VA manages its intramural research program through ORD. According to ORD’s 2009 to 2014 strategic plan, ORD has 10 research priority areas, which are topics of research that are considered important to VA. The research priority areas are the health care needs of veterans who have served in Operation Enduring Freedom and Operation Iraqi Freedom, aging-related conditions, mental health care and well-being, chronic diseases, long-term care and caregiving, deployment-related exposure to hazardous environmental agents, equity in care, access in rural areas, women’s health, and personalized medicine. According to VA officials, all of these research priority areas could include PTSD research. VA funds intramural research through the following: VA’s Merit Review Program: This program supports research studies typically conducted by one VA investigator at one VA facility and is administered by ORD’s four research and development services, each of which has a different research focus. (See table 1.) Each research and development service is responsible for soliciting, reviewing, selecting, and funding research proposals submitted to the service. VA’s CSP: This program, which is administered by Clinical Science, funds larger-scale, multisite clinical trials and epidemiological research studies on key diseases that impact veterans. The Merit Review Program has research award funding limits, which are set by VA. In some cases, intramural research awards may only be funded for a certain number of years. See table 2 for more information. In addition to individual studies conducted at VA facilities, VA has several research centers and programs that conduct or support PTSD research. For example, the National Center for PTSD focuses on PTSD research. VA also has Research Enhancement Award Programs, which help support PTSD research by providing staff and other resources to investigators. (For more information on VA research centers and research programs that conduct or support PTSD research, see app. I.) According to a VA official from the National Center for PTSD, VA does not fund most of the PTSD research that is being conducted today. Intramural research proposals may be service-directed—solicited by ORD on specific topics—or investigator-initiated— submitted by investigators to ORD on their own initiative. Investigators submit proposals either in response to a request for proposals on a specific topic (for service- directed proposals) or to an open request for proposals (for investigator- initiated proposals). For both the Merit Review Program and CSP, proposals are typically evaluated in two review cycles per year. To be considered for intramural research funding: The proposal must be veteran-centric. The proposal must have received approval from the director of the medical center and the research and development office of the medical center where the lead investigator, known as a principal investigator, is based. The principal investigator and any coprincipal investigators must demonstrate a primary professional commitment to VA, as demonstrated by at least a 5/8 time VA appointment at the time the funding is awarded and previous VA experience, including experience in research and patient care. Research must be conducted primarily on VA premises. The principal investigator and any coprincipal investigators must have designated research space within a VA medical center. Overall intramural PTSD research funding from VA’s medical and prosthetic research appropriation increased from $9.9 million in fiscal year 2005 to $24.5 million in fiscal year 2009. The number of intramural PTSD research studies funded through the Merit Review Program and CSP increased from 47 in fiscal year 2005 to 96 in fiscal year 2009. Based on the VA data we obtained and summarized, we found that overall intramural PTSD research funding from VA’s medical and prosthetic research appropriation increased from about $9.9 million in fiscal year 2005 to about $24.5 million in fiscal year 2009, or by about 150 percent (see fig. 1). Overall intramural PTSD research funding included funding for specific PTSD studies as well as for other PTSD research-related funding, such as career development awards provided to junior VA investigators to conduct PTSD studies, salaries for VA investigators who are not VA clinicians, funding for PTSD research conducted within ORD research centers, and PTSD research meetings. Of the $80.2 million provided for PTSD studies from fiscal year 2005 through fiscal year 2009, $51.3 million, or about 64 percent, was for studies funded through the Merit Review Program. The remaining approximately $28.9 million, or about 36 percent, was for CSP studies. (See fig. 2.) From fiscal year 2005 through fiscal year 2009, intramural PTSD research funding ranged from 2.5 percent to 4.8 percent of VA’s medical and prosthetic research appropriation. (See table 3 for VA intramural PTSD research funding and VA’s medical and prosthetic research appropriations from fiscal year 2005 through fiscal year 2009.) For comparison, according to a 2009 report prepared by ORD staff for VA’s National Research Advisory Council, for fiscal year 2009, funding for intramural traumatic brain injury research was about $14.6 million, 2.9 percent of the medical and prosthetic research appropriation. Funding for spinal cord injury research was $27.2 million, 5.3 percent of the medical and prosthetic research appropriation. Funding for intramural cardiovascular disease and stroke research was $53.1 million, 10.4 percent of the medical and prosthetic research appropriation. Similarly, we found that the number of PTSD studies funded from VA’s medical and prosthetic research appropriations through VA’s intramural research program increased from fiscal year 2005 through fiscal year 2009. (See fig. 3.) Specifically, in fiscal year 2005, 47 intramural PTSD research studies were funded while in fiscal year 2009, 96 intramural PTSD research studies were funded. This represented an increase of more than 100 percent. Of all the studies funded each fiscal year, only a small number were CSP studies. According to VA officials, intramural research proposals, including those on PTSD, are reviewed and funded in VA’s Merit Review Program and VA’s CSP primarily according to scientific merit. VA’s Merit Review Program Intramural research proposals submitted to VA’s Merit Review Program are reviewed through a series of steps prior to funding. See figure 4 for an overview of the submission, review, and funding process for proposals submitted to the Merit Review Program. (For more detailed information on this process, see app. II.) First, investigators submit proposals electronically. Investigators typically submit Merit Review Program proposals to grants.gov, the government’s central grant identification and proposal portal, in response to a request for proposals. Submitted proposals are then transferred to eRA Commons, an electronic system for grant administration functions, for VA processing and review. Second, each proposal is assigned to a merit review panel for evaluation. Each merit review panel reviews proposals in a specific research topic area, and is composed of panelists, typically associate-level professors, who are selected based on their expertise in this area. According to VA documents, as of 2010, there were a total of 35 merit review panels across VA’s research and development services. The merit review panels evaluate each proposal based on its scientific merit. Panelists consider several criteria in evaluating the overall scientific merit of a proposal. (See table 4 for criteria used to determine scientific merit.) Third, the merit review panelists score the proposals to determine their rank. Each panelist provides a score to each of the proposals reviewed by the panel. The scores are averaged to create a “priority score” for the proposal. (See app. II for specific scoring guidelines given to panelists in all research and development services.) All proposals scored by the merit review panel are then ranked by priority score among all of the proposal scores recently assigned by the merit review panel. The rank of the proposal is used to determine the “percentile” of the proposal. Finally, research and development service directors determine how many proposals to fund. All of the proposals scored by all merit review panels in a research and development service in the review cycle are ranked together by their percentiles to be considered for funding. According to VA officials, research and development service directors typically fund up to the 25th percentile of proposals in a review cycle, beginning with those with the most scientific merit, although the number of proposals funded may vary depending on the budget. According to VA, research and development service directors may also choose to fund a small number of additional proposals at the margin that respond to research priority areas. For example, if the fundable range determined by a research and development service director was up to the 25th percentile, proposals at the 26th percentile related to research priority areas could also be considered for funding. VA’s Cooperative Studies Program VA intramural research proposals submitted to CSP are reviewed and scored in a process similar to that of the Merit Review Program prior to consideration for funding. To help develop the CSP proposal, investigators are assisted by members of a CSP center, a VA entity that provides guidance and support for research across multiple sites. (See fig. 5 for an overview of the process for submitting, reviewing, and funding a CSP proposal. For more information on ORD’s CSP review process, see app. III.) Before submitting a research proposal, investigators submit a letter of intent, or a preliminary outline of a proposal, to the Director of Clinical Science to be approved for planning a CSP proposal. Based on the merit of the letter of intent, as determined by three or more reviewers, the Clinical Science Director decides whether to fund planning efforts to develop a CSP proposal. When the principal investigator receives approval to begin planning efforts, the Clinical Science Director assigns a CSP center to provide statistical and methodological guidance to the investigator. The director of the CSP center designates a project manager and methodologist, such as a person with expertise in biostatistics, to provide guidance to the principal investigator. The Clinical Science Director, with recommendations from the principal investigator, then forms a planning committee of additional experts to assist in developing a CSP proposal.