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Outcome after Major Trauma: 12-Month and 18-Month Follow-Up Results from the Trauma Recovery Project

Holbrook, Troy L. PhD; Anderson, John P. PhD; Sieber, William J. PhD; Browner, Dierdre MPH; Hoyt, David B. MD, FACS

The Journal of Trauma: Injury, Infection, and Critical Care: May 1999 - Volume 46 - Issue 5 - p 765-773
Article: Presented At The 58Th Annual Meeting Of The American Association For The Surgery Of Trauma Meeting Jointly With The Trauma Association Of Canada, September 24-26, 1998, Baltimore, Maryland
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Background The importance of outcome after major injury has continued to gain attention in light of the ongoing development of sophisticated trauma care systems in the United States. The Trauma Recovery Project (TRP) is a large prospective epidemiologic study designed to examine multiple outcomes after major trauma in adults aged 18 years and older, including quality of life, functional outcome, and psychologic sequelae such as depression and posttraumatic stress disorder (PTSD). Patient outcomes were assessed at discharge and at 6, 12, and 18 months after discharge. The specific objectives of the present report are to describe functional outcomes at the 12-month and 18-month follow-ups in the TRP population and to examine the association of putative risk factors with functional outcome.

Methods Between December 1, 1993, and September 1, 1996, 1,048 eligible trauma patients triaged to four participating trauma center hospitals in the San Diego Regionalized Trauma System were enrolled in the TRP study. The admission criteria for patients were as follows: (1) age 18 years or older; (2) Glasgow Coma Scale score on admission of 12 or greater; and (3) length of stay greater than 24 hours. Functional outcome after trauma was measured before and after injury using the Quality of Well-Being (QWB) Scale, an index sensitive to the well end of the functioning continuum (0 = death, 1.000 = optimum functioning). Follow-up at 12 months after discharge was completed for 806 patients (79%), and follow-up at 18 months was completed for 780 patients (74%). Follow-up contact at any of the study time points (6, 12, or 18 months) was achieved for 926 (88%) patients.

Results The mean age was 36 +/- 14.8 years, and 70% of the patients were male; 52% were white, 30% were Hispanic, and 18% were black or other. Less than 40% of study participants were married or living together. The mean Injury Severity Score was 13 +/- 8.5, with 85% blunt injuries and a mean length of stay of 7 +/- 9.2 days. QWB scores before injury reflected the norm for a healthy adult population (mean, 0.810 +/- 0.171). At the 12-month follow-up, there were very high levels of functional limitation (QWB mean score, 0.670 +/- 0.137). Only 18% of patients followed at 12 months had scores above 0.800, the norm for a healthy population. There was no improvement in functional limitation at the 18-month follow-up (QWB mean score, 0.678 +/- 0.130). The majority of patients (80%) at the 18-month follow-up continued to have QWB scores below the healthy norm of 0.800. Postinjury depression, PTSD, serious extremity injury, and intensive care unit days were significant independent predictors of 12-month and 18-month QWB outcome.

Conclusion This study demonstrates a prolonged and profound level of functional limitation after major trauma at 12-month and 18-month follow-up. This is the first report of long-term outcome based on the QWB Scale, a standardized quality-of-life measure, and provides new and provocative evidence that the magnitude of dysfunction after major injury has been underestimated. Postinjury depression, PTSD, serious extremity injury, and intensive care unit days are significantly associated with 12-month and 18-month QWB outcome.

From the Department of Family and Preventive Medicine (T.L.H., J.P.A., W.J.S., D.B.) and the Division of Trauma, Department of Surgery (D.B.H.), University of California, San Diego, California.

This work was supported by grant R01 HS 07611-05 from the Agency for Health Care Policy and Research.

Presented at the 58th Annual Meeting of the American Association for the Surgery of Trauma and the Trauma Association of Canada, September 24-26, 1998, Baltimore, Maryland.

Address for reprints: Troy L. Holbrook, PhD, Trauma Recovery Project, Department of Family and Preventive Medicine, University of California San Diego Medical Center, 200 West Arbor Drive, San Diego, CA 92103-8213.

The importance of outcome after major injury has continued to gain attention in light of the ongoing development of sophisticated trauma care systems in the United States. [1-10] Indeed, injury is the leading cause of functional limitation in adults younger than 45 years of age and in children.

In recent years, numerous studies have examined disability after trauma using widely different approaches to the measurement of disability. This has resulted in a correspondingly wide variability in both the rate and degree of reported dysfunction after serious injury. [8-20] Wide variability in disability was also noted in some of the earliest reports of outcome after trauma. [21-25] Predictors of disability such as mechanism, injury severity, sociodemographic status, social support, and psychologic sequelae, e.g., depression, also have not been systematically reported. Although some of this variation is attributable to differences in the trauma populations and follow-up periods selected for study, the sensitivity and design of the disability measurement is probably a major contributory factor. The Trauma Recovery Project (TRP) was the first study to report short-term outcome after trauma using a standardized quality-of-life measure. [26] To our knowledge, there are no existing studies of long-term outcome after trauma that have used quality-of-life measures.

Outcomes at 12 and 18 months after injury are reported from the TRP, a large prospective epidemiologic study designed to examine multiple outcomes after major trauma in adults aged 18 years and older, including quality of life, functional outcome, and psychologic sequelae such as depression and posttraumatic stress disorder.

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PATIENTS AND METHODS

Study Population

Between December 1, 1993, and September 1, 1996, 1,048 eligible trauma patients triaged to four participating trauma center hospitals in the San Diego Regionalized Trauma System were enrolled in the TRP study. The admission criteria for patients were as follows: (1) age 18 years or older; (2) Glasgow Coma Scale score on admission of 12 or greater; and (3) length of stay greater than 24 hours. Enrollment criteria also included a current address in California, Arizona, Utah, or Oregon, corresponding telephone numbers for follow-up contact, and English or Spanish as the primary language spoken. Refusal rates for study participation during the study enrollment period were very low, averaging about 1%.

Patient outcomes were assessed at discharge and at 6, 12, and 18 months after discharge by a trained interviewer. Institutional review board approval for the study was granted by all participating hospitals, and informed consent for the discharge and follow-up interviews was obtained from each enrolled patient. The questionnaire is designed to collect information on sociodemographic characteristics and includes several standardized survey instruments designed to measure functional status before and after injury, social support, and psychologic sequelae such as depression and posttraumatic stress disorder (PTSD). The focus of this report will be the 12-month and 18-month follow-up time points.

All study participants were contacted between December 1, 1994, and March 1, 1997, for the 12-month postdischarge follow-up by telephone interview. The follow-up interview was designed to reassess functional outcome, depression, PTSD, and social support and to check for changes in selected sociodemographic characteristics. A total of 806 12-month follow-up interviews out of the total 1,048 enrolled patients were completed, yielding a 12-month follow-up rate of 77%. Eighteen-month follow-up interviews were completed by April 1, 1998, for 780 of the total 1,048 enrolled patients (74%). Follow-up contact at any of the study time points (6, 12, or 18 months) was achieved for 926 patients (88%).

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Functional Outcome Assessment

Eunctional outcome was measured using the Quality of Well-Being (QWB) Scale, an interview-based measure of well-being. The QWB Scale combines preference-weighted measures of symptoms and functioning to provide a numerical point-in-time expression of well-being, which ranges from 0 for death to 1.0 for asymptomatic full functioning. [27-29] The QWB Scale includes a symptom scale and three scales of function: mobility, physical activity, and social activity. Each symptom and step on these scales has its own associated preference weight. The overall QWB score is based on a preference-weighted average of functioning for the previous 6 days with respect to symptoms and the three function scales. A "preinjury" QWB score thus may be computed for patients with an injury event during the 6-day reporting period by using scores from those days recorded before the injury occurred. Individual subscale and symptom scores are not routinely reported because of both the preference-weighting and the greater utility and generalizability of a summary score. A list of symptom/problem complexes and subscale items along with their associated calculating weights and formulas are shown in an earlier publication from the TRP. [26]

The overall QWB score, when combined with terms for the number of people involved and the duration, produces the expression well-years (or quality-adjusted life-years). It can thus be used to measure the outcome of various health programs and policies with a single evaluative expression, thus allowing comparison of results across diseases and treatments (e.g., chemotherapy for lung cancer vs. Tylenol for headache). The validity of the measure is well established, [30] and both the sensitivity and the predictive value independent of the measure have been estimated to be greater than 0.90. [31,32]

The QWB Scale was chosen for the following reasons: (1) the documented sensitivity of the index to the well end of the functioning continuum [33]; and (2) consensus recommendations by the Agency for Health Care Policy and Research and the National Institutes of Health for the use of quality-of-life outcome measures with wide generalizability in health research. [33,34]

Functional limitation was also assessed with the Functional Disability Score, a modification of an Activities of Daily Living (ADL) Scale, developed by Mackenzie et al. [21] In this report, individual items were examined to provide a more specific functional outcome comparison with the QWB Scale.

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Depression

Depression at discharge and at each follow-up was measured using the Center for Epidemiologic Studies Depression (CES-D) Scale, a validated instrument developed to detect clinically significant depression. [35] All CES-D Scale questions were specifically targeted to ask only about the postinjury period. On the CES-D Scale, the range varies between 0 for no depressive symptoms to 60 for maximum number of depressive symptoms. Respondents with scores of 16 or higher were classified as depressed in accordance with published guidelines.

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Posttraumatic Stress Disorder

Each patient was assessed at discharge for posttraumatic stress syndrome (PTSS), an important early predictor of later PTSD. PTSS was measured after injury at discharge using the Impact of Events Scale (IES), a validated scale developed to detect clinically significant PTSS. [36] Two main features of PTSS were measured, intrusive thoughts (IES-I) and avoidance (IES-A). For analysis, each subscale was divided into tertiles; the highest tertile was designated as clinically significant IES-I or IES-A and was compared with the lower two tertile groups.

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Social Support

Social support was measured at discharge and at the 6-month follow-up using the methods developed by Sarason et al. [37] This index, the Social Support Questionnaire-R, consists of two subscales that assess (1) social network, i.e., the perceived number of social supports, and (2) satisfaction with social support. The score for social support is computed from the number of support persons listed for each of six questions, with a maximum of nine persons per question, yielding a range of 0 to 54. The satisfaction score is based on a rating of satisfaction between 1 and 6 for each corresponding social support question (1 = very dissatisfied, 6 = very satisfied), yielding a range of 6 to 36. For analysis, social network and satisfaction were each dichotomized to reflect a negative change (6-month score less than discharge score) versus no change or a positive change.

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Injury Characteristics

Injury characteristics, including mechanism, Injury Severity Score (ISS), and Abbreviated Injury Scale score, for each patient were obtained from the computerized San Diego County Trauma Registry, [38-40] which includes selected injury-related information on patients triaged to trauma center hospitals in the San Diego Regionalized Trauma System.

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Statistical Analysis

The 12-month and 18-month follow-up QWB scores were considered as primary outcome variables. Normal least squares-regression was used to examine the association of sociodemographic, injury-related, social support, and psychologic variables with the 12-month and 18-month follow-up QWB scores. To further describe risk differences, patients were also classified into two functional outcome groups: (1) patients with 12-month or 18-month follow-up QWB scores less than 90% of their preinjury QWB scores (poor recovery); and (2) patients with 12-month or 18-month follow-up QWB scores equal to or greater than 90% of their preinjury QWB scores or greater than the normal cutoff point of 0.800 (good recovery). The association of putative risk factors with functional outcome was examined using the odds ratio, comparing the proportion of patients classified into each group. [41]

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RESULTS

Sociodemographic Characteristics

The distribution of sociodemographic characteristics of the 1,048 TRP study participants was as follows: (1) the mean age was 36 +/- 14.8 years, with a range of 18 to 91 years; (2) 70% male; (3) 52% white, 30% Hispanic, and 18% black or other. Only 41% of patients had annual incomes greater than $20,000, and 85% had a high school education or higher. Less than 40% of study participants were married or living together.

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Injury Characteristics

The mean ISS was 13 +/- 8.5, with a range of 4 to 66. The majority of injuries were blunt (85%), with a mean length of stay of 7 +/- 9.2 days. The proportion of patients injured by Abbreviated Injury Scale score body region was: head, 44%; face, 13%; chest, 36%; abdomen, 29%; extremities, 54%; and skin/wound, 80%. The most common mechanism of injury was motor vehicle crash (50%), followed by assault (18%), fall (9%), pedestrian struck (8%), and bicycle crash (4%).

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Functional Limitation Outcome

In Table 1, the distribution of QWB scores at the 12-month and 18-month follow-ups are shown. QWB scores before injury reflected the norm for a healthy adult population (mean score, 0.810 +/- 0.171). At the 12-month follow-up, there were very high levels of functional limitation (QWB mean score, 0.670 +/- 0.137). Only 18% of patients followed at 12 months had scores above 0.800, the norm for a healthy population. There was no improvement in functional limitation at the 18-month follow-up (QWB mean score, 0.678 +/- 0.130). The majority of patients (80%) at the 18-month follow-up continued to have QWB scores below the healthy norm of 0.800. The mean percent change in QWB score between the 6-month and 12-month follow-ups was minimal (7.2%), and it was also markedly low between the 12-month and 18-month time points (3.6%).

Table 1

Table 1

For comparison, Table 2 shows the distribution of individual ADL items from the Functional Disability Score by level of difficulty in performing those activities for the 12-month follow-up. With the exception of standing for long periods of time, more than 94% of patients with follow-up at 12 months had little or no difficulty performing any of the activities. For the majority of activities, difficulty or inability to perform the activity was present for only 1 to 3% of patients. The distribution of level of difficulty for standing for long periods of time showed a higher rate of inability to perform this activity (13.4%), but more than 86% of patients could perform this activity with either no help or moderate help.

Table 2

Table 2

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Predictors of 12-Month and 18-Month Outcome

Twelve-month and 18-month QWB scores were significantly lower with increasing age, a finding consistent with published norms for the QWB Scale. [30]Figure 1 shows age-adjusted mean QWB scores at the 12-month follow-up for selected sociodemographic, injury-related, and psychological variables. Results were nearly identical for the 18-month follow-up. QWB scores were significantly lower in women versus men (p < 0.001). Lower education and income were also significantly associated with outcome (p < 0.001).

Figure 1

Figure 1

For injury-related variables, injury to the head, face, chest, abdomen, or skin was not significantly associated with outcome (not shown). Injury to the extremities was significantly and negatively associated with 12-month QWB scores (p < 0.001). A length of stay of 7 days or longer, and intensive care unit (ICU) stays of 4 days or longer, were also significantly and negatively associated with QWB outcome (p < 0.001). An ISS > 10 was only weakly associated with outcome at 12 months (data not shown).

Depression at discharge through the 6-month and 12-month follow-ups was strongly and negatively associated with outcome, as was PTSD, shown for the IES-I subscale (p < 0.001). A negative change in social satisfaction was also significantly associated with lower QWB outcome scores (p < 0.001; data not shown).

In Table 3, results from normal least-squares regression analyses with the 12-month and 18-month follow-up QWB scores as the dependent variable are shown. Variables examined included all variables significantly associated with outcome in the analyses shown in Figure 1, and only final models for multiply adjusted variables are presented. Model 1 and model 2 are based on 501 observations with complete information for all variables included in the analyses (62% of the 806 patients followed at 12 months). Variables were entered as coded in Figure 1. In model 1, depression at both discharge and the 6-month follow-up, entered as a single variable coded to represent depression present at both time points or neither time point, was the variable most strongly associated with QWB outcome at 12 months. When depression at all time points from discharge through 12 months was substituted in the model (model 2), the results were similar (F = 77.84, p < 0.0001). Other variables that were independently associated with 12-month QWB scores were IES-I scores, ICU days, negative change in social satisfaction, and major injury to the extremities (model 2). Twenty-three percent of the variance was explained by model 1, and 26% was explained by model 2. Additional analysis did not reveal any significant interaction terms in either model for any variable combination, including age, depression, IES-I scores, length of stay, ICU days, or major injury to the extremities.

Table 3

Table 3

Model 3 represents a similar analysis for the 18-month outcome. Results were similar to those for the 12-month outcome, with the exception of injury to the extremities, which was no longer independently associated with outcome. Note that with increasing duration of depression, shown in models 4, 5, and 6, the strength of the independent association became more marked.

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Good Versus Poor Recovery

When patients were classified into good recovery (12-month or 18-month QWB score 90% or better than preinjury QWB score or greater than the norm of 0.800) or poor recovery (12-month or 18-month QWB score less than 90% of preinjury QWB score), good recovery was achieved for only 59% of patients (n = 308) with complete preinjury and 12-month or 18-month follow-up QWB data. More than 40% of patients were classified with poor recovery according to these criteria. Odds ratios for the comparison of patients classified into the poor versus the good recovery group by selected variables are shown in Table 4. These results were generally similar to those shown in Figure 1 and the multivariate analyses presented in Table 3: marital status, education, and social satisfaction were marginally associated with recovery; major injury to the extremities was the only injury-related variable that was significantly associated with recovery. Length of stay and ICU days were not associated with recovery. IES-I score and depression at any or all time points were significantly and strongly associated with recovery.

Table 4

Table 4

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DISCUSSION

The 12-month and 18-month QWB outcomes reported here demonstrate a prolonged and profound level of functional limitation in the TRP patients. The 12-month and 18-month mean QWB scores, 0.670 and 0.678, respectively, are well below the healthy norm of 0.800 for adult populations. The level of dysfunction in TRP patients is perhaps even better documented by the finding that at the 18-month follow-up, the majority of patients (80%) continued to have QWB scores below the healthy norm. In addition, QWB scores improved only minimally between the 6-month and 12-month follow-ups (7%), and they improved even less between the 12-month and 18-month follow-ups (4%). More than 40% of patients with complete 12-month or 18-month follow-up data had not achieved good recovery, defined as 90% or better of the preinjury QWB score.

Even allowing for the highly sensitive and finely tuned discriminatory power of the QWB Scale at the well end of the functioning continuum, [33] the profound level of long-term dysfunction observed in the TRP was a surprising result. Although these results support the earlier findings from the TRP for the 6-month outcome [26] and a pilot study, [14] there was no indication in these earlier reports that the high level of functional limitation would persist into the 18-month follow-up. It is important to take into account that the interpretation of the low scores in terms of what a patient can and cannot do may be misleading, because nearly all ADL items could be performed by more than 90% of the patients at the 12-month follow-up.

To our knowledge, no other studies have used standardized quality-of-life measures such as the QWB Scale for measuring functional outcome after major trauma. A direct comparison with other data, therefore, is not feasible. There is evidence that long-term dysfunction is prevalent based on a variety of studies, with rates of disability ranging from 19 to 80%. [8-20] As noted above, some of this variation is attributable to differences in the trauma populations and follow-up periods selected for study, but the sensitivity and design of the disability measurement is probably a major contributory factor. The most important difference between the findings from the TRP and other studies is the degree of long-term functional limitation observed. Outcome based on the TRP QWB data shows that dysfunction is not only prolonged, but that the magnitude of dysfunction resulting from injury has been underestimated.

The potential impact of postinjury psychologic morbidity, such as depression and PTSD, on functional outcome has been recognized only recently. [26,42,43] Our finding of a strong, independent, and prolonged association of postinjury depression with long-term outcome has not been reported previously and lends support to the importance of this observation at the 6-month follow-up. [26] Although a few other studies have noted postinjury depression, these were based on the use of less rigorously defined criteria than the CES-D Scale and must be interpreted with caution. [8,18] Similarly, early onset of IES-I symptoms were significantly associated with functional outcome. This supports observations made recently by Michaels et al. [42] and in the TRP at the 6-month follow-up. [26] Further analyses are under way in the TRP to examine the effect of PTSD on outcome at the later follow-up time points.

The observed significant independent association of serious extremity injuries with functional outcome in the TRP study has been observed previously, and this is the subject of several long-term follow-up reports of lower extremity injury. [12,13,16,17] Severe lower extremity injuries such as open leg fractures were shown to be predominant factors in predicting long-term disability in a study by Seekamp et al. [10] In conjunction with this observation, additional analyses are under way in the TRP to delineate the precise impact of particular extremity injuries on functional outcome.

ICU days were significantly and independently associated with QWB outcome scores at the 12-month and 18-month follow-ups, a result nearly identical to that reported for the 6-month outcome in the TRP. [26] This finding continues to be puzzling, because adjustment for age, ISS, and body region injured did not change the results, and curiously, ICU days were not significantly associated with good or poor recovery. We postulate that these variables are serving as proxy variables for other factors associated with functional outcome, such as surgery, complications, or specific diagnoses, and are conducting new analyses to isolate these factors.

Although the role of social support has been investigated in nearly all published outcome studies, it remains difficult to draw a conclusion regarding its contribution to outcome because of widely different approaches to measurement. The association of decline in the level of social network satisfaction with disability in this study supports that observed at the 6-month follow-up in the TRP [26] and similarly in an earlier study by Anke et al. [11] The relatively weak strength of the association with outcome observed in the TRP, compared with other factors such as depression, may be realistic but also may reflect inadequate assessment of social networks by the Social Support Questionnaire-R in trauma patients. We plan to reexamine our data on social support to clarify these issues.

The issue of possible response bias, i.e., whether there is any difference between patients who were and were not followed at 6 months, was addressed at length in a previous TRP publication. [26] Based on that earlier analysis and because patients followed at 12 and 18 months were largely the same group, we believe that it is unlikely that the major findings were affected by response bias.

This study demonstrates a prolonged and profound level of functional limitation after major trauma at 12-month and 18-month follow-ups. This is the first report of long-term outcome to be based on the QWB Scale, a standardized quality-of-life measure, and provides new and provocative evidence that the magnitude of dysfunction after major injury has been underestimated in previous studies. The elucidation of the important role of depression and other factors such as PTSD and serious extremity injury in determining outcome is a novel finding that will serve to stimulate the development of future studies oriented toward intervention, treatment, and the improvement of outcome. Because major trauma largely affects young to middle-aged healthy individuals, an essential goal of trauma care must be to return trauma survivors to preinjury functional status and active functional roles in society. This effort is central and indeed critical to the continuing evolution and future efficacy of trauma systems. The importance of our findings lies in contributing to a better understanding of the impact and predictors of dysfunction after injury.

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DISCUSSION

Dr. John A. Morris, Jr. (Nashville, Tennessee): Every once in a while, you read a manuscript or listen to a presentation that provides a wake-up call for the entire profession. The manuscript that Dr. Holbrook has submitted is one such jolt. It serves as a scientific reminder that return to productivity, and not survival, should be our ultimate mission.

The Trauma Recovery Project is a large prospective epidemiologic study designed to examine multiple outcomes after major trauma in adults, including quality of life, functional outcome, depression, and posttraumatic stress disorder. The patients' outcomes were assessed at discharge, 6, 12, and 18 months postdischarge.

Over a thousand eligible patients triaged to four participating trauma centers in San Diego were enrolled in the study. Functional outcome after trauma was measured before injury and postinjury using Quality of Well-Being Scale, a recognized index of wellness. And the investigators achieved a remarkable follow-up rate of 79% at 1 year and 74% at 18 months.

The patients had significant but not overwhelming injuries. The mean Injury Severity Score was 13, and the mean length of stay was 7 days. And at 12 months follow-up, there was a disturbingly high level of functional limitation, with only 18% of patients falling in the norm of the healthy population. Postinjury depression, posttraumatic stress disorder, serious extremity injury, and ICU days were all significant independent predictors of quality of life and well-being.

I'd like to make several observations. First, having participated in multi-institutional studies looking at long-term outcome in patients following lower extremity injury, I can tell you that these studies are tremendously time-consuming, expensive, and difficult to perform. And the authors are to be congratulated on their remarkable follow-up rates.

This study begins to apply prospective rigorous scientific technique to a general population of trauma patients and confirms the work of Mackenzie and Jurkovich and Swiontkowski and others who've shown similar limitations in both physical and functional outcome following lower extremity injuries. While the methodology of this paper is complex, using a number of scales to measure both disability and impairment, the outcome measures are reasonable and should serve as standards within our industry.

Finally, the mark of a good study is that it stimulates more questions than it answers. Dr. Holbrook has a career of work ahead of her to answer such questions as the role of preinjury health in determining the degree and prevalence of postinjury depression and posttraumatic stress disorder. One could certainly postulate that alcohol or substance abuse was a significant contributor on the preinjury side of the Equation tothe postinjury psychosocial sequela.

While Dr. Holbrook's work does not identify social support structures as a strong contributor to postinjury disability, others have demonstrated that in patients with lower extremity injury, the social support structure, including family support and socioeconomic factors, have a strong influence on return to work. Clarification of issues surrounding social support have profound health policy implications and should be addressed in future studies.

Dr. Michael L. Hawkins (Augusta, Georgia): I'd like to ask if major pelvic fractures were identified separately or if that was included as an extremity injury?

Dr. Michael H. Thomason (Charlotte, North Carolina): I think I'll ask what Dr. Morris was alluding to. Since I'm not familiar with the QWB, can you tell us, does it in any way tease out the preexisting or preinjury conditions that would help you identify whether this was part of what was going on before the patient was injured or not?

Dr. David A. Spain (Louisville, Kentucky): Since you brought it up, what percentage of your patients were involved in litigation, and did those who were involved have a higher or lower QWB score than patients who weren't? We found this to be a highly common occurrence in patients with extremity injuries to be involved in litigation.

Dr. Janice A. Mendelson (San Antonio, Texas): Have you evaluated the use of physical medicine and rehabilitation techniques in relationship to outcome in these patients? The long-range results can vary depending on factors such as whether these are initiated during the acute phase and whether they include practical occupational therapy. If the hospitals differ in these resources, it would be valuable to compare long-term physical and socioeconomic status of patients with similar injuries.

Dr. David H. Livingston (Newark, New Jersey): Excellent piece of work. From the slides you presented, it looks like you presented mean data. There are obviously patients who did get better and did get worse, and most of them probably stayed somewhat similar. Is there any way to tease out the data and the issues about those patients who actually did get better versus did get worse, compared to the rest, which I imagine is the majority of the patients?

Dr. Gregory J. Jurkovich (Seattle, Washington): Although we have made some strides in injury prevention, we as trauma surgeons remain illness-oriented. We treat disease. And hence, when you hear of a quality-of-life or well-being or outcome assessment, I've often wondered what the status of the patient was before they were injured, and how good we are at getting them back to their preinjury state. After all, that seems to me to be the best that we can accomplish: getting the patient to their preinjury state.

I know this would be extremely difficult, but can you give us some hint as to how we would go about determining what exactly were the ratings or scores in these people before they were injured, and how close we got to them afterwards? And secondly, what is it that we do within our acute care environment that may influence how patients recover? In other words, is there something we do in our acute care hospital environment that influences return to preinjury quality-of-life or well-being scores?

Dr. Jack Bergstein (Peoria, Illinois): Actually, Dr. Jurkovich stole part of my thunder. I rose to ask the same question. QWB is an interesting concept in that we learn that, as "healthy" adults, our average QWB is 80, in other words, we're only about 80% between dead and perfect. The older I get, the happier I am to achieve even 60% on any given day. We also know that trauma patients are different from healthy adults in that they have a higher rate of readmission, reinjury, and a higher rate of risk factors.

And so I think it becomes particularly important to know what the QWB baseline would be for a cohort of trauma patients. It probably is possible to ask trauma patients on their first day of admission what their QWB was for the prior 6 days, since it's a retrospective questioning of them.

But the new question I would like to ask is if any of the patients were readmitted during the study time? Since we know that trauma readmission is a risk that happens in 20% of severely injured patients on follow-up, and it would probably affect their QWB.

Dr. Charles F. Rinker (Bozeman, Montana): I wonder if any of your analysis is directed at the type of cognitive problems seen in patients with so-called minor head injury, and if you'd looked at that particular subset of problems?

Dr. Troy L. Holbrook (closing): Thank you, Dr. Morris, and others for your comments. I will try to address them all in a timely fashion.

With respect to alcohol and substance abuse that Dr. Morris brought up, we are in the process of looking at that with respect to recovery. We do have information about whether it was present before injury, also whether or not alcohol and substance abuse occurred in the postdischarge period throughout the follow-up, and whether or not that influences the level of recovery. And in fact, we hypothesize it quite well may. We should have that data available very soon and hope to publish it.

Likewise, we are a bit surprised that social support was as weak an indicator as it was in our data with respect to outcome. We are reanalyzing our social support data to try to understand better and try to replicate what this group and other groups have shown, meaning that it is important and we would like to understand why the instrument that we used performed so poorly with respect to this. We should have some data on that available soon too.

I do not have the data with me that Dr. Hawkins asked regarding extremity injury, but I can provide that to him later if he's interested.

There was not time in the presentation to emphasize any more than I did how the QWB is done, but there were several questions relating to preinjury conditions. The QWB is a 6-day recall, and it's always, always done that way. In many cases, patients stayed in the hospital less than 6 days, and because we do a 6-day recall, we did have several days of preinjury report, which we are able to assess.

So we know for a substantial portion of our cohort what their QWB scores were before the injury event which put them in the hospital. And interestingly enough, their average score is about 0.810, and what you typically see if you look at day-by-day charting of the QWB is score above 0.9 in a young, healthy adult male. On the injury day, they will drop to 0.38 immediately, and they stay like that usually until after they're out of the hospital.

There was a question about litigation, and I do not have the percentage of patients involved in litigation. I believe it was about 30%. It quite likely does have an impact on recovery, and we are undergoing some analysis to attempt to look at that, especially if litigation has continued throughout the follow-up period.

There was a question from Dr. Mendelson about rehabilitation, and I remember this question from last year as well. We did not have any patients, except one or two, out of this entire cohort that got rehabilitative care. We did ask this explicitly. We asked throughout the follow-up period. And to my knowledge, it was less than 1% of our patients responded that they had occupational or physical therapy. I think that this is a very important question, and I cannot tell you why this is so. But I think the effect of rehabilitation on our outcomes might be quite profound.

With respect again to the QWB, I've already given you some detail about preinjury QWB. Many of these adults had scores close to 1, almost perfect, before injury. And it's quite powerful to see the QWB drop to what it does after the injury event. And we are again doing more analysis on that data and hope to publish it so that we can provide that level of detail to our readers.

Were any patients readmitted? To my knowledge, out of the 1,048 in the study, we didn't have any readmissions. We did have two people who ultimately later in the follow-up period were admitted to nursing homes. They were elderly. I will double-check this and get back to you, but as far as I know, we didn't have any readmissions.

Regarding the question whether we have analysis with cognitive effects that might be important, the QWB includes many questions on its symptom complex that do get at some level of cognitive functioning, and we can analyze the data like that, and in fact I think that would be a very good idea to do that.

And last but not least, there was this issue: could we look at more of a recovery indicator? In the manuscript you will see that I have the capability to classify people into groups of whether or not they achieved their preinjury QWB, and that would be a good recovery group, or whether they never achieved it during the 18-month follow-up. That's quite an interesting analysis because of the power of that preinjury QWB assessment, and we are looking at that as perhaps a more clinically accurate indicator of recovery.

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