Commentary on the federal role in clinical prevention research

Effective clinical prevention practice is the objective of the long journey from laboratory and epidemiologic studies to clinical understanding, interventions, and prevention practice with individual patients. The ability to ask ever more fundamental questions about the molecular basis of disease, as is rapidly being developed by NIH's Human Genome Project, promises to make this journey even longer and more complicated, but eventually to make screening and intervention for preventable disease even more amenable to clinical intervention. As we expect in the future, much of what we currently do in clinical prevention practice had its genesis in earlier federal support for basic and clinical research. We comment on the content and major points of the papers on the federal role in prevention research. These papers, in addition to describing the past accomplishment, current state, and future opportunities for prevention research, raise questions about the ultimate application of the enormous and successful national investment in prevention research. A fault line exists among the increasing knowledge of prevention practice, the rapid changes in the way services are delivered, and demonstration of the effectiveness of prevention procedures applied for the good of the whole population. The federal agencies most concerned with the application of prevention knowledge are those most limited in their research budgets: the Agency for Health Care Policy and Research (AHCPR) and the Centers for Disease Control and Prevention (CDC). The National Institutes of Health (NIH), with the greatest research dollars for investment, also has the broadest mandate for investment in research. Meeting all the demands to fund high-quality research is challenging; however, NIH may have review procedures that disadvantage clinical researchers and, among these, applied prevention researchers. The restructuring of the health care system by managed care promises opportunity for more effectiveness research. However, the same competition that fosters the development of managed care may limit the extent of prevention experimentation and the dissemination of results. Current national concerns for the weakening of support for clinical research are in part due to the reduced availability of patient care revenue to support clinical research brought about by managed care. The academic and practice communities that share concern for prevention research should recognize the increasing gap between basic and applied prevention knowledge. Those committed to the clinical application of this knowledge should encourage increased federal research support to assure that what we think we know is indeed so, that what is efficacious is available to all in the society that so generously supports research.