Developing a national trauma research action plan: Results from the Burn Research Gap Delphi Survey

High Priority Traumatic Brain Injury Science: Analysis of the National Trauma Research Action Plan

INTRODUCTION

The National Trauma Research Action Plan convened 11 topic area panels to complete consensus-driven Delphi surveys to identify high priority trauma research questions. The Neurotrauma Panel identified questions relating to interventional and comparative effectiveness trials in severe traumatic brain injury (sTBI) critical care as highest priority. This qualitative secondary analysis aims to translate results across several Delphi panels into potential studies in sTBI critical care.

METHODS

High priority consensus research questions related to sTBI in the critical phase of care (ranked >6.5 on a 1-9 Likert scale) were screened from the Neurotrauma, Critical Care, Geriatric, and Long-Term Outcomes Panels results. Using grounded theory, two reviewers inductively open-coded questions independently and then refined them for consensus. A similar approach was used to recategorize questions into codes. Each code was then characterized into research project(s) with an aim, design, exposure(s), and outcome(s).

RESULTS

Among 376 high-priority questions reaching consensus, 55 related to sTBI critical care. Twelve projects emerged across eight consensus thematic codes: biomarkers (1 project, average priority score/range 6.92), imaging (1, 6.84), prognostication (1, 6.77), novel neuromonitoring (3, 6.61-6.77), intracranial pressure/cerebral perfusion pressure (2, 6.67-6.76), coagulopathy (2, 6.66-6.74), early rehabilitation (1, 6.67), and pharmacologic intervention (1, 6.66).

CONCLUSIONS

This National Trauma Research Action Plan secondary analysis identified several high-priority research projects in sTBI critical care. While some questions are being addressed in ongoing trials, investigators and funding agencies should consider using these consensus-driven Delphi panel results and subsequent analyses to prioritize future research proposals.

Mental Health Support Is an Unmet Need for Long-term Burn Survivors: A Web-based Survey

A National Trauma Research Action Plan identified the involvement of burn survivors as critical informants to determine the direction of research. This study employed a web-based survey to identify care gaps in a sample of burn survivors. We surveyed burn survivors from around the United States through social media and email contact with the Phoenix Society for Burn Survivors. We elicited demographic info, burn history, and unmet needs. Statistical analysis was performed to test our hypothesis that lack of access to mental health support/professionals would be identified as an unmet need in long-term burn survivors. Of 178 survey respondents, most were at least 10 years removed from the date of their burn injury (n = 94, 53%). Compared with those less than 3 years from their burn injury, individuals greater than 10 years were at least 5 times more likely to note a lack of access to mental health support [11-20 years OR 8.7, P < .001; >20 years OR 5.7, P = .001]. About 60% of Spanish speakers reported lack of support group access was among their greatest unmet needs, compared with 37% of English speakers (P = .184). This study highlights the need for ongoing access to mental health resources in burn survivors. Our findings emphasize that burn injury is not just an acute ailment, but a complex condition that evolves into a chronic disease. Additional studies should focus on the experiences of Spanish-speaking burn survivors, given small sample size leading to a likely clinically significant but not statistically different lack of access to support groups.

An executive summary of the National Trauma Research Action Plan

ABSTRACT

The National Trauma Research Action Plan project successfully engaged multidisciplinary experts to define opportunities to advance trauma research and has fulfilled the recommendations related to trauma research from the National Academies of Sciences, Engineering and Medicine report. These panels identified more than 4,800 gaps in our knowledge regarding injury prevention and the optimal care of injured patients and laid out a priority framework and tools to support researchers to advance this field. Trauma research funding agencies and researchers can use this executive summary and supporting manuscripts to strategically address and close the highest priority research gaps. Given that this is the most significant public health threat facing our children, young adults, and military service personnel, we must do better in prioritizing these research projects for funding and providing grant support to advance this work. Through the Coalition for National Trauma Research, the trauma community is committed to a coordinated, collaborative approach to address these critical knowledge gaps and ultimately reduce the burden of morbidity and mortality faced by our patients.

Trauma Research Funding: An Emergency in Emergency Care

INTRODUCTION

Trauma remains a significantly underfunded area of medical research despite its status as a leading cause of death and substantial economic burden in the United States. This study explores the disparity in trauma research funding, focusing on Oklahoma compared to neighboring and populous states.

METHODS

Using data from the Centers for Disease Control and Prevention (CDC)'s Web-based Injury Statistics Query and Reporting System (WISQARS™) and the National Institutes of Health (NIH)'s RePORT databases, we analyzed age-adjusted years of potential life lost (YPLL) due to trauma and corresponding NIH funding across different states and nationally. Statistical analyses included bivariate comparisons and standardization of funding data per population and YPLL.

RESULTS

From 2010 to 2020, NIH allocated approximately $124 billion nationally, with only 5% dedicated to trauma, amounting to $1,772.32 per age-adjusted YPLL. Oklahoma and Kansas exhibited the lowest NIH funding per YPLL compared to New York and California. Funding for the National Injury Prevention and Control, a subdivision of the CDC, has shown significant increases, ranking third in 2022.

CONCLUSION

This study highlights the urgent need for enhanced trauma research funding to address its disproportionate impact on mortality and healthcare costs. Strategic allocation of resources is essential to advance trauma care and align research priorities with public health needs.

Research priorities in venous thromboembolism after trauma: Secondary analysis of the National Trauma Research Action Plan

BACKGROUND

Venous thromboembolism (VTE) is a significant cause of morbidity and mortality during recovery from injury and can result in significant health care costs. Despite advances in the past several decades in our approach to VTE prophylaxis after injury, opportunities exist to improve the delivery and implementation of optimal VTE prophylaxis. Here, we aim to identify consensus research questions related to VTE across all National Trauma Research Action Plan (NTRAP) Delphi expert panels to further guide the research agenda aimed at preventing VTE after injury.

METHODS

This is a secondary analysis of consensus-based research priorities that were collected using a Delphi methodology by 11 unique NTRAP panels that were charged with unique topic areas across the spectrum of injury care. The database of questions was queried for the keywords "VTE," "venous thromboembo," and "DVT" and then grouped into relevant topic areas.

RESULTS

There were 86 VTE-related research questions identified across 9 NTRAP panels. Eighty-five questions reached consensus with 24 rated high priority; 60, medium priority; and 1, low priority. Questions related to the timing of VTE prophylaxis (n = 17) were most common, followed by questions related to risk factors for the development of VTE (n = 16), the effects of tranexamic acid on VTE (n = 11), the approach to dosing of pharmacologic prophylaxis (n = 8), and the pharmacologic prophylactic medication choice for optimal VTE prophylaxis (n = 6).

CONCLUSION

National Trauma Research Action Plan panelists identified 85 consensus-based research questions that should drive dedicated extramural research funding opportunities to support quality studies aimed at optimizing VTE prophylaxis after injury.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Burn Wound Bed Management

Critical to the success of modern burn care is the management of the burn wound. Timely and complete removal of nonviable tissue is complicated by the irreplaceable nature of the tissue lost either through the burn injury or as "collateral damage" as part of the treatment. Challenges in distinguishing between viable and nonviable tissue and "replacing the irreplaceable" are discussed alongside potential disruptive technologies which could fundamentally change how burn care is delivered. Advances in burn wound bed management forms the foundation on which the goal of zero preventable death and disability after burn injury can be achieved.

Developing a National Trauma Research Action Plan: Results from the postadmission critical care research gap Delphi survey

INTRODUCTION

The 2016 National Academies of Science, Engineering and Medicine report included a proposal to establish a National Trauma Research Action Plan. In response, the Department of Defense funded the Coalition for National Trauma Research to generate a comprehensive research agenda spanning the continuum of trauma and burn care from prehospital care to rehabilitation as part of an overall strategy to achieve zero preventable deaths and disability after injury. The Postadmission Critical Care Research panel was 1 of 11 panels constituted to develop this research agenda.

METHODS

We recruited interdisciplinary experts in surgical critical care and recruited them to identify current gaps in clinical critical care research, generate research questions, and establish the priority of these questions using a consensus-driven Delphi survey approach. The first of four survey rounds asked participants to generate key research questions. On subsequent rounds, we asked survey participants to rank the priority of each research question on a 9-point Likert scale, categorized to represent low-, medium-, and high-priority items. Consensus was defined as ≥60% of panelists agreeing on the priority category.

RESULTS

Twenty-five subject matter experts generated 595 questions. By Round 3, 249 questions reached ≥60% consensus. Of these, 22 questions were high, 185 were medium, and 42 were low priority. The clinical states of hypovolemic shock and delirium were most represented in the high-priority questions. Traumatic brain injury was the only specific injury pattern with a high-priority question.

CONCLUSION

The National Trauma Research Action Plan critical care research panel identified 22 high-priority research questions, which, if answered, would reduce preventable death and disability after injury.

LEVEL OF EVIDENCE

Diagnostic Tests or Criteria; Level IV.

Developing a National Trauma Research Action Plan: Results from the long-term outcomes research gap Delphi survey

BACKGROUND

In the National Academies of Sciences, Engineering, and Medicine 2016 report on trauma care, the establishment of a National Trauma Research Action Plan to strengthen and guide future trauma research was recommended. To address this recommendation, the Department of Defense funded the Coalition for National Trauma Research to generate a comprehensive research agenda spanning the continuum of trauma and burn care. We describe the gap analysis and high-priority research questions generated from the National Trauma Research Action Plan panel on long-term outcomes.

METHODS

Experts in long-term outcomes were recruited to identify current gaps in long-term trauma outcomes research, generate research questions, and establish the priority for these questions using a consensus-driven, Delphi survey approach from February 2021 to August 2021. Panelists were identified using established Delphi recruitment guidelines to ensure heterogeneity and generalizability including both military and civilian representation. Panelists were encouraged to use a PICO format to generate research questions: Patient/Population, Intervention, Compare/Control, and Outcome model. On subsequent surveys, panelists were asked to prioritize each research question on a 9-point Likert scale, categorized to represent low-, medium-, and high-priority items. Consensus was defined as ≥60% of panelists agreeing on the priority category.

RESULTS

Thirty-two subject matter experts generated 482 questions in 17 long-term outcome topic areas. By Round 3 of the Delphi, 359 questions (75%) reached consensus, of which 107 (30%) were determined to be high priority, 252 (70%) medium priority, and 0 (0%) low priority. Substance abuse and pain was the topic area with the highest number of questions. Health services (not including mental health or rehabilitation) (64%), mental health (46%), and geriatric population (43%) were the topic areas with the highest proportion of high-priority questions.

CONCLUSION

This Delphi gap analysis of long-term trauma outcomes research identified 107 high-priority research questions that will help guide investigators in future long-term outcomes research.

LEVEL OF EVIDENCE

Diagnostic Tests or Criteria; Level IV.

Developing a National Trauma Research Action Plan: Results from the injury prevention research gap Delphi survey

BACKGROUND

In its 2016 report on trauma care, the National Academies of Sciences, Engineering, and Medicine called for the establishment of a National Trauma Research Action Plan to strengthen and guide future trauma research. To address this recommendation, the Department of Defense funded the Coalition for National Trauma Research to generate a comprehensive research agenda spanning the continuum of trauma and burn care. We describe the gap analysis and high priority research questions generated from the National Trauma Research Action Plan panel on injury prevention.

METHODS

Experts in injury prevention research were recruited to identify current gaps in injury prevention research, generate research questions and establish the priority of these questions using a consensus-driven Delphi survey approach from December 2019 through September 2020. Participants were identified using established Delphi recruitment guidelines to ensure heterogeneity and generalizability with both military and civilian representatives. Participants were encouraged, but not required, to use a Patient/Population, Intervention, Comparison, and Outcome format to generate research questions: Patient/Population; Intervention; Compare/Control; Outcome model. On subsequent surveys, participants were asked to rank the priority of each research question on a nine-point Likert scale, categorized to represent low-, medium-, and high-priority items. Consensus was defined as 60% or greater of panelists agreeing on the priority category.

RESULTS

Twenty-eight subject matter experts generated 394 questions in 12 topic areas. By round 3 of the Delphi, 367 (93.1%) questions reached consensus, of which 169 (46.1%) were determined to be high priority, 196 (53.4%) medium priority, and 2 (0.5%) low priority. Among the 169 high priority questions, suicide (29.6%), firearm violence (20.1%), and violence prevention (18.3%) were the most prevalent topic areas.

CONCLUSION

This Delphi gap analysis of injury prevention research identified 169 high priority research questions that will help guide investigators in future injury prevention research. Funding agencies and researchers should consider these gaps when they prioritize future research.

LEVEL OF EVIDENCE

Therepeutic/Care Management; Level IV.

Developing a National Trauma Research Action Plan: Results from the Neurotrauma Research Panel Delphi Survey

BACKGROUND

In 2016, the National Academies of Science, Engineering and Medicine called for the development of a National Trauma Research Action Plan. The Department of Defense funded the Coalition for National Trauma Research to generate a comprehensive research agenda spanning the continuum of trauma and burn care. Given the public health burden of injuries to the central nervous system, neurotrauma was one of 11 panels formed to address this recommendation with a gap analysis and generation of high-priority research questions.

METHODS

We recruited interdisciplinary experts to identify gaps in the neurotrauma literature, generate research questions, and prioritize those questions using a consensus-driven Delphi survey approach. We conducted four Delphi rounds in which participants generated key research questions and then prioritized the importance of the questions on a 9-point Likert scale. Consensus was defined as 60% or greater of panelists agreeing on the priority category. We then coded research questions using an National Trauma Research Action Plan taxonomy of 118 research concepts, which were consistent across all 11 panels.

RESULTS

Twenty-eight neurotrauma experts generated 675 research questions. Of these, 364 (53.9%) reached consensus, and 56 were determined to be high priority (15.4%), 303 were deemed to be medium priority (83.2%), and 5 were low priority (1.4%). The research topics were stratified into three groups-severe traumatic brain injury (TBI), mild TBI (mTBI), and spinal cord injury. The number of high-priority questions for each subtopic was 46 for severe TBI (19.7%), 3 for mTBI (4.3%) and 7 for SCI (11.7%).

CONCLUSION

This Delphi gap analysis of neurotrauma research identified 56 high-priority research questions. There are clear areas of focus for severe TBI, mTBI, and spinal cord injury that will help guide investigators in future neurotrauma research. Funding agencies should consider these gaps when they prioritize future research.

LEVEL OF EVIDENCE

Diagnostic Test or Criteria, Level IV.

Developing a National Trauma Research Action Plan (NTRAP): Results from the Pediatric Research Gap Delphi Survey

BACKGROUND

In 2016, the National Academies of Sciences, Engineering, and Medicine trauma report recommended a National Trauma Research Action Plan (NTRAP) to "strengthen trauma research and ensure that the resources available for this research are commensurate with the importance of injury and the potential for improvement in patient outcomes." With a contract from the Department of Defense, the Coalition for National Trauma Research (CNTR) created 11 expert panels to address this recommendation, with the goal of developing a comprehensive research agenda, spanning the continuum of trauma and burn care. This report outlines the work of the group focused on pediatric trauma.

METHODS

Experts in pediatric trauma clinical care and research were recruited to identify gaps in current clinical pediatric trauma research, generate research questions, and establish the priority of these questions using a consensus-driven Delphi survey approach. Using successive surveys, participants were asked to rank the priority of each research question on a 9-point Likert scale categorized to represent priority. Consensus was defined as >60% agreement within the priority category. Priority questions were coded based on a dictionary of 118 NTRAP taxonomy concepts in nine categories to support comparative analysis across all panels.

RESULTS

37 subject matter experts generated 625 questions. 493 questions (79%) reached consensus on priority level. Of those reaching consensus, 159 (32%) were High, 325 (66%) Medium and 9 (2%) Low priority. The highest priority research questions related to surgical interventions for traumatic brain injury (ICP monitoring and craniotomy); second highest priority was hemorrhagic shock. The prehospital setting was the highest priority phase of care.

CONCLUSIONS

This diverse panel of experts determined that most significant pediatric trauma research gaps were in traumatic brain injur, hemorrhagic shock, and the prehospital phase of care. These research domains should be top priorities for funding agencies.

LEVEL OF EVIDENCE

IV.