Predicting health status in the first year after trauma.

BACKGROUND: Although mortality rates following major trauma are continuing to decline, a growing number of patients are experiencing long-term disability. The aim of this study was to identify factors associated with health status in the first year following trauma and develop prediction models based on a defined trauma population. METHODS: The Brabant Injury Outcome Surveillance (BIOS) study was a multicentre prospective observational cohort study. Adult patients with traumatic injury were included from August 2015 to November 2016 if admitted to one of the hospitals of the Noord-Brabant region in the Netherlands. Outcome measures were EuroQol Five Dimensions 5D-3L (EQ-5D™ utility and visual analogue scale (VAS)) and Health Utilities Index (HUI) 2 and 3 scores 1 week and 1, 3, 6 and 12 months after injury. Prediction models were developed using linear mixed models, with patient characteristics, preinjury health status, injury severity and frailty as possible predictors. Predictors that were significant (P < 0·050) for one of the outcome measures were included in all models. Performance was assessed using explained variance (R2 ). RESULTS: In total, 4883 patients participated in the BIOS study (50·0 per cent of the total), of whom 3366 completed the preinjury questionnaires. Preinjury health status and frailty were the strongest predictors of health status during follow-up. Age, sex, educational level, severe head or face injury, severe torso injury, injury severity, Functional Capacity Index score, co-morbidity and duration of hospital stay were also relevant in the multivariable models predicting health status. R2 ranged from 35 per cent for EQ-VAS to 48 per cent for HUI 3. CONCLUSION: The most important predictors of health status in the first year after trauma in this population appeared to be preinjury health status and frailty.

Prevalence, recovery patterns and predictors of quality of life and costs after non-fatal injury: the Brabant Injury Outcome Surveillance (BIOS) study.

INTRODUCTION: Trauma is a major public health problem worldwide that leads to high medical and societal costs. Overall, improved understanding of the full spectrum of the societal impact and burden of injury is needed. The main purpose of the Brabant Injury Outcome Surveillance (BIOS) study is to provide insight into prevalence, predictors and recovery patterns of short-term and long-term health-related quality of life (HRQoL) and costs after injury. MATERIALS AND METHODS: This is a prospective, observational, follow-up cohort study in which HRQoL, psychological, social and functional outcome, and costs after trauma will be assessed during 24 months follow-up within injured patients admitted in 1 of 10 hospitals in the county Noord-Brabant, the Netherlands. Data will be collected by self-reported questionnaires at 1 week (including preinjury assessment), and 1, 3, 6, 12 and 24 months after injury. If patients are not capable of filling out the questionnaires, proxies will be asked to participate. Also, information about mechanism and severity of injury, comorbidity and indirect and direct costs will be collected. Mixed models will be used to examine the course of HRQoL, functional and psychological outcome, costs over time and between different groups, and to identify predictors for poor or good outcome. RELEVANCE: This study should make a substantial contribution to the international collaborative effort to assess the societal impact and burden of injuries more accurately. The BIOS results will also be used to develop an outcome prediction model for outcome evaluation including, besides the classic fatal, non-fatal outcome. TRIAL REGISTRATION NUMBER: NCT02508675.

The prevalence and prognostic factors of psychological distress in older patients with a hip fracture: A longitudinal cohort study.

INTRODUCTION: A hip fracture can be experienced as a traumatic event that can induce psychological distress. The aim of this study is to give more insight into the prevalence of symptoms of psychological distress in older patients following the first year after a hip fracture. In addition, prognostic factors were determined for psychological distress after hip fracture. MATERIALS AND METHODS: This hip fracture cohort data was derived from the Brabant Injury Outcome Surveillance, a multicenter longitudinal prospective cohort study. Hip fracture patients (≥65years) admitted to a hospital between August 2015 and November 2016 were asked to complete a questionnaire at 1 week, and 1, 3, 6 and 12 months. The Hospital Anxiety and Depression Scale (HADS) was used to assess symptoms of anxiety and depression and the Impact of Event Scale (IES) was used to assess symptoms of posttraumatic stress (PTS). Prognostic factors were assessed with multivariable logistic mixed models. RESULTS: In total 570 patients (inclusion rate: 69.7%) were included. The prevalence of psychological distress ranged from 36% at 1 week to 31% at 1 year after hip fracture. Frailty at onset of hip fracture was the most important prognostic factor of symptoms of depression (Odds ratio (OR), 2.74; 95% Confidence interval (CI) 1.41 to 5.34) and anxiety (OR, 2.60; 95% CI 1.15 to 5.85) on average in the year following hip fracture. Frailty was not a prognostic factor of symptoms of PTS (OR, 1.97; 95% CI 0.42 to 9.23). CONCLUSIONS: The prevalence of psychological distress is high in the first year after a hip fracture. Frailty at onset of a hip fracture is the most important prognostic factor of symptoms of depression and anxiety. These findings have important implications for strategies with early identification of frail patients with a hip fracture at high risk of psychological distress.

Medical and productivity costs after trauma.

BACKGROUND: Well-advised priority setting in prevention and treatment of injuries relies on detailed insight into costs of injury. This study aimed to provide a detailed overview of medical and productivity costs due to injury up to two years post-injury and compare these costs across subgroups for injury severity and age. METHODS: A prospective longitudinal cohort study followed all adult (≥18 years) injury patients admitted to a hospital in Noord-Brabant, the Netherlands. Patients filled out questionnaires 1 week, 1, 3, 6, 12 and 24 months after trauma, including items on health care consumption from the medical consumption questionnaire (iMCQ) and productivity loss from the productivity cost questionnaire (PCQ). Furthermore, injury severity was defined by Injury Severity Score (ISS). Data on diagnostics was retrieved from hospital registries. We calculated medical costs, consisting of in-hospital costs and post-hospital medical costs, and productivity costs due to injury up to two years post-injury. RESULTS: Approximately 50% (N = 4883) of registered patients provided informed consent, and 3785 filled out at least one questionnaire. In total, the average costs per patient were €12,190. In-hospital costs, post-hospital medical costs and productivity costs contributed €4810, €5110 and €5830, respectively. Total costs per patient increased with injury severity, from €7030 in ISS1-3 to €23,750 in ISS16+ and were lowest for age category 18-24y (€7980), highest for age category 85 years and over (€15,580), and fluctuated over age groups in between. CONCLUSION: Both medical costs and productivity costs generally increased with injury severity. Furthermore, productivity costs were found to be a large component of total costs of injury in ISS1-8 and are therefore a potentially interesting area with regard to reducing costs.

Validation and reliability of the Abbreviated World Health Organization Quality of Life Instrument (WHOQOL-BREF) in the hospitalized trauma population.

INTRODUCTION: While the number of trauma patients surviving their injury increase, it is important to measure Quality of Life (QoL). The Abbreviated World Health Organization Quality of Life (WHOQOL-BREF) questionnaire can be used to assess QoL. However, its psychometric properties in trauma patients are unknown and therefore, we aimed to investigate the validity and reliability of the WHOQOL-BREF for the hospitalized trauma population. METHODS: Data were derived from the Brabant Injury Outcome Surveillance. Floor and ceiling effects and missing values of the WHOQOL-BREF were examined. Confirmatory factor analysis (CFA) was performed to examine the underlying 4 dimensions (i.e. physical, psychological, social and environmental) of the questionnaire. Cronbach's alpha (CA) was calculated to determine internal consistency. In total, 42 hypotheses were formulated to determine construct validity and 6 hypotheses were created to determine discriminant validity. To determine construct validity, Spearman's correlations were calculated between the WHOQOL-BREF and the EuroQol-five-dimension-3-level questionnaire, the Health Utility Index Mark 2 and 3, the Hospital Anxiety and Depression Scale and the Impact of Event Scale. Discriminant validity between patients with minor injuries (i.e. Injury Severity Score (ISS)≤8) and moderate/severe injuries (i.e. ISS ≥ 9) was examined by conducting Mann-Whitney-U-tests. RESULTS: In total, 202 patients (median 63y) participated in this study with a median of 32 days (interquartile range 29-37) post-trauma. The WHOQOL-BREF showed no problematic floor and ceiling effects. The CFA revealed a moderate model fit. The domains showed good internal consistency, with the exception of the social domain. All individual items and domain scores of the WHOQOL-BREF showed nearly symmetrical distributions since mean scores were close to median scores, except of the 'general health' item. The highest percentage of missing values was found on the 'sexual activity' item (i.e. 19.3%). The WHOQOL-BREF showed moderate construct and discriminant validity since in both cases, 67% of the hypotheses were confirmed. CONCLUSION: The present study provides support for using the WHOQOL-BREF for the hospitalized trauma population since the questionnaire appears to be valid and reliable. The WHOQOL-BREF can be used to assess QoL in a heterogeneous group of hospitalized trauma patients accurately. TRAIL REGISTRATION: ClinicalTrials.gov identifier: NCT02508675.

The effect of socio-economic status on non-fatal outcome after injury: A systematic review.

BACKGROUND: Over the past decades, the number of survivors of injuries has rapidly grown. It has become important to focus more on the determinants of non-fatal outcome. Although socio-economic status (SES) is considered to be a fundamental determinant of health in general, the role of SES as a determinant of non-fatal outcome after injury is largely unknown. METHODS: An online search was conducted in November 2015 using Embase, Medline, Web of Science, Cinahl, Cochrane, Google scholar and PubMed. Studies examining the relation between SES and a physical or psychological outcome measure, or using SES as a confounder in a general trauma population were included. There were no restrictions regarding study design. The 'Quality in Prognostic Studies tool' was used to assess the methodological quality of the included studies. RESULTS: The 24 included studies showed large variations in methodological quality. The number of participants ranged from 56 to 4639, and assessments of the measures ranged from immediately to 6year post-injury. Studies used a large number of variables as indicators of SES. Participant's educational level was used most frequently. The majority of the studies used a multivariable technique to analyse the relation between SES and non-fatal outcome after injury. All studies found a positive association (80% of studies significant, n=19) between increased SES and better non-fatal outcome after injury. CONCLUSION: Although an adequate and valid measure of SES is lacking, the results of this review showed that SES is an important determinant of non-fatal outcome after injury. Future research should focus on the definition and measurement of SES and should further underpin the effect of SES on non-fatal outcome after injury.

A randomized controlled trial of an asthma clinical pathway for children in general practice.

AIMS: To evaluate the effect of the implementation of an asthma clinical pathway on asthma in children in general practice. METHODS: A randomized, controlled trial involving 270 general practitioners. One group of general practitioners implemented the asthma clinical pathway for children (intervention group) and the control group continued with their usual asthma medical care management. The main outcome measures were admissions to hospital for asthma and attendance at the Children's Emergency Department. Compliance with the guidelines was assessed by examining asthma drug prescriptions. RESULTS: Admissions to hospital for asthma dropped 40% in the intervention group, by 33% in the control group and by 22% in general practitioners not participating in the trial. The differences between the intervention and control and between the intervention and non-participating general practitioners were not statistically significant. The decrease in attendance at the Children's Emergency Department decreased by 25%, 30% and 19%, respectively, but this was not statistically significant. There was a significant decrease in prescriptions for oral relievers, dry powder relievers in the under 6s, mast cell stabilizers and methylxanthines in both control and intervention groups. However, only for oral relievers was there a significant difference between the intervention group and control, with the decrease larger in the intervention group (p < 0.001). CONCLUSIONS: Admissions to hospital for asthma decreased, as did attendance at the Children's Emergency Department. Prescriptions for asthma medication changed in the direction anticipated with compliance with the asthma clinical pathway. However, we found no evidence within the study that implementation of the asthma clinical pathway by general practitioners resulted in lower morbidity than those general practitioners who did not implement the pathway. Possible explanations are that these general practitioners were already providing care according to the recommendations of the pathway, or that there was contamination of the control group by the intervention, or that the guidelines, although based on currently accepted recommendations, are ineffective.