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Trauma systems provide an organized approach to the care of injured patients within a defined geographic region. When fully operational, the systems ensure a continuum of care involving public access through 911 calls, emergency medical services, timely triage and transport to acute care, and transfer to rehabilitation services. Substantial progress has been made in establishing statewide trauma systems, which are seen as the prototype for regionalized care for other time-sensitive, emergency conditions such as stroke. Trauma systems provide a model of care that is consistent with the goals of the Affordable Care Act, which authorizes $100 million in annual grants to ensure the continued availability of trauma services. Full funding of these provisions is needed to stabilize statewide systems that are struggling to survive. We describe the components of a regionalized trauma system, review the evidence in support of this approach, and discuss the challenges to sustaining systems that are accountable and affordable.

The calcaneous is the largest tarsal bone in the foot and plays an important role in walking and running. Motor vehicle crashes and falls from elevation have been associated with calcaneal fractures. Although not life-threatening, these injuries may result in permanent disability. This study used the Crash Injury Research and Engineering Network (CIREN) database to describe calcaneal fractures and concomitant lower extremity skeletal injury patterns for occupants involved in motor vehicle crashes. Sixty-three drivers and 7 front row passengers with calcaneal fractures were identified in the CIREN database during 1997-2005. Almost all these occupants were involved in severe (based on the delta V and vehicle crush) frontal or off-set frontal crashes with toe pan intrusion. Eighty-four percent of the calcaneal fractures were intra-articular or partially articular. Overall, 93% of occupants also had injury to other body regions with 84% having other lower extremity fractures. One year after the crash, most occupants had not returned to their prior level of physical functioning. Surgically managing patients with calcaneal fractures for an optimal outcome remains a challenge for orthopedic surgeons. Because lower extremity injuries, including calcaneal fractures, may cause permanent disability, it is important to prevent these injuries through structural improvements in motor vehicle design.

Introduction: Appropriate stratification of injury severity is a critical tool in the assessment of the treatment and the prevention of injury. Since its inception, the Injury Severity Score (ISS) has been the generally recognized "gold standard" for anatomic injury severity assessment. However, there is considerable time and expense involved in the collection of the information required to calculate an accurate ISS. In addition, the predictive power of the ISS has been shown to be limited. Previous work has demonstrated that the anatomic information about injury contained in the International Classification of Diseases Version 9 (ICD-9) can be a significant predictor of survival in trauma patients. The goal of this study was to utilize the San Diego County Trauma Registry (SDTR), one of the nation's leading trauma registries, to compare the predictive power of the ISS with the predictive power of the information contained in the injured patients' ICD-9 diagnoses codes. It was our primary hypothesis that survival risk ratios derived from patients' ICD-9 diagnoses codes would be equal or better predictors of survival than the Injury Severity Score. The implications of such a finding would have the potential for significant cost savings in the care of injured patients., Methods: Data for the test population were obtained from the SDTR, which contains data from 1985 through 1993 from five participating hospitals. Four data sources were utilized to estimate the expected survival rate/mortality rate for each ICD-9 code in the SDTR. These were (1) the SDTR patients themselves, (2) the North Carolina State Hospital Discharge Database, (3) the North Carolina Trauma Registry Database, and (4) the Agency for Health Care Policy Research's Health Care Utilization Project Database. Each of these data sources was separately utilized to develop a survival risk ratio (SRR) for each ICD-9 diagnoses code. The SRR was calculated by dividing the number of survivors for patients with each ICD-9 code by the total number of all patients with the particular ICD-9 diagnoses code. The four groups of SRRs derived from our four data sources were used as predictors of survival and the ability of the SRRs to predict survival was compared with the predictive power of the ISS using measures of accuracy, sensitivity, specificity, and receiver operator characteristic curves., Results: During the years 1985 through 1993, complete data were available for analysis on 44,032 patients. Of these, 2,848 patients died during their hospitalization (6%). Survival risk ratios were calculated for each of the diagnoses in the data base. Logistic regression, using the SAS System for statistical analysis, was used to assess the relative predictive power of the ISS and the survival risk ratios derived from the ICD-9 diagnoses codes from each of the four data bases. The analyses demonstrated that the regression models using the SRRs were generally as good or better than ISS as predictors of survival. The predictive power of the SRRs derived from the SDTR data, the North Carolina Trauma Registry data and the Health Care Utilization Report data were the best. In a subsequent analysis, the SRR values and the ISS were added to the patient's age and the revised Trauma Scores to create new predictive models in the mode of TRISS methodology. The analyses again indicated that the models using SRRs had as good or better predictive power than the model using the ISS., Conclusions: The present study confirms previous work showing that survival risk ratios derived from injured patients' ICD-9 diagnoses codes are as good as or better than ISS as predictors of survival.

An in-depth understanding of the economic problems confronting trauma centers is essential for their continued development and to address impending changes of health care reform. A comprehensive financial and demographic survey was sent to 839 hospitals identified as potential trauma centers. A total of 313 surveys from 48 states were returned. Extensive information was collected in several areas including financial status (58% reported serious financial problems and 36% reported minor financial problems; 68% reported a financial loss), cost containment and management strategies, marketing, "halo" effect (53% reported positive effect), operational impacts, physician support (47% reported problems), malpractice (92% reported no special problem), role of auto insurance reimbursement, and access to rehabilitation. Detailed financial data of actual costs and reimbursements (95 respondents) were analyzed with the costing method used by the Health Care Financing Administration (HCFA). These data will allow us to develop better strategies to deal with the problems of uncompensated and underfunded trauma care and improve trauma center viability.

Injury is our nation's leading public health problem. Victims of violence need expert and immediate medical attention. A model exists for optimal care of the injured patient--the trauma care, the components of the ideal, inclusive history of trauma care, the components of the ideal, inclusive trauma care system, its efficacy, and the challenges and opportunities facing those who advocate such systems.

There is a widespread perception that many trauma centers are poorly reimbursed, and many hospitals that once cared for trauma victims no longer do so, primarily for financial reasons. The problem is blamed on both uninsured and underinsured patients, but data supporting this perception are lacking. To determine the validity of these perceptions and to better understand the nature of trauma center reimbursement, a survey was conducted. A questionnaire on the volume of trauma seen annually and the reimbursement experience for trauma center (TC) and hospital (HO) patient populations was mailed to representative but nonrandomly chosen trauma centers. Seventy-one surveys were mailed and 25 were returned (35%). There were 15 Level I and 10 Level II centers; 16 were urban, seven were suburban, and two were rural. Eighteen centers (72%) reported significant underfunding of the TC in contrast to the HO, and 11 indicated that they would not be able to continue their current level of TC services with present reimbursement. For Medicare patients, HO cost recovery rates averaged 93%, but recovery rates were only 64% for TCs. For Medicaid beneficiaries, the HO cost recovery rate averaged 85%, but it was only 49% for TCs. Thirty-one percent of TC patients had no insurance coverage at all, in contrast to only 9% of HO patients. An aggregate loss equal to 19.9% of total costs was reported by respondents. This survey, while not representative of trauma centers as a whole throughout the United States, does suggest that there is a basis for the perception of underfunding of trauma care and indicates that such underfunding results from the combination of adverse selection and disproportionate share. We also describe a new method for assessing and comparing trauma center reimbursement.

Regional trauma system implementation is proceeding in a number of areas of the United States in response to a demonstrated need for improved trauma care to prevent unnecessary death. The critical questions underlying the design of such systems and the current state of knowledge and opinion regarding each of them have been defined and these provide a framework for system planning. Additional data are badly needed in several areas to provide a more rational basis for system configuration. It is hoped that systems currently being implemented will include appropriate data elements in their trauma registries to answer the remaining questions in succeeding years.