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Flaura Koplin Winston, M.D., Ph.D., is Founder and Co- Scientific Director, Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, and Senior Fellow, Leonard Davis Institute of Health Economics at the University of Pennsylvania.
In Their Own Words

An Interview with Flaura Koplin Winston
Raising a Mensch Editor, and Recipient of the John M. Eisenberg Patient Safety and Quality Award.

-- David A. Asch, M.D., M.B.A.

Dr. Winston's primary research focus is traffic injury. She is the Principal Investigator for research funded by the National Highway Traffic Safety Administration, the National Science Foundation, the Maternal and Child Health Bureau, and State Farm Insurance Companies. Some of her most notable research findings include the identification of the first cases of child fatalities from air bags and the delineation of the mechanisms of injury, the importance and prevalence of suboptimal restraint of children in motor vehicles, the incidence of and risk factors for posttraumatic stress disorder in children and parents after child traffic injuries, and the teen perspective on driving risks and their prevalence.

Your background as an engineer and a pediatrician with a background in public health seems ideal for the job you have in traffic injury prevention. In fact, I have heard you referred to as "the link." What has your cross-disciplinary training taught you?

Important problems in our society require more than a multipronged approach; they demand interdisciplinary work. Without such integration, approaches to finding and implementing solutions can be fragmented and inefficient. Injury epidemiologists recognize the wide range of variability in humans and can provide accurate estimates of the magnitude of a hazard. They answer who, what, where, and when children are typically injured in this way. Injury engineers apply laws and principles of physics and other basic sciences to systematically analyze injuries to children as vehicle and restraint design failures. They answer how the injury occurred to recommend prevention strategies. Injury behavioral scientists view the injury from the human and social contexts and answer why it happened, recognizing that we can never engineer out behavior. Epidemiologists, engineers, and behavioral scientists are necessary to create a full picture of the often fragmented injury puzzle and provide insights into solutions. However, without cross-disciplinary exchange, the picture will remain a pile of disconnected pieces.

Over the past decade, I have worked to ensure that our injury research and prevention team at The Children's Hospital of Philadelphia and the University of Pennsylvania is truly integrated and interdisciplinary. I believe that this is why our work has had both breadth and depth. My engineering colleagues know the limits of engineering and when epidemiology, behavioral science, or another approach is needed to solve a problem and vice versa. When this scientific handoff is required, a nearseamless transition occurs. Bringing their different viewpoints, multiple experts come together to interpret one another’s work. This rich environment is found in the most productive medical laboratories and has been recognized as an integral part of the National Institutes of Health (NIH) Road Map. I suggest that future medical, health services research, and public health training include at least an introduction to the principles of behavioral science and engineering to facilitate our efforts to find answers to the complex problems that we face in medicine. In addition to conducting clinical research and engineering studies, I remain a practicing clinician. This regular contact with patients keeps me grounded in reality and the ongoing high prevalence of injury and its prevention. As a result, I work to advance my science from "the bench to the bedside" to provide optimal care.

I suspect that when many people think of patient safety, they only consider those who are sick in hospitals or clinics. Your work focuses at least as much on what happens in the community—before people become "patients" in the first place. Is our current thinking about patient safety too constrained?

Hospital-based patient safety is necessary but insufficient if we truly want to make a difference in our nation’s health. Physician error reduction plays an important role in tertiary prevention: decreasing morbidity and mortality once a patient has a disease or injury. We will have much more impact, however, if the patient never contracts the disease or suffers an injury.

To achieve this goal, we need to focus on community and ambulatory-based prevention strategies that are primary (reducing risk and exposure) and secondary (reducing incidence and severity). Quality improvement programs should be expanded to identify and address "prevention errors," such as the health system’s inability to effect changes that reduce crashes and increase use of appropriate restraints in motor vehicles. This is not a new concept for disease prevention: think "vaccine failure." When a child today contracts a vaccine-preventable disease, physicians are required to notify the health authorities, and steps are taken to avoid a recurrence in another child. For example, a recent response to post-vaccination varicella occurrence was a requirement for a booster dose of vaccine.

Once we have an understanding of the necessary prevention strategies, we need to deliver them through effective programs and to sufficiently fund the initiatives. It is also imperative to develop best practice guidelines for prevention and counseling and to measure the effectiveness of our programs. For this to occur, we must develop sound prevention quality performance and effectiveness metrics. Policymakers might consider requiring their measurement by health care entities, possibly as part of accreditation by The Joint Commission, and, if so, health care funding should reimburse for this time well spent. "Do no harm" is an important goal for protecting our patients, but it is not enough.

You helped "medicalize" child passenger safety. But you also brought in nonmedical stakeholders to join you. Why was this important, and how can these partnerships be expanded to other areas of health care and other areas of health?

As an academic physician, I recognize that my work will have little impact on the public’s health if my end goal is publication in high-impact journals. For each of my research findings I know that there are many nonmedical audiences needing to be reached. These include legislators, policymakers, employers, engineers, designers, and families, all of whom have a stake in translating injury prevention research into action. Unfortunately, our academic publications are not easily accessible by them.

In my approach, I incorporate these stakeholders, the end users of my research, into the research plan. Before I embark on a study, I review the research question and proposed data collection with representatives of the stakeholder groups to determine if my planned data set is complete. Would the relevance of the research be enhanced by additional questions with associated data elements? Once my team conducts the study and analyzes the data, I return to these groups of "policy influencers" to help interpret the results and to suggest plans of action. Finally, I translate the science into terms that matter and create materials and training on their use for these various groups, the "stakeholders for the science." This integrated "research-to-action" approach fosters efficient knowledge transfer, due in part to the tremendous buy-in from the beginning of the research by the people who have the power to implement change based on the findings.

The National Science Foundation awarded our Center an Industry/University Cooperative Research Center designation, which is another example of how this knowledge translation works. This little-known program was established several decades ago to promote efficient corporate/ academic exchange and to leverage resources for fundamental research. This model of cooperation was adopted recently by the National Cancer Institute investigation of orphan cancers. I believe that such industry/academic partnerships, with safeguards in place for academic freedom and scientific integrity, are essential to advancing health.

Whose job is child passenger safety? If the buck stops here, where is here?

There are many people who have much to gain by universal child passenger safety. If I had to say where the buck stops, however, it is with the parent or caregiver who is transporting the child. Unfortunately, the answer is not that simple. Many parents lack the necessary knowledge about or access to appropriate automotive child restraints. As a result, the safety of our children in motor vehicles is in jeopardy. The issue is paramount. Consider these statistics:

  • In 2000, injuries to children ages 10 and under resulted in an estimated $5.7 billion in direct medical expenditures.
  • For every child injured, the total cost is more than $12,700, including $650 in medical costs, more than $1,000 in future earnings lost, and nearly $11,000 in lost quality of life.
  • Every dollar spent on a child safety seat saves this country $32 in direct medical costs and other costs to society.

These statistics translate the human costs of injury into financial costs. Not only are child restraint systems effective in reducing injuries and deaths; they’re also cost-effective. In a recent analysis, we demonstrated that child safety seat and booster seat disbursement and education are just as cost-effective as several of the vaccines delivered as part of the Vaccine for Children program. It is time for the health care community to recognize the medical benefits of safety devices.

You break down car crashes into what happens before the crash, during the crash, and after the crash. Clearly, all of these time frames are important, but does intervention in any of these offer more promise for success than others?

Have you ever heard the old saying, "An ounce of prevention is worth a pound of cure"? Preventing the crash is the obvious best approach. One specific way to prevent crashes is to develop strategies to improve teen driving, particularly during the first six months, and to reduce drinking and driving in all age groups.When we fail to prevent the crash, we need to be sure that backup prevention strategies are in place. Optimal restraint for every trip is a proven effective strategy. We reduce by half the risk of injury in a crash by restraint use; for our children, we achieve another 2/3 reduction in risk by placing them in age-appropriate restraints and seating them in the rear seat until at least age 13.

As a final backup strategy, we rely on the most expensive and most intensive resources, including trauma resuscitation, acute care, and rehabilitation. Survival after injury greatly depends on the strength of the victim’s local trauma system. The system must include rapid emergency medical response teams qualified in adult and pediatric trauma care and qualified trauma medical facilities. To guarantee high quality, rapid trauma care delivery for all Americans, regardless of geography, continued investment and expansion is required.

But to ensure optimal outcomes, trauma care has to look beyond the physical injury realm to address the prevalent psychosocial consequences of the injury and to minimize the trauma of medical care. Even in the absence of injury, the trauma of a crash can have detrimental psychological effects.

Recently, the Substance Abuse and Mental Health Services Administration coined the term "traumainformed care." Such ideal clinical care for injury and violence would address not only the survivor’s medical and surgical needs, but also the survivors’ response to the trauma. This care would thereby aid the healing and rehabilitation process. Moreover, from a staff perspective, a trauma-informed approach would result in a cultural shift that recognizes and addresses the personal, emotional stress associated with caring for these patients. With this approach, the work environment would become more effective, patient outcomes would improve, and, ultimately, bottom-line costs would be reduced.

Some people probably don’t see child restraints as sufficiently medical, but you’ve demonstrated how profoundly you can affect health with them. Why can’t medical providers prescribe child safety seats?

Child safety seats, booster seats, helmets, and other safety devices are proven to prevent injury. Despite this knowledge, many children in our country ride in vehicles without appropriate restraints, creating a health disparity in injury. In particular, minority and non-English-speaking parents lack the resources to purchase child safety seats and belt-positioning booster seats or lack the knowledge to use them correctly. Therefore, their children ride unprotected and are at disproportionate risk of injury. Pediatricians highlight the importance of appropriate child restraints in motor vehicles as part of anticipatory guidance despite the fact that they do not receive reimbursement for this counseling. However, they are precluded from eliminating the access barrier because child restraint systems are not allowable as a direct medical expense.

Similarly, effective and promising interventions are under development to prevent crashes among novice teen drivers, the population with the highest fatal crash risk. Restrictions on prevention services by some insurance plans will limit physician referral for these remedial and prevention strategies. As a result, effective prevention interventions will have limited avenues for dissemination despite the fact that some states require pre-driving physical evaluations by physicians. Physicians are forced to make determinations of risk without being able to offer the antidote. If our health system continues to limit prevention activities by physicians, our current level of annual crash fatalities, if left unabated, predicts that more than 100,000 children, youths, and young adults will die in crashes in the next 10 years.

As a society we can no longer sustain a health care system that relies on treatment for disease and injury as our primary clinical strategy. We need to begin to allow medical expenses for prevention, particularly safety devices and interventions. We also must now invest in research to determine cost-effective, best practice models for the dissemination of prevention strategies and metrics to measure compliance and effectiveness. This is imperative not only through the health care system, but also through other touch points for guidance and resource distribution, such as schools and day care centers.

What are the pressing needs for the advancement of injury prevention and trauma care?

I believe that injury research, training, and translation are the areas of greatest need to address the "epidemic" of injury, but current allocation for these areas of focus are only pennies on the dollar of funds allocated to disease. As a result, it is difficult to attract the most promising scientists and clinicians to the field. With limited funding available they see a difficult future: Scientists have no guarantee that important, resource-intensive studies and trials will be conducted to advance their area of study, while clinicians fear that they will not be reimbursed for their services.

It is the domino effect. Since there’s insufficient funding and little emphasis placed on them by the medical community, many proven effective prevention strategies are not implemented. As a result, preventable injuries likely occur every minute in this country. Several will likely happen while you’re reading this interview. Finally, trauma care needs to go beyond the treatment of the physical injury. It has to move to treating the likely psychosocial consequences, focusing not only on full recovery, but also on prevention of recurrence. PTSD (post-traumatic stress disorder) is a common outcome of injury; yet, most injured patients with PTSD go undiagnosed and untreated. As another example, alcoholics with injuries all too often get patched up and sent out without adequate treatment to address the root cause of their injury, their addiction. Victims of domestic or interpersonal violence also are often treated and released to the same setting where the incidents occurred without any guidance or resources to prevent future injuries.

It is important to remember that injury and violence are the leading causes of death for all ages from 1 to 44 and the leading causes of acquired disability and lost years of productive life in this country. It is our responsibility as a health care delivery system to prevent or reduce the chance of injury when crashes and other potentially injurious events occur, treating the injuries for which our prevention efforts failed, and discharging our patients to a safe environment with the proper care to connect them with the interventions that will reduce their risk of recurrence. We need to optimize our health care delivery system with primary, secondary, and tertiary prevention strategies. We also must invest in the necessary training, research, and resources to advance and deliver this care. J

Dr. Winston was interviewed by David A. Asch, M.D., M.B.A., Executive Director, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia. Reprinted courtesy of the Joint Commission Journal on Quality and Patient Safety.

Previous Interviews

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