Date Published: July 5, 2017
Publisher: Public Library of Science
Author(s): Belinda J. Gabbe, Pam M. Simpson, Peter A. Cameron, Jennie Ponsford, Ronan A. Lyons, Alex Collie, Mark Fitzgerald, Rodney Judson, Warwick J. Teague, Sandra Braaf, Andrew Nunn, Shanthi Ameratunga, James E. Harrison, Karim Brohi
Abstract: BackgroundImproved 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 findingsA 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.ConclusionsThe 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.
Partial Text: The implementation of organised trauma systems has enabled considerable reductions in injury-related mortality in high-income countries [1–3]. With improving survival rates comes the potential for greater numbers of people living with long-term injury impacts, including reduced health status or health-related quality of life. An expert consensus group identified the capture of functional and quality-of-life outcomes following trauma as critically important for improving healthcare quality more than 2 decades ago . Despite this, integration of these outcomes into trauma registries and system monitoring has been largely absent, and calls for their inclusion continue [5,6].
The Victorian State Trauma Registry (VSTR) and the REcovery after Serious Trauma—Outcomes, Resource use, and patient Experiences (RESTORE) project have been approved by the Human Research Ethics Committee of each participating hospital and Monash University.
To our knowledge, we have conducted the largest, longitudinal study of health outcomes in seriously injured patients to date. Of the 2,757 hospitalised, adult major trauma patients, approximately 1 in 5 had died by 36-months postinjury, and the prevalence of persistent problems in survivors remained high for each of the EQ-5D-3L items. Forty percent of deaths in the cohort occurred after hospital discharge. Improvement to 24-months postinjury was evident for most items of the EQ-5D-3L, while improvement from 24- to 36-months postinjury was observed only for the usual activities item. Notably, the EQ-5D-3L summary score declined from 24- to 36-months postinjury, driven by an increase in reporting of pain or discomfort. Three factors were important predictors of outcome for all items of the EQ-5D-3L, age, compensable status, and level of education, while the nature of injuries sustained, gender, preinjury employment, and level of socioeconomic disadvantage were important predictors of problems on many of the 5 EQ-5D-3L items.