Skip to main content

Advertisement

SpringerLink
Log in

Accessibility, accountability, affordability: healthcare policy in orthopedic trauma

  • Orthopaedic Health Policy (A Miller, section editor)
  • Published:
Current Reviews in Musculoskeletal Medicine Aims and scope Submit manuscript

Abstract

Purpose of review

This review provides historical background on trauma care in the USA and summarizes contemporary trauma-related health policy issues. It is a primer for orthopedic surgeons who want to promote improvements in research, delivery, and cost reduction in trauma care.

Recent findings

As of 2010, funding for trauma research accounted for only 0.02% of all National Institutes of Health research funding. This is disproportionate to the societal burden of traumatic injury, which is the leading cause of death and disability among people aged 1 to 46 years in the USA. The diagnosis-related group model of hospital reimbursement penalizes level-I trauma centers, which typically treat the most severely injured patients. Treatment of traumatic injury at level-I and level-II trauma centers is associated with lower rates of major complications and death compared with treatment at non-trauma centers. Patient proximity to trauma centers has been positively correlated with survival after traumatic injury. Inadequate funding has been cited as a reason for recent closures of trauma centers.

Summary

Orthopedic surgeons have a responsibility to engage in efforts to improve the quality, accessibility, and affordability of trauma care. This can be done by advocating for greater funding for trauma research; choosing the most cost-effective, patient-appropriate orthopedic implants; supporting the implementation of a national trauma system; leading high-quality research of trauma patient outcomes; and advocating for greater accessibility to level-I trauma centers for underserved populations.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: •Of importance, ••Of major importance

  1. United States Department of Health and Human Services. Health, United States, 2015: with special feature on racial and ethnic health disparities. Available at https://www.cdc.gov/nchs/data/hus/hus15.pdf#019. Accessed 1 March 2017.

  2. Murray CJL, Lopez AD. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Boston, MA: Harvard School of Public Health on behalf of the World Health Organization and the World Bank; 1996.

    Google Scholar 

  3. Trunkey DD. History and development of trauma care in the United States. Clin Orthop. 2000;374:36–46.

    Article  Google Scholar 

  4. MacKenzie EJ, Rivara FP, Jurkovich GJ, Nathens AB, Frey KP, Egleston BL, et al. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med. 2006;354(4):366–78. doi:10.1056/NEJMsa052049.

    Article  CAS  PubMed  Google Scholar 

  5. National Academy of Sciences and National Research Council Committee on Trauma, National Academy of Sciences and National Research Council Committee on Shock. Accidental death and disability: the neglected disease of modern society. Washington (DC): National Academies Press (US) Copyright (c) National Academy of Sciences; 1966.

    Google Scholar 

  6. National Traffic and Motor Vehicle Safety Act. Pub. L. 89–563, § 1, 80 Stat. 718. 1966

  7. Mitchell PM, Thakore R, Obremskey A, Sethi MK. Orthopaedic trauma and the evolution of healthcare policy in America. J Orthop Trauma. 2014;28(Suppl 10):S2–4. doi:10.1097/bot.0000000000000214.

    Article  PubMed  Google Scholar 

  8. Institute of Medicine (US), National Research Council (US) Committee on Trauma Research. Injury in America: a continuing public health problem. 1st ed. Washington DC: National Academy Press; 1985.

    Google Scholar 

  9. Trauma Care Systems Planning and Development Act HR 1602, 101st Leg. 1990.

  10. Buchmueller TC, Jacobson M, Wold C. How far to the hospital? The effect of hospital closures on access to care. J Health Econ. 2006;25(4):740–61. doi:10.1016/j.jhealeco.2005.10.006.

    Article  PubMed  Google Scholar 

  11. Sampalis JS, Lavoie A, Williams JI, Mulder DS, Kalina M. Impact of on-site care, prehospital time, and level of in-hospital care on survival in severely injured patients. J Trauma. 1993;34(2):252–61.

    Article  CAS  PubMed  Google Scholar 

  12. •• Carr BG, Bowman AJ, Wolff CS, Mullen MT, Holena DN, Branas CC, et al. Disparities in access to trauma care in the United States: a population-based analysis. Injury. 2017;48(2):332–8. doi:10.1016/j.injury.2017.01.008. This cross-sectional study included the entire US population to evaluate overall access to trauma care and factors associated with lack of access to care. Populations already considered vulerable secondary to rural location, insurance status, and income lacked access to trauma care.

    Article  PubMed  Google Scholar 

  13. • Hsia RY, Srebotnjak T, Maselli J, Crandall M, Mcculloch C, Kellermann AL. The association of trauma center closures with increased inpatient mortality for injured patients. J Trauma Acute Care Surg. 2014;76(4):1048–54. doi:10.1097/ta.0000000000000166. The trend of trauma center closures had been well documented and was widely known; however, this was the first study to demonstrate the association of these closures with increased mortality for the injured in the state of California.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Hsia RY, Shen YC. Rising closures of hospital trauma centers disproportionately burden vulnerable populations. Health Affairs (Project Hope). 2011;30(10):1912–20. doi:10.1377/hlthaff.2011.0510.

    Article  PubMed Central  Google Scholar 

  15. Glance LG, Osler TM, Mukamel DB, Dick AW. Outcomes of adult trauma patients admitted to trauma centers in Pennsylvania, 2000–2009. Archives of Surgery (Chicago, Ill : 1960). 2012;147(8):732–7. doi:10.1001/archsurg.2012.1138.

    Article  Google Scholar 

  16. Dutton RP, Stansbury LG, Leone S, Kramer E, Hess JR, Scalea TM. Trauma mortality in mature trauma systems: are we doing better? An analysis of trauma mortality patterns, 1997–2008. J Trauma. 2010;69(3):620–6. doi:10.1097/TA.0b013e3181bbfe2a.

    Article  PubMed  Google Scholar 

  17. Mullins RJ. A historical perspective of trauma system development in the United States. J Trauma. 1999;47(3 Suppl):S8–14.

    Article  CAS  PubMed  Google Scholar 

  18. American Hospital Association. TrendWatch: Rethinking the hospital readmissions reduction program. Available at http://www.aha.org/research/reports/tw/15mar-tw-readmissions.pdf. Accessed 7 March 2016.

  19. Benbassat J, Taragin M. Hospital readmissions as a measure of quality of health care: advantages and limitations. Arch Intern Med. 2000;160(8):1074–81.

    Article  CAS  PubMed  Google Scholar 

  20. van Walraven C, Bennett C, Jennings A, Austin PC, Forster AJ. Proportion of hospital readmissions deemed avoidable: a systematic review. CMAJ. 2011;183(7):E391–402. doi:10.1503/cmaj.101860.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Joynt KE, Jha AK. Characteristics of hospitals receiving penalties under the hospital readmissions reduction program. JAMA. 2013;309(4):342–3. doi:10.1001/jama.2012.94856.

    Article  CAS  PubMed  Google Scholar 

  22. Congress.gov. H.R.3982 - Omnibus Budget Reconciliation Act of 1981. Available at https://www.congress.gov/bill/97th-congress/house-bill/3982. Accessed 7 March 2017.

  23. Shen YC, Hsia RY, Kuzma K. Understanding the risk factors of trauma center closures: do financial pressure and community characteristics matter? Med Care. 2009;47(9):968–78. doi:10.1097/MLR.0b013e31819c9415.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Chandra A, Dalton MA, Holmes J. Large increases in spending on postacute care in Medicare point to the potential for cost savings in these settings. Health Affairs (Project Hope). 2013;32(5):864–72. doi:10.1377/hlthaff.2012.1262.

    Article  PubMed Central  Google Scholar 

  25. • Althausen PL, Lapham J, Mead L. Financial impact of dual vendor, matrix pricing, and sole-source contracting on implant costs. J Orthop Trauma. 2016;30(Suppl 5):S37–s9. doi:10.1097/bot.0000000000000719. Demonstrates the significant cost savings to the patient, hospital, and health system that can be achieved when the orthopaedic surgeon is involved in the implant cost negotiations.

    Article  PubMed  Google Scholar 

  26. Centers for Disease Control and Prevention. Cost of injuries and violence in the United States. Available at https://www.cdc.gov/injury/wisqars/overview/cost_of_injury.html. Accessed 7 March 2017.

  27. Lochner HV, Bhandari M, Tornetta P 3rd. Type-II error rates (beta errors) of randomized trials in orthopaedic trauma. J Bone Joint Surg Am. 2001;83-a(11):1650–5.

    Article  CAS  PubMed  Google Scholar 

  28. •• Davis KA, Fabian TC, Cioffi WG. The toll of death and disability from traumatic injury in the United States—the “neglected disease” of modern society, still neglected after 50 years. JAMA Surg. 2016; doi:10.1001/jamasurg.2016.4625. Redemonstrates the growing discrepancy between the disease burden for trauma versus other disease processes and their funding and calls into question the lack of action, attention, and funding directed at injury.

    PubMed  Google Scholar 

  29. Jenkins DH, Cioffi WG, Cocanour CS, Davis KA, Fabian TC, Jurkovich GJ, et al. Position statement of the Coalition for National Trauma Research on the National Academies of Sciences, Engineering and Medicine report, a National Trauma Care System: integrating military and civilian trauma systems to achieve zero preventable deaths after injury. J Trauma Acute Care Surg. 2016;81(5):816–8. doi:10.1097/ta.0000000000001218.

    Article  PubMed  Google Scholar 

  30. •• Berwick DM, Downey AS, Cornett E, National Academies of Sciences Engineering and Medicine (U.S.), Committee on Military Trauma Care’s Learning Health System and Its Translation to the Civilian Sector, National Academies of Sciences Engineering and Medicine (U.S.), et al. A national trauma care system: integrating military and civilian trauma systems to achieve zero preventable deaths after injury. Washington, DC: National Academies Press; 2016. Echoes the disappointment with the lack of action at improving the care for the injured and established a military and civilian collaborative committee charged with an aggressive effort to establish a National Trauma Care System that will function as a learning feedback system and build on a continuous evidence-based process improvement model that will ensure the needed in advancements in trauma care and ultimately result in zero preventable deaths.

    Book  Google Scholar 

  31. •• Major Extremity Trauma Research Consortium (METRC). Building a clinical research network in trauma orthopaedics: the Major Extremity Trauma Research Consortium (METRC). J Orthop Trauma. 2016;30(7):353–61. doi:10.1097/bot.0000000000000549. The success this collaborative network of civilian level-I trauma centers and military centers has had in multicenter prospective sutdies demonstrates the great potential for an even larger collaboration aimed at improving the overall care of injured patients guided by evidence-based medicine.

    Article  Google Scholar 

  32. Okike K, O'Toole RV, Pollak AN, Bishop JA, McAndrew CM, Mehta S, et al. Survey finds few orthopedic surgeons know the costs of the devices they implant. Health Affairs (Project Hope). 2014;33(1):103–9. doi:10.1377/hlthaff.2013.0453.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St, Baltimore, MD, USA

    Renee C. Genova, Rachel L. Box & James R. Ficke

Authors
  1. Renee C. Genova
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Rachel L. Box
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. James R. Ficke
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to James R. Ficke.

Ethics declarations

Conflict of interest

The authors declare that they have no conflicts of interest.

Human and animal rights

This article does not contain any studies with human or animal subjects performed by any of the authors.

Funding statement

The authors did not receive any funding or grants in support of their research for or preparation of this work.

Additional information

This article is part of the Topical Collection on Orthopaedic Health Policy

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Genova, R.C., Box, R.L. & Ficke, J.R. Accessibility, accountability, affordability: healthcare policy in orthopedic trauma. Curr Rev Musculoskelet Med 10, 258–264 (2017). https://doi.org/10.1007/s12178-017-9414-7

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12178-017-9414-7

Keywords

Search

Navigation