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The Board recommends that an additional $5 million be appropriated to the NIDDK and the National Heart, Lung, and Blood Institute for a joint basic research program on the etiology and pathogenesis of atherosclerosis in diabetes.

Individual Research Project Grants. The Board has received testimony concerning the exciting opportunities for diabetes research, including, but not limited to the search for the diabetes genes and the relationship of diabetes to accelerated atherosclerosis and heart disease. However, fiscal constraints have not permitted adequate numbers of high-quality, investigator. initiated research proposals to be funded.

The Board recommends that Congress provide an additional $24 million to
NIDDK in FY 1992 to support an additional 100 research project grants.

Diabetes Research Centers. The Board devoted considerable time during 1990 to an assessment of the Diabetes Research and Training Centers (DRTCs). Following this review, the Board strongly endorsed the DRTC mechanism, which combines biomedical research with demonstration and education activities. These centers, as well as the Diabetes. Endocrinology Research Centers (DERCS), are funded at levels 25 to 30 percent below approved budgets.

The Board urges the Congress to support the current DRTCs and DERCs at program levels approved by the peer-review committees.

The Board recommends that Congress provide an additional $7 million to NIDDK in FY 1992 to support the current diabetes research centers at the level of activity approved by the peer-review committees.

Total NIDDK Appropriation

The Board recommends that the total appropriation for NIDDR be increased to $784 million in 1992. This recommendation includes $50 million for the initiative to search for the diabetes genes, $5 million for a basic research program on atherosclerosis and heart disease in diabetes, $24 million to support 100 additional diabetes research project grants, and necessary funds to support existing research project grants and research centers at program levels approved by the peer review committees.

Centers for Disease Control (CDC)

CDC is the lead Federal agency for diabetes translation activities. The primary purpose of the CDC program is to encourage and facilitate the rapid and widespread community application of validated research findings. The CDC carries out these activities through state partnerships and through research, surveillance, training and community interventions. The CDC program is an essential component of the national diabetes long-range plan and additional funds should be provided to implement the program components previously recommended by the Board.

The Board recommends that an additional $6 million be appropriated to the Centers for Disease Control to expand diabetos control activities.



The American Society of Clinical Oncology (ASCO) is pleased to submit comments in support of enhanced appropriations for the National Cancer Institute (NCI). ASCO is a national medical specially society representing some 8.500 physicians and other health professionals engaged in cancer research, treatment, diagnosis, and prevention. As researchers, our members conduct clinical trials and other applied studies that lead to the transfer of basic research findings to patient care for the more than one million Americans who are diagnosed with cancer each year.

This year, as we celebrate the twentieth anniversary of the National Cancer Act, we must ensure that clinical cancer research is once again a priority at the National Institutes of Health (NIH). The advocates for the original Act recognized the essential role clinical research would play in our fight against cancer. The Act's attention to clinical research -- through the establishment of cooperative groups, the prevention and control program, and the comprehensive centers -- in many ways served to distinguish NCI from its sister institutes

While the overall NIH budget, corrected for inflation, has grown some 27 percent since 1980, NCI funding has actually decreased 6.2 percent. And clinical efforts have shouldered far more of the burden of budget cuts than have basic studies The cuts in constant dollars since 1980 are glaring: 33 percent for clinical trials through the cooperative groups; 33 percent for cancer prevention and control; and 15 percent for cancer centers. In contrast, the budget for NCI's research project grants (RPGs) has grown some 29 percent.

Despite limited resources, NCI has integrated clinical research and community practice to a degree not seen in other disease areas. This integration is an essential component to facilitating patient access to promising new therapies. However, geography, economic status, language, cultural expectations, and age remain barriers to accessing state-of-the-art cancer prevention, detection, treatment, and rehabilitation programs. Enhancing the network of Clinical Cooperative Groups, Community Clinical Oncology Programs, and the regional Comprehensive Cancer Centers would play an important role in broadening access, especially for minority and lowincome patients.

With NCI policies expressly supportive of clinical investigations, it is not readily apparent why clinical research has been subjected to such severe cuts. For the most part, programs supporting clinical research are outside of the RPG mechanism. As NIH increased its support for RPGs over the past few years, many clinical research programs were cut. While we concur that RPGs must remain a high priority, we urge a more equitable distribution of resources that balances the national need for both basic and clinical research.

For example, within the RPG funding mechanism, the NCI may be considering breaking up program project grants (POIs) and encouraging POI-supported investigators to apply upon renewal for individual investigator awards (ROls) in an effort to demonstrate an overall greater number of grants. While dismantling large grants into several smaller awards may serve the goal of suggesting stability in the grant pool, it will destroy a funding mechanism that has proven effective in integrating basic and clinical research.

Similarly, support for young clinical investigators has suffered. NIH and the scientific community are well aware of the shortage of physician scientists trained to conduct clinical studies. Yet, despite this recognition, the number of awards (K04, K07, K08, KII) from the NCI Research Career Program training mechanisms effective in attracting physicians

has not increased over the past decade. Appropriately, the NCI By-Pass Budget requests doubling these awards over the next two years. This provision, however, was overlooked in the President's budget.

In clinical oncology, we face the real danger of losing the next generation of investigators. We must find the means and the political will to significantly increase support for young clinical investigators. Their inability to obtain grant support early in their careers is forcing many to pursue other professional avenues.

Limited resources are not the only impediment to maintaining an active pool of clinical investigators. Clinical researchers often have a difficult time competing for research grants, in part because the study sections to which their proposed projects are assigned have limited expertise in clinical research. The NIH Division of Research Grants must be encouraged to work with NCI for a timely resolution of this problem.

We join the National Coalition for Cancer Research in its unequivocal support for the NCI-proposed Bypass Budget. Yet, the cancer community recognizes the fiscal constraints under which this subcommittee must operate. At a minimum, NCI as a whole should receive a proportionate share of the overall NIH increase. Our view is supported by both the Senate and House Budget Committees which recommended that the Appropriations Committees correct the Hisparities in allocations between NCI and other NIH institutes.

We have made great strides in cancer research; the cancer survival rate has increased from 38 percent to over 50 percent. Yet, clearly, much more must be accomplished. We urge chat the FY 1992 appropriation for NCI be increased $200 million over the President's budget request. Such an increase should be equitably divided among the various NCI programs, including those supporting clinical efforts. We firmly believe that well funded NCI program chat strikes a better balance between laboratory and clinical research offers our greatest hope for Emproving cancer care.



The American Association of Colleges of Nursing (AACN) appreciates the opportunity to have our appropriations statement for the National Center for Nursing Research (NCNR) included in the record. Almost 20 percent of member schools are recipients of grants from a variety of Institutes and Centers at the National Institutes of Health (NIH), with a majority from the National Center for Nursing Research.

Nursing research is at a turning point with proven examples of how research findings have changed nursing practice to benefit health care. The currently proposed small increase in appropriations for NCNR would lead to declining success rates. A larger NCNR increase would expand opportunities for nurse scientists to make substantial and quantifiable gains in patient care.

For FY 1992 AACN requests a $19 million increase over FY 1991. This is a relatively small amount of money, particularly when compared to other NIH entities or the overall NIH budget. But it represents opportunities for major breakthroughs in nursing practice that will affect health care, just as have accomplishments in biomedical research.

AACN is pleased with NCNR's priorities which mirror the major health concerns of the 1990's: collaborative efforts related to HIV infection; frailty in older adults; longterm care requirements of older persons; low birthweight re: prevention and neonatal nursing care; management of Alzheimer's disease symptoms; minority health; nursing interventions and women's health; and rural health care of vulnerable populations.

In its first five years, research supported by NCNR is contributing to the improvement of nursing practice. The following are examples of success.

A study funded by NCNR at The Johns Hopkins University is following pediatric AIDS in high risk infants by examining health characteristics of three groups of HIVrisk infants up to age 36 months. Interview, clinical and laboratory data are collected every 1-2 months in a primary care setting or in the home of an infant by pediatric nurse practitioners. Preliminary findings show that home visitation provides opportunities for detection of acute health care problems, and that access to caring for these infants must include close monitoring of clinic appointments, frequent home visits/outreach and close cooperation with protective services.

Informal caregiving, for older people, a family choice for some, a financial necessity for other has become better understood in the last decade due in large part to NCNR supported research. Informal caregiving for the elderly presently is provided by

over four million people, 1.5 million of whom are also full-time workers. Currently, NCNR studies on Alzheimer's disease focus on developing and testing nursing Techniques to improve home and institutional care of patients, and developing more effective ways to educate and assist family caregivers.

An NCNR grantee from lowa is interviewing family members who provide home care for patients with Alzheimer's disease and collecting information from 40 families about the most frequent memory and behavior problems they observe in the patients, how they manage these behaviors, and how useful each behavior management technique is. The successful care methods will be incorporated into a model for interdisciplinary health team to use in helping families manage the needs and demands of the Alzheimer's patient.

Respiratory distress syndrome, a disease of premature infants, is the fourth leading cause of infant mortality. Infants with respiratory distress syndrome require endotracheal suctioning to remove secretions from their endotracheal or breathing tube. Though a routine nursing procedure, it is traumatic for the baby. An NCNR grantee from Tacoma, Washington, has determined that the effects of head rotation and several suctioning passes, as current practice requires, actually decreases the infant's oxygen supply and increases intracranial pressure. The investigator recommends that nurses not use head rotation and use fewer suctioning passes to facilitate breathing in newborn infants. This is a clear example of how research can improve nursing practice and outcomes.

Due to funding shortfalls, NCNR has not been able to fund many worthy projects. The following are examples of projects that received high priority scores from peer review panels, but were unfunded:

A meritorious application proposed a study of pregnant black and Hispanic teenagers and their infants from time of delivery to twelve months after delivery, to look at avoidance of repeat pregnancy, return to school, mothering behaviors, and infant outcomes. Many previous studies have examined negative outcomes of teenage pregnancy, but this study focused on the positive outcomes for teenagers to predict areas of success for this vulnerable population group.

• A proposed study on the prevention of serious pulmonary complications in patients who have feeding tubes inserted was also of great interest. When feeding tubes are inserted, nurses must confirm correct feeding tube location upon insertion of the tube and at regular intervals. This study would allow nurses to insert feeding tubes correctly without the expense and danger of repeated x-rays by merely examining and testing for the presence of certain enzymes in gastric fluid.

These projects of merit are only a few that NCNR could have supported if more funds were available.

We appreciate the subcommittee's past support for NCNR, but those large percentage increases rested on a small dollar base, one of the smallest, in fact, at NIH. Due to the rapid growth of high quality applications and in order to attain a critical mass of nursing research projects and scientists, NCNR needs a substantially bigger base for both research and training. For that reason, we respectfully request $58.8 million, the FY92 professional judgement figure, for NCNR.

This figure will raise NCNR's success rate for awards from 10.3 percent under the FY 1992 President's budget to 20 percent, which would begin to approach the NIH overall rate 26 percent for FY 1992, and boost traineeships from 257 to 290 (still short of the 320 the Institute of Medicine has recommended for 1992). Without this level of funding, NCNR's success rate would fall from 16.1 percent to 10.3 percent and the number of traineeships would remain the same.

AACN appreciates the support of the chairman and the subcommittee for NCNR since its establishment in 1986. We ask for your continued interest and support.



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The American Society of Allied Health Professions (ASAHP) ----a national non-profit scientific and professional organization serving the needs of of educators, practitioners, professional institutions and organizations, and others whose mission is to improve health care by enhancing the effectiveness of education for allied health professionals----urgently seeks Congressional support and commitment to address an allied health personnel shortage which diminishes the quality of health care available to the American people. Specifically, Congress needs to remedy the:

Severe current and growing shortages of allied health personnel including
occupational and physical therapists, imaging technologists including radiation
therapists, speech-language pathologists, medical record technicians, audiologists,
and clinical laboratory professionals;
Underrepresentation of minority persons in the allied health professions;
Undersupply of practitioners in rural and densely-populated, poverty-ridden urban
Rapid growth in the number of older persons needing the services of allied health
personnel; and
Lack of Federal programs to support allied health education. During the period
1981 to 1989 (almost a decade), there were no Federal programs authorized to
support allied health education. For FY 1991, the sum of $1,659,000 was made
available for a narrowly-defined set of activities, an amount not even barely
sufficient given the enormity of the problems that must be addressed.

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RECOMMENDED ACTION ASAHP urges Congress for FY 1992 to appropriate funds in the amounts shown below for the following activities:

Entry-level education traineeships ($12 million)
Advanced-level traineeships ($12 million)
Grants and Contracts ($12 million)
Allied health research ($20 million)
Commission on Allied Health ($1.5 million)
Allied Health Data System ($5 million)
Division of Allied Health within the Bureau of Health Professions

(5 Full-Time Equivalent Personnel) The Society believes that these measures constitute a comprehensive approach to correcting serious imbalances in the supply of allied health personnel. H.R. 1466 which was introduced by Congressman Terry Bruce (D-IL) and S. 694 which was introduced by Senator Tom Harkin (D-IA) on March 19 of this year focus on the reauthorization of Title VII of the Public Health Service Act, existing legislation that provides a vehicle for such initiatives. These bills seek the following amounts for FY 1992: $10 million for entry-level traineeships, $7 million for advanced-level traineeships, $7 million for grants and contracts, and an unspecified amount for a Commission on Allied Health.

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While supporting this legislation, ASAHP wishes to go on record as noting that the main focus of the proposed bills is on programs for the training of medical rehabilitation health personnel. Since the problem of personnel shortages encompasses a much broader range of allied health professionals, including those who work in laboratories,

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