Priorities for research in trauma care: creating a bucket list

Abstract

Trauma represents a major global health burden [1Haagsma JA Graetz N Bolliger I Naghavi M Higashi H Mullany EC et al.The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study 2013.Inj Prev. 2016; 22: 3-18Crossref PubMed Scopus (577) Google Scholar, 2Søreide K. Epidemiology of major trauma.Br J Surg. 2009; 96: 697-698Crossref PubMed Scopus (127) Google Scholar], yet receives disproportionally less funding compared to other medical conditions [[3]Glass NE Riccardi J Farber NI Bonne SL Livingston DH Disproportionally low funding for trauma research by the National Institutes of Health: A call for a National Institute of Trauma.J Trauma Acute Care Surg. 2020; 88: 25-32Crossref PubMed Scopus (8) Google Scholar]. One report found that injury research constituted only 6% of all research grants provided by major funders [[4]Ralaidovy AH Adam T Boucher P Resource allocation for biomedical research: analysis of investments by major funders.Health Res Policy Syst. 2020; 18: 20Crossref PubMed Scopus (5) Google Scholar]. Alas, if only there was an endless funding resource for trauma and critical care research. Indeed, only those who have tried to get past the high doors of the federal and institutional research funding programmes (where these even exist) can tell of the intricacies involved, the frustration and pain of rejections, the hard work and relentless hours of tedious reporting to reach an even remotely slim chance for a well-funded research programme on a perceived valuable theme and a well-designed project [[5]Branas CC Wiebe DJ Schwab CW Richmond TS Getting past the "f" word in federally funded public health research.Inj Prev. 2005; 11: 191Crossref PubMed Scopus (18) Google Scholar]. Clearly, there is a need to prioritize. The critical questions are what to investigate, what to fund and, what are the clinical implications and for whom? And, hence, how to strengthen the trauma chain of survival [[6]Søreide K. Strengthening the trauma chain of survival.Br J Surg. 2012; 99: 1-3Crossref PubMed Scopus (13) Google Scholar] (Fig. 1)? Defining a research agenda or even a priority among the topics viewed as ‘research worthy’ may prove hard. Clearly, priority is based on perspective, which again is all about location and situation of the beholder. So, for a US trauma researcher, among all of the important research themes that may come up on any given agenda, the prevention of deaths and injuries caused by gun violence cannot escape attention, as it is a major trauma-related research challenge from so many perspectives [7Manley NR Fischer PE Sharpe JP Stranch EW Fabian TC Croce MA et al.Separating Truth from Alternative Facts: 37 Years of Guns, Murder, and Violence Across the US.J Am Coll Surg. 2020; 230: 475-481Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar, 8Kaufman EJ Richmond TS. Beyond Band-Aids for Bullet Holes: Firearm Violence As a Public Health Priority.Crit Care Med. 2020; 48: 391-397Crossref PubMed Scopus (4) Google Scholar]. However, other regions of the world have a much lower burden of penetrating trauma and hence view other aspects in need of research attention. In less ‘developed’ countries (for the lack of a better definition) the research agenda may be viewed quite differently, as the interest may lie in gathering an overview of the data and numbers involved (e.g. through development of a registry) or, even identifying barriers to care may be the top priority on the research agenda [[9]Gobyshanger T Bales AM Hardman C McCarthy M Establishment of a road traffic trauma registry for northern Sri Lanka.BMJ Glob Health. 2020; 5e001818Crossref PubMed Scopus (3) Google Scholar]. Further, the specific specialisms involved in trauma management may view priorities specifically from their standpoint of care, as has been reported for physician-manned pre-hospital care [[10]Rehn M Bache KG Lossius HM Lockey D Top five research priorities in physician-provided pre-hospital critical care - appropriate staffing, training and the effect on outcomes.Scand J Trauma Resusc Emerg Med. 2020; 28: 32Crossref PubMed Scopus (2) Google Scholar], for surgical critical care [[11]Kim DY Lissauer M Martin N Brasel K Defining the surgical critical care research agenda: Results of a gaps analysis from the Critical Care Committee of the American Association for the Surgery of Trauma.J Trauma Acute Care Surg. 2020; 88: 320-329Crossref PubMed Scopus (2) Google Scholar] (including trauma) and for specific age-groups and associated skeletal injuries [[12]Sheehan WJ Williams MA Paskins Z Costa ML Fernandez MA Gould J et al.Research priorities for the management of broken bones of the upper limb in people over 50: a UK priority setting partnership with the James Lind Alliance.BMJ Open. 2019; 9e030028Crossref PubMed Scopus (5) Google Scholar]. Also, public and patients perspectives can be incorporated into the broad range of trauma research [13Hawarden A Jinks C Mahmood W Bullock L Blackburn S Gwilym S et al.Public priorities for osteoporosis and fracture research: results from a focus group study.Arch Osteoporos. 2020; 15: 89Crossref PubMed Scopus (3) Google Scholar, 14Godat LN Jensen AR Stein DM Patient-centered outcomes research and the injured patient: a summary of application.Trauma Surg Acute Care Open. 2020; 5e000422Crossref PubMed Scopus (2) Google Scholar]. Moreover, cultural and societal differences in priorities are important but less well investigated [[15]Huh S Ko HY. Recovery target priorities of people with spinal cord injuries in Korea compared with other countries: a survey.Spinal Cord. 2020; Crossref PubMed Scopus (1) Google Scholar]. In this issue of INJURY, Curtis and colleagues have identified clinical research priorities for Australia and New Zealand trauma researchers [[16]Curtis K Nahidi S Gabbe B Vallmuur K Martin K Shaban RZ et al.Identifying the priority challenges in trauma care delivery for Australian and New Zealand trauma clinicians.Injury. 2020; Google Scholar]. The work builds on parallel efforts to define the challenges for trauma care delivery [[17]Curtis K Gabbe B Vallmuur K Martin K Nahidi S Shaban RZ et al.Challenges to trauma care delivery for Australian and New Zealand trauma clinicians.Injury. 2020; 51: 1183-1188Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar] and the priorities for quality improvement and registry use [[18]Curtis K Gabbe B Shaban RZ Nahidi S Pollard Am C Vallmuur K et al.Priorities for trauma quality improvement and registry use in Australia and New Zealand.Injury. 2020; 51: 84-90Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar]. The researchers should be congratulated for their systematic approach to identifying the current state of trauma management and directing the way forward. The presented data are of interest and have wider application outside Australia and New Zealand. However, the results may be viewed in the context of the specific population demographics in both urban and rural regions, geographical challenges related to distances and coverage for transport, injury patterns and the maturity of the current trauma system. In their report based on a modified Delphi technique, Curtis et al. identified 5 priority areas [[16]Curtis K Nahidi S Gabbe B Vallmuur K Martin K Shaban RZ et al.Identifying the priority challenges in trauma care delivery for Australian and New Zealand trauma clinicians.Injury. 2020; Google Scholar]. Briefly put, the top priorities concern the injured patient at the extremes of age (the elderly and children); the role of performance indicators; the management of traumatic brain injury, and; prehospital triage criteria [[16]Curtis K Nahidi S Gabbe B Vallmuur K Martin K Shaban RZ et al.Identifying the priority challenges in trauma care delivery for Australian and New Zealand trauma clinicians.Injury. 2020; Google Scholar]. All 5 areas can easily be agreed as challenging topics and areas worthy of further investigation. However, it might be of interest to look at some of the topics that just did not make the cut in the Delphi process– specifically those that had a high initial score during the first Delphi round but fell out in favour of other topics in subsequent rounds. Among these are ‘classical’ trauma research topics including “managing the bleeding trauma patient” with subtopics including blood product ratios for transfusion and handling of pelvic injuries. Further, imaging-based decision-making had a high initial score (same initial score as management of traumatic brain injury) but for some reason dropped below the 70% criteria set for consensus. The same occurred for “methods to enhance exposure to trauma in low volume centres” and topics related to trauma team training and team dynamics to enhance clinical practice. The latter had a high consensus (77%) but below the 80% score to make the top 5 priority list. Notably, had the group decided to expand the priority list to a ‘top 10’ rather than the arbitrarily set threshold of ‘top 5’, several of the topics that just missed the cut would have been included. Also, while the Delphi group was made up of persons from a multidisciplinary setting, a diverse background and various locations, there was a notable change between rounds (e.g. number of surgeons increased to almost double in round two; prehospital personnel were absent in round one, but appeared in round two) and slightly skewed towards metropolitan practice (threequarters) and some geographical regions (New South Wales) compared to others. Hence, the composition of the Delphi group may provide an inherent bias towards certain viewpoints, which is a recognized limitation to this type of consensus work, sometimes having the risk of becoming an echo chamber. For example, had a higher number of rural practitioners been involved, the focus on team training and exposure in low volume settings may have received a higher priority score, reflecting a need possibly viewed differently form a rural perspective than an urban. The researchers have recognized some of these limitations to the study design [[16]Curtis K Nahidi S Gabbe B Vallmuur K Martin K Shaban RZ et al.Identifying the priority challenges in trauma care delivery for Australian and New Zealand trauma clinicians.Injury. 2020; Google Scholar], which the reader and interpreter of the report must take into consideration as well. Notably, other stakeholders, such as government officials and patients may have other views of the set priorities. Nonetheless, the report provides a valuable “bucket list” of areas in need of new data and better evidence to inform improved decision-making for the clinician. The objectives for clinical research in trauma care should be to strengthen the trauma chain of survival [[6]Søreide K. Strengthening the trauma chain of survival.Br J Surg. 2012; 99: 1-3Crossref PubMed Scopus (13) Google Scholar] (Fig. 1). Good quality trauma care does not happen by accident, nor does it occur in isolation. The multidisciplinary care of the injured patients involves a considerable number of care takers with varying views and perspective to delivery and decisions in care [[19]Stey AM Wybourn CA Lyndon A Knudson MM Dudley RA Liu P et al.How care decisions are made among interdisciplinary providers caring for critically injured patients: A qualitative study.Surgery. 2020; 167: 335-339Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar]. While ‘survival’ may be a valid and hard endpoint in trauma and critical care [[20]Søreide E Morrison L Hillman K Monsieurs K Sunde K Zideman D et al.The formula for survival in resuscitation.Resuscitation. 2013; 84: 1487-1493Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar], the end-product relies on several components that lead to the outcome (Fig. 2). The role of survival as an endpoint is arguably a valid outcome metric, yet Curtis et al [[16]Curtis K Nahidi S Gabbe B Vallmuur K Martin K Shaban RZ et al.Identifying the priority challenges in trauma care delivery for Australian and New Zealand trauma clinicians.Injury. 2020; Google Scholar] have identified a need for other outcome metrics and key performance indicators in trauma care. Where these are eventually identified, one may use the formula (Fig. 2) to generate an ‘equation’ for achieving best performance of the chosen outcome metric. Generating new data (‘medical science’) is only helpful where knowledge is understood by clinicians (‘educational efficacy’) and brought into clinical care under the given local conditions (‘local implementation’) to enhance patient outcome. The Delphi process has identified a set of top priorities, generating a “bucket list” of themes to investigate. Subsequent areas may follow suit to adjust the list to the chain of survival and the formula of survival. Notably, identification of what to research may be the low hanging fruit. Addressing how and by which methods these themes may be best investigated will be the next quest for the trauma researchers. Lastly, funders will still need to be convinced that the topics and methods proposed are good ‘value for money’ and competitive against other conditions and ailments in society. Only then can the evidence-based and optimal quality of care be brought to the injured patient.

Topics & Concepts