Comparing the Responsiveness of Functional Outcome Assessment Measures for Trauma Registries

HIP fracture Supplemental Therapy to Enhance Recovery (HIPSTER): a protocol for a randomised controlled trial

INTRODUCTION

Hip fractures result in substantial health impacts for patients and costs to health systems. Many patients require prolonged hospital stays and up to 60% do not regain their prefracture level of mobility within 1 year. Physical rehabilitation plays a key role in regaining physical function and independence; however, there are no recommendations regarding the optimal intensity. This study aims to compare the clinical efficacy and cost-effectiveness of early intensive in-hospital physiotherapy compared with usual care in patients who have had surgery following a hip fracture.

METHODS AND ANALYSIS

This two-arm randomised, controlled, assessor-blinded trial will recruit 620 participants who have had surgery following a hip fracture from eight hospitals. Participants will be randomised 1:1 to receive usual care (physiotherapy according to usual practice at the site) or intensive physiotherapy in the hospital over the first 7 days following surgery (two additional sessions per day, one delivered by a physiotherapist and the other by an allied health assistant). The primary outcome is the total hospital length of stay, measured from the date of hospital admission to the date of hospital discharge, including both acute and subacute hospital days. Secondary outcomes are functional mobility, health-related quality of life, concerns about falling, discharge destination, proportion of patients remaining in hospital at 30 days, return to preadmission mobility and residence at 120 days and adverse events. Twelve months of follow-up will capture data on healthcare utilisation. A cost-effectiveness evaluation will be undertaken, and a process evaluation will document barriers and facilitators to implementation.

ETHICS AND DISSEMINATION

The Alfred Hospital Ethics Committee has approved this protocol. The trial findings will be published in peer-reviewed journals, submitted for presentation at conferences and disseminated to patients and carers.

TRIAL REGISTRATION NUMBER

ACTRN12622001442796.

Analysis of Trauma Characteristics Between the Older and Younger Adult Patient from the Pan Asian Trauma Outcome Study Registry (PATOS)

OBJECTIVE

Asia is experiencing a demographic shift toward an aging population at an unrivaled rate. This can influence the characteristics and outcomes of trauma. We aim to examine different characteristics of older adult trauma patients compared to younger adult trauma patients and describe factors that affect the outcomes in Asian countries.

METHODS

This is a retrospective, international, multicenter study of trauma across participating centers in the Pan Asian Trauma Outcome Study (PATOS) registry, which included trauma cases aged ≥18 years, brought to the emergency department (ED) by emergency medical services (EMS) from October 2015 to November 2018. Data of older adults (≥65 years) and younger adults (<65 years) were analyzed and compared. The primary outcome measure was in-hospital mortality, and secondary outcomes were disability at discharge and hospital and intensive care unit (ICU) length of stays.

RESULTS

Of 39,804 trauma patients, 10,770 (27.1%) were older adults. Trauma occurred more among older adult women (54.7% vs 33.2%, p < 0.001). Falls were more frequent in older adults (66.3% vs 24.9%, p < 0.001) who also had higher mean Injury Severity Score (ISS) compared to the younger adult trauma patient (5.4 ± 6.78 vs 4.76 ± 8.60, p < 0.001). Older adult trauma patients had a greater incidence of poor Glasgow Outcome Scale (GOS) (13.4% vs 4.1%, p < 0.001), higher hospital mortality (1.5% vs 0.9%, p < 0.001) and longer median hospital length of stay (12.8 vs 9.8, p < 0.001). Multiple logistic regression revealed age (adjusted odds ratio [AOR] 1.06, 95%CI 1.02-1.04, p < 0.001), male sex (AOR 1.60, 95%CI 1.04-2.46, p = 0.032), head and face injuries (AOR 3.25, 95%CI 2.06-5.11, p < 0.001), abdominal and pelvic injuries (AOR 2.78, 95%CI 1.48-5.23, p = 0.002), cardiovascular (AOR 2.71, 95%CI 1.40-5.22, p = 0.003), pulmonary (AOR 3.13, 95%CI 1.30-7.53, p = 0.011) and cancer (AOR 2.03, 95%CI 1.02-4.06, p = 0.045) comorbidities, severe ISS (AOR 2.06, 95%CI 1.23-3.45, p = 0.006), and Glasgow Coma Scale (GCS) ≤8 (AOR 12.50, 95%CI 6.95-22.48, p < 0.001) were significant predictors of hospital mortality.

CONCLUSIONS

Older trauma patients in the Asian region have a higher mortality rate than their younger counterparts, with many significant predictors. These findings illustrate the different characteristics of older trauma patients and their potential to influence the outcome. Preventive measures for elderly trauma should be targeted based on these factors.

Association between anticoagulants and mortality and functional outcomes in older patients with major trauma

BACKGROUND

The number of trauma patients taking anticoagulants and antiplatelet agents is increasing as society ages. However, there have been limited and inconsistent reports of the association between anticoagulants and mortality and functional outcomes. This study aimed to quantify the association between anticoagulant/antiplatelet medication at the time of injury and both short-term and longer-term outcomes in older major trauma patients.

METHODS

This was a population-based registry study using data from the Victorian State Trauma Registry from July 2017 to June 2018. We included patients with major trauma aged 65 years and older. The outcomes of interest were in-hospital mortality, hospital length of stay, intensive care unit length of stay and the Extended Glasgow Outcome Scale (GOS-E) at 6 months after injury. We examined the association between the outcomes and anticoagulants/antiplatelet agents at the time of injury and used multivariable logistic regression models to account for known confounders.

RESULTS

There were 1323 older adults eligible for inclusion in the study, of which 249 (18.8%) were taking anticoagulants (n=8 were taking both anticoagulants and antiplatelet agents), 380 (28.7%) were taking antiplatelet agents and 694 (52.5%) were not using either. Any anticoagulant use was associated with higher odds of in-hospital mortality (adjusted OR (AOR), 2.38; 95% CI 1.58 to 3.59) compared with not using anticoagulants. No differences were observed in the GOS-E at 6 months after injury between any anticoagulants use, antiplatelet use and no anticoagulant use (anticoagulant AOR, 0.71; 95% CI 0.48 to 1.05, antiplatelet AOR, 1.02; 95% CI 0.73 to 1.42).

CONCLUSION

Anticoagulant use at the time of injury was associated with higher odds of in-hospital mortality but did not adversely impact functional outcomes at 6 months after injury. These findings demonstrate the importance of seeking an accurate history of anticoagulant use and its indication, as well as the immediate initiation of reversal therapies.

Epidemiology of pregnant patients with major trauma in Victoria

OBJECTIVE

Trauma is one of the most common contributors to maternal and foetal morbidity and mortality. The aim of the present study was to describe the characteristics and outcomes of major trauma in pregnant patients using a population-based registry.

METHODS

Registry-based study using data from the Victorian State Trauma Registry (VSTR), a population-based database of all hospitalised major trauma (death due to injury, Injury Severity Score [ISS] ≥12, admission to an intensive care unit [ICU] for more than 24 h and requiring mechanical ventilation for at least part of their ICU stay or urgent surgery) in Victoria, Australia, from 1 July 2007 to 30 June 2019. Pregnant patients with major trauma were identified on the VSTR. We summarised patient data using descriptive statistics.

RESULTS

Over the 12-year study period, there were 63 pregnant major trauma patients. Fifty-two (82.5%) patients sustained injuries resulting from road transport collisions. The maternal survival rate was 98.4% and the foetal survival rate was 88.9%. Thoracic injury was the most common injury (25/63), followed by abdominal injury (23/63). Eighty-six percent of the third trimester patients (19/22) were transported directly to a major trauma service with capacity for definitive care of the pregnancy.

CONCLUSION

The present study demonstrated road transport injury was the most common mechanism of injury and both maternal survival rates and foetal survival rates were high. This information is essential for trauma care system planning and public health initiatives to improve the clinical management and outcomes of pregnant women with major trauma.

Relationship between health status and functional outcome during two years after a severe trauma

BACKGROUND

With the improved survival rates after trauma, the population of patients with disabilities increased. The knowledge about functional outcome and the relationship between health status and functional outcome is limited. The aim of the present prospective cohort study was to describe the functional outcome and health status over time, and the relationship between both.

METHODS

Adult severely injured patients (ISS≥16) were included if hospitalised in Noord-Brabant within 48 h after injury between August 2015 and December 2016. The functional outcome (Glasgow Outcome Scale Extended - GOSE) and health status (EQ-5D) were measured at 1, 3, 6, 12 and 24 months after injury. Logistic and linear mixed models were used to examine functional outcome and health status over time. Measurements were divided into short- (1-3 months), mid- (6-12 months) and long-term (24 months).

RESULTS

In total 239 severely injured patients were included. Functional outcome and health status improved over time. Prognostic factors during two years were a longer hospital length of stay, female gender and Glasgow Coma Scale. Besides age was a prognostic factor for health status and education level for functional outcome. A higher ASA classification was a long-term prognostic factor for a lower functional outcome and a lower health status. The patients with a good functional recovery showed a significant higher EQ-5D utility score and patients with a poor functional recovery reported significant more problems in the EQ-5 domains.

CONCLUSION

There is a good relationship between the functional outcome and the health status during two years after a severe injury. It appears reliable to use functional outcome in terms of physical impairments in daily clinic to determine patients at risk for both a lower functional outcome and a lower health status over time.

Ability of the PILOT score to predict 6-month functional outcome in pediatric patients with moderate-severe traumatic brain injury

PURPOSE

To assess the Pediatric Intensity Level of Therapy (PILOT) score alone and in combination with Emergency Department (ED) GCS and Rotterdam score of initial head CT to predict functional outcomes in children with traumatic brain injury (TBI).

METHODS

Children (n=108) aged 31months-15years with moderate to severe TBI were prospectively enrolled at two sites. The ability of PILOT, ED GCS, and Rotterdam scores to predict the 6-month Pediatric Injury Functional Outcome Scale (PIFOS) was evaluated using multivariable regression models with enrollment site, age, and sex as covariates.

RESULTS

PILOT total (sum) score was more predictive of PIFOS (R²=0.23) compared to mean (R² = 0.20) or peak daily PILOT scores (R²=0.11). PILOT total score predicted PIFOS better than ED GCS (R²=0.01) or Rotterdam score (R²=0.06) and was similar to PILOT, ED GCS, and Rotterdam score combined. PILOT total score performed better in patients with intracranial pressure monitors (n=30, R²=0.28, slope=0.30) than without (n=78, R²=0.09, slope=0.36).

CONCLUSIONS

The PILOT score correlated moderately with functional outcome following TBI and outperformed other common predictors. PILOT may be a useful predictor or moderator of functional outcomes.

LEVEL OF EVIDENCE

Prognosis study, Level II.

Long-term outcomes of major trauma with unstable open pelvic fractures: A population-based cohort study

Aims

The aims of this study were to describe the profile and longer-term outcomes of major trauma patients with unstable open pelvic fractures.

Patients and methods

An observational study was performed using data from the population-based Victorian State Trauma Registry. Adult (≥16 years) major trauma patients who had sustained an unstable open pelvic fracture between 1 July 2010 and 30 June 2017 in Victoria (Australia) were included. Patient demographics, injury event, severity and management data were extracted. Patients were followed up at 6, 12 and 24 months post-injury to collect information about health status, function and return to work.

Results

There were 67 patients. The mean (SD) age was 41.4 (18.3) years, and 66% were male. Seventy-six per cent were road traffic injuries, 96% were managed at Level 1 trauma centres and all were multi-trauma patients. A third were Tile C fractures and 80% underwent surgical stabilisation of the pelvic injury. Eighty per cent were admitted to intensive care. The in-hospital mortality rate was 9%. Most (89%) survivors were discharged to an inpatient rehabilitation facility. The proportion classified as ‘severe disability’ on the Glasgow Outcome-Scale Extended declined from 38% at 6 months to 19% at 24 months. The overall three-level EuroQoL five-dimensional instrument score increased with time indicating better health status, and 50% of patients returned to work by 24 months.

Conclusions

Major trauma with unstable, open pelvic fracture is rare. Low in-hospital mortality was observed. Most survived to hospital discharge and outcomes improved with time post-injury, but 75% of patients experienced persistent pain and ongoing mobility and activity restrictions.

Twelve month mortality rates and independent living in people aged 65 years or older after isolated hip fracture: A prospective registry-based study

INTRODUCTION

This study investigated which patient and injury characteristics are associated with 12-month mortality rates and living independently after isolated hip fracture.

METHODS

Older adults aged ≥65 years were included if they had an isolated hip fracture, were admitted to hospital between July 2009 and June 2016, inclusive, and were registered to the Victorian Orthopaedic Trauma Outcomes Registry. Mortality up to 12 months (365 days) post-injury, and functional outcomes (Glasgow Outcome Scale-Extended; GOS-E) at 12 months post-injury were examined. Multivariable Cox proportional hazards regression was used to estimate adjusted hazard ratios (aHRs), and multivariable logistic regression was used to identify predictors of living independently compared with severe disability or death on the GOS-E.

RESULTS

4,912 patients were included, of whom 28% died, 46% had moderate-severe disability, and 26% were living independently 12 months post-injury. Mortality rates were lower in women (aHR=0.56, 95%CI: 0.50, 0.63), and in people injured in a high fall vs low fall (aHR=0.47, 95%CI: 0.31, 0.72). Mortality rates were higher in people in the older age groups (75-84 years: aHR=1.53, 95%CI: 1.21, 1.93; 95+ years: aHR=3.58, 95%CI: 2.68, 4.77), living in areas with the highest level of socioeconomic disadvantage (aHR=1.25, 95%CI: 1.01, 1.55), with a Charlson Comorbidity Index weighting of one (aHR=1.60, 95%CI: 1.36, 1.88) or more than one (aHR=2.21, 95%CI: 1.94, 2.53), whose injury occurred in a residential institution versus at home (aHR=2.63, 95%CI: 1.97, 3.52), that resulted in intensive care unit admission (aHR=1.68, 95%CI: 1.21, 2.32), and in people who did not have surgery versus people who had internal fixation (aHR=1.65, 95%CI: 1.33, 2.04). Independent living was inversely associated with most of the same characteristics; however, people also had lower odds of living independently if they were from metropolitan residential areas versus rural areas (aOR=0.77, 95%CI: 0.62, 0.96), or had mild to moderate (aOR=0.33, 95%CI: 0.27, 0.39) or marked to severe (aOR=0.13, 95%CI: 0.09, 0.20) preinjury disability vs no preinjury disability.

CONCLUSIONS

Characteristics that are associated with social disadvantage, frailty, poor health and reduced independence before injury were associated with increased rates of death and reduced odds of living independently 12 months after isolated hip fracture.

Measurement of mobility and physical function in hospitalised trauma patients: A systematic review of instruments and their measurement properties

Introduction

It is well recognised that organised trauma systems reduce trauma patient mortality. As established systems mature, there is an increasing need to better understand the patient recovery trajectory. Mobility and physical function are key aspects of recovery, but the optimal instruments for measurement in the acute hospital setting remain unclear.

Methods

A systematic review was undertaken to identify and describe mobility and physical function instruments scored by direct patient assessment, in adult trauma patients in an acute hospital setting. Databases were searched with no date restrictions. Instruments that were specific to subgroups or related to individual conditions, diseases or joints were excluded. The consensus-based standards for the selection of health measurement instruments checklist was used to assess risk of bias where relevant. Clinimetric properties were reported where possible, including reliability, validity and responsiveness.

Results

Fourteen thousand one hundred and fourteen articles were identified with 37 eligible for final review, including six instruments. None had been specifically designed for use in a heterogeneous range of trauma patients. The Functional Independence Measure was the most commonly cited (n = 10 studies), with evidence of construct validity, responsiveness and minimal floor/ceiling effects (<3%). The Acute Care Index of Function (n = 1 study) was found to be valid and responsive whilst the modified Iowa Level of Assistance (n = 2 studies) was reliable and responsive, but ceiling effects ranged from 26% to 37%. Little clinimetric data were available for other measures.

Conclusion

Evidence from a few studies show promise for the use of the Functional Independence Measure, Acute Care Index of Function and modified Iowa Level of Assistance to measure mobility and physical function in trauma patients, however comprehensive clinimetric data are lacking. Future research should test these scores in specifically designed clinimetric property studies in defined trauma patient populations. This would enable the identification of a gold standard measure for evaluating treatment effectiveness, enabling benchmarking between centres, allow prediction of recovery pathways and optimise trauma patient outcomes.

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.

Mental fatigue assessment may add information after aneurysmal subarachnoid hemorrhage

BACKGROUND

Mental fatigue, as part of cognitive dysfunction, has been reported to be common after subarachnoid hemorrhage and it significantly affects quality of life.

AIMS OF THE STUDY

The aim of this study was to assess mental fatigue one year after an aneurysmal subarachnoid hemorrhage and to correlate the degree of mental fatigue to functional outcome assessed with the Extended Glasgow Outcome Scale (GOSE).

METHODS

One year after an aneurysmal subarachnoid hemorrhage, the GOSE was assessed and a questionnaire for self-assessment of mental fatigue, the Mental Fatigue Scale, was distributed to all included patients. The maximum score is 42 and a score of ≥10.5 indicates mental fatigue.

RESULTS

All patients with GOSE 8, indicating full recovery, had a mental fatigue score of <10.5. A linear correlation between the GOSE and the mental fatigue score was observed (p < 0.0001).

CONCLUSIONS

Patients with a favorable outcome and GOSE 5-7 could benefit from the assessments of mental fatigue in order to receive satisfactory rehabilitation.

The Residential Status of Working Age Adults Following Severe Traumatic Brain Injury

Objective: To describe place of residence and examine factors associated with place of residence following severe traumatic brain injury (TBI) in working age adults.

Setting, participants, design: Retrospective cohort study (1 January 2007 to 31 December 2013) of adults (16–64 years) with severe TBI who survived to hospital discharge in Victoria, Australia.

Main measures: Place of residence (dichotomised as ‘private residence’ and ‘other destination’) at 6, 12 and 24 months post injury. A modified Poisson model was fitted with a random effect for the participant.

Results: There were 684 cases that were followed-up at one or more time points. At 24 months post injury, 87% (n = 537) adults with TBI were living at a private residence, of whom 66% did not require additional support. Cases were more likely to be living at a private residence at 24 months post injury compared to 6 months (adjusted relative risk = 1.08, 95% Confidence Interval, 1.04–1.11, p < .001). At 24 months post injury, 5% (n = 29) remained in rehabilitation and 4% (n = 23) lived in a nursing home.

Conclusion: While the majority of cases were living at a private residence at 2 years post injury, 13% were residing in rehabilitation, a nursing home or other supported living. Longer follow-up is needed to understand if a transition to a private residence is possible for these groups.

Predictors of Change in Functional Outcome at six months and twelve months after Severe Injury: A Retrospective Cohort Study

Background

There is increasing focus on long-term survival, function and quality-of-life for trauma patients. There are few studies tracking longitudinal changes in functional outcome over time. The goal of our study was to compare the Glasgow Outcome Scale-Extended (GOSE) at 6 months and 12 months in blunt trauma survivors with an Injury Severity Score (ISS) of more than 15.

Methods

Using the Singapore National Trauma Registry 2011–2013, patients with 6-month GOSE and 12-month GOSE scores were analysed. Patients were grouped into three categories—those with the same score at 6 months and 12 months, an improvement in score, and a worse score at 12 months. Ordinal regression was used to identify risk factors for improved score. Patients with missing scores at either 6 months or 12 months were excluded.

Results

We identified 478 patients: 174 had an improvement in score, 233 stayed the same, and 71 had worse scores at 12 months compared to 6 months. On univariate ordinal regression, the following variables were associated with same or better function at 12-months compared to 6-months: male gender, being employed pre-injury, thoracic Abbreviated Injury Scale (AIS) of 3 or more, anatomical polytrauma (AIS of 3 or more in 2 or more body regions), and road traffic injury mechanism. Older age, low fall, increasing Charlson comorbidity scores, new injury severity score, and head and neck AIS of 3 or more were associated with worse function at 12 months compared to 6 months. ISS and revised trauma score were not significant predictors on univariate or multivariable analysis.

On multivariable ordinal regression, motor vehicle mechanism (OR 2.78, 1.51–5.12, p = 0.001) was associated with improved function, while male gender (OR 1.36, 95% CI 1.02–1.82, p = 0.039) predicted improved function at 12 months.

Conclusions

Females experience worse functional outcomes at 12 months, potentially due to majority of female injuries being low falls in the elderly. In contrast, motor vehicle injury patients had better functional outcomes at 12 months. Additional interventional strategies for high-risk groups should be explored.

Major trauma in older persons

Background

Globally, populations are ageing, creating challenges for trauma system design. Despite this, little is known about causes of injury and long-term outcomes in older injured patients. This study aims to describe temporal trends in the incidence, causes and functional outcomes of major trauma in older adults.

Methods

The population-based Victorian State Trauma Registry was used to identify patients with major trauma aged 65 years and older with a date of injury between 1 January 2007 and 31 December 2016. Temporal trends in population-based incidence rates were evaluated. Functional outcome was measured using the Glasgow Outcome Scale - Extended.

Results

There were 9250 older adults with major trauma during the study period. Low falls were the most common mechanism of injury (62·5 per cent), followed by transport-related events (22·2 per cent) and high falls (9·5 per cent). The number of patients with major trauma aged 65 years and older more than doubled from 2007 to 2016, and the incidence increased by 4·3 per cent per year (incidence rate ratio 1·043, 95 per cent c.i. 1·035 to 1·050; P < 0·001). At 12 months after injury, 41·8 per cent of older adults with major trauma had died, and 52·2 per cent of those who survived to hospital discharge were not living independently.

Conclusions

The number and proportion of older adults with major trauma are increasing rapidly and this will impact on trauma system design. Given the poor long-term outcomes, there needs to be greater emphasis on ensuring that appropriate interventions are targeted to the right patients and enhanced efforts in primary prevention.

The Feasibility of Telephone-Administered Cognitive Testing in Individuals 1 and 2 Years after Inpatient Rehabilitation for Traumatic Brain Injury

Traumatic brain injury (TBI) often results in cognitive impairment, and trajectories of cognitive functioning can vary tremendously over time across survivors. Traditional approaches to measuring cognitive performance require face-to-face administration of a battery of objective neuropsychological tests, which can be time- and labor-intensive. There are numerous clinical and research contexts in which in-person testing is undesirable or unfeasible, including clinical monitoring of older adults or individuals with disability for whom travel is challenging, and epidemiological studies of geographically dispersed participants. A telephone-based method for measuring cognition could conserve resources and improve efficiency. The objective of this study is to examine the feasibility and usefulness of the Brief Test of Adult Cognition by Telephone (BTACT) among individuals who are 1 and 2 years post-moderate-to-severe TBI. A total of 463 individuals participated in the study at Year 1 post-injury, and 386 participated at Year 2. The sample was mostly male (73%) and white (59%), with an average age of (mean ± standard deviation) 47.9 ± 20.9 years, and 73% experienced a duration of post-traumatic amnesia (PTA) greater than 7 days. A majority of participants were able to complete the BTACT subtests (61-69% and 56-64% for Years 1 and 2 respectively); score imputation for those unable to complete a test due to severity of cognitive impairment yields complete data for 74-79% of the sample. BTACT subtests showed expected changes between Years 1-2, and summary scores demonstrated expected associations with injury severity, employment status, and cognitive status as measured by the Functional Independence Measure. Results indicate it is feasible, efficient, and useful to measure cognition over the telephone among individuals with moderate-severe TBI.

Development and validation of an ICD-10-based disability predictive index for patients admitted to hospitals with trauma

BACKGROUND

There was no established disability predictive measurement for patients with trauma that could be used in administrative claims databases. The aim of the present study was to develop and validate a diagnosis-based disability predictive index for severe physical disability at discharge using the International Classification of Diseases, 10th revision (ICD-10) coding.

METHODS

This retrospective observational study used the Diagnosis Procedure Combination database in Japan. Patients who were admitted to hospitals with trauma and discharged alive from 01 April 2010 to 31 March 2015 were included. Pediatric patients under 15 years old were excluded. Data for patients admitted to hospitals from 01 April 2010 to 31 March 2013 was used for development of a disability predictive index (derivation cohort), while data for patients admitted to hospitals from 01 April 2013 to 31 March 2015 was used for the internal validation (validation cohort). The outcome of interest was severe physical disability defined as the Barthel Index score of <60 at discharge. Trauma-related ICD-10 codes were categorized into 36 injury groups with reference to the categorization used in the Global Burden of Diseases study 2013. A multivariable logistic regression analysis was performed for the outcome using the injury groups and patient baseline characteristics including patient age, sex, and Charlson Comorbidity Index (CCI) score in the derivation cohort. A score corresponding to a regression coefficient was assigned to each injury group. The disability predictive index for each patient was defined as the sum of the scores. The predictive performance of the index was validated using the receiver operating characteristic curve analysis in the validation cohort.

RESULTS

The derivation cohort included 1,475,158 patients, while the validation cohort included 939,659 patients. Of the 939,659 patients, 235,382 (25.0%) were discharged with severe physical disability. The c-statistics of the disability predictive index was 0.795 (95% confidence interval [CI] 0.794-0.795), while that of a model using the disability predictive index and patient baseline characteristics was 0.856 (95% CI 0.855-0.857).

CONCLUSIONS

Severe physical disability at discharge may be well predicted with patient age, sex, CCI score, and the diagnosis-based disability predictive index in patients admitted to hospitals with trauma.

Temporal Trends in Functional Outcomes after Severe Traumatic Brain Injury: 2006-2015

Severe traumatic brain injury (TBI) is associated with poor outcomes; however, little is known about whether these outcomes are improving over time. This study examined temporal trends in functional outcomes of severe TBI at six months post-injury. We conducted a retrospective cohort study (January 1, 2006 to December 31, 2015) of hospitalized adult (≥16 years) patients with severe TBI using data from the population-based Victorian State Trauma Registry. The primary outcome was the Glasgow Outcome Scale-Extended (GOS-E) at six months post-injury, dichotomized as upper severe disability or worse (GOS-E ≤4, termed "unfavorable outcome") and lower moderate disability or better (GOS-E ≥5; termed "favorable outcome"). Multivariable logistic regression was used to investigate temporal trends in functional outcomes at six months post-injury. Of the 1966 patients with severe TBI who were followed up at six months post-injury (median age, 42 years (interquartile range [IQR]: 25-68); male, 73%), a majority of patients had an unfavorable outcome (GOS-E ≤4; n = 1372, 70%). After adjusting for confounders, there was no change in functional outcomes over time (adjusted odds ratio [AOR] = 1.02, 95% confidence interval [CI]: 0.98,1.06; p = 0.35). Similarly, there was no change in the adjusted odds of death (GOS-E = 1) at six months post-injury (AOR = 1.04, 95% CI: 1.00,1.08; p = 0.08). Using a population-wide, high quality, comprehensive registry, we demonstrated no change in death or functional outcomes after severe TBI between 2006 and 2015 in a mature trauma system. There is a clear need to identify targeted improvements in the treatment of these patients with the aim of reducing in-hospital death and improving long-term outcomes.

Discharge from the acute hospital: trauma patients' perceptions of care

Objective The involvement of orthopaedic trauma patients in the decision-making regarding discharge destination from the acute hospital and their perceptions of the care following discharge are poorly understood. The aim of the present study was to investigate orthopaedic trauma patient experiences of discharge from the acute hospital and transition back into the community. Methods The present qualitative study performed in-depth interviews, between October 2012 and November 2013, with patients aged 18-64 years with lower limb trauma. Thematic analysis was used to derive important themes. Results Ninety-four patients were interviewed, including 35 discharged to in-patient rehabilitation. Key themes that emerged include variable involvement in decision-making regarding discharge, lack of information and follow-up care on discharge and varying opinions regarding in-patient rehabilitation. Readiness for discharge from in-patient rehabilitation also differed widely among patients, with patients often reporting being ready for discharge before the planned discharge date and feeling frustration at the need to stay in in-patient care. There was also a difference in patients' perception of the factors leading to recovery, with patients discharged to rehabilitation more commonly reporting external factors, such as rehabilitation providers and physiotherapy. Conclusion The insights provided by the participants in the present study will help us improve our discharge practice, especially the need to address the concerns of inadequate information provision regarding discharge and the role of in-patient rehabilitation. What is known about the topic? There is no current literature describing trauma patient involvement in decision-making regarding discharge from the acute hospital and the perception of how this decision (and destination choice; e.g. home or in-patient rehabilitation) affects their outcome. What does this paper add? The present large qualitative study provides information on patients' opinion of discharge from the acute hospital following trauma and how this could be improved from their perception. Patients are especially concerned with the lack of information provided to them on discharge, their lack of involvement and understanding of the choices made with regard to their discharge and describe concerns regarding their follow-up care. There is also a feeling from the patients that they are ready to leave rehabilitation before their actual planned discharge date, a concept that needs further investigation. What are the implications for practitioners? The patient insights gained by the present study will lead to a change in discharge practice, including increased involvement of the patient in the decision-making in terms of discharge from both the acute and rehabilitation hospitals and a raised awareness of the need to provide written information and follow-up telephone calls to patients following discharge. Further research into many aspects of patient discharge from the acute hospital should be considered, including the use of rehabilitation prediction tools to ensure patient involvement in decision-making and a discharge and/or follow-up coordinator to ensure patients are aware of how to access information after discharge.

Predictors of recovery in cyclists hospitalised for orthopaedic trauma following an on-road crash

BACKGROUND

As cycling-related injury rates are on the rise, there is a need to understand the long term outcomes of these patients in order to quantify the burden of injury and to inform injury prevention strategies. This study aimed to investigate predictors of return to work and functional recovery in a cohort of cyclists hospitalised for orthopaedic trauma from crashes occurring on-road.

METHODS

A retrospective analysis of data from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) was conducted for patients who were hospitalised for orthopaedic trauma following a cycling crash that occurred on-road between July 2007 and June 2015.

RESULTS

There were 1787 injured cyclists admitted at the participating hospitals. Most cyclists were male (79%), resided in major cities (89%) and were in the highest socioeconomic quintile (52%). The majority of crashes were either non-collisions (41%) or collisions with a motor vehicle (35%). A smaller proportion of cyclists who collided with motor vehicles had returned to work and had returned to pre-injury functional levels at 12 months post-injury, when compared to collisions with other impact counterparts and non-collisions. Mixed effects logistic regression models revealed that compensable patients demonstrated lower odds of complete functional recovery and return to work when compared with non-compensable patients.

CONCLUSION

Cyclists who collided with motor vehicles had worse outcomes compared to crashes with other impact counterparts and non-collision events. These findings provide support for reducing the potential for interaction between cyclists and motor vehicles.

Bicycling crash characteristics: An in-depth crash investigation study

The aim of this study was to describe the crash characteristics and patient outcomes of a sample of patients admitted to hospital following bicycle crashes. Injured cyclists were recruited from the two major trauma services for the state of Victoria, Australia. Enrolled cyclists completed a structured interview, and injury details and patient outcomes were extracted from the Victorian State Trauma Registry (VSTR) and the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). 186 cyclists consented to participate in the study. Crashes commonly occurred during daylight hours and in clear weather conditions. Two-thirds of crashes occurred on-road (69%) and were a combination of single cyclist-only events (56%) and multi-vehicle crashes (44%). Of the multi-vehicle crashes, a motor vehicle was the most common impact partner (72%) and distinct pre-crash directional interactions were observed between the cyclist and motor vehicle. Nearly a quarter of on-road crashes occurred when the cyclist was in a marked bicycle lane. Of the 31% of crashes that were not on-road, 28 (15%) occurred on bicycle paths and 29 (16%) occurred in other locations. Crashes on bicycle paths commonly occurred on shared bicycle and pedestrian paths (83%) and did not involve another person or vehicle. Other crash locations included mountain bike trails (39%), BMX parks (21%) and footpaths (18%). While differences in impact partners and crash characteristics were observed between crashes occurring on-road, on bicycle paths and in other locations, injury patterns and severity were similar. Most cyclists had returned to work at 6 months post-injury, however only a third of participants reported a complete functional recovery. Further research is required to develop targeted countermeasures to address the risk factors identified in this study.

Twelve-month mortality and functional outcomes in hip fracture patients under 65 years of age

INTRODUCTION

There has been a recent call for improved functional outcome reporting in younger hip fracture patients. Younger hip fracture patients represent a different population with different functional goals to their older counterparts. Therefore, previous research on mortality and functional outcomes in hip fracture patients may not be generalisable to the younger population. The aims of this study were to report 12-month survival and functional outcomes in hip fracture patients aged <65 years and predictors of functional outcome.

METHODS

Hip fracture patients aged <65years (range 17-64) registered by the Victorian Orthopaedic Trauma Outcomes Registry over four years were included and their 12-month survival and functional outcomes (Extended Glasgow Outcome Scale) reported. Ordered multivariable logistic regression was used to identify predictors of higher function.

RESULTS

There were 507 patients enrolled in the study and of the 447 patients (88%) with 12-month outcomes, 24 (5%) had died. The majority of patients had no comorbidities or pre-injury disability and were injured via road trauma or low falls. 40% of patients sustained additional injuries to their hip fracture. 23% of patients had fully recovered at 12 months and 39% reported ongoing moderate disability. After adjusting for all key variables, odds of better function 12-months post-fracture were reduced for patients with co-morbidities, previous disability or additional injuries, those receiving compensation or injured via low falls.

CONCLUSIONS

While 12-month survival rates were satisfactory in hip fracture patients aged under 65 years, their functional outcomes were poor, with less than one quarter having fully recovered 12 months following injury. This study provides new information about which patients may have difficulty returning to their pre-injury level of function. These patients may require additional or more intensive post-discharge care in order to fulfil their functional goals and continue to contribute productively to society.

Return to Work and Functional Outcomes After Major Trauma: Who Recovers, When, and How Well?

OBJECTIVE

To describe the long-term outcomes of major trauma patients and factors associated with the rate of recovery.

BACKGROUND

As injury-related mortality decreases, there is increased focus on improving the quality of survival and reducing nonfatal injury burden.

METHODS

Adult major trauma survivors to discharge, injured between July 2007 and June 2012 in Victoria, Australia, were followed up at 6, 12, and 24 months after injury to measure function (Glasgow Outcome Scale-Extended) and return to work/study. Random-effects regression models were fitted to identify predictors of outcome and differences in the rate of change in each outcome between patient subgroups.

RESULTS

Among the 8844 survivors, 8128 (92%) were followed up. Also, 23% had achieved a good functional recovery, and 70% had returned to work/study at 24 months. The adjusted odds of reporting better function at 12 months was 27% (adjusted odds ratio 1.27, 95% confidence interval [CI] 1.19-1.36) higher compared with 6 months, and 9% (adjusted odds ratio 1.09, 95% CI, 1.02-1.17) higher at 24 months compared with 12 months. The adjusted relative risk (RR) of returning to work was 14% higher at 12 months compared with 6 months (adjusted RR 1.14, 95% CI, 1.12-1.16) and 8% (adjusted RR 1.08, 95% CI, 1.06-1.10) higher at 24 months compared with 12 months.

CONCLUSIONS

Improvement in outcomes over the study period was observed, although ongoing disability was common at 24 months. Recovery trajectories differed by patient characteristics, providing valuable information for informing prognostication and service planning, and improving our understanding of the burden of nonfatal injury.

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.

Inter-rater agreement on assessment of outcome within a trauma registry

INTRODUCTION

To better evaluate the degree of ongoing disability in trauma patients, it has been recommended that trauma registries introduce routine long-term outcome measurement. One of the measures recommended for use is the Extended Glasgow Outcome Scale (GOS-E). However, few registries have adopted this measure and further research is required to determine its reliability with trauma populations. This study aimed to evaluate the inter-rater agreement of GOS-E scoring between an expert rater and trauma registry follow-up staff with a sample of detailed trauma case scenarios.

METHODS

Sixteen trauma registry telephone interviewers participated in the study. They were provided with a written summary of 15 theoretical adult trauma cases covering a spectrum of disability and asked to rate each case using the structured GOS-E interview. Their ratings were compared with those of an expert rater in order to calculate the inter-rater agreement for each individual rater-expert rater pair. Agreement was reported as the percentage of agreement, the kappa statistic, and weighted kappa. A multi-rater kappa value was also calculated for agreement between the 16 raters.

RESULTS

Across the 15 cases, the percentage of agreement between individual raters and the expert ranged from 63% to 100%. Across the 16 raters, the percentage of agreement with the expert rater ranged from 73-100% (mean=90%). Kappa values ranged from 0.65 to 1.00 across raters (mean=0.86) and weighted kappa values ranged from 0.73 to 1.00 (mean=0.89) The multi-rater kappa value was 0.78 (95% CI: 0.66, 0.89).

CONCLUSIONS

Sixteen follow-up staff achieved 'substantial' to 'almost perfect' agreement with an expert rater using the GOS-E outcome measure to score 15 sample trauma cases. The results of this study lend support to the use of the GOS-E within trauma populations and highlight the importance of ongoing training where multiple raters are involved to ensure reliable outcome reporting. It is also recommended that the structured GOS-E interview guide be used to achieve better agreement between raters. Ensuring the reliability of trauma outcome scores will enable more accurate evaluation of patient outcomes, and ultimately, more targeted trauma care.

Association between perception of fault for the crash and function, return to work and health status 1 year after road traffic injury: a registry-based cohort study

OBJECTIVES

To establish the association between the patient's perception of fault for the crash and 12-month outcomes after non-fatal road traffic injury.

SETTING

Two adult major trauma centres, one regional trauma centre and one metropolitan trauma centre in Victoria, Australia.

PARTICIPANTS

2605 adult, orthopaedic trauma patients covered by the state's no-fault third party insurer for road traffic injury, injured between September 2010 and February 2014.

OUTCOME MEASURES

EQ-5D-3L, return to work and functional recovery (Glasgow Outcome Scale-Extended score of upper good recovery) at 12 months postinjury.

RESULTS

After adjusting for key confounders, the adjusted relative risk (ARR) of a functional recovery (0.57, 95% CI 0.46 to 0.69) and return to work (0.92, 95% CI 0.86 to 0.99) were lower for the not at fault compared to the at fault group. The ARR of reporting problems on EQ-5D items was 1.20-1.35 times higher in the not at fault group.

CONCLUSIONS

Patients who were not at fault, or denied being at fault despite a police report of fault, experienced poorer outcomes than the at fault group. Attributing fault to others was associated with poorer outcomes. Interventions to improve coping, or to resolve negative feelings from the crash, could facilitate better outcomes in the future.

Temporal trends in surgical intervention for severe traumatic brain injury caused by extra-axial hemorrhage, 1995 to 2012

BACKGROUND

Surgical intervention for severe traumatic brain injury (TBI) caused by extra-axial hemorrhage has declined in recent decades. The effect of this change on patient outcomes is unknown.

OBJECTIVE

To determine the change over time in surgical intervention in this population and to assess changes in patient outcomes.

METHODS

In this retrospective cohort study, the Washington State Trauma Registry was queried from 1995 to 2012 for patients with extra-axial hemorrhage and head Abbreviated Injury Scale score of 3 to 5. Data were linked to the state-wide death registry to analyze long-term mortality. The primary outcome was inpatient mortality. Secondary outcomes included 6- and 12-month mortality and modified Functional Independence Measure at discharge. Multivariable analyses were completed for all outcomes.

RESULTS

A total of 22974 patients met inclusion criteria. Over the study period, surgical intervention for severe TBI declined from 36% to 7%. There was a decline in case fatality from 22% to 12%. In 2012, the relative risk of inpatient mortality was 23% lower compared with 1995 (adjusted mortality risk ratio, 0.77; 95% confidence interval, 0.63-0.94). Changes in 6- and 12-month adjusted mortality and modified Functional Independence Measure were not statistically significant.

CONCLUSION

The decline in surgical intervention for severe TBI caused by extra-axial hemorrhage in Washington State was ubiquitous across regional, demographic, and injury characteristic strata. There was concurrently a reduction in inpatient mortality in this population. Functional status and long-term mortality, however, have remained the same. Future studies are needed to better identify modifiable risk factors for improvement in functional status and long-term mortality in this population.

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.

Validation of the quality of life after brain injury in Chinese persons with traumatic brain injury in Taiwan

OBJECTIVE

To determine the psychometric properties of the Quality of Life After Brain Injury (QOLIBRI) in Chinese persons with traumatic brain injury (TBI) in Taiwan.

PARTICIPANTS

Three hundred one patients with TBI were interviewed face-to-face at baseline; of these, 132 completed a follow-up assessment 1 year later.

SETTINGS

Neurosurgery clinics of 6 teaching hospitals in northern Taiwan.

MEASURE

The 37-item QOLIBRI, including 6 domains of Cognition, Self, Daily Life and Autonomy, Social Relationships, Emotions, and Physical Problems.

RESULTS

A small percentage (<1%) of responses were missing, except the Sex Life item under the Social domain (5.9%). The QOLIBRI achieved adequate percentages for the floor value (0%-4%), ceiling value (1%-3.3%), internal consistency (0.79-0.95), and test-retest reliability (0.81-0.89). For construct validity, correlation coefficients (rs) for the QOLIBRI domains and selected clinical measures conceptually related to that domain were all 0.4 or more, except rs for QOLIBRI Cognition and Mini-Mental State Examination scores. A principal components analysis found that one item (Loneliness) of the Emotions domain did not converge with its corresponding domain of the original QOLIBRI (loading score <0.4). Effect sizes of responsiveness to changes in the Glasgow Outcome Scale-Extended over the 1-year period were clinically meaningful for all the QOLIBRI domains except the Emotions domain.

CONCLUSION

With modifications to the Emotions domain, the QOLIBRI would be suitable for use with Chinese people in Taiwan who have TBI.

A comparison of functional outcome in patients sustaining major trauma: a multicentre, prospective, international study

Objectives

To compare 6 month and 12 month health status and functional outcomes between regional major trauma registries in Hong Kong and Victoria, Australia.

Summary Background Data

Multicentres from trauma registries in Hong Kong and the Victorian State Trauma Registry (VSTR).

Methods

Multicentre, prospective cohort study. Major trauma patients and aged ≥18 years were included. The main outcome measures were Extended Glasgow Outcome Scale (GOSE) functional outcome and risk-adjusted Short-Form 12 (SF-12) health status at 6 and 12 months after injury.

Results

261 cases from Hong Kong and 1955 cases from VSTR were included. Adjusting for age, sex, ISS, comorbid status, injury mechanism and GCS group, the odds of a better functional outcome for Hong Kong patients relative to Victorian patients at six months was 0.88 (95% CI: 0.66, 1.17), and at 12 months was 0.83 (95% CI: 0.60, 1.12). Adjusting for age, gender, ISS, GCS, injury mechanism and comorbid status, Hong Kong patients demonstrated comparable mean PCS-12 scores at 6-months (adjusted mean difference: 1.2, 95% CI: −1.2, 3.6) and 12-months (adjusted mean difference: −0.4, 95% CI: −3.2, 2.4) compared to Victorian patients. Keeping age, gender, ISS, GCS, injury mechanism and comorbid status, there was no difference in the MCS-12 scores of Hong Kong patients compared to Victorian patients at 6-months (adjusted mean difference: 0.4, 95% CI: −2.1, 2.8) or 12-months (adjusted mean difference: 1.8, 95% CI: −0.8, 4.5).

Conclusion

The unadjusted analyses showed better outcomes for Victorian cases compared to Hong Kong but after adjusting for key confounders, there was no difference in 6-month or 12-month functional outcomes between the jurisdictions.

Assessment of quality of life and functional outcome in patients sustaining moderate and major trauma: a multicentre, prospective cohort study

BACKGROUND

Trauma care systems aim to reduce both death and disability, yet there is little data on post-trauma health status and functional outcome.

OBJECTIVES

To evaluate baseline, discharge, six month and 12 month post-trauma quality of life, functional outcome and predictors of quality of life in Hong Kong.

METHODS

Multicentre, prospective cohort study using data from the trauma registries of three regional trauma centres in Hong Kong. Trauma patients with an ISS≥9 and aged≥18 years were included. The main outcome measures were the physical component summary (PCS) score and mental component summary (MCS) scores of the Short-Form 36 (SF36) for health status, and the extended Glasgow Outcome Scale (GOSE) for functional outcome.

RESULTS

Between 1 January 2010 and 31 September 2010, 400 patients (mean age 53.3 years; range 18-106; 69.5% male) were recruited to the study. There were no statistically significant differences in baseline characteristics between responders (N=177) and surviving non-responders (N=163). However, there were significant differences between these groups and the group of patients who died (N=60). Only 16/400 (4%) cases reported a GOSE≥7. 62/400 (15.5%) responders reached the HK population norm for PCS. 125/400 (31%) responders reached the HK population norm for MCS. If non-responders had similar outcomes to responders, then the percentages for GOSE≥7 would rise from 4% to 8%, for PCS from 15.5% to 30%, and for MCS from 31% to 60%. Univariate analysis showed that 12-month poor quality of life was significantly associated with age>65 years (OR 4.77), male gender (OR 0.44), pre-injury health problems (OR 2.30), admission to ICU (OR 2.15), ISS score 26-40 (OR 3.72), baseline PCS (OR 0.89), one-month PCS (OR 0.89), one-month MCS (OR 0.97), 6-month PCS (OR 0.76) and 6-month MCS (OR 0.97).

CONCLUSION

For patients sustaining moderate or major trauma in Hong Kong at 12 months after injury<1 in 10 patients had an excellent recovery, ≤3 in 10 reached a physical health status score≥Hong Kong norm, although as many as 6 in 10 patients had a mental health status score which is≥Hong Kong norm.

Understanding post-hospital morbidity associated with immobilisation of cervical spine fractures in older people using geriatric medicine assessment techniques: A pilot study

INTRODUCTION

There is a paucity of research into the outcomes and complications of cervical spine immobilisation (hard collar or halothoracic brace) in older people.

AIMS

To identify morbidity and mortality outcomes using geriatric medicine assessment techniques following cervical immobilisation in older people with isolated cervical spine fractures.

PATIENTS AND METHODS

We identified participants using an injury database. We completed a questionnaire measuring pre-admission medical co-morbidities and functional independence. We recorded the surgical plan and all complications. A further questionnaire was completed three months later recording complications and functional independence.

RESULTS

Sixteen patients were recruited over a three month period. Eight were immobilised with halothoracic brace, 8 with external hard collar. Three deaths occurred during the study. Lower respiratory tract infection was the most common complication (7/16) followed by delirium (6/16). Most patients were unable to return home following the acute admission, requiring sub-acute care on discharge. The majority of patients were from home prior to a fall, 6/16 were residing there at 3 months. Most participants had an increase in their care needs at 3 months. There was no difference in the type or incidence of complications between the different modes of immobilisation.

CONCLUSIONS

Geriatric medicine assessment techniques identified the morbidity and functional impairment associated with cervical spine immobilisation. This often results in a prolonged length of stay in supported care. This small pilot study recommends a larger study over a longer period using geriatric medicine assessment techniques to better define the issues.

Assessment of the internal construct validity of the revised High-Level Mobility Assessment Tool for traumatic orthopaedic injuries

OBJECTIVE

To determine whether the revised High-Level Mobility Assessment Tool (HiMAT) was valid for measuring mobility for people with multi-trauma orthopaedic lower limb injuries.

DESIGN

Cross-sectional study.

SUBJECTS

Participants with lower limb multi-trauma orthopaedic injuries.

METHODS

One complete revised HiMAT was obtained for 106 people within 12 weeks of being allowed to fully weight bear. Rasch analysis was used to assess the overall fit of the model for individuals and items, differential item functioning, local dependency, targeting of items and dimensionality.

RESULTS

The mean revised HiMAT score was 10.5 (SD = 6.8) with a range of 5-30. Rasch analysis of revised HiMAT showed adequate overall fit to the model (P = 0.29) with no misfitting items (fit residual SD = 0.69) or persons (fit residual SD = 0.62). The scale showed good internal consistency (Person Separation Index = 0.91). One item (hopping) demonstrated disordered thresholds, however this item had good fit to the model in all other aspects. The revised HiMAT was unidimensional, and no differential item functioning was detected for gender or age. The revised HiMAT was well targeted for this group with a range of items across all ability levels.

CONCLUSION

The results of this study support the internal construct validity of the revised HiMAT as a well-targeted, unidimensional measure of high-level mobility with no ceiling or floor effect for males and females recovering from multi-trauma orthopaedic lower limb injuries.

Comparison of measures of comorbidity for predicting disability 12-months post-injury

BACKGROUND

Understanding the factors that impact on disability is necessary to inform trauma care and enable adequate risk adjustment for benchmarking and monitoring. A key consideration is how to adjust for pre-existing conditions when assessing injury outcomes, and whether the inclusion of comorbidity is needed in addition to adjustment for age. This study compared different approaches to modelling the impact of comorbidity, collected as part of the routine hospital episode data, on disability outcomes following orthopaedic injury.

METHODS

12-month Glasgow Outcome Scale - Extended (GOS-E) outcomes for 13,519 survivors to discharge were drawn from the Victorian Orthopaedic Trauma Outcomes Registry, a prospective cohort study of admitted orthopaedic injury patients. ICD-10-AM comorbidity codes were mapped to four comorbidity indices. Cases with a GOS-E score of 7-8 were considered "recovered". A split dataset approach was used with cases randomly assigned to development or test datasets. Logistic regression models were fitted with "recovery" as the outcome and the performance of the models based on each comorbidity index (adjusted for injury and age) measured using calibration (Hosmer-Lemshow (H-L) statistics and calibration curves) and discrimination (Area under the Receiver Operating Characteristic (AUC)) statistics.

RESULTS

All comorbidity indices improved model fit over models with age and injuries sustained alone. None of the models demonstrated acceptable model calibration (H-L statistic p < 0.05 for all models). There was little difference between the discrimination of the indices for predicting recovery: Charlson Comorbidity Index (AUC 0.70, 95% CI: 0.68, 0.71); number of ICD-10 chapters represented (AUC 0.70, 95% CI: 0.69, 0.72); number of six frequent chronic conditions represented (AUC 0.70, 95% CI: 0.69, 0.71); and the Functional Comorbidity Index (AUC 0.69, 95% CI: 0.68, 0.71).

CONCLUSIONS

The presence of ICD-10 recorded comorbid conditions is an important predictor of long term functional outcome following orthopaedic injury and adjustment for comorbidity is indicated when assessing risk-adjusted functional outcomes over time or across jurisdictions.