The 1966 landmark report Accidental Death and Disability: The Neglected Disease of Modern Society was a clarion call to launch what it termed a "frontal attack" on the care of the injured. At the time, the problem of injury in the United States was met with public apathy, a dearth of 9-1-1 systems, and inadequate provision of care (NRC, 1966). Since then, much progress has been made in developing systems of care that strive to reduce injury-related morbidity and mortality. Trauma care systems deliver a continuum of prehospital, acute care, and rehabilitation services. Yet, despite their public health mission, only a handful of states have put into place comprehensive regional systems of trauma care, although some of the system elements are present in many states and communities (West et al., 1988; Bazzoli et al., 1995). Trauma care is integral to the injury field because it is critical to lessening the consequences of injury.
The purposes of this chapter are to describe trauma care systems, their organization, roles, and patient outcomes; to explore what is known about their costs and cost-effectiveness; to delve into the cardinal problem of financing the high cost of infrastructure and patient care, a problem that has been solved by some states through motor vehicle fees and other creative sources of financing; and to explore the impact of managed care on trauma care systems. The committee decided to focus on these issues rather than explore the fundamental issues related to trauma care and the rehabilitation sciences, since several other reports have discussed specific priorities for research in trauma care and rehabilitation (e.g., NCIPC [1993;]; IOM [1991, 1997a]; NIH ).
OVERVIEW OF TRAUMA CARE SYSTEMS
A trauma care system is an organized and coordinated effort in a defined geographic area to deliver the full spectrum of care to an injured patient, from the time of the injury through transport to an acute care facility and to rehabilitative care (Eastman et al., 1991; Mendeloff and Cayten, 1991). A trauma care system consists of three major providers—prehospital, acute care, and rehabilitation—that, when closely integrated, ensure a continuum of care. For general descriptions of prehospital, acute, and rehabilitative care, see Box 6.1. This chapter concentrates on prehospital and acute care rather than rehabilitation because the latter was the subject of two recent Institute of Medicine (IOM) reports (IOM, 1991, 1997a).
In a trauma system, the integration of prehospital, acute care, and rehabilitation providers is administered by a public agency whose cardinal roles are to provide leadership, coordinate service delivery, establish minimum standards of care, designate trauma centers (offering 24-hour specialized treatment for the most severely injured patients), and ensure system evaluation and refinement. Trauma care systems are best endowed with the following major clinical or operational components: medical direction, prevention, communication, training, triage, prehospital care, transportation, hospital care, public education, rehabilitation, and medical evaluation (ACEP, 1992; HRSA, 1992; ACS, 1993). How these components are configured, organized, and emphasized differs according to state, regional, and local circumstances, as there are many examples of trauma systems throughout the United States.
An overarching goal of a trauma care system is to match the severity of the injury to the most appropriate and cost-effective level of care in a geographic region (ACEP, 1992; HRSA, 1992; ACS, 1993). Patient matching is thought to be accomplished best by an inclusive trauma care system (i.e., one that harnesses the resources of all hospitals and trauma care providers in a community or region to meet the needs of all injured patients, the majority of whom [85–90 percent] are not severely injured; ACS ). Most existing trauma systems are "exclusive" in orientation insofar as they focus mostly on the major trauma patient. Exclusive systems do not include all area hospitals, only prehospital providers and trauma centers to which the major trauma patient is triaged. Trauma centers are hospitals that are specially designed to care for the most critically injured patients. There are four levels of trauma center designation (Box 6.2), the pinnacle of which is the Level I center. Inclusive trauma care systems incorporate all hospitals and acute care facilities in a region to deliver quality care for all injured patients, regardless of severity. Inclusive trauma care systems marshal communitywide resources, broaden the number of stakeholders, enhance surveillance capacity, and seek to avert the overburdening of trauma centers with non-critically injured patients for whom expensive trauma center care is unnecessary. An inclusive philosophy of trauma care was espoused by federal legislation, the Trauma Care Systems Planning and Development Act of 1990 (P.L. 101-590),
which until 1995 encouraged the development of, and provided funding for, inclusive systems (see later discussion of financing). The effectiveness of an inclusive system has yet to be empirically evaluated (NCIPC, 1993).
BOX 6.1 The Continuum of Care
Prehospital Emergency Medical Services (EMS) Prehospital care is the gateway to the trauma care system and a major determinant of patient outcome (Jacobs et al., 1984; Rutledge et al., 1993; Regel et al., 1997). The goals of prehospital care are prompt arrival at the scene, assessment of patients' needs through medically approved protocols for triage (the classification of injury severity and the selection of a hospital destination that matches patients with appropriate clinical resources); preliminary resuscitation and treatment; and rapid transport to the nearest, most appropriate acute care facility (ACS, 1993; Jacobs and Jacobs, 1993). Access to prehospital care is provided almost universally throughout the United States by a telephone call to 9-1-1 (NHTSA, 1997a). There are four levels of EMS providers: (1) first responder, (2) emergency medical technician (EMT)-Basic, (3) EMT-Intermediate, and (4) EMT-Paramedic. The paramedic has substantially more training than the others and is the provider of most advanced life support given outside the hospital.
Acute Care Hospitals and primary care providers diagnose and treat the majority of injured patients, but the cornerstone of the trauma care system is the trauma center. Trauma centers are highly sophisticated facilities geared to the most gravely injured. Four levels of trauma center, each with detailed qualifying criteria, have been established and revised by the American College of Surgeons (ACS, 1993). (See Box 6.2 for a description of Level I–IV trauma centers). Many states with the legal authority to designate trauma centers use the ACS's criteria for designation. Hospitals seeking designation in states where such formal authority is lacking often rely on verification by the ACS that they have met its criteria.
Rehabilitation Rehabilitation forms the final, and generally the longest, phase of treatment in a trauma care system. The goals of rehabilitation are to improve physical and mental health, reduce disability, and enhance personal autonomy and productivity. Rehabilitation is defined as the process by which physical, sensory, or mental capacities are restored or developed. It is a process that is accomplished through functional improvements in the patient, as well as through changes in the physical and social environment (IOM, 1997a). Rehabilitation is offered on an inpatient or outpatient basis in a designated hospital unit, a freestanding rehabilitation hospital, or in a clinic. In a model trauma care system, rehabilitation begins at the earliest stage possible after admission to an acute care hospital (HRSA, 1992; NCIPC, 1993).
BOX 6.2 Levels of Trauma Centers
Trauma centers are acute care facilities that are specially designed to care for the most critically injured patients. There are four types—or levels—of trauma centers, the qualifying criteria for which were established by the American College of Surgeons (ACS, 1993):
The plight of rural areas has been a major factor propelling an inclusive philosophy of trauma care systems (Shackford, 1995). Rural emergency medical services have lagged behind their urban counterparts for a host of reasons, including greater transport times, insufficient volume of patients to maintain the skills of providers, and too sparse a population density to sustain local public financing (OTA, 1989; HRSA, 1990). In comparison with urban areas, rural areas experience higher mortality rates for motor vehicle crashes (Baker et al., 1987; Mueller et al., 1988; Flowe et al., 1995) and a higher proportion of deaths at the scene (Rogers et al., 1997b). To incorporate rural acute care facilities into an integrated system of care, the American College of Surgeons (ACS) created a new level of trauma center (Level IV) in 1993 and specified the organizational and clinical criteria needed for a facility to meet this level (Box 6.2). The facility may be a clinic or hospital, with or without a physician available. The purpose of
this classification was to provide optimal care in remote areas with limited resources and, when necessary, to ensure linkage to higher levels of care.
Children and the elderly are among the special populations that merit emphasis by trauma care systems. Injury is the foremost cause of death among children above 1 year of age and the fifth leading cause of death for the elderly age 65 or over (Chapter 2). Congress authorized the Emergency Medical Services for Children (EMS-C) Program in 1984 to ensure state-of-the-art emergency medical care for injured children and adolescents and to ensure that pediatric services are integrated into trauma systems. The program funds demonstration, implementation, and targeted-issues grants to states and medical schools for the provision of emergency medical services geared to children (IOM, 1993; NIH, 1995). The program grew out of the awareness that children have unique physiological responses to illness and injury and that their treatment requires specific training, equipment, and approaches not ordinarily available in systems designed for adults. The program focuses on the entire continuum of pediatric emergency services, from injury prevention through prehospital, acute care, and rehabilitation services. The committee commends the collaborative efforts of the Maternal and Child Health Bureau (MCHB) and the National Highway Traffic Safety Administration (NHTSA) on the EMS-C Program and urges similar collaborative efforts between MCHB and the National Institute of Child Health and Human Development for investigator-initiated research in the areas of childhood injury epidemiology and prevention.
Research has demonstrated that specialized pediatric trauma care is associated with lower rates of pediatric morbidity and mortality compared with rates at adult trauma care centers (or national norms), although adult trauma centers with a pediatric component may be able to achieve outcomes comparable to those of pediatric trauma centers (Pollack et al., 1991; Fortune et al., 1992; Knudson et al., 1992; Nakayama et al., 1992; Cooper et al., 1993; Hall et al., 1993, 1996; Rhodes et al., 1993; Bensard et al., 1994; Hulka et al., 1997). As important, targeted pediatric injury prevention programs have been shown in population-based studies to result in substantial decreases in the incidence of serious childhood injuries (Davidson et al., 1994; Durkin et al., 1996). The National Pediatric Trauma Registry (NPTR), was established in 1985 to study the causes, circumstances, and consequences of injuries to children. Sponsored by the National Institute on Disability and Rehabilitation Research and by the American Pediatric Surgical Association, the NPTR has detailed information on over 50,000 cases of injuries to children. As of October 1996, there were 78 participating centers (pediatric trauma centers or children's hospitals with pediatric trauma units) located in 28 states, Puerto Rico, and Ontario, Canada (NPTR, 1998).
The elderly account for a disproportionate share of injury-related hospitalizations (see Chapter 2). Demographic projections suggest that their share of hospitalizations is likely to grow even more. The need for the full range of treatment efforts targeted to the elderly is especially critical, particularly the need for a seamless transition from prehospital to acute care to high-quality rehabilitation services tailored to their needs (IOM, 1997a). There is some evidence that the elderly with major trauma have an inferior quality of trauma care compared to other age groups. This problem may be the result of two factors: (1) inadequate triage criteria for dispatching an elderly patient to a trauma center, resulting in undertriage (Phillips et al., 1996; Ma, 1997), and (2) a higher risk of complications and death during hospitalization (DeMaria et al., 1987; Champion et al., 1989a; Finelli et al., 1989; Chen et al., 1995; Ma, 1997). More research is needed to identify causes, sequela, and interventions to ensure the highest quality of care for elderly patients.
System Management and State or Regional Agencies
It has long been recognized that trauma care systems are best managed on a regional basis by virtue of the opportunity to pool and centralize resources and the relative infrequency of major trauma (NRC, 1978; Eastman et al., 1987; Stewart et al., 1995). Major trauma generally accounts for a small percentage (10–12 percent) of overall injury admissions (MacKenzie et al., 1990; National Trauma Data Project, 1996). Injury admissions—of all types and levels of severity—ranged in 1993 from 6.19 to 9.02 admissions per thousand population (National Trauma Data Project, 1996). Consequently, state and regional agencies have come to play essential roles in establishing and coordinating regional and local trauma care systems, many of which receive assistance from the federal government.
Federal legislation since the 1970s, such as the Emergency Medical Services Systems Act of 1973 and the Trauma Care Systems Planning and Development Act of 1990, channeled funds to states and regions in order to cultivate the development of systems of care (Table 6.1 contains a chronology of federal trauma system legislation). The 1990 legislation not only authorized funding for development and planning activities (albeit unsustained funding; see later section on financing trauma systems), but also stipulated the creation of a Model Trauma Care System Plan (HRSA, 1992).
TABLE 6.1 Chronology of Trauma System Legislation
Highway Safety Act authorizes funding for, and requires states to develop, regional EMS systems; also authorizes the Department of Transportation to develop standards for EMS provider training.
Emergency Medical Services Systems Act (P.L. 93-154) authorizes additional federal guidelines and funding for the development of regional EMS systems.
Omnibus Budget Reconciliation Act consolidates EMS funding into state preventive health and health services block grants under the Centers for Disease Control and Prevention (CDC).
Health Services, Preventive Health Services, and Home and Community-Based Services Act (P.L. 98-555) authorizes the Emergency Medical Services for Children Program.
Trauma Care Systems Planning and Development Act (P.L. 101-590) authorizes funding for state and regional trauma systems development.
Trauma Care Systems Planning and Development Act is not reauthorized.
The Model Trauma Care System Plan offers a framework for states to build trauma care systems once they have procured legislative authority.1 In broad terms, the plan calls for states to link prehospital, acute care, and rehabilitation providers through leadership, systems development, planning, and evaluation, and through securing financing for system administration and patient care (HRSA, 1992). More specifically, the plan exhorts states to designate trauma centers, establish trauma registries, and ensure, in concert with communities, that triage and transport protocols are in place for the timely assessment and movement of patients to the most suitable acute care facility. Bazzoli and coworkers (1995) found that the most common problem for states was to limit the number of designated trauma centers based on community need. The ACS (1993) underscored the importance of states' limiting the number of designated centers for two primary reasons: (1) trauma teams must treat sufficient numbers of major trauma patients to maintain their expertise, and (2) unnecessary duplication of centers yields excessively high societal health care costs (see also Goldfarb et al. ). The importance of maintaining sufficient patient volume as a determi-
nant of patient survival has been confirmed (Smith et al., 1990; Konvolinka et al., 1995). Still, there is no consensus on the amount of patient volume necessary for optimal performance of a trauma center (Moore, 1995).
Personnel and Training
More than 30 years ago, the National Research Council (NRC, 1966) spotlighted the paucity of trained emergency personnel at every level of care. The growth in the number of prehospital providers and the increase in their level of training are among the major achievements of the past three decades. The number of prehospital providers is estimated today at about 650,000 nationwide (W.E. Brown, National Registry of Emergency Medical Technicians, personal communication, 1998). Accompanying this growth has been the creation and standardization of the prehospital curriculum. Since the enactment of the 1966 Highway Safety Act, NHTSA has spearheaded the development of standardized curricula for multiple types of prehospital personnel (U.S. DOT, 1996b). In a series of evaluations conducted from 1988 to 1994, NHTSA found that 72.5 percent of 40 states used standardized curricula (primarily NHTSA's) in training courses for prehospital providers (U.S. DOT, 1995). NHTSA's FY 1997 budget for the EMS division responsible for curriculum development is $1.5 million. By virtue of its leadership and support for prehospital training and state highway grants, NHTSA is the federal agency with the most consistent and long-standing presence in trauma systems development (U.S. DOT, 1996b).
Certification of prehospital providers also has progressed, with all 50 states having some kind of certification procedure (BLS, 1997). However, there is much variability in requirements for certification (U.S. DOT, 1996b). Thirty-nine states certify prehospital providers who have passed written and practical examinations administered by the National Registry of Emergency Medical Technicians, a nonprofit certifying organization (NREMT, 1998). Yet, most states do not adhere to the registry's biennial reregistration requirement. Less than one quarter of the estimated 650,000 emergency medical technicians (EMTs) nationwide maintained their registration as of November 1997 (W.E. Brown, National Registry of Emergency Medical Technicians, personal communication, 1998).
There also has been considerable growth in the field of emergency medicine. The first emergency medicine residency program was formed in 1970. By 1998, the number of accredited residency programs had expanded to 120 (M. Schropp, Society for Academic Emergency Medicine, personal communication, 1998). The first certifying examination was given in 1980, one year after emergency medicine was recognized as a specialty by the American Medical Association Committee on Medical Education and the American Board of Medical Specialties. The number of board-certified emergency physicians catapulted to 15,202 by 1997 (American Board of Emergency Medicine, personal communi-
cation, 1998). The stature of the profession has also improved with the ascension of emergency medicine to full department status in many academic medical centers.
Finally, the profession of emergency nursing has grown and flourished. The field emerged as a nursing specialty around 1970, when the Emergency Nurses Association was formed. By 1997, membership in this organization rose to about 24,000, as did membership in related organizations such as the Society of Trauma Nurses. Emergency nurses practice mostly in the prehospital and acute care setting. They typically are responsible for assessing and initiating care to stabilize and resuscitate patients and for care during transport of critical care patients. The role of the emergency nurse in the prehospital arena is continuing to evolve (Adams and Trimble, 1994).
ROLE OF TRAUMA SYSTEMS IN PRIMARY PREVENTION, SURVEILLANCE, AND RESEARCH
Community-based primary prevention programs have been demonstrated to avert injury-related morbidity and mortality and to reduce health care costs. Trauma care systems have traditionally focused on secondary and tertiary prevention (i.e., efforts to reduce re-injury and to curtail the impact of an injury once it has occurred). Yet consensus has emerged that health professionals who manage trauma patients also should engage in primary prevention to keep an injury from occurring in the first place (U.S. DHHS, 1992; NCIPC, 1993; U.S. DOT, 1996a; Garrison et al., 1997). The rationale for broadening the role of trauma providers to include primary prevention is that these health professionals have unique and direct experience with, and knowledge of, the consequences of injury, as well as a professional obligation to improve health and safety and to control health care costs. After reviewing the biomedical literature on existing and recommended primary prevention activities for out-of-hospital providers (Kinnane et al., 1997), a consensus statement on prevention by the EMS community was prepared under the aegis of the National Association of EMS Physicians. The statement recommended leadership activities and knowledge areas that are either essential or desirable. Some of the leadership activities deemed to be essential were the provision of education to EMS providers on primary injury prevention, the protection of individual EMS providers from injury, and the collection and use of injury data (Garrison et al., 1997). Although a number of primary prevention programs by prehospital. and acute care providers have been implemented in various states or regions, none has been evaluated as yet (Kinnane et al., 1997). The committee suggests that enhanced emphasis be placed on the development and evaluation of prevention programs by these providers, as well as by rehabilitation providers to prevent secondary complications of injuries. Further, the committee believes that primary injury prevention should be incorporated into training curricula and continuing medical education pro-
grams for prehospital and acute care providers. Finally, the committee believes that there are financial incentives for employers, insurers, and others who pay for health care to adopt injury prevention, a point discussed later in the section on health care financing.
Surveillance data from trauma systems are indispensable for monitoring outcomes, assessing system performance, determining the etiology and scope of the injury problem in a community, and influencing public policy. Yet no nationwide or nationally representative surveillance systems are operational for trauma systems as a whole nor for their separate elements (i.e., prehospital, acute care, and rehabilitation services). Most surveillance systems currently in place are kept by individual trauma centers as a condition of trauma center designation (Pollock and McClain, 1989).2 In addition, although 48 percent of states have some type of hospital-based trauma registries, there is great variability in their nature, scope, purpose, and data elements (Shapiro et al., 1994). To instill greater uniformity, federal agencies and professional organizations have taken the initiative to develop and encourage the use of a variety of uniform data sets from prehospital, acute care, and rehabilitation providers. Working with the EMS community, NHTSA sponsored a conference in 1993, the final product of which was a proposed set of 81 uniform prehospital EMS data elements, either essential or desirable, for patient severity and treatment, cause of injury, response, and transfer times, but not for outcomes (under the rationale that these would have required linkages to the emergency department) (U.S. DOT, 1994). CDC's National Center for Injury Prevention and Control (NCIPC) supported the development of a uniform data set for 24-hour, hospital-based emergency departments, the Data Elements for Emergency Department Systems (DEEDS) (NCIPC, 1997a). The ACS developed, specifically for trauma centers, the National Trauma Data Bank to serve as a voluntary national repository of data from trauma centers. The Uniform Data System for Medical Rehabilitation was developed with support from the National Institute on Disability and Rehabilitation Research to capture the severity of patient disability and the outcomes of rehabilitation.
A number of states and regions have implemented laws that mandate inclusive trauma systems with comprehensive trauma registries. These registries include data retrieved from prehospital services, police and ambulance records, hospitals, rehabilitation centers, and medical examiners' files. These data systems are driven by E-codes (see Chapter 3) and have disease- and severity-specific information, as well as length of stay, morbidity and mortality, and charge information. Linkages between data sets covering prehospital, acute care, and rehabilitation providers are envisioned as a pivotal means of integrating information across trauma systems nationwide and of formulating public policy.
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
easy. States vary in their ability to collect data, and there are no ongoing and systematic nationwide or nationally representative surveillance systems (U.S. DHHS, 1991).
The greatest growth appears to be in prehospital care. All but nonexistent in the 1960s, prehospital care has become ubiquitous today. In the early 1990s, the Journal of Emergency Medical Services (JEMS) began an annual survey of prehospital providers in the 200 most populous cities, the so-called JEMS 200 City Survey, which captures 25 percent of the U.S. population. Although the sample is not nationally representative and the methods and results are not peer reviewed, the survey is one of the only indicators of growth and trends. The 1995 survey found 9-1-1 access to be available in more than 99 percent of the cities surveyed, and 82 percent of surveyed cities have so-called enhanced 9-1-1 service, in which the caller's street address is automatically provided to the dispatcher (W. Stanton, National Emergency Number Association, personal communication, 1998).
The nationwide status of regional trauma system development has been evaluated about every five years since 1987 through voluntary surveys of state EMS directors or health departments. Before 1987, state efforts waxed and waned depending on the vicissitudes of federal, state, and local support (Bazzoli et al., 1995). By 1987, West and colleagues (1988) found only two states that had fulfilled eight components judged essential by the authors to constitute a regional trauma system (see Table 6.2); 19 states and the District of Columbia missed meeting one or more of the criteria; and 29 states had not yet started the process of trauma center designation. By 1992, when the survey was updated by Bazzoli and colleagues (1995), five states were judged to have met the eight criteria. More states would have qualified except that they had failed to limit the number of trauma centers, depending on community need. The survey also found that states lacked standardized policies for interhospital transfer and systemwide evaluation. The authors advocated that more research on useful and valid outcome measures be included in trauma systems registries in order to assess system effectiveness. Subsequent nationwide updates were conducted in 1996 by Goodspeed (1997) and in 1997 by Bass (1997). Both studies found 27 states reported an established trauma system (although the defining criteria for a system were left to state discretion by Goodspeed). Thus, there is evidence to suggest that the past decade has witnessed an increase in trauma systems. The increase is thought to be related to the availability of federal funding, especially through the catalytic role of the Federal Trauma Care Systems Planning and Development Act, which required state matching funds. However, the authorization for this legislation lapsed in 1995, and it remains to be seen whether states will continue to invest in trauma systems development and maintenance without federal assistance.
TABLE 6.2 Essential Criteria to Identify Regional Trauma Systems
Legal authority to designate trauma centers
Formal process to designate trauma centers
Use of ACS criteria for classifying trauma centers
Out-of-area survey team for trauma center designation
Number of trauma systems limited by need (i.e., volume of patients or population of the area)
Written triage criteria
Ongoing monitoring system
Statewide trauma center coverage
SOURCE: West et al. (1988).
Although the surveys cited above provide insight into trauma systems development, they do not identify the actual growth in the number of trauma centers, as opposed to systems, nationwide. In an effort to identify hospitals either formally designated or self-designated as trauma centers between 1980 and 1991, Bazzoli and MacKenzie (1995) found 471 trauma centers. More recent figures from the ACS Committee on Trauma, which began a program to verify centers in 1987, reveal that, from 1987 to 1997, 285 hospitals were verified by the ACS as trauma centers (G. Strauch, American College of Surgeons, personal communication, 1998).
Rehabilitation is among the fastest-growing provinces of health care, with the number of freestanding rehabilitation hospitals and inpatient units increasing by more than 100 percent between 1985 and 1994 (IOM, 1997a). Even though injury patients account for a minority of all rehabilitation patients, their use of rehabilitation services is likely to increase for two key reasons: (1) the increased survival of more injured patients (HRSA, 1992) and (2) reduced lengths of stay in acute care services or hospitals, instituted in response to cost containment policies (IOM, 1997a). Nevertheless, there is anecdotal information about the lack of coordination between rehabilitation and acute care providers. The committee endorses full-fledged coordination between rehabilitation and acute care providers in an inclusive trauma system (for a complete discussion of rehabilitation research and the effectiveness of acute care interventions, see IOM [1997a]).
OUTCOMES OF TRAUMA CARE SYSTEMS
Does the establishment of trauma systems increase trauma patients' survival? This is a seminal question governing trauma systems research since the 1970s. Many outcome studies have focused on ''preventable mortality" (i.e., the percentage of deaths retrospectively judged to have been preventable had optimal care been available from a trauma system). Although estimates vary, some studies have found preventable deaths to range as high as 20–40 percent of
deaths due to injury (Trunkey and Lewis, 1991). These figures translate into nationwide annual estimates of approximately 20,000 to 25,000 lives saved (Champion and Teter, 1988). Nonetheless, studies of preventable deaths are beset by methodological limitations (Cales and Trunkey, 1985; Roy, 1987; Mendeloff and Cayten, 1991; MacKenzie et al., 1992). The purpose of this section is not to review comprehensively the peer-reviewed, published literature on patient outcomes with trauma systems, but rather to point to some illustrative studies, including more recent studies employing refined methodologies.
One noteworthy study of preventable mortality assessed the implementation of a regional trauma system in San Diego County, California (Shackford et al., 1986). The study found that after the implementation of a regional trauma system, the proportion of preventable fatalities fell from 13.6 to 2.7 percent. Such studies have been instrumental in stimulating the wider adoption of trauma systems.
Other approaches that are more objective than studies of preventable mortality have been developed to assess the benefits of trauma systems implementation. The Trauma and Injury Severity Score (TRISS) offers a means of predicting patient mortality based on injury severity, age, and revised trauma score (blood pressure, respiratory rate, and Glasgow Coma Scale for brain injury) (Boyd et al., 1987). With TRISS, the actual death rate in a hospital or trauma center can be compared to the predicted death rate from a large national data set of seriously injured trauma center patients voluntarily submitted to the Major Trauma Outcome Study (Champion et al., 1990). Champion and colleagues (1992) employed TRISS to assess longitudinally a reduction in trauma deaths in a center undergoing improvements from 1977 to 1982. They found an average of 13.4 more survivors per 100 seriously injured patients treated per year over the course of the improvements. Similarly, Stewart and colleagues (1995) found with TRISS that designation of a Canadian hospital as a trauma center led to a reduction in unexpected deaths from motor vehicle crashes from 8.8 percent before its designation to 3.6 percent after designation.
A newer method of evaluating outcomes related to trauma system implementation relies on population-based registries. The first study to capitalize on a comprehensive statewide population-based registry was performed by Mullins and coworkers (1994). They analyzed mortality outcomes among 70,350 patients who were hospitalized with injuries before and after institution of a trauma system in the Portland, Oregon metropolitan area. They found that the adjusted rate of mortality at Level I trauma centers was lowered by one-third compared to the pre-trauma system rate (the adjusted odds ratio for death declined from 1.00 before system establishment to 0.65 afterward). The impact was significant enough to be detected as an overall decline in the regional injury death rates, according to their analyses of two vital statistics databases. They also determined that the Portland metropolitan trauma system, through its prehospital triage criteria, was successful at shifting more seriously injured patients to trauma centers. Similar results were found when the authors broadened their analysis to cover five categories of injury across the entire state of Oregon before and after the implementation of a statewide trauma
system (Mullins et al., 1996). A more recent publication reinforced earlier findings, demonstrating that mortality improvements were attributable to the introduction of the trauma system rather than to concurrent improvements in new technologies and treatments (Mullins et al., 1998).
The studies cited above focus on the hospital phase of care. There is scanty knowledge of outcomes in the prehospital (Spaite et al., 1993) and rehabilitation phases of care (IOM, 1997a). For example, there is incomplete understanding of the effectiveness of many widely used prehospital interventions, such as fluid repletion, its nature and timing, as a means of patient resuscitation (NIH, 1994). There is another critical gap in research on outcomes relating to morbidity, in both the short and the long term (NIH, 1994). Measures of morbidity have to transcend the traditional medical model to encompass measures of productivity, disability, and quality of life. Morbidity outcomes also need to be tracked post-discharge from acute and rehabilitative care. Additionally, research on the design and effectiveness of trauma systems must take into account the differences between trauma systems that are related to the mechanism of injury (e.g., blunt versus penetrating trauma) in each system.
In summary, studies demonstrate that acute trauma care reduces patient mortality. However, very few studies have addressed improved long-term morbidity with trauma systems (Rhodes et al., 1988) and improved quality of care (Shackford et al., 1986). Much work remains in order to demonstrate the benefits of trauma care in relation to morbidity. Additional work also is necessary to identify which elements of a trauma system are most responsible for reductions in morbidity and mortality. Research that identifies the most effective elements is difficult to perform for the following reasons: the elements have to be carefully defined and measured for comparative analysis, major trauma itself requires better definition, and an appropriate comparison group has to be identified as a control population.
RESEARCH ON TREATMENT OUTCOMES AND CLINICAL EFFECTIVENESS
Evaluating outcomes of trauma systems often depends on the availability of research measures for evaluating patient outcomes and clinical effectiveness. Research is needed to develop more reliable and valid measures of (1) injury severity and case mix and (2) short- and long-term outcomes that are sensitive to changes over time and to differences in treatment. These two areas are discussed below.
Injury Severity and Case Mix
Indicators used as a basis for assessing the severity of an injury include anatomical descriptors for assessing the extent of tissue damage; the mechanism
of the injury; the physiological response of the body to the injury; and a priori or host factors such as age, gender, and coexisting disease that mediate the response of the body to the injury. There is general consensus that all four indicators or parameters are important for characterizing the impact of an injury or a constellation of injuries on outcome. More research is needed to improve the measurement of each parameter and to develop better models that establish the relationship between these parameters and outcomes, as discussed below.
The Abbreviated Injury Scale (AIS) has become a standard for measuring the extent of tissue damage (AAAM, 1990), yet its usefulness in detailed clinical studies of trauma involving specific organ systems is limited. Other classifications have been developed, such as to classify solid organ injuries (Moore et al., 1995) and long-bone fractures (Muller et al., 1990). The harmonization of these classifications should be encouraged. The AIS rates the severity of single injuries only. The Injury Severity Score (ISS) (Baker and O'Neill, 1976), defined as the sum of the squares of the maximum AIS obtained in each of the three most severely injured body regions, is currently the most widely used method for assessing the combined effect of multiple injuries. However, recent work has pointed to inadequacies of the ISS (Copes et al., 1988; Cayten et al., 1991). Alternatives such as the Anatomic Profile (Copes et al., 1990) and the New Injury Severity Score (Osler et al., 1997) have been proposed in order to account more adequately for the severity of multiple injuries to a single body system and for the important contribution of head injury in predicting outcome. These newer methods must be evaluated more broadly before their widespread use.
For large, population-based studies, use of the AIS (and its derivatives for scaling multiple injuries) is often not practical, since it takes, on average, between 10 and 20 minutes to score a single patient. Alternative scoring systems based on the International Classification of Diseases (ICD) have been proposed (MacKenzie et al., 1989; Rutledge et al., 1997). Although not as detailed a classification as the AIS, the clinical modification of the Ninth Revision of the ICD (ICD-9CM) does provide an alternative set of anatomic descriptors that is useful for characterizing the nature of traumatic injuries. Given the widespread use of the ICD, the further development and evaluation of ICD-based scoring systems should receive high priority.
The Revised Trauma Score (RTS)—based on the Glasgow Coma Score, systolic blood pressure, and respiratory rate—is the most widely used measure of injury severity based on physiologic parameters (Champion et al., 1989b). Although it has been shown to be a good predictor of mortality when combined with age and mechanism of injury, the RTS is inaccurate when the patient either is under the influence of drugs or alcohol or is intubated, paralyzed, or both (Offner et al., 1992). In addition, RTS values fluctuate over time and are sensitive to prehospital treatment. Further work is needed to better understand how these factors affect RTS values and how this information can be used to identify which values obtained over the course of time and treatment should be used retrospectively as fixed-point indicators of severity. In addition, further research
is necessary to better characterize the physiologic response to injury at the extremes of age.
Statistical modeling techniques have been used to combine information on the anatomic descriptors of tissue damage, the physiologic response of the body to the injury, age, preexisting chronic conditions, and mechanism of injury in order to produce estimates of the probability of survival. The two most widely used models are the TRISS and ASCOT (A Severity Characterization of Trauma), both of which are based on the AIS, elements of the RTS, age, and mechanism of the injury (Champion et al., 1994, 1996). Refinements of TRISS and ASCOT have been proposed (Cayten et al., 1991). In addition, models using ICD-based versus AIS-based measures of severity have been introduced (Rutledge et al., 1997). Research is needed to validate existing models and to develop new models where necessary. Common databases and standard measures of scale performance should be employed.
Finally, and perhaps most importantly, research is needed to extend existing approaches or to develop new approaches for modeling outcomes other than death, including resource utilization and functional outcomes. Existing measures of severity and case mix have been developed principally for use in studies of mortality and are inadequate for assessing severity in terms of hospital length of stay, treatment costs, or disability (Bull, 1985; MacKenzie et al., 1986; Rutledge et al., 1998). With increasing attention to the determinants and consequences of nonfatal injuries, several efforts have been undertaken to develop a companion to the AIS that maps AIS injury descriptors into scores that better reflect probable degree of impairment or disability when the patient survives the injury (AAAM, 1994; MacKenzie et al., 1996; McClure and Douglas, 1996). Additional work is under way to develop approaches for predicting hospital length of stay and charges (Rutledge et al., 1998). High priority should be given to the evaluation of these approaches across the wide range of injury types and severities.
Evaluation of the effectiveness of trauma care has traditionally focused on survival. However, as more lives are saved, attention also is shifting to nonfatal outcomes. However, in measuring nonfatal outcomes following trauma, it is important to move beyond the use of narrowly defined measures of morbidity, impairment, and performance in basic activities of daily living to include more global measures of health status and health-related quality of life (HRQOL). Ultimately, the goal of good trauma care is the restoration of function that will allow the patient to resume his or her normal everyday activities. Although numerous measures of health status and HRQOL have been proposed in the literature, few have been applied to the study of trauma care and rehabilitation. There is an urgent need for broader use of these measures and for the development of
standard approaches to assess trauma outcomes. The challenges are summarized below.
The Functional Independence Measure (FIM) (Keith et al., 1987) has gained wide acceptance in the field of medical rehabilitation as a measure of the "burden of care" associated with an illness or injury. The FIM score is generally assigned by a caregiver on the basis of direct observations of performance, although more recently developed telephone versions of the FIM rely on the individual's own assessment of his or her performance. Although further testing of the FIM is warranted, it holds promise as an effective tool for assessing the impact of inpatient rehabilitation on outcomes following serious trauma. However, the FIM does not encompass broader issues of outcome related to role activity, psychological well-being, and general health perceptions. It has also been criticized for its lack of sensitivity to the range of disabilities associated with traumatic brain injury.
Less frequently applied in the evaluation of trauma care and rehabilitation have been the wide array of health status and HRQOL measures. Although these measures vary widely in form and content, they share two important characteristics. First, they all measure function across multiple domains, including not only physical health, but also mental and cognitive health, social function, role function, and general health perceptions. Second, and even more important, health status and HRQOL measures assess outcomes from the patient's or consumer's perspective through the use of well-constructed questionnaires. One of the more important developments in health care over the past several years has been the recognition that the patient's point of view is important in evaluating the success of alternative therapies (Ware, 1995). Increasingly, patient-oriented measures of health status are playing a central role in health care evaluations (Relman, 1988). Examples of health status measures that have been used in measuring outcomes following trauma include the Sickness Impact Profile (Bergner et al., 1985), the General Health Status Measure Short Form-36 (Ware and Sherbourne, 1992), the Quality of Well-Being Scale (Kaplan et al., 1989; Holbrook et al., 1998), and the Rand Health Insurance Study Measures for Child Health Status (Eisen et al., 1980). However, their application has not been widespread, and important questions remain regarding their discriminate validity and their responsiveness to different treatments and to changes over time. Few studies have compared and contrasted available measures across the wide range of types and severities of injuries. Methodological research is critical in identifying and promoting the use of appropriate measures. An important issue is the extent to which available measures are sensitive to the cognitive deficits and behavioral changes that often accompany head injury.
Broad application of appropriate health status and HRQOL measures using standard protocols is essential for developing benchmarks for trauma outcomes. Substantial progress has been made over the past decade in establishing hospital-based trauma registries and defining the minimal data set needed for quality improvement activities. Typically, however, registries are not designed to collect
information on outcomes beyond hospital mortality and morbidity. Efforts are needed to extend the current concept of a trauma registry to include information on longer-term and nonfatal outcomes to develop norms for outcomes other than mortality. Clearly, significant challenges exist in developing and maintaining such registries. First, there is a need for practical tools that can be applied routinely at low cost. Considerable effort has been focused over the past several years in developing shortened versions of some of the longer, time-consuming instruments. It will be important to evaluate these instruments for their sensitivity and responsiveness to the broad range of trauma patients. Second, effective and efficient systems for tracking patients are needed to facilitate assessment of outcomes at uniform time periods postinjury for patients who do and do not receive postacute care. Guidelines for developing and maintaining these registries are critical to ensure that information on long-term outcomes is collected with attention to data quality.
In assessing outcomes using health status and HRQOL measures, it will be important to simultaneously collect information on patient risk factors. Even with high-quality measures of outcome, determining the influence of trauma care and rehabilitation on these outcomes is difficult without an understanding of patient risk factors (MacKenzie et al., 1987; Wilson and Cleary, 1995). In part, this is because some of the greatest observed differentials in health outcomes are related more to patient risk factors than to the receipt of medical care. Thus, the analysis of clinical outcomes must take into account the complex interactions between the health care system and patient factors in order to effectively identify the potential for intervention and how this potential might vary for different subgroups of the population.
COSTS OF TRAUMA CARE SYSTEMS
There has been scanty systematic study of the overall cost of trauma systems (Mendeloff and Cayten, 1991). The reasons are essentially twofold: (1) Costs are incurred by multiple organizations (i.e., public agencies, and prehospital, acute care, and rehabilitation providers); and (2) costs fall under multiple categories, such as administration and planning, infrastructure and equipment, communications, additional staffing, and patient care. For simplicity, these costs reduce to either patient care or system infrastructure. Infrastructure costs, which are generally shouldered by public agencies, vary greatly depending on whether the trauma system is built de novo or whether elements of the system (e.g., prehospital care) are already in place. A state or region already equipped with an array of prehospital, acute care, and rehabilitation services geared for all types of trauma incurs modest additional costs to establish a trauma system, primarily for public administration, trauma center designation, and coordination; whereas a region without a continuum of care and with no public commitment to systemwide integration may incur substantial start-up and maintenance expenditures. The
degree of public costs, for both start-up and maintenance, varies depending on how sophisticated a system is desired. However, there is no formal study of nationwide public and private costs for trauma systems.
Hospital charges, at 55 percent of the total costs of injury, represented the largest single type of direct cost (Rice et al., 1989). Using data from the 1984, 1985, and 1986 National Hospital Discharge Surveys, MacKenzie and coworkers (1990) determined that hospital, including trauma center, expenditures for all types of trauma in 1985 totaled $11.4 billion (inclusive of professional fees). This study also estimated that 25 percent of the total charges (or $2.8 billion) would be incurred by trauma centers treating the severely injured if such centers were available throughout the United States. Even though only 12 percent of trauma patients are severely injured, they disproportionately incur 26 percent of the charges (MacKenzie et al., 1990). Goldfarb and colleagues (1996) used a large national hospital discharge database to find that the average charge per hospital stay for severely injured patients in 1987 ranged from $12,891 to $28,464. The highest charges were incurred at Level I trauma centers that were part of a formal system. The lowest average charges for the severely injured were incurred at hospitals that were neither publicly designated nor self-designated as trauma centers. The study controlled for patient severity and hospital and community characteristics. A separate study of 12,088 trauma center admissions over a five-year period (1989–1993) by O'Keefe and colleagues (1997) found per-patient costs at a single regional trauma center to average $15,032 for victims of all ages with blunt and penetrating injuries. Several categories of complications greatly enhanced costs, such as pneumonia, adult respiratory distress syndrome, and acute kidney failure. According to 1995 data from the Health Services Cost Review Commission in Maryland, the mean hospital charge for a trauma admission is about 40 percent higher than that for a non-trauma admission (H. Champion, University of Maryland, Baltimore, personal communication, 1998).
There appear to be few studies of prehospital or rehabilitation costs for patients with injuries. The IOM (1997a) noted some studies that combine acute care and rehabilitation charges for a subset of the most severely injured, those with spinal cord and traumatic brain injuries. It also noted studies of total medical expenditures for people with disabling conditions, yet only a fraction of these people were disabled as a result of injury. Consequently, there is a noticeable lack of studies strictly of rehabilitation charges for injured patients of varying levels of severity. Since there is increasing recognition that a significant portion of an injured patient's clinical and financial experience occurs in the rehabilitation setting, a major challenge yet to be addressed is to measure objectively patients' outcomes and costs, including unreimbursed costs, of prehospital through rehabilitative care.
Cost-Effectiveness of Trauma Care Systems
The cost-effectiveness of trauma care systems only recently has begun to be explored. Miller and Levy (1995) were among the first to study the cost-effectiveness of these systems. Using 217,000 randomly sampled workers' compensation claims from 17 states (1979–1988), these investigators examined the cost-effectiveness in terms of lowered direct medical costs and increased worker productivity. They determined that, in states with trauma care systems, hospital and nonhospital medical care payments for acute care and rehabilitation for four types of injuries were, on average, 5–18 percent less costly per episode than those in states without such systems. Likewise, productivity (in terms of days at work) was enhanced. Extrapolating their figures to the nation as a whole, the authors estimated that if trauma systems were implemented nationwide, savings of $10.3 billion (in 1988 dollars) would be realized in increased productivity and lower medical payments. The largest portion of savings would be from productivity gains ($7.1 billion). The authors were careful to point out the limitations of their data set, namely, that results may not generalize to nonworker populations and to certain types of injury (e.g., head injuries). With enhanced productivity accounting for such a large proportion of savings, it may be difficult to establish the cost-effectiveness of trauma systems for older patients. The authors also acknowledged that their analysis fails to include potential indirect effects of trauma care systems on cost.
Targeted studies have addressed the cost-effectiveness of select elements of prehospital and rehabilitation care. For example, a recently published analysis of 13 previously published data sets found that helicopter medical transport is cost-effective in terms of cost per year of life saved, and is more cost-effective than other emergency medical interventions (Gearhart et al., 1997). Helicopter and ground transport directly from the scene of injury to a trauma center led to significantly shorter lengths of stay and charges than did matched interhospital transfers (i.e., patients transferred to a trauma center from a local hospital; Schwartz et al. ). A study in a rural area found substantial delays, averaging about 70 minutes, between the time of arrival of the patient at a referring emergency department (ED) and the time a request is made by that ED for emergency helicopter transport to a trauma center (Garrison et al., 1989). Despite these findings, the use of helicopters is not systematized. Maryland and Connecticut are among the few states with centralized dispatch of helicopters.
Paramedic EMS in the treatment of prehospital cardiopulmonary arrest were found to be more cost-effective than heart, liver, and bone marrow transplantation and chemotherapy for acute leukemia (Valenzuela et al., 1990). Likewise, early, aggressive, and expert application of rehabilitation in brain injury and spinal cord injury patients is associated with economic savings (Cope and O'Lear, 1993). Much research remains to be performed on the cost-effectiveness of rehabilitation services for many other types of injuries (U.S. DHHS, 1992; IOM, 1997a).
Research undertaken thus far indicates that trauma systems and select elements of systems are cost-effective for some groups. Yet far more research must be conducted on the cost-effectiveness of trauma care systems and system characteristics such as organization, configuration, and elements of care (Spaite et al., 1993; NIH, 1994). For example, research is critically needed to determine which elements of prehospital, acute, and rehabilitative care are the most cost-effective in reducing patient morbidity and mortality. Better methods are needed for arriving at true costs, rather than charges, and better methods are needed for capturing outcomes in terms of later productivity (NIH, 1994). There may be some populations, such as the elderly, for whom cost-effectiveness is difficult to establish. For such vulnerable populations, continued public support is likely to be necessary. The key is to devise adequate sources of financing for trauma systems and patient care.
FINANCING OF TRAUMA SYSTEMS
This section covers public and private financing of trauma systems. The first part discusses federal and state funding for system infrastructure, and later sections cover the financing of patient care and the advent of managed care. The availability of financing is a prime determinant of trauma systems development, proliferation, and endurance.
History of Federal and State Support for Trauma Systems
For the past three decades, federal and state governments have assumed much of the responsibility for trauma systems development. A major impetus came from the publication of Accidental Death and Disability: The Neglected Disease of Modern Society (NRC, 1966). Another major factor was awareness of the military's prowess at triage, transport, and field hospital care in Korea and Vietnam. Federal and state support, however, has not been consistent. The record of support has been erratic, shifting over time, depending on the vicissitudes of legislative and public support, competing budget priorities, and health care costs. The history of federal and state support is captured in more detail elsewhere (Boyd, 1983; IOM, 1993; Mustalish and Post, 1994). Nevertheless, a few general observations and legal milestones are worth chronicling (Table 6.1).
Since the passage of the 1966 Highway Safety Act, the federal role traditionally has been to provide leadership, technical assistance, and systemwide models and guidelines for states and regions; to establish curricula for EMS providers; and to offer financial support to states for planning and infrastructure. States have assumed responsibility for dispersing federal and state funds; developing, coordinating, and administering systems; designating trauma centers; and ensuring quality. Yet both federal and state activities historically have concen-
trated upon the development of prehospital EMS care. It was not until 1990, with the passage of the Federal Trauma Care Systems Planning and Development Act (P.L. 101-590), that a broader approach to trauma systems, one that systematically organizes prehospital care, acute care, and rehabilitation, was promulgated. This legislation, which called for an inclusive approach to trauma systems development, authorized grants to states and regions for planning, implementing, and monitoring statewide trauma care systems. The Division of Trauma and EMS (DTEMS) was established by the Health Resources and Services Administration (HRSA) to serve as a focal point, implement the legislation, and offer technical assistance to states.
The five-year history of P.L. 101-590 was marked by unfulfilled expectations because appropriations fell substantially short of the $60 million authorization, and states had difficulty during and after the second year in procuring matching funds (Hackey, 1995). Federal appropriations ranged from $4.4 million to 4.9 million from 1992 to 1995 (U.S. Executive Office of the President, 1992–1995). DTEMS was dissolved in 1995 when the legislation was not reauthorized, apparently the result of indiscriminate congressional efforts to reduce the federal deficit rather than to rebuke the program (ACS, 1995). There is some evidence that during its years of implementation, the legislation began to achieve its purpose, insofar as many more states began to launch or fully develop trauma care systems. Still, by 1997, only half of the states reported having trauma systems (Bass, 1997; Goodspeed, 1997).
Current Federal and State Funding for Trauma Care Systems
In a recent survey, 49 states and the District of Columbia reported the receipt of $14.5 million in FY 1996 for EMS and trauma systems funding (Goodspeed, 1997). The funds emanated mostly from block and categorical grants to states and regions and were not necessarily targeted to trauma systems development. Funds are distributed by three federal agencies: CDC, NHTSA, and HRSA.3 Actual federal funding appears to be higher than that reported by states, but cannot be known with precision. Under block or formula grant funding, states are not required to report on the amounts that they allocate specifically to trauma system development. Block and formula grants are designed to give wide discretion to states, in contrast to categorical grant programs, such as that jointly administered by HRSA and NHTSA for the EMS-C Program.
States expend significant resources for trauma care systems, well in excess of the federal resources they receive, but there is no ongoing monitoring of annual amounts nationwide. A recent survey found that, in 1996, states spent more than $161.6 million on EMS and trauma care combined. The states' average annual per capita expenditure was $0.57 (Goodspeed, 1997). The methods by which states finance EMS and trauma care systems vary markedly. Methods include direct legislative appropriations (from general revenues or earmarked funds), fees for vehicle or driver licenses and motor vehicle violations, and other tax revenues (Swor, 1994; Goodspeed, 1997). Some states and localities finance EMS via subscriptions (e.g., residents voluntarily can pre-pay for ambulance services through an annual fixed fee, whereas those who do not subscribe are charged the full cost if they use the service). Local tax subsidies and fee-for-service billings (some of which are paid by third-party insurers) are the two most important sources of revenues for prehospital care (Stout, 1994).
In summary, trauma systems development is a shared responsibility of federal, state, and local agencies. The federal role has diminished substantially with the lapse in authorization of the 1990 Federal Trauma Care Systems Planning and Development Act. Consequently, there is no longer a focal point at the federal level to cultivate trauma systems development.
The committee supports a greater national commitment to, and support of, trauma care systems at the federal, state, and local levels, and recommends the reauthorization of trauma care systems planning, development, and outcomes research at the Health Resources and Services Administration.
To ensure the success of this recommendation, resources should be provided to stimulate the development and evaluation of trauma systems in states and regions with the greatest need for systems development. Further, states and regions should adhere to the Model Trauma System Care Plan for guidance about trauma systems design (HRSA, 1992); ensure that their trauma systems collect surveillance and outcome information related to all system elements, including rehabilitation (systems should perform periodic evaluations, especially of outcomes); and finance trauma systems development, coordination, and implementation with funds from dedicated revenue streams, such as surcharges on motor vehicle registration, motor vehicle violations, and other mechanisms.
Financing of Patient Care
The financing of patient care is the Achilles' heel of trauma systems. A well-cited publication has referred to the financing problem as a ''crisis in trauma care reimbursement" (Champion and Mabee, 1990). One survey of 313 trauma centers in 1992 found that 58 percent reported serious financial problems and an
other 36 percent reported minor financial problems (Eastman et al., 1994). From 1983 to 1990, 66 trauma centers closed, with economic strains ranked as four of the five most important reasons for closure (Dailey et al., 1992). Although the pace of closures appears to have abated more recently (Bazzoli et al., 1995), the current changes wrought by managed care may imperil trauma systems once again (see below).
Several interrelated factors explain the economic strains on trauma centers (GAO, 1991; Dailey et al., 1992; Hackey, 1995). The first is the high cost of care and overhead relative to other types of care. The second factor is the growth in uncompensated care. From 1984 to 1994, the percentage of uninsured Americans grew from 15.4 to 17.8 percent (HRSA, 1995). The problem of uncompensated care is compounded in urban and public hospitals, especially due to increases in violent injury during the 1980s and early 1990s (Mendeloff and Cayten, 1991; Bazzoli et al., 1996). The third factor is inadequate patient care financing by Medicare and Medicaid (MacKenzie et al., 1991; Mendeloff and Cayten, 1991; Hackey, 1995). For example, Medicare's prospective reimbursement system, which has been adopted by some state Medicaid programs, did not adequately adjust reimbursement rates to account for the greater severity of patients' injuries seen in trauma centers, although Medicare did make an adjustment for this problem in 1991 (Dailey et al., 1992; Bazzoli et al., 1996). Medicare and Medicaid are among the mix of major payers of patient care in trauma centers, and the recovery rates to hospitals are among the lowest (Figure 6.1).
The most important sources of patient care financing for trauma center care are, in decreasing order of recovery rate,4 private insurance and workers' compensation, Medicare, Medicaid, and self-pay (Eastman et al., 1991, 1994). In terms of the percentage of total trauma care charges, the leaders are workers' compensation and private insurance (i.e., health insurance and auto insurance) at 42.8 percent of charges, followed by Medicaid at 19.1 percent and Medicare at 13.5 percent (Figure 6.1). With this mix of payers and recovery rates, Eastman and coworkers (1994) found that trauma centers experienced an overall loss of 8.4 percent of costs. Yet when they proceeded to stratify the data by service location (urban, suburban, and rural), a more complex picture emerged: trauma centers in urban and suburban areas reported losses at 11.7 and 5.7 percent, respectively, whereas trauma centers in rural areas had the most favorable financial performance—the only area of the three to show a small aggregate surplus of 3.7 percent (although only 11 rural centers were studied). A more recent study at a rural trauma center in Vermont attributes its financial profitability to lower injury severity among patients and a more favorable payer mix, with about 50 percent of injury patients being covered by private insurance (Rogers et al., 1997a).
The cost-recovery profile presented in Figure 6.1, although limited to a sample of trauma centers surveyed in 1992, illustrates the general principle that the most generous rates of recovery for patient care costs are from fee-for-service health insurance, auto insurance, and workers' compensation. This profile, however, fails to capture the great degree of expansion of managed care into the private and public sectors (see following section). As managed care continues to infiltrate the health care market, the ability of trauma centers and hospitals to shift costs from publicly to privately insured patients is jeopardized. This trend is likely to present new challenges in trauma care financing, the viability of trauma centers, and the quality of patient care in the future.
The increasing cost of patient care provides financial incentives for payers such as employers and health insurers to embrace injury prevention, both in occupational and in nonoccupational settings. Prevention programs have the potential to reduce health care costs. With an effective prevention program, reductions in health care costs may even be experienced in the short term (i.e., while the enrollee is still covered), compared to prevention programs for chronic conditions, such as heart disease, where cost reductions are more likely to be experienced in the long term (i.e., after enrollment has lapsed). The immediacy of prevention payoffs for injuries is likely an important consideration for payers. Payers should be eager to support injury prevention programs with their potential for short-term results because enrollee turnover tends to be high.
ADVENT OF MANAGED CARE
The managed care juggernaut has transformed health care. Managed care entails dramatic changes in the organization, financing, and delivery of health services, all in pursuit of containing costs, increasing access to health insurance through greater affordability, and maintaining quality (IOM, 1989, 1997b). The impact has been so profound that the diminishing numbers of providers not governed by managed care are compelled to respond with cost-cutting measures to remain competitive. Enrollment in managed care has burgeoned from virtual obscurity a decade ago to more than 70 percent of working Americans in 1995 (Foster Higgins, 1995). Millions more are covered through Medicaid and Medicare (Retchin, 1997), where the greatest growth in managed care is occurring. In 1996, 13.3 million Medicaid beneficiaries were enrolled in some form of managed care, a fourfold increase since 1991 (Kaiser Family Foundation, 1998). The most common types of managed care are health maintenance organizations (HMOs) and preferred provider organizations (PPOs), in which a group of hospitals or physicians provides services to plan members at discounted rates, or mixes of the two (Gold et al., 1995). In most PPOs and some HMOs, emergency care is provided through contracts with select EDs and trauma centers, whereas other HMOs provide emergency services directly.
Although the configurations of plans vary widely, managed care generally employs a common set of methods to attain the goal of cost containment, including selective contracting, special financing structures through capitation or discounted fees, benefit structures, and mechanisms for monitoring or managing services (IOM, 1996). From the point of view of the trauma patient, the latter is among the most significant because of the "gatekeeping" functions of managed care organizations (MCOs). Gatekeeping typically requires the patient or the provider to seek pre-authorization to receive payment for emergency care. The intent of preauthorization is to discourage ED use for patients who do not require such care. Although it is strictly for payment purposes, preauthorization is often misunderstood as preauthorization for treatment. However, federal law (the Emergency Medical Treatment and Active Labor Act of 1985) requires that all emergency patients be evaluated or screened and, if necessary, stabilized in the emergency room before release or transfer (GAO, 1991).5
What is the impact of managed care on trauma systems? The simple answer is that the full verdict is not yet in, and may never be, because of the dynamic nature of managed care and the difficulty of securing funding for research on its impact. Most of the accusations against managed care surround gatekeeping functions in relation to ED use—accusations that have prompted several states to
pass, and Congress to consider, proposed legislation to protect consumers (Derlet and Young, 1997; ACEP, 1998). Specifically, managed care has been charged with the delay of emergency care through preauthorization requirements; denial or undercoverage at EDs that are not part of a managed care network of providers; inadequate information about the use of 9-1-1; and premature discharge from acute care or rehabilitation (ACEP, 1993, 1998; Kilborn, 1997). The net effect may be an interruption in the continuity of care and poorer patient outcomes (Derlet, 1997). Counterbalancing these charges are the purported benefits of managed care. Among them is the possibility of promoting a better match between available resources and patient needs; reducing unnecessary costs; and emphasizing prevention, cost-effectiveness, data acquisition, and the use of treatment guidelines (IOM, 1996). What may be lost amidst the entry of managed care into trauma systems is the fact that some underlying goals of managed care and trauma care are similar, particularly the emphasis on prevention and on a match between available resources and patient needs. Congress is currently considering the passage of proposed federal legislation requiring public and private health insurance coverage for ED visits that any "prudent layperson" considers to be medically necessary.
The remainder of this section describes the modest body of peer-reviewed literature on the impact of managed care on trauma systems utilization, costs, and outcome. To place this literature in the context of managed care across all types of health care, a comprehensive literature analysis of studies since 1980 found HMOs, in comparison with fee-for-service plans, to have lower hospital admission rates, shorter lengths of stay (LOS), the same or more physician office visits per enrollee, less use of expensive procedures and tests, greater use of preventive services, mixed results on outcomes, and somewhat lower enrollee satisfaction with services (Miller and Luft, 1994).
With respect to managed care and trauma systems, the main measures of utilization have been 9-1-1 access, emergency room visits, and LOS. In terms of 9-1-1 access, one study found that virtually all Chicago-based HMOs surveyed in the late 1980s advised enrollees in case of emergency to contact the HMO office, primary physician, or a toll-free number, whereas only one HMO advised enrollees to go to the nearest hospital, yet made no mention of calling 9-1-1 (Hossfeld and Ryan, 1989). This study may be limited in applicability or dated, but it was among the first and only study of its kind. In another study, ED visits were reduced by at least 15 percent during one hospital's transition to managed care that was mandated by the State of Connecticut for all Medicaid recipients (Powers, 1997). Since access to emergency services is crucial, it is important for research to monitor the impact of managed care on trauma system access and related outcomes.
Under managed care, LOS would be expected to be lower for trauma patients. Yet two published studies that bear either directly or indirectly on LOS offer conflicting results. In the first study, Campbell and coworkers (1995) found that the mean LOS for 89 HMO trauma center patients in San Francisco from 1989 to 1993 were actually higher than those for non-HMO controls matched for
age, injury severity, and other characteristics. In fact, one subset of HMO patients, those transferred from the trauma center to the HMO hospital, had the longest LOS. The authors speculate that the possible reasons for the increased LOS among transferred patients are the disruption in continuity of care, problems in discharge planning, and medical complications that occur after transfer. On the other hand, a study of 3,141 admissions from 1990 to 1992 to a Seattle trauma center found LOS to be similar among motor vehicle crash patients with and without commercial insurance (Rhee et al., 1997). (Those without commercial insurance were either Medicaid or self-pay.) Although this study did not specifically compare managed care and fee-for-service patients, it found no effect of payer status on utilization. Part of the difficulty of monitoring LOS among managed care and fee-for-service patients is that LOS has declined in general in response to nationwide trends in cost containment.
Outcomes under managed care have been studied with respect to mortality and morbidity, but studies are sparse and not necessarily comparable. In the study by Campbell and coworkers cited above, HMO patients experienced lower mortality rates (4.1 percent) relative to non-HMO patients (9.9 percent), after adjustment for severity of injury and other factors, but HMO patients were younger, more often male, and more likely to have blunt injuries. The study by Rhee and colleagues (1997) found no differences in mortality between patients with commercial insurance and those without, but as pointed out above, the study was not of managed care per se. On the other hand, Young and Lowe (1997) found gatekeeping by managed care to be associated with adverse outcomes. After reviewing solicited case reports of 29 patients denied authorization by MCOs for ED payment, they determined that 14 percent had adverse outcomes (mortality and morbidity), 14 percent were at increased risk, and 72 percent were near misses (i.e. cases in which adverse outcomes were averted by ED care despite denial of authorization). Their findings confirmed earlier published reports about adults and children being denied authorization for ED payment (Derlet and Young, 1997). These findings are disturbing and warrant examination in a larger, random sample in which there is no selection bias.
The quest for cost containment also is significantly felt in EMS. There are several important and interrelated trends transforming EMS: (1) the consolidation of small, independent public and private EMS providers into large, publicly traded corporations that can realize economies of scale; (2) increased contracting between MCOs and EMS agencies in capitated or risk-sharing agreements; and (3) the development of new triage guidelines for EMS dispatchers designed to steer non-emergency calls away from the EMS system to more appropriate community resources (Neely, 1997; Neely et al., 1997; NHTSA, 1997b). It is important to monitor these trends with respect to their impact on EMS access, utilization, cost, and patient outcomes. The development of new triage guidelines is a special concern because of the potential for undertriage, which occurs when patients are not administered the emergency services they need. Public health professionals are concerned that the development of new triage guidelines is
being driven more by cost containment pressures than by empirical evaluation to ensure their effectiveness in matching patient needs with available resources. With one exception (Neely, 1998), very few such evaluations have been published thus far.
Managed care has extensively penetrated rehabilitation services in some major cities and is growing rapidly elsewhere (DeJong et al., 1996). There is a paucity of research on the impact of managed care on rehabilitation services. So many questions remain unanswered that a blueprint for research on managed care and people with disabilities has been developed (U.S. DHHS, 1995; IOM, 1997a). Although 70 percent of working Americans are enrolled in managed care, the need to demonstrate the relationship between quality of trauma care and rehabilitation and costs and outcomes is important for all Americans. This information is needed for defining best practices and for shaping treatment guidelines. It is also essential to the development of innovative service delivery models that benefit the patient while attending to the escalating costs of health care.
The committee recommends intensified trauma outcomes research, including research on the delivery and financing of acute care services and rehabilitation. The committee envisions that HRSA and other appropriate federal agencies (e.g., NCIPC, AHCPR) will collaborate on this research.
Specific areas of research that should be addressed include the following:
the cost-effectiveness of specific clinical and service interventions to establish best practices in trauma care;
the most efficient and effective strategies for organizing and financing the delivery of both acute care services and rehabilitation, including the impact of managed care arrangements on access to services, quality of care, and outcomes; and
the development of improved methods for measuring the severity of injury, particularly for those at high risk of adverse outcomes.
Finally, managed care accrediting organizations should support the development, coordination, and implementation of trauma care systems. They should mandate, as a condition of facility accreditation, participation in an inclusive trauma care system in states and regions with such systems and should promote the development of trauma care systems in states and regions without them.
Great strides have been made over the past decades in developing trauma systems covering a continuum of prehospital, acute care, and rehabilitation
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.
AAAM (Association for the Advancement of Automotive Medicine). 1990. The Abbreviated Injury Scale. Des Plaines, IL: AAAM
AAAM (Association for the Advancement of Automotive Medicine). 1994. The Injury Impairment Scale, 1994. Des Plaines, IL: AAAM.
ACEP (American College of Emergency Physicians). 1992. Guidelines for trauma care systems. Annals of Emergency Medicine 22:1079–1100.
ACEP (American College of Emergency Physicians). 1993. America's Health Care Safety Net, Emergency Medicine: 1968–1993 and Beyond. Dallas, TX: ACEP.
ACEP (American College of Emergency Physicians). 1998. ACEP [World Wide Web document]. URL http://www.acep.org (accessed January 1998).
ACS (American College of Surgeons). 1993. Resources for Optimal Care of the Injured Patient. Chicago: ACS.
ACS (American College of Surgeons). 1995. Trauma funding is threatened. Bulletin of the American College of Surgeons 80:7.
Adams BL, Trimble MP. 1994. Nurses. In: Kuehl AE, ed. Prehospital Systems and Medical Oversight, 2d edition. St. Louis: Mosby-Year Book. Pp. 76–80.
Baker SP, O'Neill B. 1976. The injury severity score: An update. Journal of Trauma 16(11):882–885.
Baker SP, Whitfield MA, O'Neill B. 1987. Geographic variation in mortality from motor vehicle crashes. New England Journal of Medicine 316:1384–1387.
Bass R. 1997. Data Obtained from a Survey by the National Association of State EMS Directors. Presented to the National Association of EMS Physicians, EMS Research Meeting, July 10. Lake Tahoe, NV.
Bazzoli GJ, MacKenzie EJ. 1995. Trauma centers in the United States: Identification and examination of key characteristics. Journal of Trauma 38(1):103–110.
Bazzoli GJ, Madura KJ, Cooper GF, MacKenzie EJ, Maier RV. 1995. Progress in the development of trauma systems in the United States: Results of a national survey. Journal of the American Medical Association 273(5):395–401.
Bazzoli GJ, Meersman PJ, Can C. 1996. Factors that enhance continued trauma center participation in trauma systems. Journal of Trauma 41(5):876–885.
Bensard DD, McIntyre RC, Moore EE, Moore FA. 1994. A critical analysis of acutely injured children managed in an adult level I trauma center. Journal of Trauma 35:384–393.
Bergner M, Bobitt RA, Carter WB, Gilson BS. 1985. The SIP: Development and final revision of a health status measure. Medical Care 19:787–805.
BLS (Bureau of Labor Statistics). 1997. Occupational Outlook Handbook [World Wide Web document]. URL http://stats.bls.gov/oco/ocos101.htm (accessed July 1998).
Boyd CR, Tolson MS, Copes WS. 1987. Evaluating trauma care: The TRISS method. Journal of Trauma 27:370–378.
Boyd DR. 1983. The history of emergency medical systems in the United States of America. In: Boyd DR, Edlich RF, Micik SH, eds. Systems Approach to Emergency Medical Care. Norwalk, CT: Appleton-Century-Crofts.
Bull JP. 1985. Disabilities caused by road traffic accidents and their relation to severity scores. Accident Analysis and Prevention 17:355–366.
Cales RH, Trunkey DD. 1985. Preventable trauma deaths: A review of trauma care systems development. Journal of the American Medical Association 254(8):1059–1063.
Campbell AR, Vittinghoff E, Morabito D, Paine M, Shagoury C, Praetz P, Grey D, McAninch JW, Schecter WP. 1995. Trauma centers in a managed care environment. Journal of Trauma 39(2):246–251.
Cayten CG, Stahl WM, Murphy JG, Agarwal N, Byrne DW. 1991. Limitations of the TRISS Method for interhospital comparisons: A multihospital study. Journal of Trauma 31(4):471–482.
Champion HR, Mabee MS. 1990. An American Crisis in Trauma Care Reimbursement . Washington, DC: Washington Hospital Center.
Champion HR, Teter H. 1988. Trauma care systems: The federal role. Journal of Trauma 28(6):877–879.
Champion HR, Copes WS, Buyer D, Flanagan ME, Bain L, Sacco WJ. 1989a. Major trauma in geriatric patients. American Journal of Public Health 79(9):1278–1282.
Champion HR, Sacco WJ, Copes WS, Gann DS, Gennarelli TA, Flanagan, ME. 1989b. A revision of the trauma score. Journal of Trauma 29(5):623–629.
Champion HR, Copes WS, Sacco WJ, Lawnick MM, Keast SL, Bain LW, Flanagan ME, Frey CF. 1990. The major trauma outcome study: Establishing national norms for trauma care. Journal of Trauma 30:1356–1365.
Champion HR, Sacco WJ, Copes WS. 1992. Improvement in outcome from trauma center care. Archives of Surgery 127:333–338.
Champion HR, Copes WS, Sacco WJ. 1994. The major trauma outcome study: Establishing norms for trauma care. Journal of Trauma 36:499–503.
Champion HR, Copes WS, Sacco WJ, Frey CF, Folcroft JW, Hoyt DB, Weigelt JA. 1996. Improved predictions from A Severity Characterization of Trauma (ASCOT) over Trauma and Injury Severity Score (TRISS): Results of an independent evaluation. Journal of Trauma 40:40–49.
Chen B, Maio RF, Green PE, Burney RE. 1995. Geographic variation in preventable deaths from motor vehicle crashes. Journal of Trauma 38(2):228–232.
Cooper A, Barlow B, DiScalla C, String D, Ray K, Mottley L. 1993. Efficacy of pediatric trauma care: Results of a population-based study. Journal of Pediatric Surgery 31:72–77.
Cope DN, O'Lear J. 1993. A clinical and economic perspective on head injury rehabilitation. Journal of Head Trauma Rehabilitation 8:1–14.
Copes WS, Champion HR, Sacco WJ, Lawnick MM, Keast SL, Bain LW. 1988. The injury severity score revisited. Journal of Trauma 28(1):69–77.
Copes WS, Champion HR, Sacco WJ, Lawnick MM, Gann DS, Gennarelli T, MacKenzie E, Schwaitzberg S. 1990. Progress in characterizing anatomic injury. Journal of Trauma 30(10):1200–1207.
Copes WS, Stark MM, Lawnick MM, Tepper S, Wilderson D, DeJong G, Brannon R, Hamilton BB. 1996. Linking data from national trauma and rehabilitation registries. Journal of Trauma 40(3):428–436.
Dailey JT, Teter H, Cowley RA. 1992. Trauma center closures: A national assessment. Journal of Trauma 33:539–547.
Davidson LL, Durkin MS, Kuhn L, O'Connor P, Barlow B, Heagarty MC. 1994. The impact of the Safe Kids/Healthy Neighborhoods Injury Prevention Program in Harlem, 1988 through 1991. American Journal of Public Health 84:580–586.
DeJong G, Wheatley B, Sutton J. 1996. Perspective and analysis: Medical rehabilitation undergoing major shakeout in advanced managed care markets. Bureau of National Affairs' Managed Care Reporter 2:138–141.
DeMaria E, Kenney PR, Merriam MA, Casanova LA, Gann DS. 1987. Survival after trauma in geriatric patients. Annals of Surgery 206(6):738–743.
Derlet RW. 1997. Locked gates: Profit and pain. Academic Emergency Medicine 4:1099–1100.
Derlet RW, Young GP. 1997. Managed care and emergency medicine: Conflicts, federal law, and California legislation. Annals of Emergency Medicine 30:292–300.
Durkin MS, Kuhn L, Davidson LL, Laraque D, Barlow B. 1996. Epidemiology and prevention of severe assault and gun injuries to children in an urban community. Journal of Trauma 41:667–673.
Eastman AB, Lewis FR, Champion HR, Mottox KL. 1987. Regional trauma system design: Critical concepts. American Journal of Surgery 154:79–87.
Eastman AB, Rice CL, Bishop GS, Richardson JD. 1991. An analysis of the critical problem of trauma center reimbursement. Journal of Trauma 31:920–960.
Eastman AB, Bishop GS, Walsh JC, Richardson JD, Rice CL. 1994. The economic status of trauma centers on the eve of health care reform. Journal of Trauma 36(6):835–844.
Eisen M, Donald CA, Ware JE, Brook RH. 1980. Conceptualization and Measurement of Health for Children in the Health Insurance Study. Santa Monica, CA: RAND Corporation. Publication No. R-2313. HEW.
Finelli FC, Jonsson J, Champion HR, Morelli S, Fouty WJ. 1989. A case control study for major trauma in geriatric patients. Journal of Trauma 29(5):541–548.
Flowe KM, Cunningham PR, Foil B. 1995. Rural trauma systems in evolution. Surgery Annual 27:29–39.
Fortune JB, Sanchez J, Graca L, Haselbarth J, Kuehler DH, Wallace JR, Edge W, Feustel PJ. 1992. A pediatric trauma center without a pediatric surgeon: A four-year outcome analysis. Journal of Trauma 33(1):130–137.
Foster Higgins. 1995. National Survey of Employer Sponsored Health Plans, 1995. New York: Foster Higgins.
GAO (General Accounting Office). 1991. Trauma Care: Lifesaving System Threatened by Unreimbursed Costs and Other Factors. Washington, DC: GAO. HRD-91-57.
Garrison HG, Benson NH, Whitley TW. 1989. Helicopter use by rural emergency departments to transfer trauma victims: A study of time-to-requests intervals. American Journal of Emergency Medicine 7:384–386.
Garrison HG, Foltin GL, Becker LR, Chew JL, Johnson M, Madsen GM, Miller DR, Ozmar BH. 1997. The role of emergency medical services in primary injury prevention. Annals of Emergency Medicine 30(1):84–91.
Gearhart PA, Wuerz R, Localio AR. 1997. Cost-effectiveness analysis of helicopter EMS for trauma patients. Annals of Emergency Medicine 30:500–506.
Gold MR, Hurley R, Lake T, Ensor T, Berenson R. 1995. A national survey of the arrangements managed-care plans make with physicians. New England Journal of Medicine 333(25):1678–1683.
Goldfarb MG, Bazzoli GJ, Coffey RM. 1996. Trauma systems and the costs of trauma care. Health Services Research 31 (1):71–95.
Goodspeed DG. 1997. Benchmarking emergency medical services: Trauma systems funding in the United States. Best Practices and Benchmarking in Healthcare 2(2):45–51.
Hackey RB. 1995. Politics of trauma system development. Journal of Trauma 39(6):1045–1053.
Hall JR, Reyes HM, Meller JL, Stein RJ. 1993. Traumatic death in urban children, revisited. American Journal of Diseases of Children 147:102–107.
Hall JR, Reyes HM, Meller JL, Loeff DS, Dembek R. 1996. The outcome for children with blunt trauma is best at a pediatric trauma center. Journal of Pediatric Surgery 31(1):72–76.
Holbrook TL, Anderson JP, Sieber WJ, Browner D, Hoyt DB. 1998. Outcome after major trauma: Discharge and 6-month follow-up results from the Trauma Recovery Project. Journal of Trauma 45(2):315–324.
Hossfeld G, Ryan M. 1989. HMOs and utilization of emergency medical services: A metropolitan survey. Annals of Emergency Medicine 18(4):374–377.
HRSA (Health Resources and Services Administration). 1990. Success and Failure: A Study of Rural Emergency Medical Services. Prepared by the National Rural Health Association. Rockville, MD: HRSA.
HRSA (Health Resources and Services Administration). 1992. Model Trauma Care System Plan. Rockville, MD: HRSA Division of Trauma and Emergency Medical Systems.
HRSA (Health Resources and Services Administration). 1995. Five-Year Plan: Emergency Medical Services for Children, 1995–2000. Washington, DC: Emergency Medical Services for Children National Resource Center.
Hulka F, Mullins RJ, Mann NC, Hedges JR, Rowland D, Worrall WH, Sandoval RD, Zechnich A, Trunkey DD. 1997. Influence of a statewide trauma system on pediatric hospitalization and outcome. Journal of Trauma 42:514–519.
IOM (Institute of Medicine). 1989. Controlling Costs and Changing Patient Care? The Role of Utilization Management. Washington, DC: National Academy Press.
IOM (Institute of Medicine). 1991. Disability in America: Toward a National Agenda for Prevention. Washington, DC: National Academy Press.
IOM (Institute of Medicine). 1993. Emergency Medical Services for Children. Washington, DC: National Academy Press.
IOM (Institute of Medicine). 1996. Pathways of Addiction: Opportunities in Drug Abuse Research. Washington DC: National Academy Press.
IOM (Institute of Medicine). 1997a. Enabling America: Assessing the Role of Rehabilitation Science and Engineering. Washington, DC: National Academy Press.
IOM (Institute of Medicine). 1997b. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: National Academy Press.
Jacobs BB, Jacobs L. 1993. Prehospital emergency medical services. In: Kravis TC, Warner CG, Jacobs LM, eds. Emergency Medicine, 3d edition. New York: Raven Press. Pp. 1–29.
Jacobs LM, Sinclair A, Beiser A, D'Agostino RB. 1984. Prehospital advance life support: Benefits in trauma. Journal of Trauma 24(1):8–13.
Kaiser Family Foundation. 1998. Fact sheet: Medicaid and Managed-Care. [World Wide Web document]. URL http://www.kff.org:80/archive/health_policy/kcfm/mmcare/mmcare.html (accessed May 1998).
Kaplan RM, Anderson JB, Wu AW, Mathers WC, Kozin F, Orenstein D. 1989. The quality of well-being scale: Applications in AIDS, cystic fibrosis and arthritis. Medical Care 27(3):S27–S43.
Keith RA, Granger CV, Hamilton BB, Sherwin FS. 1987. The functional independence measure: A new tool for rehabilitation. In: Eisenberg MG, ed. Advances in Clinical Rehabilitation. Vol. 1. New York: Springer. Pp. 6–18.
Kilborn PT. 1997. Fitting managed care into emergency rooms. New York Times, December 28, p. 10.
Kinnane JM, Garrison HG, Coben JH, Alonso-Serra HM. 1997. Injury prevention: Is there a role for out-of-hospital emergency medical services? Academic Emergency Medicine 4(4):306–312.
Knudson MM, Shagoury C, Lewis FR. 1992. Can adult trauma surgeons care for injured children? Journal of Trauma 32(6):729–737.
Konvolinka CW, Copes WS, Sacco WJ. 1995. Institution and per surgeon volume vs. survivor outcome in Pennsylvania's trauma centers. American Surgeon 170:333–340.
Ma MH-M. 1997. System Performance and Appropriateness of Care for Elderly Trauma Patients. Doctoral dissertation. Johns Hopkins University, Baltimore, MD.
MacKenzie EJ, Shapiro S, Moody M, Siegel JH, Smith RT. 1986. Predicting posttrauma functional disability for individuals without severe brain injury. Medical Care 24(5):377–387.
MacKenzie EJ, Shapiro S, Smith RT, Siegel JH, Moody M, Pitt A. 1987. Influencing return to work following hospitalization for traumatic injury. American Journal of Public Health 77(3):329–334.
MacKenzie EJ, Morris JA, Edelstein SL. 1989. Effect of pre-existing disease on length of stay in trauma patients. Journal of Trauma 29(6):757–765.
MacKenzie EJ, Morris JA, Smith GS, Fahey M. 1990. Acute hospital costs of trauma in the U.S.: Implications for regionalized systems of care. Journal of Trauma 30(9):1096–1103.
MacKenzie EJ, Steinwachs DM, Ramzy AI, Ashworth JW, Shankar B. 1991. Trauma case mix and hospital payment: The potential for refining DRGs. Health Services Research 26(1):5–26.
MacKenzie EJ, Steinwachs DM, Bone LR, Floccare DJ, Ramzy AI. 1992. Inter-rater reliability of preventable death judgments. The Preventable Death Study Group. Journal of Trauma 33(2):292–302.
MacKenzie EJ, Damiano A, Miller T, Luchter S. 1996. The development of the functional capacity index. Journal of Trauma 41(5):799–807.
McClure RJ, Douglas RM. 1996. The public health impact of minor injury. Accident Analysis and Prevention 28:443–451.
Mendeloff JM, Cayten CG. 1991. Trauma systems and public policy. Annual Review of Public Health 12:401–424.
Miller RH, Luft HS. 1994. Managed care plan performance since 1980: A literature analysis. Journal of the American Medical Association 271:1512–1519.
Miller TR, Levy DT. 1995. The effect of regional trauma care systems on costs. Archives of Surgery 130:188–193.
Moore EE. 1995. Trauma systems, trauma centers, and trauma surgeons: Opportunities in managed competition. Journal of Trauma 39(1):1–11.
Moore EE, Cogbill TH, Jurkovich GJ, Mallangoni MA, Shackford SR, Champion HR. 1995. Organ Injury Scaling: Spleen and liver (1994 Revision). Journal of Trauma 38(3):323–324.
Mueller BA, Rivara, FB, Bergman A. 1988. Urban-rural location and a risk of dying in a pedestrian-vehicle collision. Journal of Trauma 28:91–94.
Muller ME, Nazarian S, Koch P, Schatzker J. 1990. Classification of Long Bone Fractures. Berlin: Springer-Verlag.
Mullins RJ, Veum-Stone J, Helfand M, Zimmer-Gembeck M, Hedges JR, Southard PA, Trunkey DD. 1994. Outcome of hospitalized injured patients after institution of a trauma system in an urban area. Journal of the American Medical Association 271(24):1919–1924.
Mullins RJ, Veum-Stone J, Hedges JR, Zimmer-Gembeck MJ, Mann NC, Southard PA, Helfand M, Gaines JA, Trunkey DD. 1996. Influence of a statewide trauma system on location of hospitalization and outcome of injured patients. Journal of Trauma 40(4):536–545.
Mullins RJ, Mann NC, Hedges JR, Worrall W, Jurkovich GJ. 1998. Preferential benefit of implementation of a statewide trauma system in one of two adjacent states. Journal of Trauma 44(4):609–616.
Mustalish AC, Post C. 1994. History. In: Kuehl AE, ed. Prehospital Systems and Medical Oversight. 2d edition. St. Louis: Mosby-Year Book. Pp. 3–23.
Nakayama DK, Copes WS, Sacco W. 1992. Difference in trauma care among pediatric and nonpediatric trauma centers. Journal of Pediatric Surgery 27(4):427–431.
National Trauma Data Project. 1996. A Report to the Division of Trauma and Emergency Medical Systems, Health Resources and Services Administration . Conducted by John V. Udell, Augusta, ME.
NCIPC (National Center for Injury Prevention and Control). 1993. Injury Control in the 1990s: A National Plan for Action. A Report to the Second World Conference on Injury Control. Atlanta, GA: Centers for Disease Control and Prevention.
NCIPC (National Center for Injury Prevention and Control). 1997a. Data Elements for Emergency Department Systems (DEEDS) [World Wide Web document]. URL http:www.cdc.gov/ncipc/pub-res/deedspage.htm (accessed December 1997).
NCIPC (National Center for Injury Prevention and Control). 1997b. Inventory of Federally Funded Research in Injury Prevention and Control . Atlanta, GA: NCIPC.
Neely K. 1997. Demand management: The new view of EMS? Prehospital Emergency Care 1(2):114–118.
Neely K. 1998. Can Emergency Medical Service Dispatchers Identify Callers Suitable For Non-Emergency Medical Service Resources? Presentation at the 1998 Society for Academic Emergency Medicine Research Forum, Steamboat Springs, CO. January 1998.
Neely K, Drake ME, Moorhead JC. 1997. Multiple options and unique pathways: A new direction for EMS? Annals of Emergency Medicine 30:797–799.
NHTSA (National Highway Traffic Safety Administration). 1997a. Emergency Access: Extending the Nation's Emergency Medical Safety Net. Washington, DC : NHTSA.
NHTSA (National Highway Traffic Safety Administration). 1997b. Working with managed care organizations. EMS and Managed Care Bulletin. [World Wide Web document]. URL http://www.nhtsa.dot.gov:80/people.injury/ems/bulletin/bullet97.htm (accessed July 1998).
NIH (National Institutes of Health). 1994. A Report of the Task Force on Trauma Research. Bethesda, MD: NIH.
NIH (National Institutes of Health). 1995. Disease-Specific Estimates of Direct and Indirect Costs of Illness and NIH Support. Bethesda, MD: NIH.
NPTR (National Pediatric Trauma Registry). 1998. The National Pediatric Trauma Registry. [World Wide Web document]. URL http://www.nemc.org/rehab/nptrhome.htm (accessed September 1998).
NRC (National Research Council). 1966. Accidental Death and Disability: The Neglected Disease of Modern Society. Washington, DC: National Academy Press.
NRC (National Research Council). 1978. Emergency Medical Services at Midpassage. Washington, DC: National Academy Press.
NREMT (National Registry of Emergency Medical Technicians). 1998. NREMT [World Wide Web document]. URL http://www.nremt.org (accessed January 1998).
Offner PJ, Jurkovich GJ, Gurney J, Rivara FP. 1992. Revision of TRISS for intubated patients . Journal of Trauma 32(1):32–35.
O'Keefe GE, Maier RV, Diehr P, Grooseman D, Jurkovich GJ, Conrad D. 1997. The complications of trauma and their associated costs in a level I trauma center. Archives of Surgery 132(8):920–924.
Osler T, Baker S, Long W. 1997. A modification of the Injury Severity Scale that both improves accuracy and simplifies scoring. Journal of Trauma 43:922–926.
OTA (Office of Technology Assessment). 1989. Rural Emergency Medical Services—Special Report. Washington, DC: OTA. OTA-H-445.
Phillips S, Rond PC, Kelly SM, Swartz PD. 1996. The failure of triage criteria to identify geriatric patients with trauma: Results from the Florida Trauma Triage Study. Journal of Trauma 40(2):278–283.
Pollack MM, Alexander SR, Clarke N, Ruttimann UE, Tesselaar HM, Bachulis AC. 1991. Improved outcomes from tertiary center pediatric intensive care: A statewide comparison of tertiary and nontertiary facilities . Critical Care Medicine 19(2):150–159.
Pollock DA, McClain PW. 1989. Trauma registries: Current status and future prospects. Journal of the American Medical Association 226:2280–2283.
Powers RD. 1997. Medicaid managed care and the emergency department: The first 100 days. Journal of Emergency Medicine 15(3):393–396.
Regel G, Stalp M, Lehmann U, Seekamp A. 1997. Prehospital care, importance of early intervention on outcome. Acta Anaesthesiologica Scandinavica Supplementum 110:71–76.
Relman AS. 1988. Assessment and accountability: The third revolution in medical care. New England Journal of Medicine 319:1220–1222.
Retchin SM. 1997. Heterogeneity of health maintenance organizations and quality of care. Journal of the National Cancer Institute 89(22):1654–1655.
Rhee PM, Grossman D, Rivara F, Mock C, Jurkovich G, Maier RV. 1997. The effect of payer status on utilization of hospital resources in trauma care. Archives of Surgery 132(4):399–404.
Rhodes M, Aronson J, Moerkirk G, Petrash E. 1988. Quality of life after the trauma center. Journal of Trauma 8(7):931–938.
Rhodes M, Smith S, Boorse D. 1993. Pediatric patients in an ''adult" trauma center. Journal of Trauma 35:384–393.
Rice DP, MacKenzie EJ, Jones AS, Kaufman SR, deLissovoy GV, Max W, McLoughlin E, Miller TR, Robertson LS, Salkever DS, Smith GS. 1989. Cost of Injury in the United States. San Francisco, CA: Institute for Health and Aging, University of California and Injury Prevention Center, The Johns Hopkins University.
Rogers FB, Osler TM, Shackford SR, Cohen M, Camp L. 1997a. Financial outcome of treating trauma in a rural environment. Journal of Trauma 43(1):65–72.
Rogers FB, Shackford SR, Hoyt DB, Camp L, Osler TM, MacKersie RC, Davis JW. 1997b. Trauma deaths in a mature urban vs. rural trauma system. Archives of Surgery 132(4):376–381.
Roy PD. 1987. The value of trauma centers: A methodological review. Canadian Journal of Surgery 30:17–22.
Rutledge R, Fakhry SM, Meyer A, Sheldon GF, Baker CC. 1993. An analysis of the association of trauma centers with per capita hospitalization and death rates from injury. Annals of Surgery 218(4):512–524.
Rutledge R, Hoyt D, Eastman AB, Sise MJ, Velky T, Canty T, Wachtel T, Osler TM. 1997. Comparison of the ISS and ICD-9 diagnoses codes as predictors of outcome in injury. Journal of Trauma 42(3):477–489.
Rutledge R, Osler T, Emery S, Kromhout-Schiro S. 1998. The end of ISS and the TRISS: ICISS outperforms both ISS and TRISS as predictors of trauma patient survival, hospital charges and hospital length of stay. Journal of Trauma 44:41–49.
Schwartz RJ, Jacobs LM, Yaezel D. 1989. Impact of pre-trauma center care on length of stay and hospital charges. Journal of Trauma 29:1611–1615.
Shackford SR. 1995. The evolution of modern trauma care. Surgical Clinics of North America 75(2):147–156.
Shackford SR, Hollingsworth-Fridlund P, Cooper GF, Eastman AB. 1986. The effect of regionalization upon quality of trauma care as assessed by concurrent audit before and after institution of a trauma system: A preliminary report. Journal of Trauma 26(9):812–820.
Shapiro MJ, Cole KE, Keegan M, Prasad CN, Thompson RJ. 1994. National survey of state trauma registries—1992. Journal of Trauma 37(5):835–840.
Smith JS, Martin LF, Young WW, Macioce DP. 1990. Do trauma centers improve outcome over non-trauma centers? The evaluation of regional trauma care using discharge abstract data and patient management categories. Journal of Trauma 30(12):1533–1538.
Spaite DW, Valenzuela TD, Meislin HW. 1993. Barriers to EMS system evaluation: Problems associated with field data collection. Prehospital and Disaster Medicine 8:S35–S40.
Stewart TC, Lane PL, Stefanits T. 1995. An evaluation of patient outcomes before and after trauma center designation using trauma and injury severity score analysis. Journal of Trauma 39:1036–1040.
Stout JL. 1994. System financing. In: Roush WR, ed. Principles of EMS Systems. Dallas: American College of Emergency Physicians. Pp. 451–473.
Swor R. 1994. Funding strategies. In: Kuehl AE, ed. Prehospital Systems and Medical Oversight, 2d edition. St. Louis: Mosby-Year Book. Pp. 76–80.
Trunkey D, Lewis FR. 1991. Preventable mortality. In: Trunkey D, Lewis FR, eds. Current Therapy of Trauma, 3d edition. Philadelphia, PA: Decker. Pp. 3–4.
U.S. DHHS (Department of Health and Human Services). 1991. Healthy People 2000: National Health Promotion and Disease Prevention Objectives . Washington, DC: U.S. Government Printing Office. (PHS) 91-50212.
U.S. DHHS (U.S. Department of Health and Human Services). 1992. Position Papers from the Third National Injury Conference, Setting the National Agenda for Injury Control in the 1990s, April 22–25, 1991, Denver, CO. Washington, DC: DHHS.
U.S. DHHS (Department of Health and Human Services). 1995. Managed Care for People with Disabilities: Developing a Research Agenda. Washington, DC: U.S. DHHS.
U.S. DOT (Department of Transportation). 1994. Uniform PreHospital EMS Data Conference Final Report, 1994. Washington, DC: U.S. DOT. DOT-3P0081.
U.S. DOT (Department of Transportation). 1995. EMS Systems Development: Results of the Statewide EMS Assessment Program. Washington, DC: U.S. DOT. DOT-3P0067.
U.S. DOT (Department of Transportation). 1996a. Consensus Statement on the EMS Role in Primary Injury Prevention. Washington, DC: U.S. DOT. DOT-3P0081.
U.S. DOT (Department of Transportation). 1996b. Emergency Medical Services: Agenda for the Future. Washington, DC: U.S. DOT. DOT HS 808 441; NTS-42.
U.S. Executive Office of the President, Office of Management and Budget. 1992–1995. Budget of the United States Government Fiscal Years 1992–1995. Washington, DC: U.S. Government Printing Office.
Valenzuela TD, Criss EA, Spaite D, Meislin HW, Wright AL, Clark L. 1990. Cost effectiveness analysis of paramedic emergency medical services in the treatment of prehospital cardiopulmonary arrest. Annals of Emergency Medicine 19(12):1407–1411.
Ware JE. 1995. The status of health assessment 1994. Annual Review of Public Health 16:327–354.
Ware JE, Sherbourne CD. 1992. The MOS 36-Item Short-Form Health Survey (SF-36). Medical Care 30:473–483.
West JG, Williams MJ, Trunkey DD, Wolferth CC. 1988. Trauma systems: Current status—future challenges. Journal of the American Medical Association 259(24):3597–3600.
Wilson IB, Cleary PD. 1995. Linking clinical variables with health-related quality of life: A conceptual model of patient outcomes. Journal of the American Medical Association 273(1):59–65.
Young GP, Lowe RA. 1997. Adverse outcomes of managed care gate keeping. Academic Emergency Medicine 4(12):1129–1135.