructure.'' Given that this matter has
garnered little attention over the past 5 years, I am sure that the
situation has deteriorated further.
I do have several recommendations for the Committee in dealing with
these needs. First, the Committee could charge the Office of Research
and Development in VA to update the previous VA research report
cataloging the unmet needs for research construction and facilities
modernization. I would estimate that such an activity should take no
more than 90 to 120 days. The Committee could compare the original
report and the new report, where VA would again prioritize its
facilities needs in terms of minor construction or new facility
construction. I would estimate that if the Congress would create a new
line item for VA research facilities construction of approximately $40-
50 million per year, VA would be able to refurbish and upgrade its
thirty (30) most pressing infrastructure problems in as little as 2
years.
In addition, the Committee could direct that any construction funds
not allocated for renovation and remodeling of existing facilities
should be applied to modernization with replacement of state-of-the-art
research equipment.
Finally research facility construction is a separate and serious
challenge. And as you recall, the joint facility built in Charleston in
1996 cost $31 million a decade ago. Individual research buildings
constructed in multiple locations would probably cost upwards of $50
million per building with 2006 dollars. I would recommend that if the
Congress wishes to fund selected new construction, that the VA could
request matching monies in a joint venture effort with the affiliated
research universities. Several areas in need of serious research
construction in 2002 were the Pittsburgh VA (affiliated with the
University of Pittsburgh); the Los Angeles VA (affiliated with UCLA);
the VA Puget Sound (affiliated with the University of Washington); the
Philadelphia VA (affiliated with the University of Pennsylvania); the
Iowa City VA (affiliated with the University of Iowa) and the Nashville
VA (affiliated with Vanderbilt University) as several examples. New
construction is fundamentally more expensive and challenging than
renovations, and I would recommend the renovations proceed first.
As you already know Mr. Chairman, the VA research is superb in its
own right. The affiliation between Department of Veterans Affairs and
research universities benefits VA in ways that are numerous and
recognizable to VA leadership. As the VA's research infrastructure
continues to deteriorate, the VA will become a less viable and less
attractive site for new physician specialists who wish to develop a
research career. Any progress that this Committee can make in this
critically important area of medical care and biomedical research will
greatly benefit current and future generations of veterans. Given the
stellar performance of VA research in the past, this investment will
inevitably return superior dividends to all Americans. Mr. Chairman, I
can not thank you enough for your persistent interest in this important
issue and your unflagging support for veterans' needs.
Chairman Craig. Doctor, thank you very much.
Now we turn to Dr. John Kennedy. Welcome.
STATEMENT OF JOHN I. KENNEDY, JR., M.D., PROFESSOR,
DEPARTMENT OF MEDICINE, UNIVERSITY OF ALABAMA AT BIRMINGHAM,
BIRMINGHAM VA MEDICAL CENTER,
BIRMINGHAM, ALABAMA; ON BEHALF OF THE ALLIANCE FOR ACADEMIC
INTERNAL MEDICINE
Dr. Kennedy. Good morning, Mr. Chairman and Senator Akaka.
I am honored to be here today. As you know, I am a professor of
medicine at the University of Alabama at Birmingham. I am proud
to tell you that I spend the majority of my professional time
at the Birmingham VA where I hold the positions of Associate
Chief of Staff for Acute and Subspecialty Care and Chief of the
Medical Service there. I am also a funded investigator, and I
take care of patients. I am testifying today, however, on
behalf of the Alliance for Academic Internal Medicine, so I
want to thank you again for providing me the opportunity to
testify about VA research.
I am here today to tell you that the VA research program
works, but as you know, it also faces important challenges. My
examples of its success will come from my local experience in
Birmingham, but the Nation is replete with similar stories.
We have many successful research programs in our center. I
want to highlight two of the large multi-investigator programs.
The first is VA's Birmingham Atlanta Geriatrics Research unit,
or GRECC. In their research, 22 GRECC investigators focus on
genitourinary disorders, mobility in older patients, and
palliative care. Work of these GRECC investigators has led to
the development of a new palliative care program with an
inpatient unit in Birmingham where veterans nearing the end of
life receive compassionate care from specially trained,
multidisciplinary teams. The VA's research support of the GRECC
has also leveraged funds from other sources. In fiscal year
2005, two-thirds of the GRECC's total research funding came
from sources outside of VA. However, without the VA's initial
investment in the GRECC, none of this would have materialized.
The Deep South Center on Effectiveness at the Birmingham VA
is another excellent example of VA's research successes. This
center's mission is to improve health care for veterans and the
Nation through partnerships in effectiveness research. Some
highlights of this center's success include a joint effort with
UAB to develop programs to educate providers about
bioterrorism; examining new approaches for the treatment of
PTSD, as you know an important concern both for current and
newly returning veterans; and innovative uses of the electronic
health record combined with Internet to support providers in
community-based outpatient clinics as they care for patients
after heart attacks.
Now, despite these successes of the VA research program,
AAIM has concerns for its future. The lack of growth in program
funding, as you have heard, is particularly troubling to us
all. A flat budget sends messages to young clinician-scientists
that hard times are ahead and that research may not be the
career for them. Over the past 4 years, a time of level funding
in our center, the number of funded investigators has decreased
by 30 percent and the entry of new investigators has dropped
dramatically. Senior researchers with a history of sustained
funding have found it increasingly difficult to obtain
continued funding in VA. Gaps in support lead to losses of
technicians and other key personnel and seriously erode the
momentum of the research effort. Faced with these ongoing
problems, some physicians from our center have left VA. As a
result, our ability to recruit and retain the highly skilled
specialists needed to care for our complex patient population
is seriously compromised.
AAIM thanks the Committee and its leadership for its
ongoing support of the research programs. As a member of FOVA,
AAIM supports the $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 the overall Federal support for
research in the coming year, despite your best efforts.
AAIM's second specific concern is VA's research
infrastructure. As you have heard, modern scientists need
modern facilities in which to conduct their research. I have
heard countless stories from all across the country about
difficulties in upgrading ventilation and electrical systems.
These basic needs are absolutely critical. More investment in
core facilities to house essential research tools 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 I have
reported to you inherently result from the intramural structure
of the research program, which assures that these investigators
are also available as clinicians and educators. The other
inherent element of the program is peer review, the process
through which the very best research can be identified and
priorities for funding can be determined. AAIM encourages this
Committee to lead efforts to retain these valuable aspects of
the program and to 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.
[The prepared statement of Dr. Kennedy follows:]
Prepared Statement of John I. Kennedy, Jr., M.D., Professor, Department
of Medicine, University of Alabama at Birmingham, Birmingham VA Medical
Center, Birmingham, Alabama; on Behalf of the Alliance for Academic
Internal Medicine
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 employees 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 fiscal year 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 data bases 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 data base, 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 4 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.
Chairman Craig. Dr. Kennedy, thank you very much, and to
all of our panelists, thank you.
Let me ask a question specific of you, Dr. Stevens, because
of the size of the facility in Boise compared with, I think,
your peers who are here and are dealing with probably
university settings and a larger type of research setting. And
then I want to ask a series of questions that I think all of
you might want to react to.
Dr. Stevens, I understand that you specialize in the area
of infectious diseases. Can you briefly describe the range of
research activities that are underway at your facility?
Dr. Stevens. Yes, sir. We have done basic science research
in gram-positive bacteria, such as Group A strep, Staph.
aureus, Clostridium perfringens, gas gangrene, and we have
investigated how these toxins really cause destruction of
limbs, and how they cause shock, in an effort to try to explain
why with battlefield injuries, for example, people lose arms
and legs in a matter of hours. And so we have defined the
important toxins for many of these organisms and have actually,
in collaboration with Porton Down in great Britain, developed a
vaccine to prevent gas gangrene, at least in animal models.
We also have done clinical studies with hepatitis C, and I
am happy to say that for genotype II and III, we have been able
to cure 95 percent of veterans that have hepatitis C that are
non-genotype I.
We have also done clinical studies with HIV, and we have
investigated mechanisms of actions of antibiotics and defined
some better ways to treat gram-positive infections that are
associated with toxins, like toxic shock syndrome.
Chairman Craig. What strategies have been effective in
maximizing the research funds for your relatively small-scale
type program?
Dr. Stevens. Well, I think collaborations. You know, we
don't have a critical mass of people there to collaborate with,
but we have been able to collaborate with people from all over
the world that have similar interests. So I think collaboration
is one. Partnerships with pharmaceutical companies in terms of
clinical trials as well as investigation-initiated research
projects are also important. We have worked with the various
universities that I mentioned to try to improve collaboration
and to try to develop joint graduate school programs. And I
think those are the things that are kind of in their infancy
but we are very excited about and moving forward and I think
trying to develop a critical mass there in Boise.
Chairman Craig. Gentlemen, to all of you, you bring with
you a wide range of perspectives from regionally diverse VAs,
major medical schools, and from academic clinical experiences.
If we are to move forward toward enhancing VA's university
collaboration in the area of research, your views would
certainly be welcome in all of these discussions.
Can any of you comment, or would you, on the degree of
opportunity you see in the joint operation of a VA university
research space? Do you foresee certain obstacles that the
Committee should be aware of in these kinds of relationships?
Dr. Feussner. Well, Senator, I would be happy to take that
question since we currently operate a joint research facility
between the VA and the medical university.
I think the obstacle, the operative obstacle is finding the
original startup capital to create the facilities. In our case,
it was a joint venture not between public and private partners
but between Government partners. The Federal Government
contributed dollars, the State of South Carolina contributed
dollars, and the medical university financed the rest.
We share 120,000 square feet of research space. The
investigators experience no barriers. The VA administrative
office is actually housed in the research building. If
anything, the sharing, in my opinion, facilitates
collaboration. It gets the researchers out of their silos and
gets them to collaborate with one another. In our case, two
major program project grants initially seeded by VA research
dollars, funded to our investigators, one in cardiovascular
disease, continuously funded now for almost 15 years, and
another one in diabetes, a program project funded by the NIH.
And both those major grants, the investigators for the most
part are both VA and university faculty.
So I think the real barrier, the operative barrier, is
getting the initial startup capital to make the investment
happen.
Dr. Wright. I could provide a slightly different
perspective on that in southern Connecticut. We are very
fortunate to be in a community with a large research-oriented
medical school. The challenge that we face is that our facility
is 4 miles away from Yale, and so it is difficult to co-occupy
a single facility. In the efforts that we have made in working
with the school we have found that the school, with its view on
its own concerns, is most interested in facilities that are
immediately on the campus.
As Dr. Kennedy said, that the VA-appropriated funds provide
the core support or the initiating support, is either in
projects or in capital funding, that then enable the VA to make
other funds materialize. In our experience, without adequate
appropriated funding support directed at the VA, the VA has
great difficulty in attracting the additional funds, which in
our case is two-thirds of our funding.
Chairman Craig. Dr. Kennedy.
Dr. Kennedy. Mr. Chairman, I would just agree with my
colleague Dr. Feussner that I think the major obstacle is the
capital to fund these buildings. But sort of going at a
different perspective from Dr. Wright, I think there is a
tremendous opportunity in those settings, as in Birmingham,
where the VA and the university are in very close proximity,
immediately adjacent to one another, and there are other such
arrangements where the proximity is not an issue, and these are
tremendous opportunities for joint efforts for space and other
activities.
So, again, on a positive note, seeking out opportunities, I
think this is one.
Chairman Craig. Thank you very much.
Senator Akaka.
Senator Akaka. Thank you very much, Mr. Chairman.
Dr. Stevens, you detailed the success researchers have in
areas such as cardiology, oncology, and infectious diseases.
However, these are programs that are facing the real funding
cuts. Is it not possible for VA researchers to work on service-
connected research and concurrently on diseases facing all
Americans?
Dr. Stevens. Well, thank you for that question, Senator
Akaka. I agree with you. I think that there are many priorities
for research within the veteran population, and I think that
there should be basic research and clinical research and
outcomes research in the areas of cardiovascular disease,
oncology, et cetera. Those things all affect veterans as well.
I don't think it should just be limited to war-type injuries,
although in my own case we have spent a lot of time trying to
solve some of the infectious disease problems from some of
those cases.
So I do not want to cutoff my nose to spite my face here,
but, on the other hand, I think that it should be a broad base.
Senator Akaka. You also mentioned in your testimony about
the growth of need for services in Idaho, and in 10 years you
went from 10,000 to almost double, which is 19,000, and also
the problem of recruiting for new positions because of this
kind of growth, which make it so important that we got some of
these shifts in emphasis.
Dr. Kennedy, your testimony discusses the fact that in some
cases, VA research is funded more from outside sources than
from Federal funding. For example, the GRECC, or Geriatrics
Research, Education Clinical Center, received a total of $35
million last year; only $9.9 million was from VA funds. Outside
funding then is vital in the program's success.
You have cited the lack of growth in program funding as a
concern. Can you, Dr. Kennedy, describe how continued lack of
funding will impact recruitment and retention of new clinician
scientists? And would more VA funding for programs such as
GRECC perhaps minimize attrition of researchers and continue to
encourage outside funding?
Dr. Kennedy. Thank you, Senator Akaka. That is a wonderful
question.
As you point out, this investment that you make in VA
research, as all the testimony has alluded to today, is a
tremendous bargain and the yield is phenomenal. So I do not
know any other investment where you get a two-for-one return on
investment in the short term. And this is in the grand scheme
of the Federal budget not a huge amount of money.
That said, I can tell you specific examples in Birmingham
where we have lost physicians. We were the only facility in our
network to employ a full-time neurosurgeon, who was a basic
science investigator, who lost funding and left VA. We have
senior faculty, as I have mentioned already, who have become
very discouraged. Some have gone through four cycles of repeat
submissions in order to gain continued funding after long
periods of successful funding. They have become very
discouraged, and some have left the VA, gone back solely into
the university. This is a major impact for me as the Chair of
Medicine trying to staff the wards and the clinics to provide
the specialists that we need there.
This research avenue is the critical one to help us recruit
such people. Even as the pay bill, we hope, brings the pay up
to competitive levels, that alone will not be sufficient, in my
opinion, to keep this steady supply of highly trained
specialists in VA.
Senator Akaka. Well, thank you, Mr. Chairman. If I may
proceed to another question?
Chairman Craig. Please.
Senator Akaka. Because of the shift of emphasis, I would
like to hear what your feelings about this. My question goes to
each of you. As experienced researchers, I do not have to tell
you about the value of maintaining a vital peer review process.
From my vantage point, we have seen an increase in earmarks in
the case of sending VA dollars outside of VA to other entities.
Now, my question to you is: Is the peer review process as vital
as we need it to be?
Dr. Stevens. Thank you, Senator Akaka. I would to take a
shot at that, if I may.
I think the peer review process is absolutely vital to a
healthy competitive research program, and I think the VA's
central office has just done a marvelous job in the peer review
program over the years. And I think it is impartial. I think it
gives money to the best grants, the best people. And I think
they do a wonderful job in that respect.
I think as you have pointed out, as you have both pointed
out, the research money that is allocated is, in my opinion,
inadequate and it has been inadequate for a long time. The peer
review process is excellent, but when the funding level gets
down, it is devastating. And it takes an awfully good
researcher to be able to compete with everyone else in the
world when the funding level is 10 percent or even 15 percent.
That is a destructive level. The funding level of grants'
approval rate has got to be higher than that.
You know, you would not want to just allow 20 percent to
the VAs throughout the Nation to have research programs. That
is what it boils down to.
So I think that the peer review process is excellent. It is
necessary. But, believe me, it weeds out very good people when
the funding level gets too low.
The other thing that is, I think, related to the question
of funding in the VA system is the amount of the award. And 10
or 15 years ago, I think the maximum was $150,000 per year for
a merit review. It is now $125,000 a year maximum. And so, you
know, within inflation and the cost of equipment and salaries,
that is not a lot of money. I mean, we are very grateful. We
are very grateful for it. But everything else in the world has
grown. The awards for a merit review have actually decreased in
total amount for those people that are successful. And I think
at a small VA like I am, I think this is devastating. But I
think it is equally devastating for large programs such as in
our VISN, the University of Oregon, Portland VA, the Seattle
VA. It is devastating for them as well.
Senator Akaka. Dr. Wright.
Dr. Wright. Senator, if I may, extend that briefly with our
experience: I have heard people compare the peer review system
to democracy. I think people have said about democracy that it
is painful and it can be messy and it is difficult. The peer
review system is like that also, but like democracy, we think
it is the best way to do it.
I can give an example from our recent experience this year.
When the funding level of available funds to divide up by peer
review is in this 10- to 15-percent range, that does not
necessarily mean that 85 or 90 percent of the applications are
not worthwhile. In fact, I was very disappointed this year when
one of our new potential recruits, a woman who I taught as a
medical student sometime ago, and who has now been through
residency and fellowship training and graduate training and is
ready to embark on her own research career did not receive VA
funding. My understanding is she came in about fifth out of 25
applicants in the last round and will have to reapply for
funding. So she will be treading water with us and trying to
conduct her research. She wants very much to stay at the VA and
be a clinician and an investigator.
Senator Akaka. Dr. Feussner.
Dr. Feussner. Yes, Senator. I do not think the power of
your question can be understated, and if we start by saying
what my colleagues have already said, that the start point is a
situation where research resources are precious and scarce, the
peer review process promotes very strong very rigorous science,
very rigorous research methods, and it provides an opportunity
for accountability of how the research dollars are spent.
You might say that bypassing that process in a period of
scarce resources cheats hard-working scientists who are
participating in the research process, who go through this
rigorous review with perhaps a front-end opportunity of being
succeeded one in five, or 20 percent. So I think activities
that bypass this process are--I should not say reprehensible,
but are unfortunate. And I would commend the VA. The VA has a
rigorous peer review process. It has for decades. It emulates
the peer review process of other major biomedical Federal
funders like the National Institutes of Health, to a degree the
NSF.
Senator Akaka. Dr. Kennedy.
Dr. Kennedy. I would just echo those comments from my
colleagues and point out that in this time of scarcity, any
constraint, any further constraint on funding does indeed
discourage particularly young investigators, and that
interrupts severely the pipeline as we send those people away
from VA and perhaps away from research careers altogether, then
we face a gap, a significant gap in time before replacements
will be available, people trained and able to begin to initiate
new research initiatives.
So that is a key element. This is really a vital
investment. This program cannot be sustained without steady and
predictable funding.
Senator Akaka. Thank you, Dr. Kennedy.
Thank you for the time, Mr. Chairman.
Chairman Craig. Well, gentlemen, we will end on that note.
I think that was an excellent wrap-up, Senator Akaka, that
question, and all of your responses to it. I think it
demonstrates obviously the value of the research dollar, and we
have certainly known over the years, as we brought money into
NIH and other areas and bumped those up, the level of research,
the types of research programs underway and the findings that
are now pouring out as it relates to human health and human
health-related problems. And certainly VA has played and will
continue to play a role in that, and I think that is why 62 of
us joined together to express our concern as to a bump-up in
these research dollars and at least sustaining a progressive
level of increase instead of cuts. It remains critical, and we
will continue to push to assure that happens.
So, gentlemen, again, thank you for coming. Thank you for
your time and your insight. As we continue to work on these
issues, we will be back to you to question you and to ask for
your advice as we move along.
Thank you very much. The Committee will stand adjourned.
[Whereupon, at 11:47 a.m., the Committee was adjourned.]
A P P E N D I X
----------
Department of Veterans Affairs' Medical and
Research Prosthetics Research Program.
Hon. Kay Bailey Hutchison, Chairman,
Hon. Dianne Feinstein, Ranking Member,
Subcommittee on Military Construction and Veterans
Affairs Committee on Appropriations,
U.S. Senate,
Washington, DC.
Dear Chairman Hutchison and Ranking Member Feinstein: We strongly
urge the Appropriations Subcommittee on Military Construction and
Veterans Affairs to demonstrate this Nation's commitment to its
veterans for the Department of Veterans Affairs' Medical and
Prosthetics Research program.
The Administration's proposed fiscal year 2007 budget for the
direct costs of VA research is $399 million, a $13 million cut from the
current year's level of $412 million. The proposed level of direct
funds does not keep pace with inflation and will compel VA to cut
numerous projects. Therefore, we support a fiscal year 2007 funding
level of $432 million, in order to cover inflation, sustain current VA
research and development commitments, and allow critical new research
initiatives to move forward.
If enacted, the proposed cuts to the VA research budget will result
in the loss of 96 research projects in valuable areas such as diabetes,
cancer, aging, heart disease, and 286 full-time. employees (FTE) are
projected to lose their jobs. Further, given that participation in VA's
top-notch research program is a major factor in recruiting physicians
to VA, the research program must be provided the necessary funds to
attract and retain quality clinical staff.
Another point to take into account is that the nature of modem
warfare and battlefield medicine has resulted in servicemembers coming
home with wounds that would have been fatal in previous wars. Many
wounded servicemen d women are in need of prosthetic limbs, extensive
physical therapy, or have endured traumatic brain injuries. With
thousands of military personnel engaged in service overseas, it is
vital that Congress invest in research that could have a direct impact
on their post-deployment quality of life.
VA research programs have been instrumental in developing
innovative and effective methods of treatment since World War II,
making landmark contributions to the welfare of veterans and the
entirety of the Nation. Past VA research projects have resulted in the
first successful liver transplant performed in the U.S., development of
the cardiac pacemaker, and pioneering the concepts that led to the CT
scan. VA research also has played a vital role in treating
tuberculosis, rehabilitating blind veterans, and more recently, in
launching the largest-ever clinical trial of psychotherapy to at PTSD.
For the last 60 years, VA research has been extremely competitive with
its private sector counterparts.
Today, VA's research program continues to remain appropriately
focused. In 2004, VA research took on leadership of a $60 million
nationwide study- funded by the Nation& Institute on Aging and other
partners--to identify brain changes linked with Alzheimer's disease. VA
research, in partnership with Brown University and MIT, established a
major center of excellence to develop state-of-the-art prosthetics for
veteran amputees. In June 2005, US. News & World Report called VA
hospital care ``the best around.'' The important role VA research
played in this transformation of the VA medical care system cannot go
overlooked; its innovations improved the overall quality and delivery
of VA health care for years to come.
Keeping this distinguished record of success in mind, we ask you to
further support VA research by ensuring that an appropriate level of
funding continues for this program. These funds must be at a level that
accounts for inflation, new and daunting challenges, and most
importantly, enables VA to remain attractive option to our best and
brightest in medicine. Adequately funding VA's Medical and Prosthetics
Research Program is vital to maintaining our commitment to veterans.
Signed by,
Senators Craig, Akaka, Salazar, Johnson, Rockefeller, Kennedy,
Burns, Jeffords, Specter, Leahy, Murray, Levin, Lautenburg, Baucus,
Bingaman, Obama, Ensign, Stabenow, Clinton, DeWine, Mikulski,
Allen, Conrad, Inouye, Dorgan, Bond, Boxer, Sarbanes, Pryor, Dodd,
Santorum, Kohl, Durbin, Snowe, Kerry, Isakson, Roberts, Coleman,
Nelson, Graham, Menendez, Lott, Hagel, Dayton, Biden Jr., Talent,
Cantwell, Landrieu, Schumer, Carper, Lieberman, Lincoln, Feingold,
Crapo, Thune, Wyden, Dole, Burr, Harkin, Reed, Murkowski, and
Nelson.
______
Prepared Statement of Friends of VA Medical Care and Health Research
The Friends of VA Medical Care and Health Research (FOVA) member
organizations thank both the House and Senate Committees on Veterans
Affairs for their views and estimates with regard to fiscal year 2007
funding for the VA Medical and Prosthetic Research program. Their
recommended increases, ranging from least $28 million up to $51.5
million over the Administration's budget request for the VA research
program, affirm their ongoing support for our Nation's veterans. We
also thank the many Senators that co-signed Chairman Larry Craig's and
Ranking Member Daniel Akaka's Dear Colleague letter to Senators Kay
Bailey Hutchison and Diane Feinstein, the Chair and Ranking Member of
the Military Construction and Veterans Affairs Appropriations
Subcommittee, urging an fiscal year 2007 appropriation of $432 million
for the VA Medical and Prosthetic Research program.
FOVA is a diverse coalition of 86 national academic, medical, and
scientific societies; voluntary health and patient advocacy groups; and
veterans service organizations, all committed to high quality health
care for veterans. We appreciate the opportunity to submit a statement
today regarding the role of the VA Medical Research and Prosthetics
Research program in attracting and retaining physicians, and we urge
your support for an fiscal year 2007 appropriation of $460 million so
that this success may continue.
the role of va research in the recruitment and retention of physicians
VA Medical Care
The mission of the Veterans Healthcare System is ``to serve the
needs of America's veterans by providing primary care, specialized
care, and related medical and social support services.'' The Veterans
Health Administration (VHA) operates one of the largest comprehensive,
integrated health care delivery systems in the United States. Organized
around 21 Veterans Integrated Service Networks (VISNs), VA's health
care system includes 154 medical centers and operates more than 1,300
sites of care, including 875 ambulatory care and community-based
outpatient clinics, 136 nursing homes, 43 residential rehabilitation
treatment programs, 206 Veterans Centers, and 88 comprehensive home-
care programs.
More than 5.3 million unique patients received care in VA health
care facilities in 2005. That same year, VA inpatient facilities
treated 587,000 patients and VA's outpatient clinics registered nearly
57.5 million visits. VHA has experienced unprecedented growth in the
medical system workload over the past few years. The number of patients
treated increased by 29 percent from 4.1 million in 2001. In fiscal
year 2007, VHA estimates it will care for almost 5.5 million veterans.
The VA health care system had 7.7 million veterans enrolled to
receive VA health care benefits as of October 2005. To help VA manage
health care services within budgetary constraints, enrolled veterans
are placed in priority groups or categories. Unfortunately, with
limited resources, VA has had to restrict the number of priority 8
veterans--higher-income veterans suffering from conditions not related
to their service--who can receive VA care.
Despite limiting access of enrolled veterans, a significant backlog
of delayed appointments has resulted from an inadequate supply of
clinical physicians. While the VHA has made commendable improvements in
quality and efficiency, the Independent Budget veterans service
organizations cite excessive waiting times and delays as the primary
problem in veterans' health care. Without increases in clinical staff,
veterans' demand for health care will continue to outpace the V's
ability to supply timely health-care services and will erode the world-
renowned quality of VA medical care.
Physician Shortage
The Council on Graduate Medical Education (COGME), a national
advisory body that makes policy recommendations regarding the adequacy
of the supply and distribution of physicians, predicts that if current
trends continue, demand for physicians will significantly outweigh
supply by 2020. With the VA already struggling to meet the needs of our
Nation's sick and disabled veterans, the looming physician shortage
poses a serious threat to VA's ability to competitively recruit and
retain the physicians who wi11 be critical to its future success.
VA Medical and Prosthetic Research Program
To accomplish its aforementioned mission, VHA acknowledges that it
needs to provide ``excellence in research,'' and must be an
organization characterized as an ``employer of choice.'' The VA Medical
and Prosthetic Research program is one of the Nation's premier research
endeavors and attracts high-caliber clinicians to deliver care and
conduct research in VA health care facilities. The VA research program
is exclusively intramural; that is, only VA employees holding at least
a five-eighths salaried appointment are eligible to receive VA awards.
Unlike other Federal research agencies, VA does not make grants to
colleges and universities, or to any other non-VA entity. As such, the
program offers a dedicated funding source to attract and retain high-
quality physicians and clinical investigators to the VA health care
system. This in turn ensures that our Nation's veterans receive state-
of-the-art health care.
VA currently supports 5,143 researchers, of which nearly 83 percent
are practicing physicians who provide direct patient care to veteran
patients. As a result, the VHA has a unique ability to translate
progress in medical science directly to improvements in clinical care.
Academic Affiliations
The affiliations between VA medical centers and the Nation's
medical schools have provided a critical link that brings expert
clinicians and researchers to the VA health system. As stated in
seminal VA Policy Memorandum No. 2 published in 1946, the affiliations
allow VA to provide veterans ``a much higher standard of medical care
than could be given [them] with a wholly full-time medical service.''
At present, 130 VA medical centers have such agreements with 107 of the
126 allopathic medical schools. This represents 84 percent of the 154
VA medical centers. These long standing affiliations with the academic
health care community are a major factor in ensuring quality care for
U.S. veterans and represent a model partnership between the Federal
Government and non Federal institutions.
Over six decades, these affiliations have proven to be mutually
beneficial by affording each party access to resources that would
otherwise be unavailable. It would be difficult for VA to deliver its
high quality patient care without the physician faculty and residents
that are available through these affiliations. In return, the medical
schools gain access to invaluable undergraduate and graduate medical
education opportunities through medical student rotations and residency
positions at the VA hospitals. Faculty with joint VA appointments are
afforded opportunities for research funding that are restricted to
individuals designated as VA employees.
These faculty physicians represent the full spectrum of generalists
and specialists required to provide high quality medical care to
veterans, and, importantly, they include accomplished sub-specialists
who would be very difficult and expensive, if not impossible, for the
VA to obtain regularly and dependably in the absence of the
affiliations. According to a 1996 VA OIG report, about 70 percent of VA
physicians hold joint medical school faculty positions. These jointly
appointed clinician-investigators are typically attracted to the
affiliated VA Medical Center both by the challenges of providing care
to the veteran population and by the opportunity to conduct disease-
related research under VA auspices.
fiscal year 2007 appropriations for the va medical and prosthetic
research
FOVA recommends an fiscal year 2007 direct research appropriation
of $460 million for VA medical and prosthetic research and development.
Investments in investigator-initiated research projects at VA have led
to an explosion of knowledge that is advancing the understanding of
disease and unlocking strategies for prevention, treatment, and cures.
The complexity of research, combined with biomedical research
inflation, has increased the cost of research. Biomedical research
inflation alone, estimated at 5.5 percent for fiscal year 2005 and
projected at 4.1 percent for fiscal year 2006, has reduced the
purchasing power of the VA Research appropriation by $22.7 million and
$16.5 million respectively for a total impact of $39.2 million over
just 2 years. In the absence of commensurate increases, VA is unable to
sustain important research on diabetes, hepatitis C, heart diseases,
stroke and substance abuse while also addressing emerging needs for
more research on post traumatic stress disorder and long-term treatment
and rehabilitation of veterans with polytraumatic blast injures.
Additional funding is needed to take advantage of burgeoning research
opportunities within the VA to improve quality of life for our veterans
and the Nation as a whole.
Administration's Budget Recommendation
The Administration's fiscal year 2007 budget request includes $399
million for the VA Medical and Prosthetic Research program, a $13
million (3.2 percent) reduction from the final fiscal year 2006
appropriation of $412 million. These VA research funds provide direct
support for research projects as well as the salaries of non-clinician
investigators.
FOVA members are deeply disappointed with the Administration's
budget request and note that if enacted, it will have significant
adverse consequences for the VA research program. In its budget
summary, the VA anticipates that this $13 million reduction will result
in the elimination of 82 investigator-initiated programs, 15 special
research initiatives, and 7 multi-site research projects. Furthermore,
the department would reduce the number of VA's direct research
employees by 286.
In fiscal year 2007, VA expects to increase funding for studies of
acute and traumatic injury as well as central nervous system injury and
related disorders. However, to fund these new studies with a shrinking
budget, VA projects cuts to research in aging, cancer, infectious
diseases, kidney diseases, diabetes, lung disorders, and heart
diseases, among others. In other words, VA is proposing to rob Peter to
pay Paul.
As in prior years, the Administration's fiscal year 2007 budget
includes projections for VA research spending from the VA medical
services appropriation. This ``medical care support'' is slated for a
$13 million increase, from $353 million in fiscal year 2006 to $366
million in fiscal year 2007. While this increase might seem to offset
the proposed cut to direct research funding, the medical care support
allocation does not directly support research projects. As the budget
submission indicates, this allocation funds ``facility costs of heat,
light, telephone, and other utilities associated with laboratory space;
the administrative cost of human resource support, fiscal service, and
supply service attributable to research; research's portion of a
medical center's hazardous waste disposal and nuclear medicine
licenses; and, most importantly, the time clinicians devote to their
research activities.''
The VA budget also includes non-VA funding sources among the lines
of support for VA research. The budget optimistically projects a $13.24
million increase (from $662 million in FY 2006 to $675 million in
fiscal year 2007) in other federally funded research conducted at VA,
funds that have primarily come from the National Institutes of Health
(NIH).
However, the Administration's fiscal year 2007 budget for the NIH
is flat, making it highly unlikely that VA will enjoy significant
growth in NIH-funded research grants.
Though the Administration's projections of private contributions
for VA research have been inflated in previous years, the VA budget
anticipates a reasonable $4 million increase for fiscal year 2007 (from
$204 million in fiscal year 2006 to $208 million in fiscal year 2007).
This funding comes from industry for support clinical trials as well as
foundations and other non-profit entities to support a variety of
research projects.
Programmatically, the VA research budget includes plans for two
special research projects to begin in fiscal year 2007. The first
project focuses on the special needs of service personnel returning
from Operation Iraqi Freedom and Operation Enduring Freedom. The
project envisions wide ranging research efforts, including post-
traumatic stress disorder and other mental health issues; amputation
and prosthetics research; and returning personnel reentry and
reintegration. A second special project would focus on genomic
medicine. The thrust of this project is to link veterans' genetic
information with the VA electronic health record. According to the
budget submission, ``The goal is to develop genetic assessments that
will potentially enable `mass customization' of medical treatment.''
These new projects necessitate additional funding over FY 2006 levels
plus an accommodation for biomedical research inflation if VA is to
continue pre-existing endeavors as well implementing these new
initiatives.
The coalition wholeheartedly supports the vision to expand the VA
research program to encompass the needs of service personnel returning
from current conflicts, whether they include polytrauma, massive burn
injury, or mental conditions. Such expansion of the program requires
new resources so VA's other research areas, which are equally important
to the care of large numbers of veterans, do not languish in the
meantime.
Earmarks and Designation of VA Research Funds
The members of FOVA oppose earmarking the VA research appropriation
because they jeopardize the strengths of the VA Research program. VA
has well-established and highly refined policies and procedures for
peer review and national management of the entire VA research
portfolio. Peer review of proposals ensures that VA's limited resources
support the most meritorious research. Additionally, centralized VA
administration provides coordination of VA's national research
priorities, aids in moving new discoveries into clinical practice, and
instills confidence in overall oversight of VA research, including
human subject protections, while preventing costly duplication of
effort and infrastructure.
VA research encompasses a wide range of types of research.
Designated amounts for specific areas of research compromise VA's
ability to fund ongoing programs in other areas and force VA to delay
or even cancel plans for new initiatives. While Congress certainly
should provide direction to assist VA in setting its research
priorities, earmarked funding exacerbates resource allocation problems.
FOVA urges Congress to preserve the integrity of the VA research
program as an intramural program firmly grounded in scientific peer
review. These are principles under which it has functioned so
successfully and with such positive benefits to veterans and the Nation
since its inception.
VA Research Infrastructure
State-of-the-art research requires state-of-the-art technology,
equipment, and facilities. Such an environment promotes excellence in
teaching and patient care as well as research. It also helps VA recruit
and retain the best and brightest clinician scientists. In recent
years, funding for the VA medical and prosthetics research program has
failed to provide the resources needed to maintain, upgrade, and
replace aging research facilities. Many VA facilities have run out of
adequate research space, and ventilation, electrical supply, and
plumbing appear frequently on lists of needed upgrades along with space
reconfiguration. Under the current system, research must compete with
other facility needs for basic infrastructure and physical plant
improvements which are funded through the minor construction
appropriation.
FOVA appreciates the attention the Appropriations Committee gave to
this problem in the House Report accompanying the fiscal year 2006
appropriations bill (P.L. 109-114), which expresses concern that
equipment and facilities to support the research program may be lacking
and that some mechanism is necessary to ensure the Department's
research facilities remain competitive. It noted that more resources
may be required to ensure that research facilities are properly
maintained to support the Department's research mission.
To ensure that funding is adequate to meet both immediate and long
term needs, FOVA recommends an annual appropriation of $45 million in
the minor construction budget dedicated to renovating existing research
facilities and additional major construction funding sufficient to
replace at least one outdated facility per year until the backlog is
addressed.
Again, FOVA appreciates the opportunity to present our views to the
Committee. While research challenges facing our Nation's veterans are
significant, if given the resources, we are confident the expertise and
commitment of the physician-scientists working in the VA system will
meet the challenge.
Administrators of Internal Medicine
Alliance for Academic Internal Medicine Alliance for Aging Research
American Academy of Child and Adolescent Psychiatry
American Academy of Neurology
American Academy of Orthopaedic Surgeons
American Association for the Study of Liver Diseases
American Association of Anatomists
American Association of Colleges of Nursing
American Association of Colleges of Osteopathic Medicine
American Association of Colleges of Pharmacy American
Association of Spinal Cord Injury Nurses
American Association of Spinal Cord Injury Psychologists and Social
Workers
American College of Chest Physicians
American College of Clinical Pharmacology
American College of Physicians
American College of Rheumatology
American Dental Education Association
American Federation for Medical Research
American Gastroenterological Association
American Geriatrics Society
American Heart Association
American Hospital Association
American Lung Association
American Military Retirees Association
American Occupational Therapy Association
American Optometric Association
American Osteopathic Association
American Paraplegia Society
American Physiological Society
American Podiatric Medical Association
American Psychiatric Association
American Psychological Association
American Society for Bone and Mineral Research
American Society for Pharmacology and Experimental Therapeutics
American Society of Hematology
American Society of Nephrology
American Thoracic Society
Association for Assessment and Accreditation of Laboratory Animal
Care
International
Association for Research in Vision and Ophthalmology
Association of Academic Health Centers
Association of American Medical Colleges
Association of Professors of Medicine
Association of Program Directors in Internal Medicine
Association of Schools and Colleges of Optometry
Association of Specialty Professors
Association of VA Chiefs of Medicine
Association of VA Nurse Anesthetists
Blinded Veterans Association
Blue Star Mothers of America
Clerkship Directors in Internal Medicine
Coalition for Heath Services Research
Digestive Disease National Coalition
Federation of American Societies for Experimental Biology
Gerontological Society of America
Gold Star Wives
Hepatitis Foundation International
International Foundation for Functional Gastroenterological
Disorders
Juvenile Diabetes Research Foundation International
Legion of Valor of the USA, Inc.
Medical Device Manufacturers Association
Medicine-Pediatrics Program Directors Association
Military Officers Association of America
National Alliance on Mental Illness
National Association for the Advancement of Orthotics and
Prosthetics
National Association for Uniformed Services
National Association of VA Dermatologists
National Association of VA Physicians and Dentists
National Association of Veterans' Research and Education
Foundations
National Mental Health Association
Nurses Organization of Veterans Affairs
Osteogenesis Imperfecta Foundation
Paralyzed Veterans of America
Paralyzed Veterans of America Spinal Cord Research Foundation
Partnership Foundation for Optometric Education
Society for Investigative Dermatology
Society for Neuroscience
Society for Women's Health Research
Society of General Internal Medicine
Spinal Cord Research Foundation
The Endocrine Society
United Spinal Association
Veterans Affairs Physician Assistant Association
Veterans of the Vietnam War and the Veterans Coalition
Vietnam Veterans of America