Long-term functional health status of severely injured patients

doi:10.1016/j.injury.2006.10.026

Injury

Volume 38, Issue 3, March 2007, Pages 280-289

https://doi.org/10.1016/j.injury.2006.10.026 Get rights and content

Summary

Background

Studies of the consequences of major trauma have traditionally focused on mortality rates. The aims of this study were, firstly, to investigate the long-term functional health status in a large, unselected group of severely injured patients and to compare this with normative data, and secondly, to explore relations between functional health status and personal and injury characteristics.

Methods

A prospective cohort study was performed at the University Medical Centre Utrecht (a level-1 trauma centre) in The Netherlands. Consecutive survivors of major trauma (ISS ≥ 16; >16 years of age) were included from January 1999 until December 2000. After an average of 15 months (range 12–18 months), 335 of the 359 eligible persons (response rate 93%) participated. Demographic and injury characteristics were retrieved from a hospital-based registration system. Functional health status was measured using the 136-item Sickness impact profile (SIP). Co-morbidity was assessed at the follow-up examination using a standard list of 26 conditions.

Results

Subjects were 249 men and 86 women, mean age 37.7 years, mean ISS was 24.9 (S.D. = 10.6). Almost, three quarters were traffic victims. Mean hospital stay was 25 days (S.D. = 23.4). Discharge destination was home in 70% of all subjects. At follow-up, the mean overall SIP score was 9.3 (S.D. = 10.1), which means mild to moderate disability. The mean score on the physical function dimension was 7.2 (S.D. = 9.8) and that on psychosocial function was 8.7 (S.D. = 12.0). Most problems were experienced in the categories of Work, Ambulation, Home Management, Recreation and Pastimes, and Alertness Behaviour. Scores of younger subjects deviated more strongly from the norm scores than those of elderly patients. Type of injury, especially lesions of traumatic brain and spinal cord and extremity injuries, was a predictor of both psychosocial and physical functioning after more than 1 year. The most important predictors, however, were age and co-morbidity.

Introduction

Traumatic injury is not only the leading cause of death, but also the most important cause of functional limitations in adults younger than 45 years of age.¹⁶ As the number of individuals who survive severe trauma increases, the study of long-term outcomes in this patient population has become an increasingly important focus of trauma research. Bare “survival” offers little information about the “quality of life”, or a person's functioning and satisfaction. Furthermore, the social costs associated with acute and long-term care and possible permanent disability of these mostly young patients justify the increasing research into the long-term consequences of major trauma and evaluation of the quality of trauma care.1, 7, 12, 18, 26

Most studies performed to date focussed not on severe trauma in general, but on orthopaedic trauma like pelvic ring fractures,¹⁵ lower extremity injury,5, 13, 31, 36 spinal cord injury23, 46 or traumatic brain injury.28, 40 Several studies including consecutive severely injured patients have been performed.3, 7, 11, 12, 16, 17, 18, 24, 25, 29, 30, 32 Some of these studies, however, included also patients with a low injury severity29, 32; had a small sample size,¹ or studied only short term consequences.³⁰ This study adds to the literature an unselected group of consecutive severely injured patients, who were referred to a level-1 trauma hospital in The Netherlands. We examined the influence of personal and injury characteristics on functional health. We also compared our results to interpretation of these results population figures to allow a more complete interpretation of these results.

The aims of this study were, firstly, to investigate long-term functional health status in a large, unselected group of severely injured patients, and secondly to explore the relation between personal and injury characteristics on the one hand and long-term health-related quality of life on the other.

Section snippets

Patients

A prospective cohort study was conducted from January 1999 to December 2000 at the University Medical Centre Utrecht, The Netherlands. This hospital is a level-1 trauma hospital with a catchment population of 1.1 million people in a densely populated region with high traffic intensity. The study included consecutive severely injured patients admitted to our hospital who had an injury severity score (ISS)² of 16 and higher and who were 16 years of age or older.

Surviving patients were asked in

Results

Four hundred and ninety-nine (n = 499) consecutive severely injured patients presented to the emergency department. Children below the age of 16 (n = 40) were excluded from the follow-up study, and 100 persons died before final assessment. Of the 359 eligible patients, 335 (93%) gave informed consent to participate in the outcome study. The reasons for non-response were: three patients lived abroad, seven addresses were untraceable, 11 patients refused to participate and three had incomplete data.

Discussion

Evaluation of the effectiveness of trauma care has traditionally focused on mortality as an outcome parameter. The purpose of this study was to investigate the long-term functional health status in a large, unselected group of severely injured patients, and to explore the relation between personal and injury characteristics and long-term outcome. Our findings show the impact of major trauma, as a high proportion of the survivors had an impaired functional health status due to persistent

Conclusion

In conclusion, our assessment of the long-term health-related quality of life of severely injured patients by means of the sickness impact profile-136 indicated mild to moderate disability. Patients older than 60 years were performing well, except in ambulation. Injury severity and injuries to the chest or abdomen did not influence the outcome. Lower quality of life was particular experienced in young, male patients and those with traumatic brain, spinal cord, and extremity injuries. The

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A total of 308,578 UEF patients and 360,510 LEF patients were identified. Within the UEF cohort, the diagnosis rates following either isolated or multiple fractures were identified: MDD (25% to 30%), GAD (10% to 11%), and PTSD (4%). LEF cohort rates were as follows: MDD (30% to 38%), GAD (11% to 14%), and PTSD (4% to 7%). Compared to non-injured controls, both the UEF and LEF cohorts were associated with higher rates of all psychiatric diagnoses. In comparing UEF and LEF cohorts, isolated UEF was associated with MDD, GAD, and PTSD; however, multiple UEF was associated with MDD and GAD, whereas multiple LEF was associated with PTSD.
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The second injury severity measurement we included was threat of disability. For this outcome we used long-term disability weights [37] from the Validating and Improving Injury Burden Estimates Study (Injury-VIBES) project [38]. The included disability weights are described in detail elsewhere [39].
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We identified 177,663 individuals (7% of the population) hospitalized with at least one acute injury in the observation period. Two percent (n = 4,186) had injuries categorized with high threat-to-life, while one quarter (n = 43,530) had injuries with high threat of disability. The overall adjusted IRR of hospitalization among people with low compared to high SES was 1.57 (95% CI 1.55, 1.60). Comparing low to high SES, injuries with low threat-to-life were associated with an IRR of 1.56 (95% CI 1.54, 1.59), while injuries with high threat-to-life had an IRR of 2.25 (95% CI 2.03, 2.51). Comparing low to high SES, injuries with low, medium, and high threat of disability were associated with IRRs of respectively, 1.15 (95% CI 1.11, 1.19), 1.70 (95% CI 1.66, 1.73) and 1.99 (95% CI 1.92, 2.07).
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Patients reported also poor quality of care and ‘not being cared for’ by specific staff groups which they expected to fulfil this role, rushed and unsympathetic care, lack of recognition for emotional impact of injury mapped onto existing quality frameworks e.g. safety, equity, accessibility and patient-centeredness as well as quality of interaction with providers, empathetic care which extended beyond medical needs, coordination of care, and the positivity of care delivery as important dimensions of quality care with implications for their recovery. The findings have implications for quality frameworks and theoretical definitions of quality of care; they demonstrate the importance of patient experience in addition to clinical effectiveness and safety as an essential dimension of quality care. In terms of practice, the findings support the need to incorporate knowledge and training of injured adults’ psychological needs, and the value of interaction with professionals as a patient defined dimension of the quality of care.

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Long-term functional health status of severely injured patients

Summary

Background

Methods

Results

Introduction

Section snippets

Patients

Results

Discussion

Conclusion

Long-term prevalence of impairments and disabilities after multiple trauma

J Trauma

The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care

J Trauma

Epidemiology of the severely injured patient. A prospective assessment of preclinical and clinical management. AG Polytrauma of DGU

Unfallchirurg

The sickness impact profile: development and final revision of a health status measure

Med Care

An analysis of outcomes of reconstruction or amputation after leg-threatening injuries

N Engl J Med

Long-term outcomes after lower extremity trauma

J Trauma

The major trauma outcome study: establishing national norms for trauma care

J Trauma

The sickness impact profile: SIP68, a short generic version. First evaluation of the reliability and reproducibility

J Clin Epidemiol

Sickness impact profile: the state of the art of a generic functional status measure

Soc Sci Med

The development of a short generic version of the sickness impact profile

J Clin Epidemiol

Quality of life experienced by severely injured trauma survivors

AACN Clin Issues

Determinants of the global quality of life after polytrauma

Chirurg

Residual impairment after lower extremity fracture

J Trauma

The sickness impact profile for nursing homes (SIP-NH)

J Gerontol

Functional outcome of patients with unstable pelvic ring fractures stabilized with open reduction and internal fixation

J Trauma

Outcome after major trauma: discharge and 6-month follow-up results from the trauma recovery project

J Trauma

Outcome after major trauma: 12-month and 18-month follow-up results from the trauma recovery project

J Trauma

Functional limitation after major trauma: a more sensitive assessment using the quality of well-being scale—the trauma recovery pilot project

J Trauma

The sickness impact profile; results of an evaluation study of the Dutch version

Ned Tijdschr Geneeskd

The sickness impact profile as a tool to evaluate functional outcome in trauma patients

J Trauma

Influence of medical comorbidities and complications on FIM change and length of stay during inpatient rehabilitation

Am J Phys Med Rehabil

Sickness impact profile score versus a modified short-form survey for functional outcome assessment: acceptability, reliability, and validity in critically ill patients with prolonged intensive care unit stays

J Trauma

Spinal cord injuries. Clinical, functional, and emotional status

Spine