A significant portion of research project costs is incurred before the receipt of grant funds. This poses a problem for the initiation of primary care research, especially in community practice settings. Potential investigators need financial support for staff time, training, pilot work, and grant proposal writing if primary care researchers are to compete successfully for grant funds. To find this support, we need to understand and eventually quantify the actual costs of research with attention to those that are incurred before the receipt of grant funds.
We outline 10 phases of the research process and provide a model for understanding where costs are incurred and by whom. Costs include those associated with maintaining practice interest in research, supporting practice participation, and disseminating research findings. They may be incurred by either an academic center or a research network, by the practices and physicians themselves, or by an extramural funding source.
The needed investment for initiating primary care research can be itemized and, with further research, quantified. This will enhance the arguments for capital investments in the primary care research enterprise.
The need for a strong research base for primary care has been generally acknowledged in the United States and elsewhere for nearly 30 years.1-5 Still, family physicians and other primary care physicians are not doing well in the competition for National Institutes of Health (NIH) funding6; this situation has changed little in more than a decade.7 Although it has been argued that the amount of NIH funding is proportional to the burden of disease,8 these analyses have not considered the potential impact of federal funding on disease burden if it were more available for research in different settings, such as those of community primary care. For example, the burden of liver disease may be reduced more by primary care research directed to helping physicians treat patients who drink too much9 than by research on liver transplantation.
A significant portion of research project costs is incurred before the receipt of grant funds. This poses a major problem for the development of a primary care research enterprise. Researchers, especially new ones, require financial support for investigator and staff time, training, pilot work, and grant proposal writing to compete successfully for grant funds. Although some institutional funding is available in academic medical centers to support the initiation of research, there is little or no comparable resource in community practices. These “laboratories” for most practice-based primary care research must find ways to integrate research activities with direct patient care needs, and a culture of support for inquiry needs to be developed and sustained along with a supporting infrastructure.
Start-up support is being reduced even within academic medical centers, and this support is especially critical for young faculty and for pilot work.10,11 The negative impact of this, while significant for all research,12 may be even more problematic for the nascent field of primary care research, which relies disproportionately on internal resources,13 and especially for practice-based research, since community physicians generally lack institutional resources. Furthermore, the critical importance of primary care clinical services to academic medical centers, with the resulting demands on faculty, can detract from allocation of time and money to research activities.14 To add to the problem of initiating research in primary care, there is evidence of a bias against patient-oriented research compared with that which is laboratory oriented, making obtaining grant funds for clinical researchers even more difficult and time consuming.15
Although the NIH has proposed solutions for increasing the number of physicians engaged in clinical research,16 the problem of developing researchers capable of maintaining research funding cycles in the primary care specialties has not been adequately addressed at the national level. Although concerned with clinical research, the NIH has not made primary care research a priority. Even programs that attempt to develop primary care researchers fail to take into account associated costs.17
In part, primary care’s disappointing research productivity has been due to a lack of the capital investment needed to develop robust research infrastructures (which include practice-based laboratories) and the limited availability of the financial and institutional support that investigators need to apply for project funding. This lack of an adequate infrastructure and sufficient funding to invest in the start-up process before the receipt of grant funding has proved to be a nearly insurmountable barrier to potential primary care investigators. It has been less a barrier to faculty in other disciplines in which long histories of grant-funded projects have enabled them to use resources from previously funded projects as the start-up capital for future ones. Although mechanisms are in place in some primary care departments for a capital investment of funds and for protected time and mentoring, these resources are generally limited and are threatened. A further problem exists in that even with start-up funding it may be difficult, if not impossible, to sustain a research program with a limited number of grant-funded projects running at any one time.18