Predictors of death and new disability after critical illness: a multicentre prospective cohort study.

PURPOSE: This study aimed to determine the prevalence and predictors of death or new disability following critical illness. METHODS: Prospective, multicentre cohort study conducted in six metropolitan intensive care units (ICU). Participants were adults admitted to the ICU who received more than 24 h of mechanical ventilation. The primary outcome was death or new disability at 6 months, with new disability defined by a 10% increase in the WHODAS 2.0. RESULTS: Of 628 patients with the primary outcome available (median age of 62 [49-71] years, 379 [61.0%] had a medical admission and 370 (58.9%) died or developed new disability by 6 months. Independent predictors of death or new disability included age [OR 1.02 (1.01-1.03), P = 0.001], higher severity of illness (APACHE III) [OR 1.02 (1.01-1.03), P < 0.001] and admission diagnosis. Compared to patients with a surgical admission diagnosis, patients with a cardiac arrest [OR (95% CI) 4.06 (1.89-8.68), P < 0.001], sepsis [OR (95% CI) 2.43 (1.32-4.47), P = 0.004], or trauma [OR (95% CI) 6.24 (3.07-12.71), P < 0.001] diagnosis had higher odds of death or new disability, while patients with a lung transplant [OR (95% CI) 0.21 (0.07-0.58), P = 0.003] diagnosis had lower odds. A model including these three variables had good calibration (Brier score 0.20) and acceptable discriminative power with an area under the receiver operating characteristic curve of 0.76 (95% CI 0.72-0.80). CONCLUSION: Less than half of all patients mechanically ventilated for more than 24 h were alive and free of new disability at 6 months after admission to ICU. A model including age, illness severity and admission diagnosis has acceptable discriminative ability to predict death or new disability at 6 months.

Comparison of Intensive Care and Trauma-specific Scoring Systems in Critically Ill Patients.

INTRODUCTION: Amongst critically ill trauma patients admitted to ICU and still alive and in ICU after 24 hours, it is unclear which trauma scoring system offers the best performance in predicting in-hospital mortality. METHODS: The Australia and New Zealand Intensive Care Society Adult Patient Database and Victorian State Trauma Registry were linked using a unique patient identification number. Six scoring systems were evaluated: the Australian and New Zealand Risk of Death (ANZROD), Acute Physiology and Chronic Health Evaluation III (APACHE III) score and associated APACHE III Risk of Death (ROD), Trauma and Injury Severity Score (TRISS), Injury Severity Score (ISS), New Injury Severity Score (NISS) and the Revised Trauma Score (RTS). Patients who were admitted to ICU for longer than 24 hours were analysed. Performance of each scoring system was assessed primarily by examining the area under the receiver operating characteristic curve (AUROC) and in addition using standardised mortality ratios, Brier score and Hosmer-Lemeshow C statistics where appropriate. Subgroup assessments were made for patients aged 65 years and older, patients between 18 and 40 years of age, major trauma centre and head injury. RESULTS: Overall, 5,237 major trauma patients who were still alive and in ICU after 24 hours were studied from 25 ICUs in Victoria, Australia between July 2008 and January 2018. Hospital mortality was 10.7%. ANZROD (AUROC 0.91; 95% CI 0.90-0.92), APACHE III ROD (AUROC 0.88; 95% CI 0.87-0.90), and APACHE III (AUROC 0.88; 95% CI 0.87-0.89) were the best performing tools for predicting hospital mortality. TRISS had acceptable overall performance (AUROC 0.78; 95% CI 0.76-0.80) while ISS (AUROC 0.61; 95% CI 0.59-0.64), NISS (AUROC 0.68; 95% CI 0.65-0.70) and RTS (AUROC 0.69; 95% CI 0.67-0.72) performed poorly. The performance of each scoring system was highest in younger adults and poorest in older adults. CONCLUSION: In ICU patients admitted with a trauma diagnosis and still alive and in ICU after 24 hours, ANZROD and APACHE III had a superior performance when compared with traditional trauma-specific scoring systems in predicting hospital mortality. This was observed both overall and in each of the subgroup analyses. The anatomical scoring systems all performed poorly in the ICU population of Victoria, Australia.

Impact of a physician - critical care practitioner pre-hospital service in Wales on trauma survival: a retrospective analysis of linked registry data.

The Emergency Medical Retrieval and Transfer Service for Wales launched in 2015. This service delivers senior pre-hospital doctors and advanced critical care practitioners to the scene of time-critical life- and limb-threatening incidents to provide advanced decision-making and pre-hospital clinical care. The impact of the service on 30-day mortality was evaluated retrospectively using a data linkage system. The study included patients who sustained moderate-to-severe blunt traumatic injuries (injury severity score ≥ 9) between 27 April 2015 and 30 November 2018. The association between pre-hospital management by the Emergency Medical Retrieval and Transfer Service and 30-day mortality was assessed using multivariable logistic regression. In total, data from 4035 patients were analysed, of which 412 (10%) were treated by the Emergency Medical Retrieval and Transfer Service. A greater proportion of patients treated by the Emergency Medical Retrieval and Transfer Service had an injury severity score ≥ 16 and Glasgow coma scale ≤ 12 (288 (70%) vs. 1435 (40%) and 126 (31%) vs. 325 (9%), respectively). The unadjusted 30-day mortality rate was 11.7% for patients managed by the Emergency Medical Retrieval and Transfer Service compared with 9.6% for patients managed by standard pre-hospital care services. However, after adjustment for differences in case-mix, the 30-day mortality rate for patients treated by the Emergency Medical Retrieval and Transfer Service was 37% lower (adjusted odds ratio 0.63 (95%CI 0.41-0.97); p = 0.037). The introduction of an emergency medical retrieval service was associated with a reduction in 30-day mortality for patients with blunt traumatic injury.

Functional Outcomes in Patients Admitted to the Intensive Care Unit with Traumatic Brain Injury and Exposed to Hyperoxia: A Retrospective Multicentre Cohort Study.

BACKGROUND: Supplemental oxygen administration to critically ill patients is ubiquitous in the intensive care unit (ICU). Uncertainty persists as to whether hyperoxia is benign in patients with traumatic brain injury (TBI), particularly in regard to their long-term functional neurological outcomes. METHODS: We conducted a retrospective multicenter cohort study of invasively ventilated patients with TBI admitted to the ICU. A database linkage between the Australian and New Zealand Intensive Care Society Adult Patient Database (ANZICS-APD) and the Victorian State Trauma Registry (VSTR) was utilized. The primary exposure variable was minimum acute physiology and chronic health evaluation (APACHE) III PaO2 in the first 24 h of ICU. We defined hypoxia as PaO2 < 60 mmHg, normoxia as 60-299 mmHg, and hyperoxia as ≥ 300 mmHg. The primary outcome was a Glasgow Outcome Scale-Extended (GOSE) < 5 at 6 months while secondary outcomes included 12 and 24 months GOSE and mortality at each of these timepoints. Additional sensitivity analyses were undertaken in the following subgroups: isolated head injury, patients with operative intervention, head injury severity, and PaO2 either subcategorized by increments of 60 mmHg or treated as a continuous variable. RESULTS: A total of 3699 patients met the inclusion criteria. The mean age was 42.8 years, 77.7% were male and the mean acute physiology and chronic health evaluation (APACHE) III score was 60.1 (26.3). 2842 patients experienced normoxia, and 783 hyperoxia. The primary outcome occurred in 1470 (47.1%) of patients overall with 1123 (47.1%) from the normoxia group and 312 (45.9%) from the hyperoxia group-odds ratio 0.99 (0.78-1.25). No significant differences in outcomes between groups at 6, 12, and 24 months were observed. Sensitivity analyses did not identify subgroups that were adversely affected by exposure to hyperoxia. CONCLUSIONS: No associations were observed between hyperoxia in ICU during the first 24 h and adverse neurological outcome at 6 months in ventilated TBI patients.

Workplace intervention programmes for decreasing alcohol use in military personnel: a systematic review.

INTRODUCTION: Harmful or risky-single occasion drinking (RSOD) alcohol use in the military is a significant problem. However, most studies of interventions have focused on veterans, representing a missed opportunity for intervention with active military personnel. Using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) framework, the aim of this systematic review was to analyse and synthesise the evidence related to workplace-based interventions for reducing alcohol use in active-duty military personnel. METHODS: Four electronic databases and reference lists of relevant articles were searched from database inception until 20 January 2020. This review focused on experimental and quasi-experimental studies of active-duty military personnel. Data extraction and methodological quality assessment were independently performed by two reviewers using a standardised checklist. A third reviewer was used to arbitrate the disputed studies for final selection. RESULTS: The search yielded seven studies from an initial 1582 records identified. A range of interventions were used in these studies (four randomised controlled trials, two non-randomised trials and one before and after cohort study), including web-based approaches, telephone-delivered interventions and individual and group-based face-to-face interventions. Seven studies found decreased drinking, measured using a range of outcomes, following the intervention. However, this was not sustained in the longer term in any of the studies. CONCLUSIONS: The low methodological rigour of most studies limited the capacity to demonstrate the efficacy of the interventions studied. Given the importance of reducing harmful or RSOD use of alcohol in the military, future studies would benefit from improved methodological rigour including ensuring adequate study power, randomisation, selection of validated outcome measures, including measures other than consumption (eg, attitudinal measures), and longer-term follow-up. There is also a need to develop methods that ensure participant loss to follow-up is minimised.

Over view of major traumatic injury in Australia--Implications for trauma system design.

BACKGROUND: Trauma registries are known to drive improvements and optimise trauma systems worldwide. This is the first reported comparison of the epidemiology and outcomes at major centres across Australia. METHODS: The Australian Trauma Registry was a collaboration of 26 major trauma centres across Australia at the time of this study and currently collects information on patients admitted to these centres who die after injury and/or sustain major trauma (Injury Severity Score (ISS) > 12). Data from 1 July 2016 to 30 June 2017 were analysed. Primary endpoints were risk adjusted length of stay and mortality (adjusted for age, cause of injury, arrival Glasgow coma scale (GCS), shock-index grouped in quartiles and ISS). RESULTS: There were 8423 patients from 24 centres included. The median age (IQR) was 48 (28-68) years. Median (IQR) ISS was 17 (14-25). There was a predominance of males (72%) apart from the extremes of age. Transport-related cases accounted for 45% of major trauma, followed by falls (35.1%). Patients took 1.42 (1.03-2.12) h to reach hospital and spent 7.10 (3.64-15.00) days in hospital. Risk adjusted length of stay and mortality did not differ significantly across sites. Primary endpoints across sites were also similar in paediatric and older adult (>65) age groups. CONCLUSION: Australia has the capability to identify national injury trends to target prevention and reduce the burden of injury. Quality of care following injury can now be benchmarked across Australia and with the planned enhancements to data collection and reporting, this will enable improved management of trauma victims.

Pay for performance and hip fracture outcomes: an interrupted time series and difference-in-differences analysis in England and Scotland.

AIMS: Hip fractures are associated with high morbidity, mortality, and costs. One strategy for improving outcomes is to incentivize hospitals to provide better quality of care. We aimed to determine whether a pay-for-performance initiative affected hip fracture outcomes in England by using Scotland, which did not participate in the scheme, as a control. MATERIALS AND METHODS: We undertook an interrupted time series study with data from all patients aged more than 60 years with a hip fracture in England (2000 to 2018) using the Hospital Episode Statistics Admitted Patient Care (HES APC) data set linked to national death registrations. Difference-in-differences (DID) analysis incorporating equivalent data from the Scottish Morbidity Record was used to control for secular trends. The outcomes were 30-day and 365-day mortality, 30-day re-admission, time to operation, and acute length of stay. RESULTS: There were 1 037 860 patients with a hip fracture in England and 116 594 in Scotland. Both 30-day (DID -1.7%; 95% confidence interval (CI) -2.0 to -1.2) and 365-day (-1.9%; 95% CI -2.5 to -1.3) mortality fell in England post-intervention when compared with outcomes in Scotland. There were 7600 fewer deaths between 2010 and 2016 that could be attributed to interventions driven by pay-for-performance. A pre-existing annual trend towards increased 30-day re-admissions in England was halted post-intervention. Significant reductions were observed in the time to operation and length of stay. CONCLUSION: This study provides evidence that a pay-for-performance programme improved the outcomes after a hip fracture in England. Cite this article: Bone Joint J 2019;101-B:1015-1023.

The Funding, Administrative, and Policy Influences on the Evaluation of Primary Prevention Programs in Australia.

Evaluation of primary prevention and health promotion programs contributes necessary information to the evidence base for prevention programs. There is increasing demand for high-quality evaluation of program impact and effectiveness for use in public health decision making. Despite the demand for evidence and known benefits, evaluation of prevention programs can be challenging and organizations face barriers to conducting rigorous evaluation. Evaluation capacity building efforts are gaining attention in the prevention field; however, there is limited knowledge about how components of the health promotion and primary prevention system (e.g., funding, administrative arrangements, and the policy environment) may facilitate or hinder this work. We sought to identify the important influences on evaluation practice within the Australian primary prevention and health promotion system. We conducted in-depth semi-structured interviews with experienced practitioners and managers (n = 40) from government and non-government organizations, and used thematic analysis to identify the main factors that impact on prevention program evaluation. Firstly, accountability and reporting requirements impacted on evaluation, especially if expectations were poorly aligned between the funding body and prevention organization. Secondly, the funding and political context was found to directly and indirectly affect the resources available and evaluation approach. Finally, it was found that participants made use of various strategies to modify the prevention system for more favorable conditions for evaluation. We highlight the opportunities to address barriers to evaluation in the prevention system, and argue that through targeted investment, there is potential for widespread gain through improved evaluation capacity.

Outcomes of midfoot and hindfoot fractures in multitrauma patients.

INTRODUCTION: Multitrauma patients suffering hindfoot fractures, including calcaneal and talar fractures, often result in poor outcomes. However, less is known about the outcomes following midfoot fracture in the mutitrauma population. This study aims to describe the epidemiology of midfoot fractures in multitrauma patients and to compare the outcomes of midfoot and hindfoot fractures in this population. METHODS: Data about multitrauma patients (Injury Severity Score >12) sustaining a unilateral midfoot or hindfoot fracture were obtained from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) and from retrospective review of medical records at a major trauma centre. Further outcome data were obtained via a survey using the American Academy of Orthopedic Surgeons Foot and Ankle Score (AAOS FAS) and the 12-item Short Form Health Survey (SF-12). RESULTS: 122 multitrauma patients were included; 81 with hindfoot fractures and 41 with midfoot fractures. The median ISS (IQR) was 22 (17-29) and 27 (17-24) for the hindfoot and midfoot groups, respectively (p = 0.23). Hindfoot and midfoot fractures were commonly associated with intracranial injuries (80.3%), spine injuries (60.7%), ipsilateral lower extremity injuries (24.6%) and pelvic injuries (16.4%). The mean (SD) time to follow up was 4.5 (±2.7) years. There were no differences in mean SF-12 physical (37.97 vs 35.22, p = 0.33) or mental (46.90 vs 46.67, p = 0.94) component summary scores between the groups. There were no differences in mean AAOS FAS standard scores (69.3 vs 69.1, p = 0.97) or shoe comfort scores (median 40 vs 40 p = 0.18) between the groups. CONCLUSION: Functional outcomes in multitrauma patients with midfoot or hindfoot fractures were comparable. These findings suggest that midfoot fractures should be treated with the same degree of due diligence as hindfoot fractures in the multitrauma patient.

Comparing short versions of the Alcohol Use Disorders Identification Test (AUDIT) in a military cohort.

BACKGROUND: The Alcohol Use Disorders Identification Test (AUDIT) is widely used for monitoring harmful alcohol consumption among high-risk populations. A number of short versions of AUDIT have been developed for use in time-constrained settings. In military populations, a range of AUDIT variations have been used, but the optimal combination of AUDIT items has not been determined. METHODS: A total of 952 participants (80% male), recruited as part of a wider study, completed the AUDIT-10. We systematically assessed all possible combinations of three or four AUDIT items and established AUDIT variations using the following statistics: Cronbach's alpha (internal consistency), variance explained (R2) and Pearson's correlation coefficient (concurrent validity). RESULTS: Median AUDIT-10 score was 7 for males and 6 for females, and 380 (40%) participants were classified as having a score indicative of harmful or hazardous alcohol use (≥8) according to WHO classifications.A novel four-item AUDIT variation (3, 4, 8 and 9) performed consistently higher than established variations across statistical measures; it explained 85% of variance in AUDIT-10, had a Pearson's correlation of 0.92 and Cronbach's alpha was 0.63. The FAST, an established shortened AUDIT variant, together with several other four-item novel variants of AUDIT-10 performed similarly. The AUDIT-C performed consistently low on all measures, but with a satisfactory level of internal consistency (75%). CONCLUSION: Shortened AUDIT variations may be suitable alternatives to the full AUDIT for screening hazardous alcohol consumption in military populations. Four-item AUDIT variations focused on short-term risky drinking and its consequences performed better than three item versions. TRIAL REGISTRATION NUMBER: ACTRN12614001332617.

Major trauma in older persons.

BACKGROUND: Globally, populations are ageing, creating challenges for trauma system design. Despite this, little is known about causes of injury and long-term outcomes in older injured patients. This study aims to describe temporal trends in the incidence, causes and functional outcomes of major trauma in older adults. METHODS: The population-based Victorian State Trauma Registry was used to identify patients with major trauma aged 65 years and older with a date of injury between 1 January 2007 and 31 December 2016. Temporal trends in population-based incidence rates were evaluated. Functional outcome was measured using the Glasgow Outcome Scale - Extended. RESULTS: There were 9250 older adults with major trauma during the study period. Low falls were the most common mechanism of injury (62·5 per cent), followed by transport-related events (22·2 per cent) and high falls (9·5 per cent). The number of patients with major trauma aged 65 years and older more than doubled from 2007 to 2016, and the incidence increased by 4·3 per cent per year (incidence rate ratio 1·043, 95 per cent c.i. 1·035 to 1·050; P < 0·001). At 12 months after injury, 41·8 per cent of older adults with major trauma had died, and 52·2 per cent of those who survived to hospital discharge were not living independently. CONCLUSIONS: The number and proportion of older adults with major trauma are increasing rapidly and this will impact on trauma system design. Given the poor long-term outcomes, there needs to be greater emphasis on ensuring that appropriate interventions are targeted to the right patients and enhanced efforts in primary prevention.

Organizational determinants of evaluation practice in Australian prevention agencies.

Program evaluation is essential to inform decision making, contribute to the evidence base for strategies, and facilitate learning in health promotion and disease prevention organizations. Theoretical frameworks of organizational learning, and studies of evaluation capacity building describe the organization as central to evaluation capacity. Australian prevention organizations recognize limitations to current evaluation effectiveness and are seeking guidance to build evaluation capacity. This qualitative study identifies organizational facilitators and barriers to evaluation practice, and explores their interactions in Australian prevention organizations. We conducted semi-structured interviews with 40 experienced practitioners from government and non-government organizations. Using thematic analysis, we identified seven key themes that influence evaluation practice: leadership, organizational culture, organizational systems and structures, partnerships, resources, workforce development and training and recruitment and skills mix. We found organizational determinants of evaluation to have multi-level interactions. Leadership and organizational culture influenced organizational systems, resource allocation and support of staff. Partnerships were important to overcome resource deficits, and systems were critical to embed evaluation within the organization. Organizational factors also influenced the opportunities for staff to develop skills and confidence. We argue that investment to improve these factors would allow organizations to address evaluation capacity at multiple levels, and ultimately facilitate effective evaluation practice.

Patterns of emergency ambulance use, 2009-13: a comparison of older people living in Residential Aged Care Facilities and the Community.

OBJECTIVE: to examine demand for emergency ambulances by older people. DESIGN: retrospective cohort study using secondary analysis of routinely collected clinical and administrative data from Ambulance Victoria, and population data from the Australian Bureau of Statistics and the Australian Institute of Health and Welfare. SETTING: Victoria, Australia. PARTICIPANTS: people aged 65 years and over, living in Residential Aged Care Facilities (RACF) and the community, attended by emergency ambulance paramedics, 2009-13. MAIN OUTCOME MEASURES: rates of emergency ambulance attendance. RESULTS: older people living in RACF experienced high rates of emergency ambulance attendance, up to four times those for age- and sex-matched people living in the community. Rates remained constant during the study period equating to a consistent, 1.45% average annual increase in absolute demand. Rates peak among the 80-84-year group where the number of attendances equates to greater than one for every RACF-dwelling person each year. Increased demand was associated with winter months, increasing age and being male. CONCLUSION: these data provide strong evidence of high rates of emergency ambulance use by people aged 65 years and over living in RACF. These results demonstrate a clear relationship between increased rate of ambulance use among this vulnerable group of older Australians and residence, sex, age and season. Overall, absolute demand continues to increase each year adding to strain on health resources. Additional research is needed to elucidate individual characteristics, illness and health system contributors to ambulance use to inform strategies to appropriately reduce demand.

Revised Functional Capacity Index as a predictor of outcome following injury.

BACKGROUND: Assessment of functional outcomes in survivors of severe injury is an identified priority for trauma systems. The predictive Functional Capacity Index (pFCI) within the 2008 Abbreviated Injury Scale dictionary (pFCI08) offers a widely available tool for predicting functional outcomes without requiring long-term follow-up. This study aimed to assess the 12-month functional outcome predictions of pFCI08 in a major trauma population, and to test the assumptions made by its developers to ensure population homogeneity. METHODS: Patients with major trauma from Victoria, Australia, were followed up using routine telephone interviews. Assessment of survivors 12 months after injury included the Glasgow Outcome Scale - Extended (GOS-E). κ scores were used to measure agreement between pFCI08 and assessed GOS-E scores. RESULTS: Of 20 098 patients with severe injury, 12 417 had both pFCI08 and GOS-E scoring available at 12 months. The quadratic weighted κ score across this population was 0·170; this increased to 0·244 in the subgroup of 1939 patients who met all pFCI assumptions. However, expanding the age range used in this group did not significantly affect κ scores until patients over the age of 70 years were included. DISCUSSION: The pFCI08 has only a slight agreement with outcomes following major trauma. However, the age limits in the pFCI development assumptions are unnecessarily restrictive. The pFCI08 may be able to contribute to future systems predicting functional outcomes following severe injury, but is likely to explain only a small proportion of the variability in patient outcomes.

Social activity and relationship changes experienced by people with bowel and bladder dysfunction following spinal cord injury.

STUDY DESIGN: Exploratory qualitative. OBJECTIVES: The aim of this study was to describe the experiences of bowel and bladder dysfunction on social activities and relationships in people with spinal cord injury living in the community. SETTING: People living with spinal cord injury experiencing bowel and bladder dysfunction. METHODS: Participants were recruited through the Australian Quadriplegic Association Victoria. Semi-structured in-depth interviews were undertaken with purposively selected participants to ensure representation of age, gender, spinal cord injury level and compensation status. A thematic analysis was performed to interpret patient experiences. RESULTS: Twenty-two participants took part in the study. Bladder and bowel dysfunction altered relationships because of issues with intimacy, strained partner relationships and role changes for family and friends. A lack of understanding from friends about bladder and bowel dysfunction caused frustration, as this impairment was often responsible for variable attendance at social activities. Issues with the number, location, access and cleanliness of bathrooms in public areas and in private residences negatively affected social engagement. Social activities were moderated by illness, such as urinary tract infections, rigid and unreliable bowel routines, stress and anxiety about incontinence and managing the public environment, and due to continuous changes in plans related to bowel and bladder issues. Social support and adaptation fostered participation in social activities. CONCLUSION: Tension exists between managing bowel and bladder dysfunction and the desire to participate in social activities. Multiple intersecting factors negatively affected the social relationships and activities of people with spinal cord injury and bowel and bladder dysfunction.

Female patients display poorer burn-specific quality of life 12 months after a burn injury.

INTRODUCTION: Although gender differences in morbidity and mortality have been measured in patients with moderate to severe burn injury, little attention has been directed at gender effects on health-related quality of life (HRQoL) following burn injury. The current study was therefore conducted to prospectively measure changes in HRQoL for males and females in a sample of burn patients. METHODS: A total of 114 adults who received treatment at a statewide burns service for a sustained burns injury participated in this study. Instruments measuring generic health status (Short Form 36 Medical Outcomes Survey version 2), burn-specific HRQoL (Burns Specific Health Scale-Brief), psychological distress (Kessler Psychological Distress Scale) and alcohol use (Alcohol Use Disorders Identification Tool) were prospectively measured at 3, 6 and 12 months post-burn. RESULTS: In the 12 months post-injury, female patients showed overall poorer physical (p=0.01) and mental health status (p<0.001), greater psychological distress (p<0.001), and greater difficulty with aspects of burn-specific HRQoL: body image (p<0.001), affect (p<0.001), interpersonal functioning (p=0.005), heat sensitivity (p=0.01) and treatment regime (p=0.01). While significant interaction effects suggested that female patients had more improvement in difficulties with treatment regime (p=0.007), female patients continued to report greater difficulty with multiple aspects of physical and psychosocial health status 12 months post-injury. CONCLUSION: Even though demographic variables, injury characteristics and burn care interventions were similar across genders, following burn injury female patients reported greater impairments in generic and burn-specific HRQoL along with psychological morbidity, when compared to male patients. Urgent clinical and research attention utilising an evidence-based research framework, which incorporates the use of larger sample sizes, the use of validated instruments to measure appropriate outcomes, and a commitment to monitoring long-term care, can only improve burn-care.

Twelve-month mortality and functional outcomes in hip fracture patients under 65 years of age.

INTRODUCTION: There has been a recent call for improved functional outcome reporting in younger hip fracture patients. Younger hip fracture patients represent a different population with different functional goals to their older counterparts. Therefore, previous research on mortality and functional outcomes in hip fracture patients may not be generalisable to the younger population. The aims of this study were to report 12-month survival and functional outcomes in hip fracture patients aged <65 years and predictors of functional outcome. METHODS: Hip fracture patients aged <65years (range 17-64) registered by the Victorian Orthopaedic Trauma Outcomes Registry over four years were included and their 12-month survival and functional outcomes (Extended Glasgow Outcome Scale) reported. Ordered multivariable logistic regression was used to identify predictors of higher function. RESULTS: There were 507 patients enrolled in the study and of the 447 patients (88%) with 12-month outcomes, 24 (5%) had died. The majority of patients had no comorbidities or pre-injury disability and were injured via road trauma or low falls. 40% of patients sustained additional injuries to their hip fracture. 23% of patients had fully recovered at 12 months and 39% reported ongoing moderate disability. After adjusting for all key variables, odds of better function 12-months post-fracture were reduced for patients with co-morbidities, previous disability or additional injuries, those receiving compensation or injured via low falls. CONCLUSIONS: While 12-month survival rates were satisfactory in hip fracture patients aged under 65 years, their functional outcomes were poor, with less than one quarter having fully recovered 12 months following injury. This study provides new information about which patients may have difficulty returning to their pre-injury level of function. These patients may require additional or more intensive post-discharge care in order to fulfil their functional goals and continue to contribute productively to society.

Twelve-month outcomes following surgical repair of the Achilles tendon.

INTRODUCTION: Incidence of Achilles tendon rupture (ATR) has increased over recent years, and debate regarding optimal management has been widely documented. Most papers have focused on surgical success, complications and short term region-specific outcomes. Inconsistent use of standardised outcome measures following surgical ATR repair has made it difficult to evaluate the impact of ATR on a patient's health status post-surgery, and to compare this to other injury types. This study aimed to report the frequency of surgical repairs of the Achilles tendon over a five-year period within an orthopaedic trauma registry, and to investigate return to work (RTW) status, health status and functional outcomes at 12 months post-surgical repair of the Achilles tendon. METHODS: Two hundred and four adults registered by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) who underwent surgical repair of the Achilles tendon between July 2009 and June 2014 were included in this prospective cohort study. The Extended Glasgow Outcome Scale (GOS-E), 3-level European Quality of Life 5 Dimension measure (EQ-5D-3L), and RTW status 12 months following surgical ATR repair were collected through structured telephone interviews conducted by trained interviewers. RESULTS: At 12 months, 92% of patients were successfully followed up. Of those working prior to injury, 95% had returned to work. 42% of patients reported a full recovery on the GOS-E scale. The prevalence of problems on the EQ-5D-3L at 12 months was 0.5% for self-care, 11% for anxiety, 13% for mobility, 16% for activity, and 22% for pain. 16% of patients reported problems with more than one domain. The number of surgical repairs of the Achilles tendon within the VOTOR registry decreased by 68% over the five-year study period. CONCLUSIONS: Overall, patients recover well following surgical repair of the Achilles tendon. However, in this study, deficits in function persisted for over half of patients at 12 months post-injury. The decreased incidence of surgical Achilles tendon repair may reflect a change in practice at VOTOR hospitals whereby surgery may be becoming less favoured for initial ATR management.

Quality of care for patients with a fracture of the hip in major trauma centres: a national observational study.

AIMS: In this study, we aimed to determine whether designation as a major trauma centre (MTC) affects the quality of care for patients with a fracture of the hip. PATIENTS AND METHODS: All patients in the United Kingdom National Hip Fracture Database, between April 2010 and December 2013, were included. The indicators of quality that were recorded included the time to arrival on an orthopaedic ward, to review by a geriatrician, and to operation. The clinical outcomes were the development of a pressure sore, discharge home, length of stay, in-hospital mortality, and re-operation within 30 days. RESULTS: There were 289 466 patients, 49 350 (17%) of whom were treated in hospitals that are now MTCs. Using multivariable logistic and generalised linear regression models, there were no significant differences in any of the indicators of the quality of care or clinical outcomes between MTCs, hospitals awaiting MTC designation and non-MTC hospitals. CONCLUSION: These findings suggest that the regionalisation of major trauma in England did not improve or compromise the overall care of elderly patients with a fracture of the hip. TAKE HOME MESSAGE: There is no evidence that reconfiguring major trauma services in England disrupted the treatment of older adults with a fracture of the hip.

Health status and return to work in trauma patients at 3 and 6 months post-discharge: an Australian major trauma centre study.

INTRODUCTION: The aim of this study was to describe post-discharge outcomes, and determine predictors of 3 and 6 months health status outcomes in a population of trauma patients at an inner city major trauma centre. METHODS: This was a prospective cohort study of adult trauma patients admitted to this hospital with 3 and 6 months post-discharge outcomes assessment. Outcome measures were the Physical Component Scores (PCS) and Mental Component Scores (MCS) of the Short Form 12, EQ-5D, and return to work (in any capacity) if working prior to injury. Repeated measures mixed models and generalised estimating equation models were used to determine predictors of outcomes at 3 and 6 months. RESULTS: One hundred and seventy-nine patients were followed up. Patients with lower limb injuries reported lower mean PCS scores between 3 and 6 months (coefficient -4.21, 95 % CI -7.58, -0.85) than those without lower limb injuries. Patients involved in pedestrian incidents or assaults and those with pre-existing mental health diagnoses reported lower mean MCS scores. In adjusted models upper limb injuries were associated with reduced odds of return to work at 3 and 6 months (OR 0.20, 95 % CI 0.07, 0.57) compared to those without upper limb injuries. DISCUSSION: Predictors of poorer physical health status were lower limb injuries and predictors of mental health were related to the mechanism of injury and past mental health. Increasing injury severity score and upper limb injuries were the only predictors of reduced return to work. The results provide insights into the feasibility of routine post-discharge follow-up at a trauma service level.