Towards an optimal outcome for trauma patients: The Transmural Trauma Care Model

Traumatic injury is one of the main causes of death and disability worldwide and poses a substantial economic burden to society. Traditionally, the organization of trauma care focused more on pre-hospital and in-hospital care than on the rehabilitation phase. Since the organization of acute trauma care has improved and mortality due to traumatic injury has decreased, the focus of trauma care has shifted from reducing mortality to improving quality of life and outcome. This in turn resulted in a growing interest in improving the quality of trauma rehabilitation, which is the main focus of this thesis. We developed and evaluated the Transmural Trauma Care Model (TTCM), an advanced transmural rehabilitation model for mild, moderate and severe trauma patients, aiming to improve patient outcomes and reduce costs by optimizing the organization, content, and quality of the rehabilitation process. The TTCM consists of four components, all of which are linked to one another, i.e. 1) a multidisciplinary team at the outpatient clinic for trauma patients, 2) coordination and individual functional goal setting for each patient by the multidisciplinary hospital-based team, 3) a network of specialized primary care physical therapists, and 4) secured email traffic between the hospital-based physical therapist and the primary care network physical therapist. The primary aim of this thesis was to assess the effectiveness and cost-effectiveness of the TTCM within a controlled-before-and-after study. Secondary aims included the assessment of the implementation of the TTCM by exploring its reach, dose delivered, dose received, and fidelity, supplemented by identifying possible barriers and facilitators associated with its implementation. Chapter 2 described the development of the TTCM, complemented by a detailed description of the study design of the controlled-before-and-after study. Chapter 3 investigated the effectiveness of the TTCM compared to regular care among trauma patients, in terms of health-related quality of life (HR-QOL), functional outcome, pain and patient satisfaction. Preliminary evidence was provided that the TTCM is effective in improving patient-related outcome measures. Chapter 4 described the results of the economic evaluation and indicated that the total societal costs were lower among patients treated with TTCM compared with those receiving regular care. However, strong conclusions about the cost-effectiveness of the TTCM cannot be made, since it is unknown what decision-makers are willing-to-pay per unit of effect gained for the outcomes included in the analyses. Chapter 5 described the results of the process evaluation and showed that the TTCM was largely implemented as intended. Various facilitators and barriers were identified that need to be considered when implementing the TTCM broadly. Chapter 6 described the results of the study assessing the association between various fracture and treatment related factors with disease-specific HR-QOL, functional outcome, and societal costs. Having a fracture of the lower extremity was found to be associated with a lower disease-specific HR-QOL and having an upper extremity fracture was associated with a better functional outcome, both compared to patients from the reference category. Chapter 7 described the study protocol of the multicenter trial that was initiated, funded, and designed based on the results of chapter 3, 4, 5 and 6 of this thesis. Chapter 8 presents an extensive discussion of our studies, the choices we made with respect to their methodology as well as their limitations that should be taken into account when interpreting the results. In conclusion, the TTCM seems feasible in practice and we found preliminary evidence that it is effective in improving patient-related outcome measures. Strong conclusions about the cost-effectiveness of the TTCM cannot be made. Results of the multicenter trial, described in chapter 7, are expected in 2023.