NTI Board Chair Advocates Case For Trauma Funding For HHS Panel

Trauma is one of the most lethal and costly healthcare conditions affecting Americans of all ages, yet to date, federal funding has been sporadic and inadequate relative to the magnitude of the problem. Additionally, trauma has not been identified by the Health and Human Services Secretary as a priority condition, as defined under the Medicare Prescription Drug, Improvement and Modernization Act of 2003.

The Federal Coordinating Council has been given a broad mandate by Congress to recommend direction for funding provided in the Recovery Act. The National Trauma Institute respectfully requests that the Council recommend that substantial Comparative Effectiveness Research funds be dedicated to trauma.

What is Trauma?

Medical trauma is any serious injury resulting from intentional or unintentional violence and can result in bone fractures, head injuries, burns, hemorrhage, or secondary complications such as shock, respiratory failure, infection, post-traumatic stress disorder or death.

Because of the scope and scale of trauma occurrences, the field of trauma is ideally suited for comparative effectiveness research. Trauma is one of the most interdisciplinary fields in all of medicine, involving the collaboration of trauma surgeons, numerous medical specialties, engineers, behavioral scientists, and epidemiologists. In other diseases, medical practitioners have the ability to try different courses of treatment over time and observe and evaluate effectiveness of alternatives. However in trauma, surgeons and other providers have seconds or minutes to evaluate the status, implement a life-saving intervention and change course if necessary. Over the past 50 years, there have been few major advances in trauma care. According to trauma surgeons, many treatments provided are not evidence-based. Trauma providers need to have evidence-based alternatives to determine the best possible treatment in an incredibly short amount of time.

Impact of Trauma on Society

Prevalence

    Traumatic injury is a major, largely unrecognized public health problem in the United States.
      Trauma is the leading cause of death for people aged 1-44 years, and is the fifth leading
      cause of death of Americans of all ages.

    Over 160,000 Americans die from injury each year.

    Trauma accounts for 37 million emergency department visits and 2.6 million hospital
      admissions across the nation per year.

    Trauma affects both civilians and military personnel.

Burden of Trauma

According to the CDC, injury accounts for 30% of all life years lost in the U.S. -- equal to the combined life years lost from cancer (16%), heart disease (12%) and HIV (2 %).

Variability in Outcomes in Trauma

The variability in outcomes in trauma is exponentially increased by the number of settings, the multitude of multidisciplinary providers, and the complexity of decisions made in all settings by all providers. This often has a confounding effect with a direct impact on the patient’s survival and outcome, especially given the inherently challenging environment within which all of this occurs.

Trauma injury is a complex condition that involves direct mechanical insult to tissues as well as systemic disturbance of the entire body. Unlike many other areas of medical research, which are strictly defined by organ systems or types of conditions, trauma injury is uniquely defined by the urgency and location of treatment. Trauma research needs to be applied in the acute setting, at the scene of injury (pre-hospital EMS or military medic), at the patient’s bedside in the hospital (ICU, OR), and during recovery and rehabilitation.

Treatment and transport of a trauma patient may involve paramedics, trauma and burn surgeons, nurses, radiology personnel, blood bank, respiratory therapy, rehabilitation and other ancillary disciplines, along with selected physicians from 16 specialties ranging from neurosurgery to OB/GYN. It is specifically because of this diversity of medical participants that standardized treatment options are not well defined. To succeed, research must be based on the establishment of large-scale multicenter research collaborations. Comparative Effectiveness Research in multicenter networks would enable researchers from the diverse disciplines of trauma and emergency care research to assemble sufficiently large data sets to establish robust research findings, and change clinical practice.

Costs of Care

The economic burden of trauma reaches $400 billion a year, including both health care costs (20% of total) and lost productivity (80%).

Trauma affects diverse patient populations

Trauma can happen to anyone. All ages and races and both sexes are affected. Trauma is the leading cause of the death of children in this country. Among people 65 years and older, falls are the leading cause of injury deaths and the most common cause of nonfatal injuries and hospital admissions for trauma, adding significantly to Medicare costs. The combined number of deaths from Operation Iraqi Freedom and Operation Enduring Freedom (OIF/OEF) just reached 5000, and the number of injuries exceeds 34,000. Virtually all of these are due to trauma injuries. Since the US is made up of many subpopulations, and none of these escape trauma, Comparative Effectiveness Research would impact all sectors of society.

Trauma needs clear, evidence-based data to reduce uncertainty

Despite some advances in medicine and technology, trauma care has in many ways been trapped in the past century. For example;

    A soldier wounded in Iraq will receive the same salt solution that was used in Korea.
     The best fluids for resuscitation are still not determined.

    Blood substitutes need to be researched and evaluated. Military doctors serving today in
     OIF/OEF have the same problems storing blood that plagued doctors decades ago.

    Traumatic brain injury has only recently become a significant field of research.

    It is still unclear whether drugs can stem hemorrhage from internal bleeding. Advances
     have been made in stemming hemorrhage to the extremities; non-compressible hemorrhage
     remains the top military research priority. Alternatives include hemostatic agents, foams,
     and compression instruments.

    The known options for appropriate ventilation management are highly debated and
     need resolution.

    Burn treatment is still plagued by a lack of effective skin covering or skin replacement.

    Many technologies such as decision assist devices, imaging systems, biosensors and
     wound therapies are being developed. Significant changes to clinical practice could be
     implemented with these technologies, but clinical effectiveness research needs to be
     conducted to determine the most effective instruments, and those that will alter long-term
     outcomes for trauma victims.

The Gap in Funding for Trauma

Forty years ago, the National Research Council report entitled “Accidental Death and Disability,” first focused attention on the inadequacy of emergency and trauma care research. Although trauma research at the NIH has grown, the growth does not come close to addressing the magnitude or scope of the problem. Among more than two dozen research institutes at the NIH, none is devoted exclusively to trauma.

In 1994, NIH convened a task force which produced a report on trauma research needs and gaps. This report recommended doubling funding to trauma research centers, but sufficient funding was never appropriated to implement this recommendation. Within the context of years of potential life lost (millions of dollars per years of potential life lost per 100,000 population), the NIH support ratio for HIV is $3.35, for Cancer $1.65, and for Trauma, just 10 cents. A 2006 Institute of Medicine Report also discussed the lack of trauma and emergency care research funding and recognized the need for a multi-disciplinary approach. In recent years, some areas of trauma research (traumatic brain injury, post-traumatic stress disorder, and orthopaedic trauma) have received substantial federal funding. However, this funding is narrowly focused and does not cover the vast majority of trauma-related medical conditions.

Potential for multiplicative effect

An initial investment of Comparative Effectiveness Research funds for trauma would address the most significant and pressing needs for evidence-based practice decisions. Initial research would promote interest and engagement of both public and private sectors, leading to further funding and research. Ultimately, funding of trauma research will reduce death and disability in America.

Conclusion

The purpose of the National Trauma Institute (NTI) is to create awareness of the burden of trauma on society and to raise a critical mass of funds from a variety of public and private sources for trauma research. NTI uses these funds to establish data registries and award research grants for translational projects, targeting those that will lead to fast, effective outcomes and then disseminating these results to the national medical community within 1-3 years. NTI organizes and sponsors multiple national investigator and educational meetings each year, including its Annual Symposium attended by over 1,000 practitioners and leaders in military and civilian trauma. NTI has national scope and leadership with a Board of Directors representing the military branches and senior leaders in trauma research and practice.

NTI represents the national community of trauma surgeons in calling for Comparative Effectiveness Research on Trauma to address this obvious and urgent medical need. We believe that trauma fits extraordinarily well into the Comparative Effectiveness Research agenda and meets all criteria for inclusion. Because trauma is a pressing national medical concern, we ask the FCC to request that the Secretary of Health and Human Services fund trauma research.