Inequalities in the distribution of National Institutes of Health research project grant funding.

Previous reports have described worsening inequalities of National Institutes of Health (NIH) funding. We analyzed Research Project Grant data through the end of Fiscal Year 2020, confirming worsening inequalities beginning at the time of the NIH budget doubling (1998-2003), while finding that trends in recent years have reversed for both investigators and institutions, but only to a modest degree. We also find that career-stage trends have stabilized, with equivalent proportions of early-, mid-, and late-career investigators funded from 2017 to 2020. The fraction of women among funded PIs continues to increase, but they are still not at parity. Analyses of funding inequalities show that inequalities for investigators, and to a lesser degree for institutions, have consistently been greater within groups (i.e. within groups by career stage, gender, race, and degree) than between groups.

Transition to Independent Research Funding Among National Institutes of Health K Grant Awardees at Departments of Orthopaedic Surgery.

BACKGROUND: The National Institutes of Health (NIH) supports mentored research career development awards (K awards) to increase the pipeline of independently funded scientists. This study analyzed the portfolio of K grants that were awarded to orthopaedic surgery departments and characterized the factors that were associated with successful transition to independent NIH research funding, including R01 grants. METHODS: This was a retrospective cohort study of K-award recipients in orthopaedic surgery departments in the United States from 1996 to 2018. A query was performed on the NIH Research Portfolio Online Reporting Tools (RePORT) database for NIH grants that were awarded to departments of orthopaedic surgery, general surgery, otolaryngology, obstetrics and gynecology, ophthalmology, and urology. Rates of transition to independent research funding were compared by specialty for K grants that were awarded from 1996 to 2011. The percentage of faculty with mentored research career development awards and the return on investment (ROI) were calculated. An internet and Scopus (Elsevier) database search determined the investigator characteristics. The factors that were associated with successful transition to independent funding were determined via chi-square and unpaired t tests. RESULTS: Sixty K-award recipients were identified in orthopaedic surgery departments. Most were men (77%) and research scientists (53%). Fifty percent of the K-award recipients transitioned to independent research funding. Research scientists had the highest rate of transition to independent research funding (71%, p = 0.016) relative to clinicians (0%) and orthopaedic surgeons (40%). Higher levels of publication productivity were associated with successful transition to independent research funding. Similar rates of transition to independent research funding existed among surgical specialties (p = 0.107). Orthopaedic surgery had the lowest percentage of faculty with a K award (1.4%) but had the highest ROI (198%) of these awards. CONCLUSIONS: Orthopaedic surgery had similar rates of transition to independent research funding when compared with other surgical specialties but had a lower prevalence of K awards among faculty. Orthopaedic surgeon-scientists have lower rates of transition to independent research funding when compared with their research-scientist colleagues. These findings highlight a need for greater support to foster the pipeline of future NIH-funded orthopaedic investigators. CLINICAL RELEVANCE: As the largest support of biomedical research in the U.S., the NIH is an important stakeholder in orthopaedic innovations and discoveries. This study highlights barriers in the procurement of NIH funding across surgical specialties and affirms the need for greater resources toward supporting NIH funding in orthopaedic surgery.

Racial inequity in grant funding from the US National Institutes of Health.

Biomedical science and federal funding for scientific research are not immune to the systemic racism that pervades American society. A groundbreaking analysis of NIH grant success revealed in 2011 that grant applications submitted to the National Institutes of Health in the US by African-American or Black Principal Investigators (PIs) are less likely to be funded than applications submitted by white PIs, and efforts to narrow this funding gap have not been successful. A follow-up study in 2019 showed that this has not changed. Here, we review those original reports, as well as the response of the NIH to these issues, which we argue has been inadequate. We also make recommendations on how the NIH can address racial disparities in grant funding and call on scientists to advocate for equity in federal grant funding.

How to Support a Surgeon Scientist: Lessons from National Institutes of Health K-Award Recipients.

BACKGROUND: Success in academic surgery is challenging and research cannot survive without funding. NIH K-awards are designed to mentor junior investigators to achieve independence. As a result we aimed to study K awardees in departments of surgery and learn from their experience. MATERIAL AND METHODS: Utilizing the NIH RePORTer database and filtering by department of surgery, clinically active surgeons receiving a K-award between 2008 and 2018 were asked to complete an online survey. Qualitative data from two open-ended questions were coded independently using standard qualitative methods by three researchers. Using grounded theory, major themes emerged from the codes. RESULTS: Of the 144 academic surgeons identified, 89 (62%) completed the survey. The average age was 39 ± 3 when the K-award was granted. Most identified as white (69%). Men (70%) were more likely to be married (P = 0.02) and have children (P = 0.05). To identify intention to pursue R01 funding, surgeons having a K-award for 5 y or more were analyzed (n = 45). Most either intended to (11%) or had already applied (80%) of which 36% were successful. Men were more likely to apply (P = 0.05). Major themes to succeed include protected time, mentorship, and support from leadership. Common barriers to overcome include balancing time, pressures to be clinically productive, and funding. CONCLUSIONS: The demographics and career trajectory of NIH K-awarded surgeons is described. The lack of underrepresented minorities receiving grants is concerning. Most recipients required more than one application attempt and plan to or have applied for R01 funding. The major themes were very similar; a supportive environment and time available for research are the most crucial factors to succeed as an academic surgeon.

National Institutes of Health Support for Clinical Emergency Care Research, 2015 to 2018.

STUDY OBJECTIVE: I determine the most recent data on National Institutes of Health (NIH) support for clinical emergency care research. METHODS: A search of the NIH category of emergency care from 2015 to 2018 was conducted, using a clinical focus and excluding animal and bench research projects, as well as career development grants. RESULTS: During the study period, the number of new emergency care projects submitted to NIH increased from 373 in 2015 to 434 in 2018. A total of 403 new applications were funded for $161.9 million, with an overall success rate of 24%. The total amount of support for both new and existing projects during the 4-year study period was $263 million. The number of funded R01 grants increased from 17 in 2015 to 32 in 2018, with an overall success rate of 21%. There were fewer emergency care grant submissions than those for other similar-sized disciplines. CONCLUSION: During the 4-year study period, emergency care research increased, but the number of grant submissions remains low.

The rise to dominance of genetic model organisms and the decline of curiosity-driven organismal research.

Curiosity-driven, basic biological research "…performed without thought of practical ends…" establishes fundamental conceptual frameworks for future technological and medical breakthroughs. Traditionally, curiosity-driven research in biological sciences has utilized experimental organisms chosen for their tractability and suitability for studying the question of interest. This approach leverages the diversity of life to uncover working solutions (adaptations) to problems encountered by living things, and evolutionary context as to the extent to which these solutions may be generalized to other species. Despite the well-documented success of this approach, funding portfolios of United States granting agencies are increasingly filled with studies on a few species for which cutting-edge molecular tools are available (genetic model organisms). While this narrow focus may be justified for biomedically-focused funding bodies such as the National Institutes of Health, it is critical that robust federal support for curiosity-driven research using diverse experimental organisms be maintained by agencies such as the National Science Foundation. Using the disciplines of neurobiology and behavioral research as an example, this study finds that NSF grant awards have declined in association with a decrease in the proportion of grants funded for experimental, rather than genetic model organism research. The decline in use of experimental organisms in the literature mirrors but predates the shift grant funding. Today's dominance of genetic model organisms was thus initiated by researchers themselves and/or by publication peer review and editorial preferences, and was further reinforced by pressure from granting agencies, academic employers, and the scientific community.

Health Literacy Research Funded by the NIH for Disease Prevention.

BACKGROUND: Advancing health literacy is a fundamental step toward achieving population health. To that end, the National Institutes of Health (NIH) funded research to increase scientific understanding of how health literacy can reduce disparities and enhance the health of the United States. OBJECTIVE: This study identified and evaluated NIH-funded health literacy research focusing on disease prevention. METHODS: New R01, R03, and R21 research project grants awarded from fiscal year (FY) 2004 to FY 2017 studying health literacy and disease prevention were identified. Study characteristics, including the role of health literacy, how health literacy was measured, populations studied, and study design, were coded for each grant. Administrative grant data were obtained from the NIH's internal database. Research impact was assessed using the relative citation ratio (RCR). KEY RESULTS: There were 192 grants studying health literacy and disease prevention awarded by 18 NIH institutes and centers from FY 2004 to FY 2017, covering a wide variety of health conditions including cancer (26.0%), infectious diseases (13.5%), nutrition (8.3%), drug/alcohol use (7.8%), and cardiovascular disease (6.3%). Most grants studied the health literacy skills of patients (88%), with a few studies assessing the health literacy practices of health care providers (2.1%) or systems (1%). There was good representation of populations with traditionally low levels of health literacy, including Black/African American participants (30.2%), Hispanic/Latinx participants (28.6%), older adults (37%), and people with low income (20.8%). The scientific articles generated by these grants were more than twice (RCR = 2.18) as influential on the field as similar articles. CONCLUSIONS: The NIH provided support for a wide array of prevention-focused health literacy research. The value of this research is highlighted by the number of funding institutes and centers, the diversity of populations and health conditions studied, and the effect these grants had on the field. Future research should move beyond patient-level health literacy to health literacy practices of health care systems and providers. [HLRP: Health Literacy Research and Practice. 2020, 4(4):e212-e223.] PLAIN LANGUAGE SUMMARY: This study describes health literacy research funded by the National Institutes of Health that focused on disease prevention. These grants sought to prevent a variety of health conditions, but health literacy research over the past 14 years continued to concentrate on the capacity of patients despite increased attention on the health literacy practices of health care providers and systems.

Applying patient-reported outcome methodology to capture patient-reported health data: Report from an NIH Collaboratory roundtable.

Patient-reported health data provide information for pragmatic clinical trials that may not be readily available from electronic health records or administrative claims data. In this report, we present key considerations for collecting patient-reported health information in pragmatic clinical trials, which are informed by best practices from patient-reported outcome research. We focus on question design and administration via electronic data collection platforms with respect to 3 types of patient-reported health data: medication use, utilization of health care services, and comorbid conditions. We summarize key scientific literature on the accuracy of these patient-reported data compared with electronic health record data. We discuss question design in detail, specifically defining the concept to be measured, patient understanding of the concept, recall periods of the question, and patient willingness to report. In addition, we discuss approaches for question administration and data collection platforms, which are key aspects of successful patient-reported data collection.

The Changing Face of Academic Surgery: Overrepresentation of Women among Surgeon-Scientists with R01 Funding.

BACKGROUND: There has been a recent focus on sex-based disparities within the field of academic surgery. However, the proportion of female surgeons conducting NIH-funded research is unknown. STUDY DESIGN: The NIH RePORTER (Research Portfolio Online Reporting Tools Expenditures and Results) was queried for R01 grants from surgery departments for which the principal investigator (PI) had a primary medical degree, as of October 2018. Characteristics of the PI and their respective grants were collected. Institutional faculty profiles were reviewed for PI and departmental characteristics. PIs were stratified by sex and compared using standard univariate statistics. RESULTS: There were a total of 212 R01 grants in surgery departments held by 159 PIs. Of these, 26.4% (n = 42) of R01-funded surgeons were female compared with the reported 19% of academic surgery female faculty (as reported by the Association of American Medical Colleges; p = 0.02). Women with R01 grants were more likely to be first-time grant recipients with no concurrent or previous NIH funding (21.4% vs 8.6%; p = 0.03) and less likely to have a previous R01 or equivalent grant (54.8% vs 73.5%; p = 0.03). Women were more likely to be from departments with a female surgery chair (31.0% vs 13.7%; p = 0.01) or a department with > 30% female surgeons (35.0% vs 18.2%; p = 0.03). CONCLUSIONS: Although female surgeons remain a minority in academic surgery, they hold a greater than anticipated proportion of NIH funding, with a high number of first-time grants, forming a crucial component of the next generation of surgeon-scientists.

Sponsorship of oncology clinical trials in the United States according to age of eligibility.

BACKGROUND: The sponsorship mix of trials relevant to young people with cancer has not been reported. Understanding this sponsorship mix may have implications for policies and regulations related to pediatric cancer drug development. METHODS: We analyzed sponsorship of interventional trials first opened in the United States from 2007 to 2018 using the ClinicalTrials.gov registry. A total of 51 781 trials across non-oncology disciplines and 18 431 oncology trials were classified according to lower age of eligibility (≥18 years vs < 18 years). Studies were stratified according to sponsorship (industry vs non-industry). Trial characteristics were compared by sponsorship category. Trends in sponsorship were tracked over time. RESULTS: Within oncology trials for patients ≥ 18 years, sponsorship was 33% industry and 67% non-industry. Among oncology trials that included patients < 18 years, sponsorship was 16.6% industry and 83.4% non-industry (P < .001). 15.5% of industry-sponsored trials in non-oncology disciplines included patients < 18 years, whereas only 5.2% of industry-sponsored oncology trials were open to patients < 18 years (P < .001). Relative to trials with non-industry sponsors, there was a statistically significant increase in industry sponsorship of oncology trials that included patients < 18 years over time (P < .001). Trial characteristics differed significantly according to sponsor type regardless of age of eligibility. CONCLUSIONS: Interventional oncology trials that include patients < 18 years are less likely to be industry-sponsored compared to oncology trials exclusively in patients ≥ 18 years. Compared to other medical disciplines, a smaller proportion of industry-sponsored oncology trials included patients < 18 years. Trial sponsorship is associated with differential trial characteristics, such as trial duration and number of patients enrolled, regardless of age.

Gender disparities in academic vascular surgeons.

OBJECTIVE: Previous studies have identified significant gender discrepancies in grant funding, leadership positions, and publication impact in surgical subspecialties. We investigated whether these discrepancies were also present in academic vascular surgery. METHODS: Academic websites from institutions with vascular surgery training programs were queried to identify academic faculty, and leadership positions were noted. H-index, number of citations, and total number of publications were obtained from Scopus and PubMed. Grant funding amounts and awards data were obtained from the National Institutes of Health (NIH) and Society for Vascular Surgery websites. Industry funding amount was obtained from the Centers for Medicare and Medicaid Services website. Nonsurgical physicians and support staff were excluded from this analysis. RESULTS: We identified 177 female faculty (18.6%) and 774 male faculty (81.4%). A total of 41 (23.2%) female surgeons held leadership positions within their institutions compared with 254 (32.9%) male surgeons (P = .009). Female surgeons held the rank of assistant professor 50.3% of the time in contrast to 33.9% of men (P < .001). The rank of associate professor was held at similar rates, 25.4% vs 20.7% (P = .187), respectively. Fewer women than men held the full professor rank, 10.7% compared with 26.2% (P < .001). Similarly, women held leadership positions less often than men, including division chief (6.8% vs 13.7%; P < .012) and vice chair of surgery (0% vs 2.2%; P < .047), but held more positions as vice dean of surgery (0.6% vs 0%; P < .037) and chief executive officer (0.6% vs 0%; P < .037). Scientific contributions based on the number of each surgeon's publications were found to be statistically different between men and women. Women had an average of 42.3 publications compared with 64.8 for men (P < .001). Female vascular surgeons were cited an average of 655.2 times, less than half the average citations of their male counterparts with 1387 citations (P < .001). The average H-index was 9.5 for female vascular surgeons compared with 13.7 for male vascular surgeons (P < .001). Correcting for years since initial board certification, women had a higher H-index per year in practice (1.32 vs 1.02; P = .005). Female vascular surgeons were more likely to have received NIH grants than their male colleagues (9.6% vs 4.0%; P = .017). Although substantial, the average value of NIH grants awarded was not statistically significant between men and women, with men on average receiving $915,590.74 ($199,119.00-$2,910,600.00) and women receiving $707,205.35 ($61,612.00-$4,857,220.00; P = .416). There was no difference in the distribution of Society for Vascular Surgery seed grants to women and men since 2007. Industry payments made publicly available according to the Sunshine Act for the year 2018 were also compared, and female vascular surgeons received an average of $2155.28 compared with their male counterparts, who received almost four times as much at $8452.43 (P < .001). CONCLUSIONS: Although there is certainly improved representation of women in vascular surgery compared with several decades ago, a discrepancy still persists. Women tend to have more grants than men and receive less in industry payments, but they hold fewer leadership positions, do not publish as frequently, and are cited less than their male counterparts. Further investigation should be aimed at identifying the causes of gender disparity and systemic barriers to gender equity in academic vascular surgery.

Resource allocation for biomedical research: analysis of investments by major funders.

BACKGROUND: Data on grants for biomedical research by 10 major funders of health research were collected from the World RePORT platform to explore what is being funded, by whom and where. This analysis is part of the World Health Organization Global Observatory on Health Research and Development's work with the overall aim to enable evidence-informed deliberations and decisions on new investments in health research and development. The analysis expands on the interactive data visualisations of these data on the Observatory's website and describes the methods used to enable the categorisation of grants by health categories using automated data-mining techniques. METHODS: Grants data were extracted from the World RePORT platform for 2016, the most recent year with data from all funders. A data-mining algorithm was developed in Java to categorise grants by health category. The analysis explored the distribution of grants by funder, recipient country and organisation, type of grant, health category, average grant duration, and the nature of collaborations between recipients of direct grants and the institutions they collaborated with. RESULTS: Out of a total of 69,420 grants in 2016, the United States of America's National Institutes of Health funded the greatest number of grants (52,928; 76%) and had the longest average grant duration (6 years and 10 months). Grants for research constituted 70.4% (48,879) of all types of grants, followed by grants for training (13,008; 18.7%) and meetings (2907; 4.2%). Of grant recipients by income group, low-income countries received only 0.2% (165) of all grants. Almost three-quarters of all grants were for non-communicable diseases (72%; 40,035), followed by communicable, maternal, perinatal and nutritional conditions (20%; 11,123), and injuries (6%; 3056). Only 1.1% of grants were for neglected tropical diseases and 0.4% for priority diseases on the WHO list of highly infectious (R&D blueprint) pathogens. CONCLUSIONS: The findings highlight the importance of considering funding decisions by other actors in future health research and capacity-strengthening decisions. This will not only improve efficiency and equity in allocating scarce resources but will also allow informed investment decisions that aim to support research on public health needs and neglected areas.

Disparities in National Institute of Health trauma research funding: The search for sufficient funding opportunities.

To evaluate disparities in the National Institute of Health (NIH) trauma research funding.Traumatic injury has increased in both prevalence and cost over the last decade. In the event of a traumatic injury, patients in the United States (US) rely on the trauma system to provide high-quality care. The current trauma research funding is not commensurate with the extent of the burden of trauma on the US population.In this qualitative study, the National Institutes of Health's Estimates of Funding for Various Research, Condition, and Disease Categories (RCDC) data were reviewed. The burden of traumatic injury on the US and the NIH trauma research funding was examined and compared with other diseases.In 2018, the NIH funded an estimated $639 million to traumatic injury research projects, <2% of the NIH budget. Comparatively, the NIH funded an estimated $6.3 billion towards cancer research in 2018. Cancer research receives extensively more funding than trauma research despite that trauma accounts for 24.1% of all years of potential life lost (YPLL) before age 75 compared with 21.3% for cancer.In the event of traumatic injury, trauma systems in the US should be able to provide high-quality care to patients yet cannot do so without adequate research funding. The federal funding contributed towards trauma research deserves a re-evaluation.

Scope, Influence, and Interdisciplinary Collaboration: The Publication Portfolio of the NIH Clinical and Translational Science Awards (CTSA) Program From 2006 Through 2017.

The Clinical and Translational Science Awards (CTSA) program sponsors an array of innovative, collaborative research. This study uses complementary bibliometric approaches to assess the scope, influence, and interdisciplinary collaboration of publications supported by single CTSA hubs and those supported by multiple hubs. Authors identified articles acknowledging CTSA support and assessed the disciplinary scope of research areas represented in that publication portfolio, their citation influence, interdisciplinary overlap among research categories, and characteristics of publications supported by multihub collaborations. Since 2006, CTSA hubs supported 69,436 articles published in 4,927 journals and 189 research areas. The portfolio is well distributed across diverse research areas with above-average citation influence. Most supported publications involved clinical/health sciences, for example, neurology and pediatrics; life sciences, for example, neuroscience and immunology; or a combination of the two. Publications supported by multihub collaborations had distinct content emphasis, stronger citation influence, and greater interdisciplinary overlap. This study characterizes the CTSA consortium's contributions to clinical and translational science, identifies content areas of strength, and provides evidence for the success of multihub collaborations. These methods lay the foundation for future investigation of the best policies and priorities for fostering translational science and allow hubs to understand their progress benchmarked against the larger consortium.

NIH Funding Ranked "Per Capita": An Alternative Method for Assessing Research Productivity.

Ordinal rankings of schools of nursing by research funding in total dollars awarded by the National Institutes of Health (NIH) is a common metric for demonstrating research productivity; however, these data are not based on the number of doctorally prepared faculty eligible to apply for funding. Therefore, we examined an alternative method for measuring research productivity which accounts for size differences in schools: NIH funding ranked "per capita." We extracted data on total average funding and compared them with average funding secured per faculty member across top-ranked schools of nursing in the United States from 2013 to 2017. When examining data by number of doctorally prepared faculty, 4 of 12 (33%) schools that ranked lower in total average funding ranked higher in average funding per faculty member. School size is an important but neglected factor in current funding rankings; therefore, we encourage schools to use multiple approaches to track their research productivity.

Disproportionally low funding for trauma research by the National Institutes of Health: A call for a National Institute of Trauma.

BACKGROUND: Trauma is a major cause of death and disability in all ages. Previous reviews have suggested that National Institutes of Health (NIH) funding for trauma is not commensurate with its burden of disease, but a detailed analysis has been lacking. We postulated that NIH spending on trauma research was lower than previously thought and was distributed widely, preventing a comprehensive research strategy that could decrease trauma morbidity and mortality. METHODS: The NIH Research Portfolio Online Reporting Tool was initially screened using a search of over 20 terms including "trauma," "injury," "shock," "MVC," and excluding clearly unrelated conditions, for example, "cancer." The details of all grants that screened positive underwent manual review to identify true trauma-related grants. An expert panel was used to adjudicate any ambiguity. RESULTS: In FY2016, NIH awarded 50,137 grants, of which 6,401 (13%) were captured by our initial screen. Following review, 1,888 (28%) were identified as trauma-related; 3.7% of all NIH grants. These grants (US $720 million) represent only 2.9% of the NIH extramural budget. In addition, the grants were funded and administered by 24 of the institutes and centers across the NIH ranging from 0.01% (National Cancer Institute) to 11% (National Institute of Neurological Disorders and Stroke and National Institute of Arthritis and Musculoskeletal and Skin Diseases) of their extramural portfolios. CONCLUSION: Given the extreme burden of trauma-related disability and years of life lost, this review of extramural NIH funding definitively demonstrates that trauma is severely underfunded. The lack of a dedicated home for trauma research at NIH leads to a diffusion of grants across many institutes and makes it impossible to direct a focused and effective national research endeavor to improve outcomes. These data demonstrate the need for a National Institute of Trauma at the NIH to help set an agenda to reach the national goal of Zero Preventable Deaths.

Characteristics of Ophthalmology Trials Registered in ClinicalTrials.gov, 2007-2018.

PURPOSE: To perform a comprehensive analysis of characteristics of ophthalmology trials registered in ClinicalTrials.gov. DESIGN: Cross-sectional study. METHODS: All 4,203 ophthalmologic clinical trials registered on ClinicalTrials.gov between October 1, 2007, and April 30, 2018, were identified by using medical subject headings (MeSH). Disease condition terms were verified by manual review. Trial characteristics were assessed through frequency calculations. Hazard ratios and 95% confidence intervals were determined for characteristics associated with early discontinuation. RESULTS: The majority of trials were multiarmed (73.6%), single-site (69.4%), randomized (64.8%), and had <100 enrollees (66.3%). A total of 33% used a data-monitoring committee (DMC), and 50.6% incorporated blinding. Other groups (51.6%) were funded by industry, whereas 2.6% were funded by the US National Institutes of Health (NIH). NIH trials were significantly more likely to address oncologic (NIH = 15.5%, Other = 3%, Industry = 1.5%; P < 0.001) or pediatric disease (NIH = 20.9%, Other = 5.9%, Industry = 1.4%; P < 0.001). Industry-sponsored trials (69.6% of phase 3 trials) were significantly more likely to be randomized (Industry = 68.7%, NIH = 58.9%, Other = 60.8%; P < 0.001) and blinded (Industry = 57.2%, NIH = 42.7%, Other = 43.5%; P < 0.001). A total of 359 trials (8.5%) were discontinued early, and 530 trials (12.6%) had unknown status. Trials were less likely to be discontinued if funded by sources other than industry (hazard ratio [HR], 0.72; 95% confidence interval [CI], 0.55-0.95; P = 0.021) and/or had a DMC (HR, 0.71; 95% CI, 0.55-0.92; P = 0.010). CONCLUSIONS: Ophthalmology trials in the past decade reveal heterogeneity across study funding sources. NIH trials were more likely to support historically underfunded subspecialties, whereas Industry trials were more likely to face early discontinuation. These trends emphasize the importance of carefully monitored and methodologically sound trials with deliberate funding allocation.

Coauthor Country Affiliations in International Collaborative Research Funded by the US National Institutes of Health, 2009 to 2017.

Importance: The US National Institutes of Health (NIH) is the largest funder of biomedical and behavioral research in the world. International collaborative research-a subset of NIH's portfolio-is critical to furthering the agency's health research mission. Objective: To quantify the extent of the NIH's international collaborations and the relative importance of this research through the lens of publications. Design, Setting, and Participants: This cross-sectional study used bibliometric data from the Web of Science database to analyze trends in the growth of NIH-funded publications from January 1, 2009, to December 31, 2017, and examined their importance using national affiliations of all coauthors listed, h indices, and citation impact scores. All countries with coauthor affiliations in NIH-funded publications during the study period were included. Data were analyzed from October 22 through November 16, 2018. Exposures: Country affiliations of coauthors' institutions in NIH-funded publications indexed in the Web of Science database from 2009 to 2017. Main Outcomes and Measures: Trends in the number of NIH-supported publications with non-US coauthors during a 9-year period and their relative importance assessed by h index per country and category-normalized citation impact (CNCI) for groups of country affiliations in 2017. Results: From 2009 to 2017, the annual count of NIH-funded publications increased 46.2% from 67 041 to 98 002. This increase was driven in part by an increase in publications with a non-US author alone or as a collaborator with a US author compared with those exclusively with US authors, reflected by an increase in the percentage of publications with non-US coauthors from 28.3% to 34.8%. Moreover, in 2017, publications coauthored by US-affiliated and non-US-affiliated investigators had a higher mean CNCI (1.99) than those whose authors were only US affiliated (1.54) or non-US affiliated (1.35). China became the most frequent publishing partner, with 6982 coauthored publications and the greatest increase over time among non-US countries. Conclusions and Relevance: In a 9-year period when the NIH budget remained relatively unchanged, an increase in the number of publications occurred with a growing trend toward more international collaborations of authorship; these publications also had a higher CNCI than publications with only US or only non-US authors. The findings suggest that international collaboration is a vital and growing component of the NIH's research output and likely reflects increased globalization of biomedical research.