As part of its objective to enhance anesthesia patient safety, the APSF has been providing funding for patient safety research since 1987. The grant program started at a time when funding for patient safety research was virtually non-existent. The objective of the grant program was (and still is) to stimulate studies leading to prevention of mortality and morbidity resulting from anesthesia mishaps. Priority is given to studies that address problems affecting relatively healthy patients or studies that are broadly applicable and promise improved methods of patient safety with a defined and direct path to implementation into clinical care. Priority is also given to studies investigating innovative methods of education and training to improve patient safety.
The APSF Scientific Evaluation Committee conducted a comprehensive evaluation of the APSF Grant Program. This evaluation included a survey of prior grant applicants plus a literature search and grant applicant survey to create a comprehensive list of publications stimulated by the APSF Grant Program.
Between 1987 and 2001, a total of 272 researchers applied for funding for 347 patient safety research projects through the APSF Grant Program. An average of 23 projects were reviewed by the APSF Scientific Evaluation Committee annually. APSF funding was restricted to 2-3 grants per year. Over the first 15 years of the APSF Grant Program, 48 projects received funding from the APSF, for a funding rate of approximately 1 in 7 applications. An anonymous survey was sent to all prior applicants who could be located (237). Responses were received from 95 prior applicants (40%), including 33 who received APSF funding (69% response rate), and 84 who did not receive funding (33% response rate).
Stimulating Patient Safety Research
The APSF is meeting its goal of stimulating anesthesia patient safety research. The APSF funded 48 patient safety projects. Nearly all funded studies were completed, with 88% resulting in publications. Two-thirds of grant recipients who responded to the survey indicated that they went on to conduct additional research along the same line of inquiry as their APSF grant. Half received additional funding, totaling over $11 million. There is also evidence that the APSF Grant Program may have stimulated research beyond the projects directly funded by APSF. Nearly half of survey respondents who did not receive APSF funding for their projects went on to complete their projects, with 31% indicating that the APSF application process helped them get started. Most of those applicants still actively conduct anesthesia research.
The survey showed a relatively good match between the stated APSF priority research areas, applications, and grant funding. Survey respondents were asked to classify their applications according to APSF research priority areas. The APSF priority research areas that were most commonly funded are illustrated in Figure 1 and include
- Identification of predictors of patients at increased risk for mishaps (40% of applications, 48% of funded studies)
- New clinical methods for prevention or early diagnosis of mishaps (28% of applications, 21% of funded studies)
- Evaluation of new or re-evaluation of old technologies for prevention and diagnosis of mishaps (28% of applications, 15% of funded studies)
- Development of innovative methods for study of low-frequency events (20% of applications, 30% of funded studies)
- Innovative methods of education and training in safety (11% of applications, 18% of funded studies).
Survey responses showed that applications and funded studies were not restricted to a focus on relatively healthy patients. Survey respondents reported that their applications and funded studies were nearly evenly split between a focus on relatively healthy patients (28% of applications; 30% of funded studies) and special patient populations such as pediatrics or the elderly (29% of applications; 30% of funded studies).
The APSF Grant Program lists a number of safety topics appropriate for APSF funding. Applicants classified their projects into multiple categories. The most common topics of projects are shown in Figure 2 and include
- Outcomes or incident measurement (38% of applications, 42% of funded studies)
- Monitoring, effectiveness, or injury prevention (36% of applications, 21% of funded studies)
- Risk assessment or risk factors (29% of applications, 39% of funded studies)
- Human factors or performance (27% of applications, 39% of funded studies)
- Prevention of a specific complication or injury (25% of applications, 30% of funded studies)
- Simulation or computer modeling (15% of applications, 30% of funded studies).
Most funded studies involved clinical trials, non-clinical research involving human subjects, database analysis or simulation, or computer modeling. Few applications or funded studies involved laboratory, bench science, or medical records review.
Improving Patient Safety
Grant recipients reported that the APSF Grant Program had a positive impact on patient safety in anesthesia and beyond. This impact consisted of direct improvements in anesthesia patient safety as well as enhancement of careers in patient safety research that would contribute toward additional patient safety improvements.
APSF grant funding was instrumental in development of successful careers in anesthesia patient safety research for APSF funded investigators as well as other research team members. Grant recipients commented that the APSF was the only funding source for patient safety research in the early years of the program. As one respondent aptly stated, “Without the APSF, I would never have been able to become a successful patient safety researcher since pre-IOM report there were really no other sources of funding for anesthesia patient safety research.” Many respondents commented on the importance of APSF funding as “seed money” that led to careers and additional funding for patient safety research. One respondent commented, “APSF funding created an active research team. One member has developed an innovative ICU ventilator. Another directs a simulation center. A third has developed a respiratory monitor for anesthesia. I have continued in anesthesia research for 15 years.” Another respondent commented that, “The APSF funding opened the doors for significant research support. Three PhD students on the project are now designing medical devices for the anesthesia industry. A fourth student is developing software for a hospital corporation.” Another respondent’s comments are representative of many others, “Impossible to have done this work without APSF funding . . . (it) made me a permanent patient safety researcher.”
Many projects funded through the APSF Grant Program led to direct improvements in anesthesia patient safety. The APSF Grant Program was instrumental in development of simulators for anesthesia, ACLS, critical care, hemodynamics, sedation, and bioterrorism management. Funding of APSF projects legitimized human factors research in clinical anesthesia, introduced human factors and crisis resource management (CRM) concepts and training in anesthesia and medicine, improved risk analysis methodology and the transfer of these methods to other fields such as trauma care and medical devices, and raised public policy issues regarding sleep and work schedules for residents. APSF funding has influenced device development including anesthesia workstations, ICU ventilators, respiratory monitors, and simulation devices, as well as contributing toward new ways of processing signals and displaying clinical data on monitors. APSF-funded researchers commented on other specific clinical safety contributions resulting from their APSF funded projects. These researchers reported that the APSF Grant Program:
- Was largely responsible for making perioperative normothermia a standard of care
- Raised awareness of postoperative cognitive deficit after non-cardiac surgery and in elderly patients
- Confirmed safety and cost-effectiveness of fast-track cardiac anesthesia
- Reduced concerns about pediatric URI history and risk of airway complications during and after general anesthesia
- Reduced concerns about the need for ambulatory patients to void before discharge
- Influenced ASA practice parameters and perioperative practices
- Raised awareness of the need to review anesthetic emergency protocols.
Publication and Dissemination of Anesthesia Patient Safety Research Results
Nearly all studies funded through the APSF Grant Program resulted in publication of their results. Only 2 studies funded prior to 1999 did not result in any publications. In addition to publication of APSF-funded project results, APSF funding contributed to additional publications beyond the initial project reporting. The 48 projects funded through the APSF Grant Program have resulted in publication of 214 publications that incorporate or discuss APSF-funded project results.
Criticisms of the APSF Grant Program
It is not surprising that few prior APSF Grant Program applicants who did not received APSF funding for their projects responded to the survey. Among the 84 responses were a number of comments indicating areas for improvement in the program. Most comments addressed feedback on applications. Other comments addressed clarity (or lack of clarity) regarding funding priorities and disagreement with APSF priorities or focus.
The most common criticisms of the program concerned feedback on unsuccessful applications. Of the 84 applicants not receiving APSF funding who responded to the survey, 9 received either no feedback on their applications or felt the feedback they did receive was not useful. Other respondents felt the APSF should clarify its research interests and perhaps broaden them. Some applicants felt misunderstood, including applicants who received funding for their projects from other sources.
The APSF Scientific Evaluation Committee has recently revised its grant guidelines to include more information on application scoring. An attempt has been made to improve the quality of feedback provided to unsuccessful applicants. These changes may address some of the criticisms expressed by survey respondents.
Over its first 15 years, the APSF Grant Program has stimulated anesthesia patient safety research directly through project funding and indirectly by stimulating careers in anesthesia patient safety research. Projects started with APSF funding have led to continued research in anesthesia patient safety by providing the necessary initial results as well as providing legitimacy to patient safety research. APSF-funded researchers can point out direct impacts on anesthesia patient safety as well as application to patient safety in general.
Dr. Posner is Vice-Chair of the APSF Scientific Evaluation Committee and is a Research Associate Professor in the Department of Anesthesiology at the University of Washington in Seattle.