National Institutes of Health Funding for Obstructive Sleep Apnea

Abstract

Objective

To describe current levels and trends of funding for the National Institutes of Health (NIH) in obstructive sleep apnea (OSA) and to recognize the current status of otolaryngologists in OSA research.

Study Design

Scientometric analysis.

Methods

The NIH RePORTER database was queried for the search term “obstructive sleep apnea” for all available years. Sex, degree, academic department, NIH funding source, geography, funding totals and years, and h-index of principal investigators (PIs) were collected and summarized.

Results

A total of 397 projects spanning 1242 total funding years were funded. Of the 273 individual PIs, 33.3% (91/273) were female. Regarding credentials, 52.4% of PIs (143/273) were MD or MD/PhD, and 41.0% (112/273) were PhD alone. Academic departments of PIs were most often medicine (34.1%), pediatrics (12.1%), cell biology/physiology (10.6%), and psychiatry (7.7%). Seven otolaryngology faculty members had received NIH funding for OSA research (2.6% of total PIs) since 2000. They accounted for 8 grants (0.25% of total grants) and $7,235,729 (1.5% of total dollars) of research funding.

Conclusion

Despite studies showing increasing levels of OSA surgery being performed and major areas of research and clinical opportunity, otolaryngologists represent a small minority of OSA research funding. This information may help direct our specialty when setting priorities regarding research funding, as research into the basic science and clinical management of OSA represents a broad and interdisciplinary pursuit.

Keywords

obstructive sleep apnea OSA National Institutes of Health funding otolaryngology

Introduction

Obstructive sleep apnea (OSA) is a major public health burden, affecting nearly 20% of the US population.^1,2 The sequelae of OSA are well documented, including increased risk of cardiovascular disease,³ decreased productivity,^4,5 and diminished quality of life.⁶ While continuous positive airway pressure (CPAP) remains the gold standard for treatment, more than 50% of patients fail this treatment, which suggests surgery as a potential alternative.⁷ With broad training in both the medical and surgical treatment of the upper airway, otolaryngologists are in a unique position to care for OSA patients. This opportunity has led to an increased interest in sleep medicine within the otolaryngology community. In recent years, the American Board of Otolaryngology has formally implemented a sleep medicine curriculum and officially recognized sleep surgery fellowships, exemplifying the support of ear, nose, and throat physicians in the management of OSA.

This recognition has extended into research, and sections for “sleep medicine” now routinely appear in otolaryngology journals and at society meetings. Research by academic otolaryngologists has documented the rapid evolution of this subspecialty including new paradigms,^8,9 novel techniques,^10,11 and a significant increase in sleep surgery being performed nationwide.¹² The National Institutes of Health (NIH) is the world’s largest funding source for biomedical research,^13-15 and numerous studies demonstrate its impact of meaningful translational work.^16-18 At present, however, there are no studies examining NIH research funding of OSA.

Our main objective is to describe the overall landscape and trends of OSA research funding by the NIH. Sleep disorders represent a multidisciplinary field, and recognizing which specialties and principal investigators are involved provides useful insight for physicians and scientists. Funding trends help indicate future resource allocation for this important disease, which is especially useful as NIH funding becomes more scarce.¹⁹ Additionally, we will analyze the current status of otolaryngologists within this realm. Well-funded specialties are often in a position to guide policy and advocate for their preferred treatment modality.^20,21

Materials and Methods

This study received approval from the Northwestern University Institutional Review Board.

NIH Database Search

The authors used the NIH Research Portfolio Online Reporting Tools Expenditures and Results (NIH RePORTER) database²² for this project. The term “obstructive sleep apnea” was placed in the search query, limited to terms found in the project titles and/or abstracts, then searched for all years (1991 through present). Data collection was performed on February 1, 2015.

Projects with “obstructive sleep apnea” or “OSA” in their titles were automatically included. Those containing “obstructive sleep apnea” only in their abstract were evaluated to determine their relevance directly to OSA. Studies focusing on other sleep disorders and studies for which OSA was not the primary focus of the study design or outcomes, as judged by the reviewing author (C.G.), were not included. For example, a study of obesity and lifestyle changes with the following in its abstract would not be included: “Obesity has established mortality and disease consequences, including heart disease, diabetes, and obstructive sleep apnea.” Several projects studying “chronic intermittent hypoxia” mentioned its shared pathophysiology with OSA. These were included if they met the above-stated criteria or there was mention of how the study pertained to the cause or disease effects of OSA.

Funding Data

Funding totals were not consistently available for projects before 2000. Funding totals and averages were thus tabulated for projects from 2000 to 2014. To assess trends in research funding, the US Department of Labor Bureau of Labor Statistics Consumer Price Index Calculator was used to adjust funding values by fiscal year.

Principal Investigator Demographics

The names and institutions of individual principal investigators (PIs) are provided by the NIH RePORTER system. The authors conducted an Internet search on each PI to find online faculty profiles or department pages to establish gender, degree, and academic department/specialty. Geographic location of each PI was classified by subregion based on the US Census Bureau classification and was based on the PI’s institution at the time of initial grant funding.

Each PI’s scholarly impact, as measured by the h-index, was documented using the Scopus database. The h-index is an objective score indicating the frequency with which an author is cited in academic literature; this index has been shown in multiple studies to be significantly associated with academic production and promotion.^17,23,24

Statistical Analysis

SPSS version 21 (SPSS Inc, Chicago, Illinois) was used for summary data and statistical analysis. Given that data were nonnormally distributed, the Mann-Whitney U test was used to assess differences in funding years, amount of funding, and h-index between specialties, with threshold for significance set at P < .05. To assess for the existence of significant trends in total funding and otolaryngology-specific funding, the nonparametric Mann-Kendall test was used. The Mann-Kendall test was performed using R statistical software version 3.1.1.

Results

Our initial search yielded 1940 results. Each individual result corresponds to a single funding year of a project. We excluded 399 results from this initial search: 323 for having no primary focus or outcomes related to OSA, 47 for focusing on other sleep disorders, and 29 for focusing on chronic intermittent hypoxia without relating it to OSA. Thus, 1541 results met criteria and were included in the study. Of the total results, 272 were from years prior to 2000 and were excluded for not having funding totals. For 27 post-2000 results, no funding data were available: These were grants given by the Department of Veterans Affairs or the Agency for Healthcare Research & Quality, which do not publicly report their funding through NIH RePORTER.

A total of 397 unique projects met inclusion criteria spanning 1242 total funding years and attributable to 273 PIs. One-third of PIs were female (n = 91, 33.3%). Grants were similarly distributed between PhDs and MDs ( Figure 1A ), and the academic departments of PIs reflected the multidisciplinary treatment of OSA, with the majority of PIs in departments of medicine, pediatrics, or cell biology/physiology ( Figure 1B ). Most projects were in medicine and its subspecialties (n = 155, 39.0%), although basic science constituted a sizable portion ( Table 1 ). The Middle Atlantic, Midwest, and New England regions have been awarded the most OSA funding dollars over time ( Figure 2 ), and numerous NIH funding agencies and grants were used ( Tables 2 and 3 ). When examining total funding trends, we found that research funding for obstructive sleep apnea is on an upward trajectory that is statistically significant (P = .001) ( Figure 3A ).

Table 1.

Number of Different Projects Funded by Academic Department of Primary Investigator.^a

Department	No. of Projects (%)
Otolaryngology	8 (2.0)
Medicine	155 (39.0)
Pediatrics	52 (13.1)
Psychiatry	25 (6.3)
Dentistry	2 (0.5)
Radiology	3 (0.8)
Neurology	24 (6.0)
Engineering/public health	16 (4.0)
Physiology/cell biology	43 (10.8)
Other clinical	69 (17.4)

Of 397 total projects funded spanning a total of 1242 fiscal years (2000 to present).

Table 2.

National Institutes of Health (NIH) Agencies Providing Project Funding.^a

NIH Funding Agency	No. of Grants (%)
National Heart, Lung, and Blood Institute (NHLBI)	232 (58.4)
National Center for Research Resources (NCRR)	79 (19.9)
National Institute of Neurological Disorders and Stroke	15 (3.8)
National Institute of Child Health and Human Development	12 (3.0)
National Institute of Nursing Research	11 (2.8)
National Institute of Mental Health	8 (2.0)
National Institute on Aging	8 (2.0)
National Institute on Minority Health and Health Disparities	6 (1.5)
National Institute of Diabetes and Digestive and Kidney Diseases	5 (1.3)
National Institute for Occupational Safety and Health	5 (1.3)
National Institute of Dental and Craniofacial Research (NIDCR)	5 (1.3)
National Institute of Deafness and Other Communication Disorders (NIDCD)	3 (0.8)
Other	8 (2.0)

Includes 397 different funded projects.

Table 3.

Types of Grants Awarded for Obstructive Sleep Apnea Research Projects.^a

Grant	No. of Grants (%)
R01	151 (38.0)
M-01	66 (16.6)
R series (not R01)	64 (16.1)
P series	44 (11.1)
K series	37 (9.3)
U series	13 (3.3)
Other	22 (5.5)

Includes 397 different funded projects.

Otolaryngology departments earned 8 of the total grants (0.25% of total grants) totaling $7,235,729 (1.5% of total funding), by 7 PIs (2.6% of total PIs). Six of the 7 PIs were MDs or MD/PhDs. Only 1 female otolaryngologist has received NIH funding for the study of OSA. All the physician-scientists with faculty information available were specialty trained: 1 in sleep, 3 in pediatrics, and 1 in facial plastic surgery. One otolaryngologist no longer worked at an academic institution, and no subspecialty information could be found for him. A summary of the PIs in otolaryngology departments is presented in Table 4 . Unlike the general trend in total OSA funding, otolaryngology funding for sleep apnea research is declining, although this value was not significant (P = .345). No research funds have been awarded to otolaryngologists for the last 3 fiscal years ( Figure 3B ).

Table 4.

Otolaryngology Faculty Principal Investigators.

	Sex	Degree	Subspecialty	Years Funded	Funding Agency^a	No. of Grants	Total $
1	F	MD	Pediatric	1	NCRR	1	22,028
2	M	MD	Pediatric	1	NIDCR	1	46,947
3	M	MD/PhD	Unavailable	8	NIDCD	1	2,383,041
4	M	MD	Facial plastics	1	NCRR	1	10,418
5	M	MD	Pediatric	2	NCRR	1	973
6	M	MD	Sleep	10	NHLBI	2	3,759,225
7	M	PhD	Not available	7	NIDCD	1	1,013,097

Abbreviations: F, female; M, male; NCRR, National Center for Research Resources; NHLBI, National Heart, Lung, and Blood Institute; NICDC, National Institute of Deafness and Other Communication Disorders; NIDCR, National Institute of Dental and Craniofacial Research.

Comparison of different academic departments showed wide variation in funding statistics and scholarly impact. Otolaryngology was the second-lowest in terms of mean funding per PI at $1,033,676, ranking above Dentistry, which was the lowest at $429,564 per PI ( Figure 4 ). Medicine had the highest mean funding per PI at $2,476,837. Otolaryngology also ranked third-lowest in mean h-index per PI at 18.4, with Dentistry as the lowest at 15.5 and Psychiatry as the highest at 39.2 ( Figure 5 ). Otolaryngology had the lowest median years funded per PI and median funding of any department ( Table 5 ). Assessing scholarly impact by median h-index showed no significant difference between PIs in otolaryngology compared with any other department, except basic science (P = .026), as seen in Table 5 .

Table 5.

Funding Organized by Specialty of Principal Investigator (PI).^a

	Years Funded per PI		$ Thousands per PI (Funding Since 2000)		h-Index
Specialty	Median (Q1, Q3)^b	P Value^c	Median (Q1, Q3)^b	P Value^c	Median (Q1, Q3)^b	P Value^c
Otolaryngology	2 (1, 8)	—	46,947 (10,418, 2,383,041)	—	19 (13, 23)	—
Medicine	3 (2, 7)	.48	945,000 (380,854, 2,498,045)	.12	27 (15, 43.5)	.13
Pediatrics	4 (2, 7)	.51	629,607 (124,048, 2,498,045)	.44	19 (14, 30)	.66
Psychiatry	2 (1, 4)	.64	421,034 (96,733, 1,540,051)	.47	32 (18, 62)	.07
Dentistry	3 (2, 3)	.89	429,564 (398,750, 429,564)	.89	15.5 (13, 15.5)	.50
Radiology	3.5 (1, 3.5)	.67	1,334,475 (395,630, 1,334,475)	.67	28 (8, 28)	.89
Neurology	4 (2, 8)	.66	833,781 (52,754, 880,561)	.53	21 (6, 35)	.63
Engineering/public health	3.5 (2, 5)	.99	690,931 (259,562, 1,923,827)	.48	28 (19, 49)	.06
Physiology/cell biology	3 (2, 6)	.64	993,533 (291,389, 1,911,247)	.21	28 (23, 39)	.03
Other clinical	3 (1, 4)	.76	504,597 (179,700, 1,638,906)	.29	14 (7, 26)	.61

Bolded values indicate statistical significance at P < .05.

Q1, Q3, first and third quartile.

P values are derived from the Mann-Whitney U test to compare differences in otolaryngologists vs other specialists.

Discussion

Due to its vast negative health consequences and rising incidence, OSA has become an important target for intervention by otolaryngologists.¹² With increased clinical responsibility comes an obligation to examine the effectiveness of therapies, to create new treatments, and to help advance the field. The NIH remains the top funder of medical research in the world, but no previous studies have assessed the funding landscape in OSA or the role of otolaryngologists in OSA research.

The goal of this study was to describe present levels and trends of NIH funding for OSA research and to recognize the current status of otolaryngologists in such. Otolaryngologists account for approximately 1.1% of active physicians,²⁵ 4.9% of American Academy of Sleep Medicine members,²⁶ and 0.74% of total NIH funding.²⁷ These numbers help contextualize our study’s findings. Our results reflect a growing research field, in which PIs from diverse medical and scientific backgrounds receive funding at increasing levels. Nearly $500 million has been awarded to researchers of OSA since 2000. However, otolaryngologists receive a small proportion of that funding and are, overall, minimally involved in this growing arena. Only 7 principal investigators in otolaryngology departments have received NIH OSA funding this century, and they account for less than 2% of total research funding. Perhaps most concerning is the steady decline in funding over the past 7 years and nonexistent NIH research funding for otolaryngologists performing OSA research for the past 3 fiscal years. In terms of making an impact on OSA care, otolaryngology is falling drastically behind.

This comes at a time when there is a need for increased knowledge about sleep medicine and surgery from our field. An estimated one-third of all adults and children with sleep disorders first present to an otolaryngologist, often for OSA.²⁸ Recent studies indicate that record levels of sleep surgery procedures are being performed, often by inexperienced providers.¹² Surveys examining resident training have shown few dedicated sleep faculty, limited resident experience with multilevel surgery, and overall discomfort with interpretation of sleep studies.^1,29 This situation, combined with meager research efforts, means it is possible that otolaryngology will become a diminishing voice in future discussions of optimal treatment and policy choices regarding OSA.

Cultivating young, academic physicians eager to advance otolaryngology’s place in OSA management is key to altering these current research and educational shortcomings. Such efforts are actively underway. Academic meetings and journals now have dedicated “sleep medicine” sections to encourage research. Seven formally recognized sleep fellowships are available for graduating otolaryngology residents,³⁰ which should produce more dedicated sleep faculty members. The formation of subspecialty organizations, such as the International Surgical Sleep Society in 2006 and the American Academy of Otolaryngology–Head and Neck Surgery Sleep Disorders Committee, further legitimizes the field and supports scholarly production. All efforts that help otolaryngologists pursue NIH research grants for OSA are worthwhile. Our data on h-index between different specialties suggest that funded otolaryngologists can be academically productive at levels similar to their colleagues in other fields ( Figure 5 ).

The importance of otolaryngologists’ involvement in OSA research cannot be overstated. The results of our study confirm active involvement of multiple other specialties in this field: predominantly medicine, pediatrics, neurology, and psychiatry ( Figure 1B ). These nonsurgical specialists have little ability to examine the upper airway and no surgical training to modify it, but they are overseeing the study of its treatment and effects. Additionally, they are often the frontline physicians for OSA patients. History has shown examples of how competing medical specialties can drastically affect one’s scope of practice. For example, the involvement of allergists in immunotherapy has directly affected the market for those same services by otolaryngologists.²¹ It is estimated that fewer than 5 otolaryngologists have completed a sleep medicine fellowship since 2011, when fellowship became a requirement for otolaryngologists to have subspecialty certification in sleep. The number of new sleep medicine board-certified otolaryngologists per year has decreased precipitously in that time.³¹ As the only surgical field directly involved in OSA care, we must assume an active role in the study and treatment of this disease in order to best serve our patients and specialty.

The present study is subject to several limitations. First, various sources of research funding are available for physician-scientists to pursue that are not included in the NIH RePORTER system. The NIH is the largest supporter of biomedical science, and it was chosen to give the best representation among all specialties for OSA. The NIH RePORTER database itself is a limitation of this study: Funding totals were not available for funding issued prior to the year 2000, which limits the study period. Still, this gives a more than decade-long experience of totals and trends. Using only “obstructive sleep apnea” for our search is another limitation; other terms including “OSA” and “sleep apnea” were separately investigated and confirmed that our chosen search term captured the full scope of OSA NIH funding without being overly broad. Using the h-index as a measure of academic prowess is imperfect, although numerous citations support its correlation with academic advancement, scholarly impact, and extramural funding.^16,17,23,24

Our study is also limited by having only 7 PIs from otolaryngology departments with NIH research funding for OSA. Such a small number makes any characteristic-based conclusions impossible. It is also likely that otolaryngology faculty members are involved in NIH OSA projects in roles other than PI, which would not be captured in this study. However, the broad message remains clear: Otolaryngologists receive a very small and diminishing fraction of OSA research funding.

Conclusion

NIH research funding for OSA is a large and growing entity involving multiple disciplines. Of all fields, otolaryngology is especially well positioned to care for patients with OSA by having both medical and surgical modalities available for management. Unfortunately, otolaryngologists make up an exceedingly small proportion of the PIs and funding for OSA research. This information may help direct our specialty when setting priorities regarding research funding and support for young physicians and training awards. Further studies may help elucidate ways to alter this trend and support more NIH-funded ear, nose, and throat physicians in OSA research. We hope that this study will encourage physicians to conduct research within this realm and will prompt our specialty as a whole to recognize the importance of OSA research.

Author Contributions

Christopher J. Gouveia, study design, data acquisition, data analysis, drafting and editing of manuscript; Hannan A. Qureshi, data acquisition, data analysis, editing of manuscript; Robert C. Kern, study design, editing of manuscript; Stephanie Shintani Smith, study design, data analysis, editing of manuscript.

Disclosures

Competing interests: None.

Sponsorships: None.

Funding source: None.

Footnotes

Acknowledgements

We would like to thank Amy Yang, M.S., of the Northwestern University Biostatistics Collaboration Center for her assistance with statistical analysis.

No sponsorships or competing interests have been disclosed for this article.

References

Shen

Shimahara

Cheng

Capasso

. Sleep medicine clinical and surgical training during otolaryngology residency: a national survey of otolaryngology residency programs. Otolaryngol Head Neck Surg. 2009;145:1043-1048.

Young

Palta

Dempsey

Skatrud

Weber

Badr

. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med. 1993;328:1230-1235.

Partinen

. Epidemiology of obstructive sleep apnea syndrome. Curr Opin Pulm Med. 1995;1:482-487.

Mulgrew

Ryan

Fleetham

. The impact of obstructive sleep apnea and daytime sleepiness on work limitation. Sleep Med. 2007;9:42-53.

Omachi

Claman

Blanc

Eisner

. Obstructive sleep apnea: a risk factor for work disability. Sleep. 2009;32:791-798.

Mitchell

. Adenotonsillectomy for obstructive sleep apnea in children: outcome evaluated by pre- and postoperative polysomnography. Laryngoscope. 2007;117:1844-1854.

Gay

Weaver

Loube

. Evaluation of positive airway pressure treatment for sleep related breathing disorders in adults. Sleep. 2006;29:381-401.

Lin

Friedman

Chang

Gurpinar

. The efficacy of multilevel surgery of the upper airway in adults with obstructive sleep apnea/hypopnea syndrome. Laryngoscope. 2008;118:902-908.

Kezirian

. Nonresponders to pharyngeal surgery for obstructive sleep apnea: insights from drug-induced sleep endoscopy. Laryngoscope. 2011;121:1320-1326.

10.

Lee

Weinstein

O’Malley

Jr Thaler

. Transoral robot-assisted lingual tonsillectomy and uvulopalatopharyngoplasty for obstructive sleep apnea. Ann Otol Rhinol Laryngol. 2012;121:635-639.

11.

Schwartz

Bennett

Smith

. Therapeutic electrical stimulation of the hypoglossal nerve in obstructive sleep apnea. Arch Otolaryngol Head Neck Surg. 2001;127:1216-1223.

12.

Ishman

Ishii

Gourin

. Temporal trends in sleep apnea surgery: 1993-2010. Laryngoscope. 2014;124:1251-1258.

13.

Kotchen

Lindquist

Malik

Ehrenfeld

. NIH peer review of grant applications for clinical research. JAMA. 2004;291:836-843.

14.

Folbe

Svider

Setzen

Zuliani

Lin

Eloy

. Scientific inquiry into rhinosinusitis: who is receiving funding from the National Institutes of Health? Laryngoscope. 2014;124:1301-1307.

15.

Hojjat

Johnson

Svider

. Scholarly investigation into otitis media: who is receiving funding support from the National Institutes of Health? [published online February 13, 2015] Laryngoscope. doi:10.1002/lary.25118.

16.

Svider

Mauro

Sanghvi

Setzen

Baredes

Eloy

. Is NIH funding predictive of greater research productivity and impact among academic otolaryngologists? Laryngoscope. 2013;123:118-122.

17.

Svider

Husain

Folbe

Couldwell

Liu

Eloy

. Assessing National Institutes of Health funding and scholarly impact in neurological surgery. J Neurosurg. 2014;120:191-196.

18.

Colaco

Svider

Mauro

Eloy

Jackson-Rosario

. Is there a relationship between National Institutes of Health funding and research impact on academic urology? J Urol. 2013;190:999-1003.

19.

Garrison

Drehman

Campbell

. NIH research funding trends: FY 1995-2014. http://www.faseb.org/Policy-and-Government-Affairs/Data-Compilations/NIH-Research-Funding-Trends.aspx. Accessed February 8, 2015.

20.

Capasso

Kezirian

Jacobowitz

Weaver

. Management of obstructive sleep apnea in adults. Ann Intern Med. 2014;160:367.

21.

Davidson

. Sleep medicine for surgeons. Laryngoscope. 2008;118:915-931.

22.

NIH RePORTER database, version 7.2.0. 2015. http://projectreporter.nih.gov/reporter.cfm. Accessed February 1, 2015.

23.

Hirsch

. An index to quantify an individual’s scientific research output. Proc Natl Acad Sci U S A. 2005;102:16569-16572.

24.

Svider

Pashkova

Choudhry

. Comparison of scholarly impact among surgical specialties: an examination of 2429 academic surgeons. Laryngoscope. 2013;123:884-849.

25.

Association of American Medical Colleges Center for Workforce Studies: 2014 physician specialty data book. https://members.aamc.org/eweb/upload/14-086%20Specialty%20Databook%202014_711.pdf. Accessed April 25, 2015.

26.

American Academy of Sleep Medicine 2014 media guide. http://www.aasmnet.org/resources/pdf/mediaguide.pdf. Accessed April 25, 2015.

27.

Blue Ridge Institute for Medical Research. NIH research funding by department. http://www.brimr.org/NIH_Awards/2013/NIH_Awards_2013.htm. Accessed April 23, 2015.

28.

Yaremchuk

Wardrop

. Sleep Medicine. San Diego, CA: Plural Publishing; 2010.

29.

Sim

Stanley

. Trends in otolaryngology residency training in the surgical treatment of obstructive sleep apnea. Laryngoscope. 2014;124:579-582.

30.

Appold

. Sleep fellowship training programs on the rise. ENTtoday, March 2015. www.enttoday.org/article/sleep-fellowship-training-programs-on-the-rise/. Accessed May 1, 2015.

31.

Dedhia

Yaremchuk

. The uncertain fate of otolaryngology in sleep medicine. Otolaryngol Head Neck Surg. 2015;152:381-382.