patients is substantial. (These figures are for one diagnosisrelated group alone--CHF is also often the secondary or incidental diagnosis for hospital admissions.)

We believe additional SCORS are essential to realize a benefit to patients with heart failure and save health care resources. The new knowledge gained has the potential for substantially reducing mortality and improving the quality of patients' lives.

Sudden cardiac death claims more than 270,000 American lives per year and accounts for 50 percent of all deaths from heart disease. Like heart failure, little is known about the mechanisms which result in sudden death. While there has been great interest in the cardiac rhythm disturbances associated with sudden death, an exploration of a broader array of potential mechanisms to trigger sudden death is urgently needed. Also, great inroads have recently been made in the treatment of life threatening arrhythmias, but we are on the verge of therapeutic breakthroughs in this important area. The College believes the SCOR program represents an ideal approach to further this research.

RESEARCH PROJECT GRANTS

As the Subcommittee is well aware, the individual investigatorinitiated Research Project Grant (RPG) remains the cornerstone of the overall effort by the NIH to advance our knowledge of the cause and cure of disease and to develop our future researchers. Regrettably, the NHLBI continues to experience a dramatic reduction in its capacity to support new competing grants.

a

A recent "cost management plan" drafted at NIH recommends a reduction in the average duration of competing grants from the current 4.3 years to 4 years. The College is concerned such target average will result in the arbitrary removal of time from quality research projects simply because they exceed four years. Longer grants allow a more stable environment for researchers and save the additional administrative cost of frequent applications. Furthermore, the College believes the attractiveness of biomedical research as a career would be enhanced by supporting a longer duration of funding.

The Administration request increases the number of competing RPGs by 63 and provides for an additional $24 million. The College recommends that additional funds and special consideration be given to the RPGs in the allocation of overall NHLBI funding.

and

TRAINING PROGRAMS AND RESEARCH CAREER AWARDS Physician researchers contribute clinical relevance to research are therefore critically important to the success of transferring basic research to the patient's bedside. The President's proposed budget would provide $47.2 million for research training programs, a one percent increase from FY 1991 and continue the freeze on the number of trainees that has been imposed since FY 1987. This vital effort should receive, at a minimum, an increase to account for the cost of inflation in order to provide needed funding stability.

Furthermore, the budget recommends a drastic change in the ratio of predoctoral to postdoctoral trainees. Postdoctoral trainees are more expensive to support. Currently, about one-third of the competing trainees are predoctoral, while two-thirds are postdoctoral. The President's budget would reverse this ratio. The College is concerned about the effect this could have on existing postdoctoral trainees and questions whether a sufficient number of highly qualified candidates for predoctoral training exists.

Cardiovascular specialty training was recently increased from two to three years and the College has repeatedly emphasized the importance of a research component to this training. Postdoctoral funding is critical to ensure the maintenance of a core of clinical researchers who conduct, for example, outcomes and appropriateness research. These researchers, working to bring research results to the bedside, are a unique group, complementing the work of basic researchers. The ACC believes these research efforts are critical to establishing soundly based practice guidelines that will influence medical practice.

The College asks that instead of rearranging the percentages of pre- and postdoctoral trainees, that Congress increase the NIH training allocation to meet existing stipend requirements.

The Administration has also suggested that the budget for and number of Research Career Awards be maintained at FY91 levels. These measures, intending to save money, could jeopardize future

research manpower needs. The need for training and specialized research experience for our future investigators is often overlooked, yet may indeed be the most important facet of our biomedical research effort. Given the rapid pace of technological innovations in the area of cardiovascular science, we cannot afford to under-fund tomorrow's innovators.

ATHEROSCLEROSIS AND HYPERTENSION

The College supports the work in progress at the Institute concerning the future of research in the treatment of atherosclerosis and hypertension, with the expectation that mortality rates can subsequently be reduced. We applaud the initiation of a clinical trial of first-line drug therapy for hypertension. We believe, however, that further research is needed in the basic sciences of molecular biology and genetics to provide further insights to the mechanisms of cardiovascular disease. In addition, epidemiological studies and clinical trials are also important in these areas. A study of hormone replacement therapy in post-menopausal women and its effect on coronary heart disease, for example, is critically needed.

EDUCATIONAL PROGRAMS

Highly effective education programs have enabled the Institute to apply the results of research to visible improvements in public health through prevention. These public education efforts include the National High Blood Pressure Education Program, the National Cholesterol Education Program, and the Smoking Education Program, all of which have successfully helped millions modify unhealthy habits by training physicians and allied health professionals to serve as intervenors.

In addition, the College urges additional funding for the Institute's new national education program intended to reduce premature morbidity and mortality from heart attack--the National Heart Attack Alert Program. The program will educate patients concerning the first symptoms and signs of a heart attack, and subsequent intervention and treatment. This important program has great potential to save both lives and money.

OTHER SIGNIFICANT INITIATIVES

Among the other promising new cardiovascular research initiatives at the NHLBI are programs in bone marrow transplantation biology, and vascular biology and medicine. Both can lead to breakthroughs which have direct applications for the treatment of heart disease. The College supports the Institute's development of interdisciplinary programs to conduct further research in these

areas.

NATIONAL LIBRARY OF MEDICINE

The College would like to take this opportunity to voice continued strong support for the work of the National Library of Medicine. All who participate in our educational and research programs benefit directly from the outstanding resources of the Library.

SUMMARY AND CLOSING REMARKS

In summary, I want to stress the critical importance of cardiovascular research and the contributions of the National Heart, Lung, and Blood Institute to the advancement of cardiovascular care for all people. Cardiovascular disease is the major cause of death in Americans and causes tremendous personal and economic loss to the citizens of this nation. We at the American College of Cardiology want to emphasize our support for funding at the highest possible level for Specialized Centers of Research, investigator-initiated research project grants, training and education programs, and Research Career Awards.

These programs, vital to the continued development of research in cardiovascular disease, are consistent with the mission of the ACC. NHLBI-sponsored research forms the primary basis for the College's commitment to the development of guidelines for the delivery of quality cardiovascular care.

Mr. Chairman, I appreciate the opportunity to appear before this distinguished Subcommittee today. On behalf of my colleagues in cardiovascular medicine and surgery, I wish to thank the members of the Subcommittee for your consistent support of the NHLBI and your help with our efforts to restrain the nation's number one killer heart disease.

Senator ADAMS. Thank you, Doctor, very much.

Under your educational programs you urge additional funding for the institute's new national education programs intended to reduce premature morbidity and mortality from heart attacks, the National Heart Attack Alert Program.

Do you have a figure on that that you wish to submit at all, or do you wish to submit it later in writing?

Dr. FRYE. I do not. We would support the NHLBI's recommendation on that. It is a critically important program, particularly now that we have very effective therapies if, in fact, patients come to the emergency room or consult their physicians promptly enough. It is really a critical issue and one that will pay off if there is appropriate education of patients and the public at large.

Senator ADAMS. A second question that I have, because you indicate that the President's budget recommends a reversal between predoctoral and postdoctoral trainees. This is on page 2 of your testimony.

Dr. FRYE. Yes.

Senator ADAMS. I simply need some information from you on that, because that is something that if we are going to change back we need to be conversant with.

Describe for me briefly, if you would, why they are trying to do this, other than to save money; or is it simply to save money? Dr. FRYE. That is my understanding.

Senator ADAMS. In other words, there is no scientific particular basis that they have advanced?

Dr. FRYE. I think everyone wishes to encourage predoctoral students in terms of potential careers in biomedical research. Our feeling is that this is perhaps not the best way to go about it. In fact, because of the budget concerns and the lack of an appropriate stipend for current postdoctoral training programs, the reversal, we think, could have a very negative effect, particularly as I have indicated, on those postdoctoral fellows and clinical research training programs as well as others.

We are very much concerned about this. As I indicated, I think particularly one of the missions of the College of Cardiology is outcomes analysis and developing appropriate practice guidelines. We need people who are properly trained in these new methods of research.

Senator ADAMS. Fine. Thank you very much, Doctor. We appreciate your testimony. It was excellent.

STATEMENT OF JOHN M. CORNMAN, EXECUTIVE DIRECTOR, THE GERONTOLOGICAL SOCIETY OF AMERICA

Senator ADAMS. Our next witness is Mr. John N. Cornman, executive director of the Gerontological Society of America.

Welcome to the committee.

Mr. CORNMAN. Thank you very much, Mr. Chairman. I will try to be very brief. I am appearing in place of Dr. Richard Adelman, a biologist from the University of Michigan and the director of the Institute on Gerontology there and chairman of the public policy of the society. He was unavoidably detained at the last minute and asked me to substitute. I would hope that his full comments could appear somewhere in the record.

Senator ADAMS. Without objection, his full statement will appear in the record as though given.

Mr. CORNMAN. I appreciate that.

By way of background, The Gerontological Society of America is the national association of researchers and educators in aging. Reflecting the nature of the field of aging, our 7,000 members come from the fields of biology, medical research, behavior and social sciences, and the various practitioners who deal with older people. This multidisciplinary character gives the Society a unique perspective on the phenomena of aging. For example, as an organization we understand and support research directed at aging-related diseases, but we also just as strongly support research directed at understanding the basic biological behavior and social processes of aging. Specifically, we urge that the NIA budget be adjusted and/ or increased to support additional research in the processes of aging.

Dr. Adelman in his comments states very well the importance of increased research and the process of aging. Let me just quote that part of his statement.

Those factors which regulate the expression and rate of the fundamental processes of aging are the primary determinants of aging-related diseases and how they will afflict the elderly. Similarly, those factors which regulate the process of caregiving will optimize the potential for performance. Therefore, the new knowledge that will enable the alteration of the aging processes will help delay the onset and/or impact of the diseases most cost effectively, in essence accomplishing prevention of the disease, extension of health and life expectancy, and reduction of associ ated health care costs.

I cannot state the importance of research on the process of aging any better than that.

In urging Congress to enlarge that proportion of the NIA budget which can be distributed in response to the continuously evolving and collaborative determined research priorities of the institute's staff and the research community-again, this is partly in response to overdirected research by Congress, I think-Dr. Adelman reminds us of the fact that time and time again the most practical and important breakthroughs inevitably are the consequences of investigator-initiated research. We very much strongly support increased support for that type of research.

It is my understanding that only about $85 million of the administration's budget request for NIA, the National Institute of Aging, will be directed toward research on understanding aging processes. A professional judgment budget analysis suggests that NIA could use an additional $81 million for such research. We urge that additional funds be made available in the NIA budget for research on the aging processes.

PREPARED STATEMENT

In closing, I would like to associate the society with many of the other comments that were made here today, and particularly we endorse the recommendations of the ad hoc group on biomedical research.

Thank you.

[The statement follows:]

STATEMENT OF DR. RICHARD C. ADELMAN

Mr. Chairman and Distinguished Committee Members and Staff: My name is Dr. Richard C. Adelman. I am testifying today in my capacities as a recent past President of the Gerontological Society of America, as well as current Chairman of its Public Policy Committee; Director of one of the nation's foremost Institutes of Gerontology at the University of Michigan; and as a continuous recipient of NIH grant support for a period of 25 years.

The history of successful lobbying strategy in seeking enhanced Congressional appropriations for the National Institute on Aging is abundantly clear. Dramatization of the tragic impact of an illness such as Alzheimer's Disease on patient and caregiver alike has provoked generous increases in the agency budget, as well as anticipated growth in the number of investigators who seek grant support in proposed pursuit of the basic understanding, treatment and prevention of such terrible and costly illnesses.

A major part of the glory of the National Institutes of Health lies in the pursuit of disease-related, biomedical research in this manner. I commend both the leadership and supporters of the National Institute on Aging, as well as distinguished participants in the appropriations process for past encouragement and support. Obviously, I also eagerly endorse more of the same essential disease-related, biomedical support for the next fiscal year and into the future.

At the same time, I have the professional responsibility to alert you to a growing danger in the nature of Congressional appropriations for the National Institute on Aging. There is a desperate need for a greater degree of flexibility that will enable the National Institute on Aging to strike a better balance in the support of their constituent research community. This need encompasses the public recognition and enhanced Congressional appropriations for under-budgeted areas of research which are as crucial as research on disease to the pursuit of an enhanced quality of life for the elderly.

The under-budgeted areas of research address fundamental biological, behavioral and social processes of aging which are expressed independently of disease. For example, thirty-year old people with rare exception do not lose their memories to Alzheimer's Disease, do not fracture their hips when they fall, are not painfully confined at home with arthritis, and so forth. At the same time, all thirty-year old people undergo increased vulnerability to virtually each of the age-associated diseases as they undergo the process of aging. Those factors which regulate the expression and rate of fundamental processes of aging are the primary determinants of those diseases which afflict the elderly. Similarly, those factors which regulate the process of care giving will optimize the potential for performance. Therefore, the new knowledge that will enable the alteration of those processes will delay the onset and/or impact of all of the diseases most cost-effectively, in essence accomplishing prevention of the disease, extension of healthy life expectancy, and reduction of associated health care costs. The incredible diversity of researchable topics ranges from underlying molecular, cellular and physiological mechanisms to cognitive function and well being, intergenerational and cross-cultural issues, the organization and delivery of care, and the outcomes of policy change.

My specific recommendation to you is to the flexibility of the budget of the National Institute on Aging. You most effectively achieve such a goal by protecting, enlarging and nurturing that proportion of your appropriations which can be distributed in response to the continuously evolving, collaboratively determined program priorities of agency staff and the research community within the context of a qualified peer review process. On the other hand, you most effectively cripple that process when you mandate the specific manner in which appropriated funds may be spent, because it rarely can be predicted whether or not a particular research project will generate the information which ultimately conquers a particular disease. The history of science reveals time and time again that the most practical and important breakthroughs inevitably are the serendipitous consequence of investigatorinitiated research for which the primary motivation is simply the individually perceived joy of discovery.

Senator ADAMS. I just wanted to state that we understand the desire of the Institute to have the funds just appropriated generally, but it is also very hard for the Congress to have the impact of a great many people, not just people but a great many physicians and others, directed toward particular diseases in this particular case it was Alzheimer's and has been Alzheimer's-in hope