Key takeaways:
- While federal funding sharply reduced for care delivery research, hospitalist researchers should consider launching more organ- and disease-specific trials.
- Promising research avenues include comparative effectiveness trials and collaborations with specialists.
- Too often, research in hospital medicine doesn’t test how to implement innovations across different hospital settings.
WHAT A DIFFERENCE a year can make. That’s evident when you compare a recently published study on research priorities in adult hospital medicine, which was based on a survey done in 2023-24, to the editorial written this year to accompany that research.
First, the study: Published this spring in the Journal of Hospital Medicine, researchers (beginning in 2023, ending in April 2024) surveyed about 80 hospitalist leaders and researchers, asking them to rank research priorities for the field. Those leaders identified these top three: care delivery innovations, value-based care and health disparities.
Coming in at No. 4 on the priorities list was research into hospital-medicine specific conditions/diseases. Still, the study authors emphasized instead the need for systems-based and operational research. “We will … advocate,” they wrote in the study, “for increased and/or aligning existing federal and society funding emphasizing healthcare systems-based rather than organ-specific mechanisms.”
“Federal funding for research right now is under siege.”
Jeffrey Schnipper, MD, MPH
Brigham & Women’s Hospital
Fast forward to this year and that study’s editorial response, which was titled “The future of hospital medicine research: Three next steps.” Unlike the study, the editorial was written in the new world of 2025 when funding for exactly the types of health services research the study authors advocated for has been drastically reduced.
Written by two heavy-hitter hospitalist researchers, Jeffrey Schnipper, MD, MPH, director of clinical research for hospital medicine at Boston’s Brigham & Women’s Hospital, and Sunil Kripalani, MD, MSc, director for the Center for Health Services Research at Vanderbilt University Medical Center in Nashville, the editorial suggests ways for the field to maneuver in a profoundly changed funding environment.
As the editorialists concluded, “we have much work to do in the field of hospital medicine research.” Here are the three steps they outlined to begin to move that work forward.
Shore up the science
Step No. 1: Recognize that a lot of the research in hospital medicine around the quality, safety and value of health care delivery is, as the editorial states, “uneven, even haphazard.” The science needs to be better, and adopting care innovations can come only after “rigorously conducted multisite studies.”
“One-site quality improvement research just doesn’t cut it anymore,” Dr. Schnipper says in an interview with Today’s Hospitalist. “We all know that, right?”
And too often, he explains, hospital medicine research doesn’t provide the evidence for how to implement health delivery innovations across different sites and in different environments. Dr. Schnipper points to one innovation in the field, medication reconciliation, that’s backed by not only rigorous study but implementation science as well—thanks in large part to his own research and that of Dr. Kripalani. But many other innovations in the field are not.
“We are starting to see more health insurance companies, technology companies and health care organizations supporting research.”
Sunil Kripalani, MD, MSc
Vanderbilt University Medical Center
“Pick a topic,” he says, “like patient falls in the hospital or hospital-acquired delirium. What is the state of the science right now for complex interventions to reduce these?” He answers his own question: “We’re not always aware of where the gaps are.”
And it’s just not enough to do a randomized controlled trial or even a systematic review of several randomized studies.
“You need to know,” says Dr. Schnipper, “does this intervention work, and has it been tried in multiple institutions—not only well-sourced academic centers, but in county hospitals and safety-net facilities? Can various types of institutions implement this successfully, and is there a record of successful implementation? Do we know how to adapt it to various environments?
Once you can answer “yes” to all those questions, “an innovation may be ready for prime time,” Dr. Schnipper says. But the evidence base for many hospital medicine innovations isn’t there yet. “We also need a searchable database that provides the state of the science for each topic area, so it is clear where further work needs to be done.
A push for pragmatic clinical trials
In their second step, the editorialists urged hospitalists to consider running “pragmatic clinical trials” on different treatments in their hospitals. They outlined how such trials could be set up: EHRs would, after confirming eligibility and getting permission from the inpatient care team, randomize patients with a particular condition to one of two (or more) acceptable treatments, then extract outcomes.
Such pragmatic trials would take only minimal funding, the two authors wrote, and can be efficiently run. As an example, they pointed to the ACORN trial published in JAMA in 2023, in which researchers at Vanderbilt compared cefepime to piperacillin-tazobactam in adults hospitalized with acute infections.
In his interview, Dr. Schnipper notes that hospitalists should lead or at least collaborate on such comparative effectiveness trials, even if they are focused on more organ- and disease-specific research. Such studies, he believes, have “tremendous potential.”
“We don’t always feel like we’re the clinical experts,” he says, “but we are the ones who take care of more patients with pneumonia, acute kidney disease and alcohol withdrawal, more than any other specialty, certainly in hospitals.”
Dr. Schnipper understands why the hospitalist leaders surveyed about research priorities back in 2023-24 emphasized care delivery innovations.
“We’re all systems thinkers,” he notes. “That’s why we got into hospital medicine. We like thinking about quality improvement and patient safety, and we don’t always think of ourselves as disease experts.”
That self-perception needs to change going forward, he adds. He also points to one big advantage of organ- and disease-specific research, particularly when done in collaboration with specialists: “These diseases have natural funding sources. The NIH is going to continue to exist.”
A new funding reality
That leads to the editorial’s third step, which is really a reality check about the new reality in federal research funding.
“Federal funding for research right now is under siege,” Dr. Schnipper says. The Agency for Healthcare Research and Quality (AHRQ) in particular, which “has funded most of my research” along with much of the health services research done in the U.S., “has been decimated.” The agency has lost at least two-thirds of its staff, he points out, and it hasn’t been capable of funding any new studies since January.
Long term, he thinks federal research funding will be restored, “although maybe not to the level it has been historically.” Short term, he thinks the country’s research enterprise will be damaged, perhaps severely.
“A lot of careers are going to be derailed, potentially permanently,” says Dr. Schnipper. “It doesn’t take that long for a study to be unfunded before you just can’t run it anymore. A lot of studies have completely stopped, and they may never start up again.” Several of the grants that supported studies in his own division have been canceled.
And while all biomedical research right now is vulnerable, hospital medicine research is even more so than other fields.
“We depend on agencies like AHRQ, which funds research that crosses diseases and organ systems,” Dr. Schnipper points out. “Nor do we have drug companies lining up to give us money to do clinical trials on drugs to treat diseases.”
Alternative funding sources
In fact, Dr. Schnipper argues, accessing drug company funding is one more reason to consider collaborating on research with organ- and/or disease-specific specialists—as long, he notes, as hospitalists can navigate around potential conflicts of interest.
“What I usually recommend to colleagues is engaging with industry in investigator-initiated studies where we design the study and keep control over both the data and the decision to publish it,” he says. Comparative effectiveness studies, as he and Dr. Kripalani outlined in their editorial, is one example—even though, he admits, pharmaceutical companies don’t always rush to bankroll such trials.
That’s because in such studies, Dr. Schnipper notes, “one treatment will win and one will lose.” Still, he believes such studies are worth hospitalists getting involved in, and he thinks some drug companies will take a chance funding those outcomes.
Along with pharma, Dr. Schnipper says that philanthropy and foundations can fill in. He credits the Robert Wood Johnson Foundation for “picking up some slack” by funding research into diversity, equity and inclusion
“It clearly cannot make up for all the grants in those areas being canceled by the federal government,” he says. “But it’s at least trying.”
Dr. Kripalani notes that many other funders are interested in evaluating treatments and supporting implementation of evidence-based practices.
“We are grateful for several research and implementation projects funded by the Patient-Centered Outcomes Research Institute (PCORI), and groups like the American Heart Association,” says Dr. Kripalani. “We are also starting to see more health insurance companies, technology companies and health care organizations supporting research to improve the efficiency and outcomes of patient care.”
Dr. Schnipper points out that hospital medicine has never had a large cadre of researchers; most hospitalists are more interested in “administrative and operational work, not research.” Still, he adds, research—comparative effectiveness trials, implementation science, pragmatic clinical trials, and organ- and disease-specific studies—is essential to advancing the field.
“There are some questions we are uniquely suited to answer,” says Dr. Schnipper. “I think we need to answer them.”
Phyllis Maguire has been Executive Editor of Today’s Hospitalist since 2006. Based in Bucks County, Pa., her health care interests are hospital medicine and long-term care options. She also likes zydeco, hiking, and reading memoirs and romances.
Has the research environment in hospital medicine improved?
The current funding crisis notwithstanding, academic hospitalists have for years bemoaned the anemic infrastructure and environment for research in hospital medicine. Too often, they’ve complained, they just don’t have enough mentors, early career support, fellowships, protected time or funding.
Jeffrey Schnipper, MD, MPH, director of clinical research for hospital medicine at Boston’s Brigham & Women’s Hospital and a professor of medicine at Harvard Medical School, has been a prominent (and continuously funded) hospitalist researcher for more than 20 years. Over his tenure, we asked, has the research enterprise for hospital medicine improved? His answer: Yes and no.
As for what’s gotten better, “Our community of researchers has gotten older and more senior, so we now feel we can spend a certain amount of time mentoring others,” says Dr. Schnipper. “That’s probably the biggest thing that has changed.”
Another robust sign: Many more studies that hospitalist-investigators now launch are based on multi-hospital collaborations. With more studies testing hypotheses in various settings, he says, “research findings now are much more generalizable, practical and useful.” And “we have all gotten more savvy in terms of quality improvement research where, before we start, we ask our institutions if they would be willing to support and sustain the intervention we want to study, should a project prove successful.”
But, as Dr. Schnipper points out, academic centers still have only a “limited appetite” for funding research internally, “so if you can get external funding to do the work, that’s great.” This year, however, external research funding—at least through the federal government—has been drastically reduced.
So has the overall research environment in hospital medicine improved? “Not tremendously,” he says. “Unfortunately.”
