Re-labeling Traumatic Injuries - Chronic Conditions Set the Stage for Meaningful Long-term Care

While mortality among individuals facing traumatic injuries has decreased over the years, this has come at the trade-off of increased morbidity, including increased rates of PTSD and chronic pain, poorer health-related quality of life, and delays in returning to work. In a Perspective piece published in the New England Journal of Medicine, Dr. Juan Herrera-Escobar of the Department of Surgery at Brigham and Women’s Hospital and Dr. Jeffrey Schneider of the Department of Physical Medicine and Rehabilitation at Spaulding Rehabilitation Hospital discuss this issue and explain how re-labeling traumatic injuries as chronic conditions may set the stage for meaningful long-term care. In this Q&A, they tell us more about that viewpoint:

?Q: You mentioned the benefit of labeling traumatic injuries as “chronic.” What are some of these types of injuries and how would care differ for these patients?

Many traumatic injuries should be classified as chronic, oftentimes, in any case of the severity. Firearm injuries are a good example of this. Regardless of the location on the body or the severity of a gunshot wound, we know that such injuries have lasting effects on survivors, particularly on their mental health (PTSD, anxiety, and depression). Other examples include survivors of mass casualties, assaults, significant falls, road traffic injuries, as well as burn, traumatic brain, and spinal cord injuries. Care would differ in several ways, but we would like to highlight three aspects: holistic, integrated, and continuous care. By holistic, we mean that all dimensions of a patient’s health are addressed. This includes their mental, physical, and social health, to name a few. Care should be integrated across specialties, ideally in the form of integrated practice units, depending on the needs of the patient. In addition, the accountability for value should be shared among the providers involved, and this should be for the patient’s “total care” and not for the specific intervention of each specialty. Finally, care should be continuous, which means that trauma patients are followed and supported for several years or throughout their lifespan in some cases.

Q: You also write about the importance of policy change and system financing in ensuring that effective care can be delivered. What is the first step in getting policymakers to prioritize this issue?

We would like to highlight two “first steps.” One is to come together as a trauma community. Professional societies across the spectrum of trauma — patients, advocacy groups, and all relevant stakeholders — need to unite efforts to have a strong voice in Congress. Another is for the Centers for Medicare and Medicaid Services to add traumatic injuries to their list of chronic conditions. This will help facilitate future policy actions that support the long-term needs of trauma survivors.

Q: Can you touch more on the role of rehabilitation in providing comprehensive care?

Rehabilitation is a key component of holistic, integrated care for trauma survivors. The process of rehabilitation utilizes a patient-centered approach to?maximize functional ability and quality of life to those with physical impairments or disabilities. The federally funded Model Systems are specialized programs of rehabilitative care for three trauma populations (spinal cord, traumatic brain, and burn injuries) that serve as examples for longitudinal care and research. Model Systems, funded by the?National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR), provide patient care, pool information in large longitudinal databases, and conduct research intended to improve the long-term functional, vocational, cognitive, and quality-of-life outcomes for individuals with the aforementioned traumatic injuries.

Q: What inspired the two of you to write this piece?

The stories of patients, especially those of the most vulnerable were our inspiration. The day someone suffers a serious traumatic injury may be the most significant day in that individual’s life — just like when someone is diagnosed with cancer, HIV, or another chronic condition. Hearing patients say how the injury they had months, years, or even decades ago is still significantly impacting their mental, physical, and social health is quite striking. But even more, it is listening to how the health system is failing them to address their needs. The lack of a robust system that follows trauma patients after hospital discharge allows the most vulnerable to suffer the worst consequences. The patients’ education level, the neighborhood where they live, and even the language they speak, become the determining factors of who has better long-term outcomes after injury.

Q: What else can be accomplished by this designation?

Recognizing traumatic injury as a chronic condition is not only a matter of improving quality of care for trauma patients; it is an equity matter as well. This would be a significant step towards addressing inequity in a health condition that disproportionally affects people of color and those who are economically disadvantaged. It is the right thing to do.

To read the full paper from Dr. Herrera-Escobar and Dr. Schneider, visit:?https://www.nejm.org/doi/10.1056/NEJMp2205162