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.

Core outcome measures for research in traumatic injury survivors: The National Trauma Research Action Plan modified Delphi consensus study

BACKGROUND

Until recently, survival has been the main outcome measure for injury research. Given the impact of injury on quality of life, the National Academies of Science, Engineering, and Medicine has called for advancing the science of research evaluating the long-term outcomes of trauma survivors. This is necessary so that treatments and interventions can be assessed for their impact on a trauma patients' long-term functional and psychosocial outcomes. We sought to propose a set of core domains and measurement instruments that are best suited to evaluate long-term outcomes after traumatic injury with a goal for these measures to be adopted as a national standard.

METHODS

As part of the development of a National Trauma Research Action Plan, we conducted a two-stage, five-round modified online Delphi consensus process with a diverse panel of 50 key stakeholders including clinicians, researchers, and trauma survivors from more than 9 professional areas across the United States. Before voting, panelists reviewed the results of a scoping review on patient-reported outcomes after injury and standardized information on measurement instruments following the Consensus-based Standards for the Selection of Health Measurement Instruments guidelines.

RESULTS

The panel considered a preliminary list of 74 outcome domains (patient-reported outcomes) and ultimately reached the a priori consensus criteria for 29 core domains that encompass aspects of physical, mental, social, and cognitive health. Among these 29 core domains, the panel considered a preliminary list of 199 patient-reported outcome measures and reached the a priori consensus criteria for 14 measures across 13 core domains. Participation of panelists ranged from 65% to 98% across the five Delphi rounds.

CONCLUSION

We developed a core outcome measurement set that will facilitate the synthesis, comparison, and interpretation of long-term trauma outcomes research. These measures should be prioritized in all future studies in which researchers elect to evaluate long-term outcomes of traumatic injury survivors.

LEVEL OF EVIDENCE

Diagnostic Test or Criteria, Level IV.

Cultural Competency Curricula in US Graduate Medical Education: A Scoping Review

BACKGROUND

Cultural competency training provides participants with knowledge and skills to improve cross-cultural communication and is required for all graduate medical education (GME) training programs.

OBJECTIVE

The authors sought to determine what cultural competency curricula exist specifically in GME.

METHODS

In April 2020, the authors performed a scoping review of the literature using a multidatabase (PubMed, Ovid, MedEdPORTAL) search strategy that included keywords relevant to GME and cultural competency. The authors extracted descriptive data about the structure, implementation, and analysis of cultural competency curricula and analyzed these data for trends.

RESULTS

Sixty-seven articles met criteria for inclusion, of which 61 (91%) were focused exclusively on residents. The most commonly included specialties were psychiatry (n=19, 28.4%), internal medicine (n=16, 23.9%), and pediatrics (n=15, 22.4%). The shortest intervention was a 30-minute online module, while the longest contained didactics, electives, and mentoring programs that spanned the entirety of residency training (4 years). The sample sizes of included studies ranged from 6 to 833 participants. Eight (11.9%) studies utilized OSCEs as assessment tools, while 17 (25.4%) conducted semi-structured interviews or focus groups. Four common themes were unique interventions, retention of learning, trainee evaluation of curricula, and resources required for implementation.

CONCLUSIONS

Wide variation exists in the design, implementation, and evaluation of cultural competency curricula for residents and fellows.

Implementation and evaluation of patient navigation in Chicago: Insights on addressing the social determinants of health and integrating HIV prevention and care services

Patient navigation is a primary element in linkage to HIV pre-exposure prophylaxis (PrEP) care and linkage to or re-engagement in HIV care, depending on the HIV status of the individual. However, there is a dearth of literature describing navigation services in these areas. In the context of Chicago Project PrIDE, this project conducted process and implementation evaluations with eight agencies leading demonstration projects to address these gaps. The evaluation team conducted semi-structured, individual interviews with agency staff (N = 20) assessing navigation implementation and fit, as well as project successes and challenges. Additionally, agency staff collected patient surveys (N = 300) assessing services provided, service quality, and satisfaction. The interview transcripts were coded and analyzed thematically and descriptive analyses were performed on the survey data. Analyses indicated that screening for social determinants of health, providing healthcare engagement guidance, and providing service referrals were frequently cited navigation activities. Most staff members indicated that navigation fits well within their agencies, and that limited staff and clinic capacity were often barriers to navigation. Patient navigation to support engagement in HIV prevention and care services is critical due to the extensive support provided by navigators to address social determinants of health impacting HIV disparity populations.

Long-term patient-reported outcomes and patient-reported outcome measures after injury: the National Trauma Research Action Plan (NTRAP) scoping review

BACKGROUND

The aim of this scoping review is to identify and summarize patient-reported outcome measures (PROMs) that are being used to track long-term patient-reported outcomes (PROs) after injury and can potentially be included in trauma registries.

METHODS

Online databases were used to identify studies published between 2013 and 2019, from which we selected 747 articles that involved survivors of acute physical traumatic injury aged 18 years or older at time of injury and used PROMs to evaluate recovery between 6 months and 10 years postinjury. Data were extracted and summarized using descriptive statistics and a narrative synthesis of the results.

RESULTS

Most studies were observational, with relatively small sample sizes, and predominantly on traumatic brain injury or orthopedic patients. The number of PROs assessed per study varied from one to 12, for a total of 2052 PROs extracted, yielding 74 unique constructs (physical health, 25 [34%]; mental health, 27 [37%]; social health, 12 [16%]; cognitive health, 7 [10%]; and quality of life, 3 [4%]). These 74 constructs were assessed using 355 different PROMs. Mental health was the most frequently examined outcome domain followed by physical health. Health-related quality of life, which appeared in more than half of the studies (n = 401), was the most common PRO evaluated, followed by depressive symptoms. Physical health was the domain with the highest number of PROMs used (n = 157), and lower-extremity functionality was the PRO that contributed most PROMs (n = 33).

CONCLUSION

We identified a wide variety of PROMs available to track long-term PROs after injury in five different health domains: physical, mental, social, cognitive, and quality of life. However, efforts to fully understand the health outcomes of trauma patients remain inconsistent and insufficient. Defining PROs that should be prioritized and standardizing the PROMs to measure them will facilitate the incorporation of long-term outcomes in national registries to improve research and quality of care.

LEVEL OF EVIDENCE

Systematic Reviews & Meta-analyses, Level IV.

A Qualitative Analysis of Surgical Faculty and Surgical Resident Perceptions of Potential Barriers to Implementing a Novel Surgical Education Curriculum

OBJECTIVE

Sociocultural differences between patients and physicians affect communication, and suboptimal communication can lead to patient dissatisfaction and poor health outcomes. To mitigate disparities in surgical outcomes, the Provider Awareness and Cultural dexterity Toolkit for Surgeons was developed as a novel curriculum for surgical residents focusing on patient-centeredness and enhanced patient-clinician communication through a cultural dexterity framework. This study's objective was to examine surgical faculty and surgical resident perspectives on potential facilitators and barriers to implementing the cultural dexterity curriculum.

DESIGN, SETTING, AND PARTICIPANTS

Focus groups were conducted at 2 separate academic conferences, with the curriculum provided to participants for advanced review. The first 4 focus groups consisted entirely of surgical faculty (n = 37), each with 9 to 10 participants. The next 4 focus groups consisted of surgical residents (n = 31), each with 6 to 11 participants. Focus groups were recorded and transcribed, and the data were thematically analyzed using a constant, comparative method.

RESULTS

Three major themes emerged: (1) Departmental and hospital endorsement of the curriculum are necessary to ensure successful rollout. (2) Residents must be engaged in the curriculum in order to obtain full participation and "buy-in." (3) The application of cultural dexterity concepts in practice are influenced by systemic and institutional factors.

CONCLUSIONS

Institutional support, resident engagement, and applicability to practice are crucial considerations for the implementation of a cultural dexterity curriculum for surgical residents. These 3 tenets, as identified by surgical faculty and residents, are critical for ensuring an impactful and clinically relevant education program.

Concordance of Resident and Patient Perceptions of Culturally Dexterous Patient Care Skills

PURPOSE

Disparities in surgical care persist. To mitigate these disparities, we are implementing and testing the Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS), a curriculum to improve surgical residents' cultural dexterity during clinical encounters. We analyzed baseline data to look for concordance between residents' self-perceived cultural dexterity skills and patients' perceptions of their skills. We hypothesized that residents would rate their skills in cultural dexterity higher than patients would perceive those skills.

METHODS

Prior to the implementation of the curriculum, surgical residents at 5 academic medical centers completed a self-assessment of their skills in culturally dexterous patient care using a modified version of the Cross-Cultural Care Survey. Randomly selected surgical inpatients at these centers completed a similar survey about the quality of culturally dexterous care provided by a surgery resident on their service. Likert scale responses for both assessments were classified as high (agree/strongly agree) or low (neutral/disagree/strongly disagree) competency. Resident and patient ratings of cultural dexterity were compared. Assessments were considered dexterous if 75% of responses were in the high category. Univariate and multivariate analysis was conducted using STATA 16.

RESULTS

A total of 179 residents from 5 surgical residency programs completed self-assessments prior to receiving the PACTS curriculum, including 88 (49.2%) women and 97 (54.2%) junior residents (PGY 1-2s), of whom 54.7% were White, 19% were Asian, and 8.9% were Black/African American. A total of 494 patients with an average age of 55.1 years were surveyed, of whom 238 (48.2%) were female and 320 (64.8%) were White. Fifty percent of residents viewed themselves as culturally dexterous, while 57% of patients reported receiving culturally dexterous care; this difference was not statistically significant (p = 0.09). Residents who perceived themselves to be culturally dexterous were more likely to self-identify as non-White as compared to White (p < 0.05). On multivariate analysis, White patients were more likely to report highly dexterous care, whereas Black patients were more likely to report poorly dexterous care (p < 0.05).

CONCLUSIONS

At baseline, half of patients reported receiving culturally dexterous care from surgical residents at 5 academic medical centers in the United States. This was consistent with residents' self-assessment of their cultural dexterity skills. White patients were more likely to report receiving culturally dexterous care as compared to non-White patients. Non-White residents were more likely to feel confident in their cultural dexterity skills. A novel curriculum has been designed to improve these interactions between patients and surgical residents.

Long-term patient-reported outcome measures after injury: National Trauma Research Action Plan (NTRAP) scoping review protocol

Background

A significant proportion of patients who survive traumatic injury continue to suffer impaired functional status and increased mortality long after discharge. However, despite the need to improve long-term outcomes, trauma registries in the USA do not collect data on outcomes or care processes after discharge. One of the main barriers is the lack of consensus regarding the optimal outcome metrics.

Objectives

To describe the methodology of a scoping review evaluating current evidence on the available measures for tracking functional and patient-reported outcomes after injury. The aim of the review was to identify and summarize measures that are being used to track long-term functional recovery and patient-reported outcomes among adults after injury.

Methods

A systematic search of PubMed and Embase will be performed using the search terms for the population (adult trauma patients), type of outcomes (long-term physical, mental, cognitive, and quality of life), and measures available to track them. Studies identified will be reviewed and assessed for relevance by at least two reviewers. Data will be extracted and summarized using descriptive statistics and a narrative synthesis of the results. This protocol is being reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines.

Dissemination

This scoping review will provide information regarding the currently available metrics for tracking functional and patient-reported outcomes after injury. The review will be presented to a multi-disciplinary stakeholder group that will evaluate these outcome metrics using an online Delphi approach to achieve consensus as part of the development of the National Trauma Research Action Plan (NTRAP). The results of this review will be presented at relevant national surgical conferences and published in peer-reviewed scientific journals.

Application of a Multisite Empowerment Evaluation Approach to Increase Evaluation Capacity Among HIV Services Providers: Results From Project Pride in Chicago

In 2015, the Centers for Disease Control and Prevention (CDC) funded Project PrIDE, a national initiative to implement and evaluate demonstration projects to increase PrEP uptake among HIV-negative individuals and to re-engage HIV-positive individuals in HIV care. Our team served as the Evaluation Center for Project PrIDE organizations in Chicago and used an empowerment evaluation (EE) approach to enhance evaluation capacity at these organizations. To evaluate our approach, we assessed organizations' evaluation capacity and engagement in technical assistance and capacity building activities in 2016 and 2018. Respondents who self-reported higher engagement with the Evaluation Center and who spent a greater number of hours engaged with our evaluators experienced greater increases in evaluation capacity tied to implementation of evaluation activities and technical assistance utilization. These findings demonstrate that multisite EE can be successfully applied to increase the evaluation capacity of organizations providing both HIV prevention and care services.