Injury, Int. J. Care Injured 45 (2014) 1–2
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Editorial
Playing darts without a dart board: Why we need to create an International Trauma Data Bank (ITDB)
Trauma continues to grow as a leading cause of morbidity and mortality. It is now thought to be responsible for every 10th death on earth and globally it costs more than half a trillion dollars each year [1]. In fact, in some countries the combined direct and indirect financial burden of motor vehicle crashes alone, exceeds the entire amount spent on health care by that country [1]. Now, more than ever, we need to bring all resources to bear to decrease the impact of trauma around the world. One accepted way to decrease the burden of injuries is to improve the quality of care for patients after trauma. Several reports including a meta-analysis by one of the Editors of this journal, Dr Civil and others, demonstrates that interventions to improve quality are successful, with studies showing that these can reliably improve processes of care, decrease mortality and decrease costs in both developed and lesser developed countries [2–8]. An important attribute of almost all trauma quality improvement strategies has been the creation of a trauma registry. These databases collect pertinent healthcare information which brings to light areas that need improvement in each programme. Registries assist in establishing baselines and identifying factors affecting care, as well as drawing inter-provider comparisons and monitoring improvements temporally. Gradually, registries have evolved into regional/national repositories that aggregate data from multiple centres and are distinguished from other administrative datasets by including trauma specific clinical information. These larger more representative registries help us understand the impact of trauma on various populations and provide outcomes data on trauma care, patient safety, and performance improvement processes [9]. These large trauma registries also have the ability to benchmark trauma sites and compare programmes to one another so that centres can learn from their peers. These inter facility comparisons have been credited with identifying areas of weakness in programmes and saving lives. In addition, using robust statistical methodologies, observational trauma studies enabled by these registries have helped guide physicians, researchers, and policy makers to improve trauma care. Multiple local and national trauma databases have been set-up across Europe, North America, Asia, Africa Israel, Japan, and Australia in the last two decades [10]. As a result, several areas of trauma care in their respective regions/countries have been both identified and improved. This proliferation of registries has set the stage for a new exciting opportunity that could revolutionize global trauma care: An International Trauma Data Bank (ITDB), that collates data from centres from different countries and can be 0020–1383/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2013.10.017
used to benchmark trauma centres across the globe and improve care everywhere. The idea for such a registry was first formally proposed at the American College of Surgeons Committee on Trauma (ACSCOT) spring 2011 meeting, by Raul Coimbra, MD, PhD, FACS. Now as we begin, a new year it is a great time to genuinely work towards creating such a registry and develop the required will among the international trauma community to bring this idea to fruition. There are several obvious advantages of developing such a global resource. It would be a mechanism for global comparative assessments of quality of trauma care (benchmarking) and could be used to identify potential areas for improvement and promote data-driven performance enhancement initiatives on a wider scale. An ITDB would allow countries and regions to learn from one another and adapt local policies and programmes for their own environment based on work that has been effective in other parts of the world. Nowadays, a kid in Auckland can play video games against another kid, across the globe in Frankfurt. There is no reason why we can’t compare our trauma outcomes across continents and push ourselves to do better for our patients. There are challenges in undertaking this endeavour. We would have to adopt a central mechanism to accept data from many different systems. We already know that lack of standardized data is a significant obstacle to establishing large trauma data repositories [11–13]. Although uniform reporting procedures can be developed, implemented and enforced locally, international standardization is difficult to achieve given the inherent differences in medical practices and national health policies. However, there are potential solutions such as the Utstein Trauma Template (UTT), a uniform data reporting standard containing 36 core variables that has been recently proposed [14–16]. The UTT contains most of the US/Canadian-based National Trauma Data Base elements and likely contains variables collected by most trauma registries internationally. Whereas, it would be ideal to have a completely uniform global dataset, this is not necessary to start an ITDB. Work by Nathens et al. has demonstrated that only a few variables are needed to adequately risk-adjust for mortality outcomes [17]. Consequently, to perform international benchmarking, the proposed ITDB would only require as few as six to seven important predictors of trauma mortality and still be effective. There will be some additional challenges for implementing the ITDB in lesser developed countries and low resource areas. The majority of injury scoring systems are difficult to implement and maintain in Lower Middle Income Countries (LMIC) and are
2
Editorial / Injury, Int. J. Care Injured 45 (2014) 1–2
resource intensive. A solution for this may be the use of low-cost alternatives, such as the Kampala Trauma Score, that have been specifically developed for LMICs [18]. Using different injury scoring systems may make benchmarking difficult across systems and research would need to be undertaken to determine the most efficient way to make robust and fair comparisons. Perhaps another solution would be to benchmark the centres that are similarly resourced with one another. Using this system, lowresourced centres could use simpler injury scoring systems while higher-resourced centres could use more elaborate systems. The result would be resource-based global benchmarking tiers, offering greater intra-tier homogeneity of trauma data and ability for centres to learn from their true peers. Now getting to the title of this editorial. A quality improvement specialist once said: ‘‘Creating a quality improvement programme without simultaneously evaluating performance metrics is like playing darts without a dart board’’. Lets make an ITDB and play with a dartboard, so we can keep score and hit a bulls eye by improving the quality of trauma care across the globe. The author is the recipient of the 2013 International Association for Trauma Surgery and Intensive Care (IATSIC)/American Association for the Surgery of Trauma (AAST) prize for his paper ‘‘Benchmarking of Trauma Care Worldwide: The Potential Value of an International Trauma Data Bank (ITDB)’’ presented at the IATSIC/AAST session during the International Surgical Week, August 2013, Helsinki, Finland. References [1] The Facts. 2010. http://whqlibdoc.who.int/publications/2010/9789241 599375_eng.pdf. [2] Juillard CJ, Mock C, Goosen J, Joshipura M, Civil I. Establishing the evidence base for trauma quality improvement: a collaborative WHO-IATSIC review. World J Surg 2009;33(May (5)):1075–86, http://www.ncbi.nlm.nih.gov/pubmed/ 19290573. [3] 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(Jan (4)):366–78, http://www.ncbi.nlm.nih.gov/pubmed/ 16436768. [4] Jurkovich GJ, Mock C. Systematic review of trauma system effectiveness based on registry comparisons. J Trauma 1999;47(3 Suppl.):S46–55, http:// www.ncbi.nlm.nih.gov/pubmed/10496611. [5] Patel HC, Bouamra O, Woodford M, King AT, Yates DW, Lecky FE. Trends in head injury outcome from 1989 to 2003 and the effect of neurosurgical care: an observational study. Lancet 2013;366(9496):1538–44, http://www.ncbi.nlm.nih.gov/pubmed/16257340. [6] Fuller G, Bouamra O, Woodford M, Jenks T, Stanworth S, Allard S, et al. Recent massive blood transfusion practice in England and Wales: view from a trauma
[7]
[8]
[9] [10]
[11]
[12]
[13]
[14]
[15] [16]
[17]
[18]
registry. Emerg Med J 2012;29(Feb (2)):118–23, http://www.ncbi.nlm.nih.gov/pubmed/21398249. Lecky F, Woodford M, Yates DW. Trends in trauma care in England and Wales 1989–97. UK Trauma Audit and Research Network. Lancet 2000;355(May (9217)):1771–5, http://www.ncbi.nlm.nih.gov/pubmed/10832827. Siman-Tov M, Radomislensky I, Peleg K. Reduction in trauma mortality in Israel during the last decade (2000–2010): the impact of changes in the trauma system. Injury 2012, http://www.ncbi.nlm.nih.gov/pubmed/23021368. Moore L, Clark DE. The value of trauma registries. Injury 2008;39(Jun (6)):686– 95, http://www.ncbi.nlm.nih.gov/pubmed/18511052. European Trauma Registry Network. Trauma Registries Worldwide. http:// www.eurotrauma.net/site2/index.php?option=com_content&view=article&id=54&Itemid=59. Edwards A, Di Bartolomeo S, Chieregato A, Coats T, Della Corte F, Giannoudis P, et al. A comparison of European Trauma Registries. The first report from the EuroTARN Group. Resuscitation 2007;75(Nov (2)):286–97, http:// www.ncbi.nlm.nih.gov/pubmed/17714850. Ringdal KG, Lossius HM. Feasibility of comparing core data from existing trauma registries in scandinavia. Reaching for a Scandinavian major trauma outcome study (MTOS). Scand J Surg 2007;96(Jan (4)):325–31, http:// www.ncbi.nlm.nih.gov/pubmed/18265862. Tohira H, Jacobs I, Mountain D, Gibson N, Yeo A. International comparison of regional trauma registries. Injury 2012;43(Nov (11)):1924–30, http:// www.ncbi.nlm.nih.gov/pubmed/22921381. Dick WF, Baskett PJ. Recommendations for uniform reporting of data following major trauma – the Utstein style. A report of a working party of the International Trauma Anaesthesia and Critical Care Society (ITACCS). Resuscitation 1999;42(Oct (2)):81–100, http://www.ncbi.nlm.nih.gov/pubmed/10617327. Coats TJ. A revised Utstein Template for trauma. Emerg Med J 2010;27(May (5)):339, http://www.ncbi.nlm.nih.gov/pubmed/20442159. Ringdal KG, Coats TJ, Lefering R, Di Bartolomeo S, Steen PA, Røise O, et al. The Utstein template for uniform reporting of data following major trauma: a joint revision by SCANTEM, TARN, DGU-TR and RITG. Scand J Trauma Resusc Emerg Med 2008;16:7, http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2568949&tool=pmcentrez&rendertype=abstract. Nathens AB, Xiong W, Shafi S. Ranking of trauma center performance: the bare essentials. J Trauma 2008;65(Sep (3)):628–35, http://www.ncbi.nlm.nih.gov/ pubmed/18784577. MacLeod JBA, Kobusingye O, Frost C. A comparison of the Kampala Trauma Score (KTS) with the Revised Trauma Score (RTS) Injury Severity Score (ISS) and the TRISS Method in a Ugandan Trauma Registry. Eur J Trauma 2003;29(6):392–8.
Adil H. Haider Center for Surgical Trials and Outcomes Research, Department of Surgery, The Johns Hopkins School of Medicine, Baltimore, MD, USA E-mail address: [email protected] (A.H. Haider)
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Editorial
Playing darts without a dart board: Why we need to create an International Trauma Data Bank (ITDB)
Trauma continues to grow as a leading cause of morbidity and mortality. It is now thought to be responsible for every 10th death on earth and globally it costs more than half a trillion dollars each year [1]. In fact, in some countries the combined direct and indirect financial burden of motor vehicle crashes alone, exceeds the entire amount spent on health care by that country [1]. Now, more than ever, we need to bring all resources to bear to decrease the impact of trauma around the world. One accepted way to decrease the burden of injuries is to improve the quality of care for patients after trauma. Several reports including a meta-analysis by one of the Editors of this journal, Dr Civil and others, demonstrates that interventions to improve quality are successful, with studies showing that these can reliably improve processes of care, decrease mortality and decrease costs in both developed and lesser developed countries [2–8]. An important attribute of almost all trauma quality improvement strategies has been the creation of a trauma registry. These databases collect pertinent healthcare information which brings to light areas that need improvement in each programme. Registries assist in establishing baselines and identifying factors affecting care, as well as drawing inter-provider comparisons and monitoring improvements temporally. Gradually, registries have evolved into regional/national repositories that aggregate data from multiple centres and are distinguished from other administrative datasets by including trauma specific clinical information. These larger more representative registries help us understand the impact of trauma on various populations and provide outcomes data on trauma care, patient safety, and performance improvement processes [9]. These large trauma registries also have the ability to benchmark trauma sites and compare programmes to one another so that centres can learn from their peers. These inter facility comparisons have been credited with identifying areas of weakness in programmes and saving lives. In addition, using robust statistical methodologies, observational trauma studies enabled by these registries have helped guide physicians, researchers, and policy makers to improve trauma care. Multiple local and national trauma databases have been set-up across Europe, North America, Asia, Africa Israel, Japan, and Australia in the last two decades [10]. As a result, several areas of trauma care in their respective regions/countries have been both identified and improved. This proliferation of registries has set the stage for a new exciting opportunity that could revolutionize global trauma care: An International Trauma Data Bank (ITDB), that collates data from centres from different countries and can be 0020–1383/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2013.10.017
used to benchmark trauma centres across the globe and improve care everywhere. The idea for such a registry was first formally proposed at the American College of Surgeons Committee on Trauma (ACSCOT) spring 2011 meeting, by Raul Coimbra, MD, PhD, FACS. Now as we begin, a new year it is a great time to genuinely work towards creating such a registry and develop the required will among the international trauma community to bring this idea to fruition. There are several obvious advantages of developing such a global resource. It would be a mechanism for global comparative assessments of quality of trauma care (benchmarking) and could be used to identify potential areas for improvement and promote data-driven performance enhancement initiatives on a wider scale. An ITDB would allow countries and regions to learn from one another and adapt local policies and programmes for their own environment based on work that has been effective in other parts of the world. Nowadays, a kid in Auckland can play video games against another kid, across the globe in Frankfurt. There is no reason why we can’t compare our trauma outcomes across continents and push ourselves to do better for our patients. There are challenges in undertaking this endeavour. We would have to adopt a central mechanism to accept data from many different systems. We already know that lack of standardized data is a significant obstacle to establishing large trauma data repositories [11–13]. Although uniform reporting procedures can be developed, implemented and enforced locally, international standardization is difficult to achieve given the inherent differences in medical practices and national health policies. However, there are potential solutions such as the Utstein Trauma Template (UTT), a uniform data reporting standard containing 36 core variables that has been recently proposed [14–16]. The UTT contains most of the US/Canadian-based National Trauma Data Base elements and likely contains variables collected by most trauma registries internationally. Whereas, it would be ideal to have a completely uniform global dataset, this is not necessary to start an ITDB. Work by Nathens et al. has demonstrated that only a few variables are needed to adequately risk-adjust for mortality outcomes [17]. Consequently, to perform international benchmarking, the proposed ITDB would only require as few as six to seven important predictors of trauma mortality and still be effective. There will be some additional challenges for implementing the ITDB in lesser developed countries and low resource areas. The majority of injury scoring systems are difficult to implement and maintain in Lower Middle Income Countries (LMIC) and are
2
Editorial / Injury, Int. J. Care Injured 45 (2014) 1–2
resource intensive. A solution for this may be the use of low-cost alternatives, such as the Kampala Trauma Score, that have been specifically developed for LMICs [18]. Using different injury scoring systems may make benchmarking difficult across systems and research would need to be undertaken to determine the most efficient way to make robust and fair comparisons. Perhaps another solution would be to benchmark the centres that are similarly resourced with one another. Using this system, lowresourced centres could use simpler injury scoring systems while higher-resourced centres could use more elaborate systems. The result would be resource-based global benchmarking tiers, offering greater intra-tier homogeneity of trauma data and ability for centres to learn from their true peers. Now getting to the title of this editorial. A quality improvement specialist once said: ‘‘Creating a quality improvement programme without simultaneously evaluating performance metrics is like playing darts without a dart board’’. Lets make an ITDB and play with a dartboard, so we can keep score and hit a bulls eye by improving the quality of trauma care across the globe. The author is the recipient of the 2013 International Association for Trauma Surgery and Intensive Care (IATSIC)/American Association for the Surgery of Trauma (AAST) prize for his paper ‘‘Benchmarking of Trauma Care Worldwide: The Potential Value of an International Trauma Data Bank (ITDB)’’ presented at the IATSIC/AAST session during the International Surgical Week, August 2013, Helsinki, Finland. References [1] The Facts. 2010. http://whqlibdoc.who.int/publications/2010/9789241 599375_eng.pdf. [2] Juillard CJ, Mock C, Goosen J, Joshipura M, Civil I. Establishing the evidence base for trauma quality improvement: a collaborative WHO-IATSIC review. World J Surg 2009;33(May (5)):1075–86, http://www.ncbi.nlm.nih.gov/pubmed/ 19290573. [3] 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(Jan (4)):366–78, http://www.ncbi.nlm.nih.gov/pubmed/ 16436768. [4] Jurkovich GJ, Mock C. Systematic review of trauma system effectiveness based on registry comparisons. J Trauma 1999;47(3 Suppl.):S46–55, http:// www.ncbi.nlm.nih.gov/pubmed/10496611. [5] Patel HC, Bouamra O, Woodford M, King AT, Yates DW, Lecky FE. Trends in head injury outcome from 1989 to 2003 and the effect of neurosurgical care: an observational study. Lancet 2013;366(9496):1538–44, http://www.ncbi.nlm.nih.gov/pubmed/16257340. [6] Fuller G, Bouamra O, Woodford M, Jenks T, Stanworth S, Allard S, et al. Recent massive blood transfusion practice in England and Wales: view from a trauma
[7]
[8]
[9] [10]
[11]
[12]
[13]
[14]
[15] [16]
[17]
[18]
registry. Emerg Med J 2012;29(Feb (2)):118–23, http://www.ncbi.nlm.nih.gov/pubmed/21398249. Lecky F, Woodford M, Yates DW. Trends in trauma care in England and Wales 1989–97. UK Trauma Audit and Research Network. Lancet 2000;355(May (9217)):1771–5, http://www.ncbi.nlm.nih.gov/pubmed/10832827. Siman-Tov M, Radomislensky I, Peleg K. Reduction in trauma mortality in Israel during the last decade (2000–2010): the impact of changes in the trauma system. Injury 2012, http://www.ncbi.nlm.nih.gov/pubmed/23021368. Moore L, Clark DE. The value of trauma registries. Injury 2008;39(Jun (6)):686– 95, http://www.ncbi.nlm.nih.gov/pubmed/18511052. European Trauma Registry Network. Trauma Registries Worldwide. http:// www.eurotrauma.net/site2/index.php?option=com_content&view=article&id=54&Itemid=59. Edwards A, Di Bartolomeo S, Chieregato A, Coats T, Della Corte F, Giannoudis P, et al. A comparison of European Trauma Registries. The first report from the EuroTARN Group. Resuscitation 2007;75(Nov (2)):286–97, http:// www.ncbi.nlm.nih.gov/pubmed/17714850. Ringdal KG, Lossius HM. Feasibility of comparing core data from existing trauma registries in scandinavia. Reaching for a Scandinavian major trauma outcome study (MTOS). Scand J Surg 2007;96(Jan (4)):325–31, http:// www.ncbi.nlm.nih.gov/pubmed/18265862. Tohira H, Jacobs I, Mountain D, Gibson N, Yeo A. International comparison of regional trauma registries. Injury 2012;43(Nov (11)):1924–30, http:// www.ncbi.nlm.nih.gov/pubmed/22921381. Dick WF, Baskett PJ. Recommendations for uniform reporting of data following major trauma – the Utstein style. A report of a working party of the International Trauma Anaesthesia and Critical Care Society (ITACCS). Resuscitation 1999;42(Oct (2)):81–100, http://www.ncbi.nlm.nih.gov/pubmed/10617327. Coats TJ. A revised Utstein Template for trauma. Emerg Med J 2010;27(May (5)):339, http://www.ncbi.nlm.nih.gov/pubmed/20442159. Ringdal KG, Coats TJ, Lefering R, Di Bartolomeo S, Steen PA, Røise O, et al. The Utstein template for uniform reporting of data following major trauma: a joint revision by SCANTEM, TARN, DGU-TR and RITG. Scand J Trauma Resusc Emerg Med 2008;16:7, http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2568949&tool=pmcentrez&rendertype=abstract. Nathens AB, Xiong W, Shafi S. Ranking of trauma center performance: the bare essentials. J Trauma 2008;65(Sep (3)):628–35, http://www.ncbi.nlm.nih.gov/ pubmed/18784577. MacLeod JBA, Kobusingye O, Frost C. A comparison of the Kampala Trauma Score (KTS) with the Revised Trauma Score (RTS) Injury Severity Score (ISS) and the TRISS Method in a Ugandan Trauma Registry. Eur J Trauma 2003;29(6):392–8.
Adil H. Haider Center for Surgical Trials and Outcomes Research, Department of Surgery, The Johns Hopkins School of Medicine, Baltimore, MD, USA E-mail address: [email protected] (A.H. Haider)
