Injury 52 (2021) 125–126
Contents lists available at ScienceDirect
Injury
journal homepage: www.elsevier.com/locate/injury
Trauma systems save lives - Is that enough?
Over the past 30 years, there have been significant and notable
reductions in injury-related mortality in high income countries [1],
attributable to public health gains in injury prevention, improved
trauma care and the introduction of organised trauma systems.
There is clear evidence that organised trauma systems save lives
through the reduction of preventable mortality [2-4]. This evidence
is more easily gleaned as most trauma systems would have sys-
tematic processes in place to monitor mortality, providing ready
access to data about trends in survival. However, most trauma pa-
tients survive and disability is an ever increasing component of
injury burden [1], providing some explanation for why the per-
centage of the global disease burden attributable to injury has not
changed from 1990 to 2019 despite mortality improvements [5].
While the preservation of life remains a critical focus of trauma
care, demonstrable improvements in outcomes for trauma sur-
vivors and the reduction of the global disability burden, requires
a system focus on measuring the quality of survival to inform im-
proved care and better support people recovering from injury. In
recognition of the importance of understanding who recovers from
injury, when and how well, there has been a growing body of
literature focused on a wide range of patient-reported outcomes
(PROs) including function, health-related quality of life and psy-
chosocial outcomes. Most involve a single centre, are standalone
research studies, and use different outcome assessments adminis-
tered at variable time points in the patient’s recovery. While these
studies have substantial merit, improving our knowledge base of
injury burden and recovery, they have limited use in benchmarking
of care between centres and systems, monitoring change in out-
comes over time, and establishing the population impacts of injury.
Advancements in trauma system design and care focused on the
long-term outcomes of people who sustain trauma requires robust
surveillance that is fit-for-purpose. Embedding collection of impor-
tant outcomes at designated time points in the patient’s recovery,
including PROs, would significantly advance our understanding of
injury outcomes and burden, and provide critical data for inform-
ing interventions and services capable of delivering improved long-
term outcomes. In this issue, Hatchimonji et al. present the find-
ings of their study exploring the acceptability of administration of
PROs as part of routine care in outpatient trauma clinics [6]. While
the completion rates were relatively low, and the focus was on the
early part of the recovery journey, the underlying premise should
be commended. Efforts to standardise and normalise the routine
collection of PROs should be a fundamental component of trauma
systems as these outcomes are relevant to more than 90% of the
trauma population.
https://doi.org/10.1016/j.injury.2021.01.024
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Robust monitoring and evaluation of the long-term outcomes
of trauma has wide reaching consequences. Investment in health
policy and social policy, relevant infrastructure (e.g. road design)
spending, and in industry innovation (e.g. safe product develop-
ment) requires accurate inputs about the incidence and burden of
injury to determine the value and cost-effectiveness of interven-
tions. If we base investment on inaccurate or incomplete estimates
and assumptions about the time course and magnitude of the im-
pacts on people’s lives, we will continue to under-invest in injury
prevention and control, discard measures and initiatives that could
impact profoundly on reducing injury burden, and therefore per-
petuate the individual, system and societal impacts of injury. Es-
tablishing routine and standardised measurement of the outcomes
of trauma along the patient’s recovery journey is possible [7,8], but
requires resources and the clinical and political will to deliver. Con-
tinued focus on measuring trauma system performance based on
mortality alone will hinder our capacity to progress trauma care,
fail to improve the outcomes of the many millions of people each
year who sustain a serious injury and survive, and continue our
under-investment in prevention and control. In 2019, 253 million
Disability Adjusted Life Years were lost to injury worldwide [5].
How can we afford to persist with the status quo?
Belinda J Gabbe
Ben Beck
School of Public Health and Preventive Medicine, Monash University,
Melbourne, Australia
E-mail addresses: belinda.gabbe@monash.edu (B.J. Gabbe),
ben.beck@monash.edu (B. Beck)
References
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tality, healthy life expectancy (HALE), and population estimates in 204 coun-
tries and territories, 1950-2019: a comprehensive demographic analysis for the
Global Burden of Disease Study 2019. Lancet 2020;396(10258):1160–203.
[2] Cameron P, Gabbe B, Cooper D, Walker T, Judson R, McNeil J. A statewide sys-
tem of trauma care in Victoria: effect on patient survival. Medical Journal of
Australia 2008;189(10):546–50.
[3] MacKenzie E, Rivara F, Jurkovich G, Nathens A, Frey K, Egleston B, et al. A na-
tional evaluation of the effect of trauma-center care on mortality. New England
Journal of Medicine 2006;354:366–78.
[4] Moran CG, Lecky F, Bouamra O, Lawrence T, Edwards A, Woodford M,
et al. Changing the System - Major Trauma Patients and Their Outcomes in the
NHS (England) 2008-17. EClinicalMedicine 2018;2-3:13–21.
[5] GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases
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for the Global Burden of Disease Study 2019. Lancet 2020;396(10258):1204–22.
B.J. Gabbe and B. Beck Injury 52 (2021) 125–126

[6] Hatchimonji J, Kaufman E, Chreiman K, Stoecker J, Reilly P, Smith B, et al. Be-
yond morbidity and mortality: The practicality of measuring patient-reported
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covers, When, and How Well? Ann Surg 2016;263(4):623–32.

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