services. Public health organizations and providers have embraced the need for a broader, more inclusive philosophy that shifts the focus from the trauma center to a system of trauma care that attends to the needs of all trauma patients over the full course of treatment.

Trauma care is lifesaving, yet expensive. The costs of trauma systems development should be shared by federal, state, and local governments. About half of the states report having some kind of trauma systems, although their nature and extent are not well documented. Some of the most successful statewide trauma systems have flourished with dedicated sources of funding through motor vehicle fees and other creative approaches. Research has begun to demonstrate that the investment in systems of care can be cost-effective in terms of long-term health care costs and productivity. However, there always may be vulnerable populations, such as the elderly, for whom cost-effectiveness may be difficult to demonstrate. More research is needed on vulnerable populations, patient outcomes, system configuration, and cost-effectiveness. A focal point at the federal level has to be reinstated to support research and to cultivate the growth of state and regional trauma systems. A federal program had been in place until 1995, when budget pressures led to the program's demise.

The financing of patient care continues to constrain trauma systems. The growth of managed care has placed further financial burdens on hospitals and trauma centers. The impact of managed care on trauma patient access, utilization, quality, and financing is essential to monitor but has been largely unexamined in the peer-reviewed biomedical literature. Financing constraints reinforce the public health imperative of primary injury prevention.


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