Research Article: The development and internal validation of a model to predict functional recovery after trauma

Date Published: March 14, 2019

Publisher: Public Library of Science

Author(s): Max W. de Graaf, Inge H. F. Reininga, Erik Heineman, Mostafa El Moumni, Galinos Barmparas.


To develop and internally validate the PROgnosis of functional recovery after Trauma (PRO-Trauma) prediction model.

A prospective single-center longitudinal cohort study. Patients were assessed at 6 weeks and 12 months post-injury.

Patients that presented at the emergency department with an acute traumatic injury, were prompted for participation. Patients that completed the assessments at 6 weeks and 12 months post injury were included. Exclusion criteria: age < 18, age > 65, pathologic fractures, injuries that resulted in severe neurologic deficits. The predicted outcome, functional recovery, was defined as a Short Musculoskeletal Function Assessment (SMFA-NL) Problems with Daily Activities (PDA) subscale ≤ 12.2 points at 12 months post-injury (Dutch population norm). Predictors were: gender, age, living with partner, number of chronic health conditions, SMFA-NL PDA score 6 weeks post-injury, ICU admission, length of stay in hospital, injury severity score, occurrence of complications and treatment type. All predictors were obtained before 6 weeks post-injury. Missing data were multiply imputed. Predictor variables were selected using backward stepwise multivariable logistic regression. Hosmer-Lemeshow tests were used to evaluate calibration. Bootstrap resampling was used to internally validate the final model.

A total of 246 patients were included, of which 104 (44%) showed functional recovery. The predictors in the final PRO-Trauma model were: living with partner, the number of chronic health conditions, SMFA-NL PDA subscale score at 6 weeks post-injury and length of stay in hospital. The apparent R2 was 0.33 [0.33;0.34], the c-statistic was 0.79 [0.79;0.80]. Hosmer-Lemeshow test indicated good calibration (p = 0.92). Optimism-corrected R2 was 0.28 [0.27;0.29] and the optimism-corrected Area Under the Curve was 0.77 [0.77;0.77].

The PRO-Trauma prediction model can be used to obtain valid predictions of attaining functional recovery after trauma at 12 months post-injury. The PRO-Trauma prediction model showed acceptable calibration and discrimination.

Partial Text

In trauma surgery, clinical outcomes and treatment effects have traditionally been assessed with measures such as mortality rates, non-union rates, radiographic evaluation of bone healing, and clinician-based measurements such as range of motion. Unfortunately, these measures of outcome, have shown to correlate poorly with patients’ view of their physical functioning (see Box 1) [1,2]. In the past decades, the number of deaths due to trauma has declined [3]. As a consequence, the burden of trauma has largely shifted from fatal to non-fatal outcomes [4].

In conclusion, a prognostic model that predicts functional recovery at 12 months post-injury is now available. The PRO-Trauma prediction model showed acceptable calibration and discrimination. Physical functioning shortly assessed after the injury, was predictive for functional recovery. The PRO-Trauma prediction model may be useful for quantifying the chance of reaching functional recovery at 12 months post-injury, identifying and informing patients that are at risk of developing a poor outcome and for adjusting treatment effects in clinical trials.




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