Long-term health status and trajectories of seriously injured patients: A population-based longitudinal study.

BACKGROUND: Improved understanding of the quality of survival of patients is crucial in evaluating trauma care, understanding recovery patterns and timeframes, and informing healthcare, social, and disability service provision. We aimed to describe the longer-term health status of seriously injured patients, identify predictors of outcome, and establish recovery trajectories by population characteristics. METHODS AND FINDINGS: A population-based, prospective cohort study using the Victorian State Trauma Registry (VSTR) was undertaken. We followed up 2,757 adult patients, injured between July 2011 and June 2012, through deaths registry linkage and telephone interview at 6-, 12-, 24-, and 36-months postinjury. The 3-level EuroQol 5 dimensions questionnaire (EQ-5D-3L) was collected, and mixed-effects regression modelling was used to identify predictors of outcome, and recovery trajectories, for the EQ-5D-3L items and summary score. Mean (SD) age of participants was 50.8 (21.6) years, and 72% were male. Twelve percent (n = 333) died during their hospital stay, 8.1% (n = 222) of patients died postdischarge, and 155 (7.0%) were known to have survived to 36-months postinjury but were lost to follow-up at all time points. The prevalence of reporting problems at 36-months postinjury was 37% for mobility, 21% for self-care, 47% for usual activities, 50% for pain/discomfort, and 41% for anxiety/depression. Continued improvement to 36-months postinjury was only present for the usual activities item; the adjusted relative risk (ARR) of reporting problems decreased from 6 to 12 (ARR 0.87, 95% CI: 0.83-0.90), 12 to 24 (ARR 0.94, 95% CI: 0.90-0.98), and 24 to 36 months (ARR 0.95, 95% CI: 0.95-0.99). The risk of reporting problems with pain or discomfort increased from 24- to 36-months postinjury (ARR 1.06, 95% CI: 1.01, 1.12). While loss to follow-up was low, there was responder bias with patients injured in intentional events, younger, and less seriously injured patients less likely to participate; therefore, these patient subgroups were underrepresented in the study findings. CONCLUSIONS: The prevalence of ongoing problems at 3-years postinjury is high, confirming that serious injury is frequently a chronic disorder. These findings have implications for trauma system design. Investment in interventions to reduce the longer-term impact of injuries is needed, and greater investment in primary prevention is needed.

Injection frequency of botulinum toxin A for spastic equinus: a randomized clinical trial.

AIM: We compared two botulinum toxin A (BoNT-A) injection frequency regimens, 12-monthly versus 4-monthly, for spastic equinus in a randomized clinical trial. The primary outcome measure was passive ankle dorsiflexion. METHOD: Forty-two ambulant children with spastic equinus, secondary to cerebral palsy (23 males and 19 females; mean age 3y 6mo, SD 13mo; GMFCS levels I [n=20], II [n=19], III [n=3]) were randomized to receive either 12-monthly or 4-monthly BoNT-A injections to the calf, over a 26-month period. Twenty-one children had spastic hemiplegia, 21 children had spastic diplegia. A fixed 6U/kg dose of Botox was injected into the gastrocnemius muscle of both limbs in children with diplegia and the gastrocsoleus of the affected limb in children with hemiplegia, under mask anaesthesia. RESULTS: Forty-two children entered the trial with 21 participants randomized to each group. There were three withdrawals and two children received serial casting midway through the trial. There was no significant difference in passive dorsiflexion between 12-monthly and 4-monthly regimens (p=0.41). There were also no significant between group differences on secondary outcome measures. There were no serious adverse events - the rate was 1.2 adverse events per child per year in the 12-monthly group and 2.2 adverse events per child per year in the 4-monthly group. Subgroup analysis revealed a significant difference in passive dorsiflexion between children with hemiplegia and diplegia (p=0.01). INTERPRETATION: There was no significant difference between 12-monthly and 4-monthly injection regimens on passive dorsiflexion or secondary outcome measures. BoNT-A injections for spastic equinus may be recommended on a 12-monthly basis.

Level of agreement between patient-reported EQ-5D responses and EQ-5D responses mapped from the SF-12 in an injury population.

BACKGROUND: Comparing health-related quality of life (HRQL) outcomes between studies is difficult due to the wide variety of instruments used. Comparing study outcomes and facilitating pooled data analyses requires valid "crosswalks" between HRQL instruments. Algorithms exist to map 12-item Short Form Health Survey (SF-12) responses to EQ-5D item responses and preference weights, but none have been validated in populations where disability is prevalent, such as injury. METHODS: Data were extracted from the Validating and Improving injury Burden Estimates Study (Injury-VIBES) for 10,166 adult, hospitalized trauma patients, with both the three-level EQ-5D (EQ-5D-3L) and SF-12 data responses at six and 12-months postinjury. Agreement between actual (patient-reported) and estimated (mapped from SF-12) EQ-5D-3L item responses and preference weights was assessed using Kappa, Prevalence-Adjusted Bias-Adjusted Kappa statistics and Bland-Altman plots. RESULTS: Moderate agreement was observed for usual activities, pain/discomfort, and anxiety/depression. Agreement was substantial for mobility and self-care items. The mean differences in preference weights were -0.024 and -0.012 at six and 12 months (p < 0.001), respectively. The Bland-Altman plot limits of agreement were large compared to the range of valid preference weight values (-0.56 to 1.00). Estimated EQ-5D-3L responses under-reported disability for all items except pain/discomfort. CONCLUSIONS: Caution should be taken when using EQ-5D-3L responses mapped from the SF-12 to describe patient outcomes or when undertaking economic evaluation, due to the underestimation of disability associated with mapped values. The findings from this study could be used to adjust expected EQ-5D-3L preference weights when estimated from SF-12 item responses when combining data from studies that use either instrument.

How well do principal diagnosis classifications predict disability 12 months postinjury?

BACKGROUND: The application of disability weights by nature of injury is central to the calculation of disability-adjusted life years (DALYs). Such weights should represent injury diagnosis groups that demonstrate homogeneity in disability outcomes. Existing classifications have not used empirical data in their development to inform groups that are homogeneous for disability outcomes, limiting the capacity to make informed recommendations for best practice in measuring injury burden. METHODS: The Validating and Improving injury Burden Estimates (Injury-VIBES) Study includes pooled data from over 30 000 injured participants recruited to six cohort studies. The International Classification of Disease 10th Revision (ICD-10) diagnosis codes were mapped to existing injury burden study groupings and prediction models were developed to measure the capacity of the injury groupings and ICD-10 diagnoses to predict disability outcomes at 12 months. Models were adjusted for age, gender and data source and investigated for discrimination using area under the receiver operating characteristic curve (AUC) and calibration using Hosmer-Lemeshow statistics and calibration curves. RESULTS: Discrimination and calibration of models varied depending on the outcome measured. Models using full four-character ICD-10 diagnosis codes, rather than groupings of codes, demonstrated the highest discrimination ranging from an AUC (95% CI) of 0.627 (0.618 to 0.635) for the pain or discomfort item of the EQ-5D to 0.847 (0.841 to 0.853) for the extended Glasgow Outcome Scale independent living outcome. However, gain over other groupings was marginal. CONCLUSIONS: Prediction performance was best for measures of function such as independent living, mobility and self-care. The classifications were poorer predictors of anxiety/depression and pain/discomfort. There was no clearly superior classification.

Reproducibility of an instrumented measure for passive ankle dorsiflexion in conscious and anaesthetized children with cerebral palsy.

AIM: The aims of this study were to (1) determine whether an instrumented measure will reduce measurement error to less than 5° in children with cerebral palsy (CP), (2) determine agreement and reliability of this instrumented measure in both conscious and anaesthetized participants, and (3) compare the method with previously reported measures. METHOD: Thirty-four ambulant children (15 males, 19 females), aged 3 to 9 years, with spastic CP were studied in a tertiary-care paediatric hospital (21 with hemiplegia, 11 with diplegia, and two with quadriplegia). The majority of children functioned at Gross Motor Function Classification System level I (n=11) or II (n=18), with five children at level III. Ankle dorsiflexion at 50% bodyweight was photographed and measured. Each child was measured when conscious and when under mask anaesthesia by two experienced assessors. RESULTS: The standard error of measurement (SEM) ranged from 3.9° (anaesthetized; 95% confidence interval [CI] 3.3-4.0°) to 6.7° (conscious; 95% CI 5.3-8.0°). This compared favourably with previously reported dorsiflexion measures (SEM range 6.5-7.8°) in conscious children with CP. Intrarater reliability was good in both conditions (intraclass correlation coefficient [ICC]: range 0.95 [anaesthetized; 95% CI 0.92-0.98] to 0.86 [conscious; 95% CI 0.76-0.95]). The ICC for interrater reliability ranged from 0.87 (anaesthetized; 95% CI 0.81-0.93) to 0.65 (conscious; 95% CI 0.50-0.81). INTERPRETATION: Passive ankle dorsiflexion using an instrumented measure has face validity and may assist in the improvement of reproducibility under anaesthesia for clinical research. When an individual is conscious, this technique is not better than trained assessors using conventional goniometry reported in the literature and is not recommended for routine clinical use.

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.

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.

Effect of spirometry and medical review on asthma control in patients in general practice: a randomized controlled trial.

BACKGROUND AND OBJECTIVE: Although guidelines for asthma emphasize the importance of spirometry for continuity and evaluation of care, it is underused in general practice. The objective of this study was to investigate the effect of spirometry and medical review on asthma control in general practice over 12 months. METHODS: Patients were recruited through 31 practices, which were randomly allocated to one of three groups: Group A had 3-monthly spirometry with medical review, Group B spirometry only before and after the trial, and Group C usual care. Asthma control data were analysed by intention to treat using non-parametric tests and logistic regression models fitted to allow for confounders, repeated measures and clustering by practice. RESULTS: The trial was completed by 195 patients (Group A 69, Group B 78, Group C 48). Asthma control improved in all groups during the 12 months trial, most impressively in Group A (odds ratio per 3 months = 1.27, 95% confidence interval: 1.08-1.49, P = 0.004), but the difference between the groups' respective 3-monthly changes was not significant. At 6 months, asthma control in Group A had increased more from baseline than in Groups B + C (P = 0.006). CONCLUSIONS: Regular spirometry with medical review was associated with improved asthma control in general practice patients, while there was less improvement in either the spirometry only or usual care group. The mechanisms of this improvement may include appropriate adjustment of medication and improved compliance.

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.

A classification system for hip disease in cerebral palsy.

In population-based studies, hip displacement affects approximately one-third of children with cerebral palsy (CP). Given the extreme range of clinical phenotypes in the CP spectrum, it is unsurprising that hip development varies from normality, to dislocation and degenerative arthritis. Numerous radiological indices are available to measure hip displacement in children with CP; however, there is no grading system for assessing hip status in broad categorical terms. This makes it difficult to audit the incidence of hip displacement, determine the relationship between hip displacement and CP subtypes, assess the outcome of intervention studies, and to communicate hip status between health care professionals. We developed a categorical, radiographic classification of hip morphology based on qualitative indices and measurement of the key continuous variable, the migration percentage of Reimers. One hundred and thirty-four radiographs were reviewed of 52 female and 82 male adolescents with CP who were at, or close to, skeletal maturity (mean age 16y 1mo [SD 1y 4mo] range 14y to 19y 1mo). Twenty-nine were classified at Gross Motor Function Classification System level I, 25 at level II, 27 at level III, 24 at level IV, and 29 at level V. A classification system was developed to encapsulate the full spectrum of hip morphology in CP, with and without intervention.

Comparing the outcomes of isolated, serious traumatic brain injury in older adults managed at major trauma centres and neurosurgical services: A registry-based cohort study.

BACKGROUND: The incidence of older adult traumatic brain injury (TBI) is increasing in both high and middle to low-income countries. It is unknown whether older adults with isolated, serious TBI can be safely managed outside of major trauma centres. This registry based cohort study aimed to compare mortality and functional outcomes of older adults with isolated, serious TBI who were managed at specialised Major Trauma Services (MTS) and Metropolitan Neurosurgical Services (MNS). METHOD: Older adults (65 years and over) who sustained an isolated, serious TBI following a low fall (from standing or ≤ 1 m) were extracted from the Victorian State Trauma Registry from 2007 to 2016. Multivariable models were fitted to assess the association between hospital designation (MTS vs. MNS) and the two outcomes of interest: in-hospital mortality and functional outcome, adjusting for potential confounders. Functional outcomes were measured using the Glasgow Outcome Scale Extended at six months post-injury. RESULTS: From 2007-2016, there were 1904 older adults who sustained an isolated, serious TBI from a low fall who received definitive care at an MTS (n = 1124) or an MNS (n = 780). After adjusting for confounders, there was no mortality benefit for patients managed at an MTS over an MNS (OR = 0.84; 95% CI: 0.65, 1.08; P = 0.17) or improvement in functional outcome six months post-injury (OR = 1.13; 95% CI: 0.94, 1.36; P = 0.21). CONCLUSION: For older adults with isolated, serious TBI following a low fall, there was no difference in mortality or functional outcome based on definitive management at an MTS or an MNS. This confirms that MNS without the added designation of a major trauma centre are a suitable destination for the management of isolated, serious TBI in older adults.

The road to recovery for vulnerable road users hospitalised for orthopaedic injury following an on-road crash.

BACKGROUND: Pedestrians, cyclists and motorcyclists are vulnerable to serious injury due to limited external protective devices. Understanding the level of recovery, and differences between these road user groups, is an important step towards improved understanding of the burden of road trauma, and prioritisation of prevention efforts. This study aimed to characterise and describe patient-reported outcomes of vulnerable road users at 6 and 12 months following orthopaedic trauma. METHODS: A registry-based cohort study was conducted using data from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) and included pedestrians, cyclists and motorcyclists who were hospitalised for an orthopaedic injury following an on-road collision that occurred between January 2009 and December 2016. Outcomes were measured using the 3-level EuroQol 5 dimensions questionnaire (EQ-5D-3 L), Glasgow Outcome Scale - Extended (GOS-E) and return to work questions. Outcomes were collected at 6 and 12 months post-injury. Multivariable generalized estimating equations (GEE), adjusted for confounders, were used to compare outcomes between the road user groups over time. RESULTS: 6186 orthopaedic trauma patients met the inclusion criteria during the 8-year period. Most patients were motorcyclists (42.8%) followed by cyclists (32.6%) and pedestrians (24.6%). Problems were most prevalent on the usual activities item of the EQ-5D-3 L at 6-months post-injury, and the pain/discomfort item of the EQ-5D-3 L at 12 months. The adjusted odds of reporting problems on all EQ-5D-3 L items were lower for cyclists when compared to pedestrians. Moreover, an average cyclist had a greater odds of a good recovery on the GOS-E, (AOR 2.75, 95% CI 2.33, 3.25) and a greater odds of returning to work (AOR = 3.13, 95% CI 2.46, 3.99) compared to an average pedestrian. CONCLUSION: Pedestrians and motorcyclists involved in on-road collisions experienced poorer patient-reported outcomes at 6 and 12 months post-injury when compared to cyclists. A focus on both primary injury prevention strategies, and investment in ongoing support and treatment to maximise recovery, is necessary to reduce the burden of road trauma for vulnerable road users.

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.

Validating injury burden estimates using population birth cohorts and longitudinal cohort studies of injury outcomes: the VIBES-Junior study protocol.

INTRODUCTION: Traumatic injury is a leading contributor to the global disease burden in children and adolescents, but methods used to estimate burden do not account for differences in patterns of injury and recovery between children and adults. A lack of empirical data on postinjury disability in children has limited capacity to derive valid disability weights and describe the long-term individual and societal impacts of injury in the early part of life. The aim of this study is to establish valid estimates of the burden of non-fatal injury in children and adolescents. METHODS AND ANALYSIS: Five longitudinal studies of paediatric injury survivors <18 years at the time of injury (Australia, Canada, UK and USA) and two whole-of-population linked administrative data paediatric studies (Australia and Wales) will be analysed over a 3-year period commencing 2018. Meta-analysis of deidentified patient-level data (n≈2,600) from five injury-specific longitudinal studies (Victorian State Trauma Registry; Victorian Orthopaedic Trauma Outcomes Registry; UK Burden of Injury; British Columbia Children's Hospital Longitudinal Injury Outcomes; Children's Health After Injury) and >1 million children from two whole-of-population cohorts (South Australian Early Childhood Data Project and Wales Electronic Cohort for Children). Systematic analysis of pooled injury-specific cohort data using a variety of statistical techniques, and parallel analysis of whole-of-population cohorts, will be used to develop estimated disability weights for years lost due to disability, establish appropriate injury classifications and explore factors influencing recovery. ETHICS AND DISSEMINATION: The project was approved by the Monash University Human Research Ethics Committee project number 12 311. Results of this study will be submitted for publication in internationally peer-reviewed journals. The findings from this project have the capacity to improve the validity of paediatric injury burden measurements in future local and global burden of disease studies.

Models developed by three techniques did not achieve acceptable prediction of binary trauma outcomes.

BACKGROUND AND OBJECTIVES: To develop prediction models for outcomes following trauma that met prespecified performance criteria. To compare three methods of developing prediction models: logistic regression, classification trees, and artificial neural networks. METHODS: Models were developed using a 1996-2001 dataset from a major trauma center in Victoria, Australia. Developed models were subjected to external validation using the first year of data collection, 2001-2002, from a state-wide trauma registry for Victoria. Different authors developed models for each method. All authors were blinded to the validation dataset when developing models. RESULTS: Prediction models were developed for an intensive care unit stay following trauma (prevalence 23%) using information collected at the scene of the injury. None of the three methods gave a model that satisfied the performance criteria of sensitivity >80%, positive predictive value >50% in the validation dataset. Prediction models were also developed for death (prevalence 2.9%) using hospital-collected information. The performance criteria of sensitivity >95%, specificity >20% in the validation dataset were not satisfied by any model. CONCLUSION: No statistical method of model development was optimal. Prespecified performance criteria provide useful guides to interpreting the performance of developed models.

Predictors of mortality, length of stay and discharge destination in blunt trauma.

BACKGROUND: The present study explored a range of variables to identify predictors of mortality and morbidity and to develop prediction models based on these variables. METHODS: Tools for predicting mortality, hospital length of stay and a patient's destination post-hospital discharge were developed using logistic regression in one dataset (design) and evaluated for prediction performance in a separate dataset (validation). The performance of the mortality model was compared to the trauma and injury severity score (TRISS) and a severity characterization of trauma (ASCOT). RESULTS: The profile of variables contributing to the final prediction models developed from the design dataset varied across the different outcomes of interest although age, injury severity score, development of complications and triage category were common predictors of all three outcomes. The performance of the new mortality prediction model was superior to both TRISS and ASCOT in the validation dataset. Overall, the new models did not meet the prespecified performance criteria. CONCLUSIONS: The present study identified key predictors of mortality and morbidity (length of hospital stay and discharge destination). The newly developed mortality model out-performed published trauma scoring methods. However, further development and trial of the new prediction models is required before implementation as definitive audit and benchmarking tools could be recommended.

Spirometry and regular follow-up do not improve quality of life in children or adolescents with asthma: Cluster randomized controlled trials.

RATIONALE: To determine whether spirometry and regular medical review improved quality of life or other outcomes in children and adolescents with asthma. METHODS: We conducted two cluster randomized controlled trials. We recruited 238 asthma patients aged between 7 and 17 years from 56 general practices in South Eastern Australia. Participants were randomized to receive an intervention that included spirometry or usual care. The main outcome measure was asthma related quality of life. RESULTS: Baseline characteristics were well matched between the intervention and control groups. Neither trial found any difference in asthma related quality of life between groups. However because of measurement properties, a formal meta-analysis could not be performed. Nor were there any significant effects of the intervention upon asthma attacks, limitation to usual activities, nocturnal cough, bother during physical activity, worry about asthma, or written asthma action plans. CONCLUSIONS: The findings do not support more widespread use of spirometry for the management of childhood asthma in general practice, unless it is integrated into a complete management model.

Validating a simple discharge planning tool following hospital admission for an isolated lower limb fracture.

BACKGROUND: Early, accurate prediction of discharge destination from the acute hospital assists individual patients and the wider hospital system. The Trauma Rehabilitation and Prediction Tool (TRaPT), developed using registry data, determines probability of inpatient rehabilitation discharge for patients with isolated lower limb fractures. OBJECTIVE: The aims of this study were: (1) to prospectively validatate the TRaPT, (2) to assess whether its performance could be improved by adding additional demographic data, and (3) to simplify it for use as a bedside tool. DESIGN: This was a cohort, measurement-focused study. METHODS: Patients with isolated lower limb fractures (N=114) who were admitted to a major trauma center in Melbourne, Australia, were included. The participants' TRaPT scores were calculated from admission data. Performance of the TRaPT score alone, and in combination with frailty, weight-bearing status, and home supports, was assessed using measures of discrimination and calibration. A simplified TRaPT was developed by rounding the coefficients of variables in the original model and grouping age into 8 categories. Simplified TRaPT performance measures, including specificity, sensitivity, and positive and negative predictive values, were evaluated. RESULTS: Prospective validation of the TRaPT showed excellent discrimination (C-statistic=0.90 [95% confidence interval=0.82, 0.97]), a sensitivity of 80%, and specificity of 94%. All participants able to weight bear were discharged directly home. Simplified TRaPT scores had a sensitivity of 80% and a specificity of 88%. LIMITATIONS: Generalizability may be limited given the compensation system that exists in Australia, but the methods used will assist in designing a similar tool in any population. CONCLUSIONS: The TRaPT accurately predicted discharge destination for 80% of patients and may form a useful aid for discharge decision making, with the simplified version facilitating its use as a bedside tool.

Association between the number of injuries sustained and 12-month disability outcomes: evidence from the injury-VIBES study.

OBJECTIVE: To determine associations between the number of injuries sustained and three measures of disability 12-months post-injury for hospitalised patients. METHODS: Data from 27,840 adult (18+ years) participants, hospitalised for injury, were extracted for analysis from the Validating and Improving injury Burden Estimates (Injury-VIBES) Study. Modified Poisson and linear regression analyses were used to estimate relative risks and mean differences, respectively, for a range of outcomes (Glasgow Outcome Scale-Extended, GOS-E; EQ-5D and 12-item Short Form health survey physical and mental component summary scores, PCS-12 and MCS-12) according to the number of injuries sustained, adjusted for age, sex and contributing study. FINDINGS: More than half (54%) of patients had an injury to more than one ICD-10 body region and 62% had sustained more than one Global Burden of Disease injury type. The adjusted relative risk of a poor functional recovery (GOS-E<7) and of reporting problems on each of the items of the EQ-5D increased by 5-10% for each additional injury type, or body region, injured. Adjusted mean PCS-12 and MCS-12 scores worsened with each additional injury type, or body region, injured by 1.3-1.5 points and 0.5 points, respectively. CONCLUSIONS: Consistent and strong relationships exist between the number of injury types and body regions injured and 12-month functional and health status outcomes. Existing composite measures of anatomical injury severity such as the NISS or ISS, which use up to three diagnoses only, may be insufficient for characterising or accounting for multiple injuries in disability studies. Future studies should consider the impact of multiple injuries to avoid under-estimation of injury burden.