Evaluating time points for measuring recovery after major trauma in adults.

OBJECTIVE: To evaluate recovery after major trauma over a 24-month time frame. BACKGROUND: Measuring disability after injury is seen as increasingly important but requires knowledge not only of the measures that should be implemented but also of the critical time points for follow-up. METHODS: Six hundred sixty-two adult major trauma patients from 2 level 1 trauma centers (October 2006 to March 2007) were followed up by telephone at 6-, 12-, 18-, and 24 months after injury. SF-12, Glasgow Outcome Scale-Extended (GOS-E), pain scores, and return to work (RTW) were collected. Multilevel mixed-effects regression models were fitted to analyze change in outcomes over time. RESULTS: Six hundred seventeen (93%) were followed up for at least 1 time point. Functional recovery (GOS-E = 8) [odds ratio (OR) 3.1, 95% CI: 1.9, 5.0] and RTW (OR 2.4, 95% CI: 1.4, 4.0) improved, and physical health (PCS-12) scores were better (mean difference 1.9, 95% CI: 0.9, 2.9), from 6 to 12 months after injury, but changed little from 12 months. Pain scores were unchanged from 6 to 12 months but were higher at 18 months than at 12 months (OR 1.8, 95% CI: 1.2, 2.8). SF-12 mental health (MCS-12) scores decreased until 18 months but improved from 18 to 24 months (mean difference 1.5, 95% CI: 0.2, 2.8). The rate of recovery differed by injury group and age. CONCLUSIONS: Different patterns of recovery were evident for each outcome, and there was a variation in the rate of recovery for some subgroups. The selection of time points for follow-up requires consideration of the outcome measurements of interest and the population being studied.

Patient perspectives of care in a regionalised trauma system: lessons from the Victorian State Trauma System.

OBJECTIVES: To explore injured patients' experiences of trauma care to identify areas for improvement in service delivery. DESIGN, SETTING AND PARTICIPANTS: Qualitative study using in-depth, semi-structured interviews, conducted from 1 April 2011 to 31 January 2012, with 120 trauma patients registered by the Victorian State Trauma Registry and the Victorian Orthopaedic Trauma Outcomes Registry and managed at the major adult trauma services (MTS) in Victoria. MAIN OUTCOME MEASURES: Emergent themes from patients' experiences of acute, rehabilitation and post-discharge care in the Victorian State Trauma System (VSTS). RESULTS: Patients perceived their acute hospital care as high quality, although 3s with communication and surgical management delays were common. Discharge from hospital was perceived as stressful, and many felt ill prepared for discharge. A consistent emerging theme was the sense of a lack of coordination of post-discharge care, and the absence of a consistent point of contact for ongoing management. Most patients' primary point of contact after discharge was outpatient clinics at the MTS, which were widely criticised because of substantial delays in receiving an appointment, prolonged waiting times, limited time with clinicians, lack of continuity of care and inability to see senior clinicians. CONCLUSIONS: This study highlights perceived 3s in the patient care pathway in the VSTS, especially those relating to communication, information provision and post-discharge care. Trauma patients perceived the need for a single point of contact for coordination of post-discharge care.

Does recall of preinjury disability change over time?

BACKGROUND: Pre-injury disability must be determined when assessing whether treatment programs return people to pre-injury status, however there is little empirical evidence to support recommendations that this be done as soon as possible after injury to prevent recall bias. OBJECTIVES: To determine disagreement between recall of pre-injury disability at different time points post-injury and bias towards under- or overestimating pre-injury disability. METHODS: Self-reported pre-injury global disability was assessed within days, 6 months and 12 months post-injury in patients admitted to two level 1 adult trauma centres. Kappa statistics and multiple logistic regression models identified predictors of disagreement between time-points. RESULTS: Pre-injury disability was measured at all time-points in 801 patients. Pre-injury disability at baseline was rated as none, mild, moderate, marked and severe in 80%, 12%, 5.1%, 1.9% and 1.0% respectively. Absolute agreement between baseline and 6 and 12 months respectively, was 79% and 80%. Corresponding kappa values (95% confidence intervals) were 0.33 (0.26-0.40) and 0.32 (0-25-0.38). Patients over 65 years or not completing high school were more likely to report less pre-injury disability at 6 and 12 months than at baseline with adjusted odds ratios (95% confidence intervals) for these groups being 8.24 (4.32-15.72) and 1.93 (1.03-3.64) respectively. CONCLUSIONS: There was little evidence of recall bias in an adult trauma population if self-reported global pre-injury disability was assessed 6 months post-injury. The recall of pre-injury disability up to 6 months post-injury can be used to determine return to pre-injury status, if assessment is not feasible shortly after injury.

Improved functional outcomes for major trauma patients in a regionalized, inclusive trauma system.

OBJECTIVE: To describe outcomes of major trauma survivors managed in an organized trauma system, including the association between levels of care and outcomes over time. BACKGROUND: Trauma care systems aim to reduce deaths and disability. Studies have found that regionalization of trauma care reduces mortality but the impact on quality of survival is unknown. Evaluation of a trauma system should include mortality and morbidity. METHODS: Predictors of 12-month functional (Glasgow Outcome Scale-Extended) outcomes after blunt major trauma (Injury Severity Score >15) in an organized trauma system were explored using ordered logistic regression for the period October 2006 to June 2009. Data from the population-based Victorian State Trauma Registry were used. RESULTS: There were 4986 patients older than 18 years. In-hospital mortality decreased from 11.9% in 2006-2007 to 9.9% in 2008-2009. The follow-up rate at 12 months was 86% (n = 3824). Eighty percent reported functional limitations. Odds of better functional outcome increased in the 2007-2008 [adjusted odds ratio (AOR): 1.22; 95% CI: 1.05, 1.41] and 2008-2009 (AOR: 1.16; 95% CI: 1.01, 1.34) years compared with 2006-2007. Cases managed at major trauma services (MTS) achieved better functional outcome (AOR: 1.22; 95% CI: 1.03, 1.45). Female gender, older age, and lower levels of education demonstrated lower adjusted odds of better outcome. CONCLUSIONS: Despite an annual decline in mortality, risk-adjusted functional outcomes improved over time, and cases managed at MTS (level-1 trauma centers) demonstrated better functional outcomes. The findings provide early evidence that this inclusive, regionalized trauma system is achieving its aims.

Comparing the responsiveness of functional outcome assessment measures for trauma registries.

BACKGROUND: Measuring long-term disability and functional outcomes after major trauma is not standardized across trauma registries. An ideal measure would be responsive to change but not have significant ceiling effects. The aim of this study was to compare the responsiveness of the Glasgow Outcome Scale (GOS), GOS-Extended (GOSE), Functional Independence Measure (FIM), and modified FIM in major trauma patients, with and without significant head injuries. METHODS: Patients admitted to two adult Level I trauma centers in Victoria, Australia, who survived to discharge from hospital, were aged 15 years to 80 years with a blunt mechanism of injury, and had an estimated Injury Severity Score >15 on admission, were recruited for this prospective study. The instruments were administered at baseline (hospital discharge) and by telephone interview 6 months after injury. Measures of responsiveness, including effect sizes, were calculated. Bootstrapping techniques, and floor and ceiling effects, were used to compare the measures. RESULTS: Two hundred forty-three patients participated, of which 234 patients (96%) completed the study. The GOSE and GOS were the most responsive instruments in this major trauma population with effect sizes of 5.3 and 4.4, respectively. The GOSE had the lowest ceiling effect (17%). CONCLUSIONS: The GOSE was the instrument with greatest responsiveness and the lowest ceiling effect in a major trauma population with and without significant head injuries and is recommended for use by trauma registries for monitoring functional outcomes and benchmarking care. The results of this study do not support the use of the modified FIM for this purpose.

Functional and health-related quality of life outcomes after pediatric trauma.

BACKGROUND: Pediatric trauma results in lower mortality than adults and a high potential for lifelong functional impairment and reduced health-related quality of life (HRQL). There is no consensus regarding the best approach to measuring outcomes in this group. METHODS: One hundred and fifty injured children admitted to a pediatric trauma center participated in this study. The Pediatric Quality of Life Inventory (PedsQL), Child Health Questionnaire (CHQ-PF28), King's Outcome Scale for Childhood Head Injury (KOSCHI), modified Glasgow Outcome Scale (mGOS), and the Functional Independence Measure (FIM) were administered at 1 month, 6 months, and 12 months after injury by telephone. Change in instrument scores was assessed using multilevel mixed effects models. Mean HRQL scores were compared with population norms for the CHQ-PF28 and with healthy children for the PedsQL. RESULTS: Follow-up at all time points was completed for 144 (96%) cases. The median injury severity score was 10, and 65% of the patients enrolled were men. At 12 months, the percentage of cases with ongoing disability was 14% for the FIM, 61% using the mGOS, and 58% for the KOSCHI. CHQ-PF28 physical and PedsQL psychosocial health scores were below healthy child norms at 12 months. Improvement across all time points was demonstrated for the KOSCHI, mGOS, CHQ-PF28 physical, and PedsQL psychosocial summary scores. CONCLUSIONS: Seriously injured children showed ongoing disability and reduced HRQL 12 months after injury. The CHQ-PF28 and PedsQL, and the mGOS and KOSCHI, performed comparably. The FIM demonstrated considerable ceiling effects, and improvement over time was not shown. The results inform the methodology of pediatric outcomes studies and protocol development for the routine follow-up of pediatric trauma patients.

Agreement between parent and child report of health-related quality of life: impact of time postinjury.

BACKGROUND: Health-related quality of life (HRQL) is subjective concept and, therefore, should be captured directly from the patient. However, proxy reporting of HRQL is widespread, particularly in pediatric studies where children have been considered unreliable respondents. This study assessed the level of agreement between proxy (parent) and child reports of HRQL at key time points after injury. METHODS: Thirty-seven seriously injured children aged 13 years to 16 years participated in this study. The Pediatric Quality of Life inventory was administered to the parent and child at 1 month, 6 months, and 12 months after injury by telephone interview. Agreement between child and parent responses was compared using Bland-Altman plots, and Pediatric Quality of Life inventory physical and psychosocial summary scales were compared using paired t tests or Wilcoxon signed-rank tests, respectively. RESULTS: At 1-month (psychosocial t = -4.6, p < 0.001; physical t = -6.5 p < 0.001) and 6-month (psychosocial z = -2.5, p = 0.01; physical z = -2.6, p = 0.01) postinjury there was a significant difference between the parent and child reports, with children rating their HRQL higher than their parents. At 12-months, there was no difference between the scores reported by parents and their children (psychosocial z = -0.3, p = 0.76; physical t = -0.7, p = 0.51). CONCLUSIONS: Agreement between parent and child ratings of HRQL improved with time postinjury. The findings have implications for the design of pediatric trauma outcomes studies and the routine collection of pediatric HRQL data. Parent and child reports should be considered separate but important information, particularly in the early stages following injury. Where collection of both is not feasible, parent or child report should be chosen, and interchangeable use of parent and child reports limited.

Functional measures at discharge: are they useful predictors of longer term outcomes for trauma registries?

OBJECTIVE: Trauma registries are integral to trauma systems, but reliance on mortality as the primary outcome measure remains a limitation. Some registries have included measures of discharge function, usually the modified Functional Independence Measure (FIM) or the Glasgow Outcome Scale (GOS), with the potential benefit being the ability to identify patients at risk for poor outcome. This study investigates the ability of these measures to predict longer term outcomes. METHODS: Two hundred forty-three blunt major trauma patients participated. Data were captured from the trauma registry and discharge function was assessed using the modified FIM, FIM, and GOS. At 6 months postinjury, the GOS, FIM, modified FIM, return to work/study, and other outcome measures were collected by telephone interview. Multivariate analyses were used to assess the performance of discharge functional measures as predictors of 6-month outcomes. RESULTS: Two hundred thirty-six (97.1%) participants were followed at 6 months postinjury. Disability was prevalent at 6 months; 42% had not returned to work/study, and only 32% were categorized as a "good recovery" by the GOS. Neither the GOS nor modified FIM at discharge were independent predictors of 6-month outcomes, whereas the FIM score and the FIM motor score were independent predictors of functional recovery (adjusted odds ratios 0.97; 95% confidence intervals: 0.96-0.99) and return to work/study (adjusted odds ratios 1.03, 95% confidence intervals: 1.01-1.04), respectively. CONCLUSIONS: For trauma registries to compare outcomes between regions and improvements over time, it is important that survivors with poor long-term outcomes are identified. Present measurement of discharge outcomes for trauma patients is inadequate for this purpose.

Can the modified functional independence measure be reliably obtained from the patient medical record by different raters?

BACKGROUND: The National Trauma Databank minimum dataset includes three items of the Functional Independence Measure (FIM) collected at hospital discharge. Reliable collection of the modified FIM through medical record review could enable trauma registries to obtain a functional outcome measure without patient interview. This study investigated the interrater reliability of the medical record modified FIM, and the level of agreement with the modified FIM scored through patient assessment. METHODS: Four raters scored the modified FIM from the medical records of 44 major trauma patients postdischarge. The medical record modified FIM scores were compared with the modified FIM score obtained through patient assessment at discharge. Weighted (Kw) and unweighted [kappa] statistics were used to describe absolute and near agreement between pairs of raters. RESULTS: The average level of agreement between raters was slight for the feeding (mean Kw, 0.13) item, fair for the expression (mean Kw, 0.28) item, and moderate for the locomotion (mean Kw, 0.47) item. Compared with the patient assessment modified FIM, the average level of agreement was moderate (mean Kw, 0.55) for the locomotion item, and fair for the expression and feeding items, with mean Kw of 0.38 and 0.20, respectively. CONCLUSION: The interrater reliability of the medical record modified FIM, and agreement with the modified FIM obtained through patient assessment, was low. Meaningful comparisons of this outcome measure across registries and hospitals could be limited, and comparisons within a registry or hospital over time may be similarly affected by changes in staff.

Use of health care services 6 months following major trauma.

To establish the use of health care services 6 months following major trauma, 243 blunt major trauma patients were recruited during their acute hospital stay and followed up by telephone interview at 6 months post-injury. Data collected at 6 months included health care service usage and their level of disability according to the Glasgow Outcome Scale--Extended (GOSE). Ninety-four percent of patients were living in the community at 6 months, and most (69%) reported continued use of health care services. Of those with ongoing disability, non-compensable patients were significantly more likely (OR 3.7; 95% CI, 1.6-8.6) to have ceased health care service use than compensable patients, independent of injury severity.

Level of agreement between patient and proxy responses to the EQ-5D health questionnaire 12 months after injury.

BACKGROUND: Health-related quality of life represents a patient's experiences and expectations and should be collected from the patient. In trauma, collection of information from the patient can be challenging, particularly for subgroups where cognitive impairment is prevalent, increasing reliance on proxy reporting. This study assessed the agreement between patient and proxy reporting of health-related quality of life 12 months after injury. METHODS: The Victorian State Trauma Registry and Victorian Orthopaedic Trauma Outcomes Registry collect EQ-5D data at 12 months after injury. Cases where data were collected from the patient and proxy were extracted. Agreement between patient and proxy responses was compared using kappa (K) coefficients for the individual EQ-5D items, and Bland-Altman plots and Wilcoxon signed-rank tests for the EQ-5D summary score and visual analog scale (VAS). RESULTS: Agreement between patient and proxy respondents was substantial for the mobility (K = 0.61) and personal care items (K = 0.67) and moderate for the usual activities (K = 0.50), pain/discomfort (K = 0.42), and anxiety/depression items (K = 0.47). The mean difference between proxy and patient-reported scores for the VAS (0.74, 95% confidence interval: -2.73, 4.21) and the EQ-5D summary score (-0.02, 95% confidence interval: -0.07, 0.03) was small, but the limits of agreement were wide (-34.22 to 35.71 for VAS and -0.55 to 0.51 for summary score), suggesting no systematic bias. CONCLUSIONS: Although proxy and patient responses for the EQ-5D VAS may differ, the differences show random variability rather than systematic bias. Group comparisons using proxy responses are unlikely to be biased, but proxy responses should be used with caution when assessing individual patient recovery.

Validity of outcome measures used to assess one and six month outcomes in orthopaedic trauma patients.

INTRODUCTION: To evaluate the validity of the 12-item Short Form Health Survey (SF-12), Sickness Impact Profile (SIP) and the Short Musculoskeletal Functional Assessment Questionnaire (SMFA) for use in an orthopaedic trauma population. MATERIALS AND METHODS: A prospective validation trial was completed at a Level 1 adult trauma centre in Melbourne, Australia. One hundred and fifty four patients with orthopaedic trauma managed or followed-up by an orthopaedic unit were prospectively recruited. Patients with pathological fractures related to metastatic disease and/or an isolated orthopaedic injury, a documented history of mental illness or dementia or those for whom follow-up was likely to be difficult were excluded. The SF-12, SIP and SMFA were administered by a trained interviewer at one and six months. Each questionnaire was scored for the physical and mental components and then compared for content and construct validity at each time point. RESULTS: Complete data were collected for 134 patients at one and six months. The one and six month component scores correlated strongly between the SF-12 physical, SIP physical (r=0.513-0.669) and SMFA dysfunction (r=0.529-0.778); the SF-12 mental, SIP mental (r=0.643-0.719) and SMFA bother (r=0.564-0.602) components. The strength of association was greater for the six month time point compared to the one month measure. The SF-12 demonstrated no ceiling or floor effects, and provided a lower time burden on participants and researchers when compared to the SIP and SMFA. CONCLUSIONS: For large population-based surveillance research into orthopaedic injury the SF-12 provides a valid and versatile tool.

Routine follow up of major trauma patients from trauma registries: What are the outcomes?

BACKGROUND: Routine measurement of outcomes other than mortality in trauma is needed to monitor trauma care, benchmark trauma hospitals and systems, and to guide resource provision. Trauma registries are ideally placed to capture morbidity outcomes such as functional loss, disability, and handicap. This study aimed to provide a broad description of the 6-month outcomes of major trauma patients captured by a population-based trauma registry, establish the follow-up rate of registry patients, and determine any biases associated with loss to follow up. METHODS: The Victorian State Trauma Registry (VSTR) is a population-based registry in Victoria, Australia. Major trauma patients captured by the VSTR with a date of injury from October 1, 2003 to September 30, 2004 were followed up at 6 months postinjury by telephone to collect information about their living status, functional levels, and return to work. RESULTS: Of the 1,102 eligible patients, 67% were successfully followed up at 6 months postinjury. Eighteen patients had died since discharge. Patients lost to follow up were less severely injured (p = 0.004) and younger (p = 0.010) at baseline than those followed up. The vast majority of major trauma patients are independent with respect to locomotion (78%), feeding (93%), and expression (93%) by 6 months postinjury. Of those working before injury, 60% had returned to work. CONCLUSIONS: The findings show that follow up of registry patients is feasible, results in few biases in the follow-up population, and reports similar findings to individual studies of trauma populations.