However, experience thus far points to the difficulty of performing such linkages for outcome studies (Copes et al., 1996). The committee supports the widespread adoption of uniform surveillance data sets, such as those recommended by NHTSA for prehospital care, by NCIPC for emergency department care, and by the ACS for trauma centers. Once adopted, demonstration projects should be developed to determine the most cost-effective means of establishing linkages between prehospital care, acute care, and rehabilitation data sets.

Research has been instrumental in the evolution of trauma systems. It has formed the underpinning for improved patient care and survival, reduced morbidity, and a national investment in trauma systems. In recognition of its vital role in advancing the trauma field, the ACS requires Level I trauma centers to conduct an active research program. Nevertheless, many prehospital, hospital, and rehabilitation providers do not participate in basic or clinical research, despite the existence of major gaps in knowledge across the entire spectrum, from basic research in tissue injury to health services research in trauma care systems.

There is a dearth of funding for research on trauma systems design, effectiveness, and cost-effectiveness. The existing research support is fragmentary at best, and there is no critical mass of support and leadership. The modest level of support comes mostly from NCIPC and the Agency for Health Care Policy and Research (AHCPR) (NCIPC, 1997b). NCIPC has sustained an investment in trauma systems research, even though its extramural research program is beset by funding limitations. The overall problem is that trauma systems research falls under health services research, an area that has not fared well in the research hierarchy and competition for resources. Health services research, despite a critical need, is a field whose recognition and importance have come only in the past decade, at a time of persistent pressures to reduce the federal budget deficit. Health services research has not grown to a level commensurate with its significance to society. As the major benefactor, AHCPR is among the newest and least-endowed agencies of the U.S. Department of Health and Human Services. The purview of AHCPR extends well beyond trauma systems to cover all areas of clinical practice. Expectations for a research center at the National Institutes of Health were temporarily aroused in 1994 with the publication of A Report of the Task Force on Trauma Research , a congressionally mandated report for research recommendations to launch a trauma research program, including research in trauma systems (NIH, 1994). However, the report went largely unnoticed; Congress did not appropriate funds for its implementation. A subsequent section of this chapter contains a recommendation to augment trauma systems evaluation and related research.

GROWTH IN TRAUMA CARE SYSTEMS

All indications point to a progressive increase in the development of trauma systems in the United States since the 1970s, yet documenting the growth is not



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