Marie-Josée Sirois

Cumulative Incidence of Functional Decline After Minor Injuries in Previously Independent Older Canadian Individuals in the Emergency Department

To estimate the cumulative incidence of functional decline in independent older adults 3 and 6 months after a minor injury treated in the emergency department (ED) and to identify predictors of this functional decline.

Pediatric trauma mortality by type of designated hospital in a mature inclusive trauma system

Background: Previous studies have shown divergent results regarding the survival of injured children treated at pediatric trauma centers (PTC) and adult trauma centers (ATC). Aims: (1) To document, in a regionalized inclusive trauma system, at which level of trauma centers were the injured children treated and (2) to compare the in-hospital mortality over five levels of trauma care, ranging from pediatric level I trauma centers (PTC) to designated local trauma hospitals (level IV) for the whole study sample and for subgroups of severely injured children and head trauma. Materials and Methods: A retrospective analysis included data on 11,053 injured children (age ≤16 years) treated between April 1998 and March 2005 in 58 designated trauma hospitals in the province of Quebec, Canada. Multiple imputation was used to handle missing physiological data and multivariate logistic regression was used to compare mortality over levels of care. Results: PTC treated 52.2% of the children. Children treated at PTC were more often transferred from another hospital (73%) and were more severely injured. ATC level I, II, III and IV centers treated, respectively, 3.0%, 16.2%, 24.3% and 4.3% of children. Compared with children treated at a PTC, the risk of mortality was higher for children treated at each other ATC, i.e. level I (adjusted odds ratio [OR] = 3.1; 95% confidence interval [CI]: 1.3–7.5), level II (OR = 2.5; 95% CI: 1.3–5.0), level III (OR = 5.2; 95% CI: 2.1–13.1) and level IV (OR = 9.9; 95% CI: 2.4–41.3). Similar findings were observed among the subsamples of children who were more severely injured (Injury Severity Score >15) and who sustained head injuries. Conclusions: In our trauma system, PTC cared for more than half of the injured children and patients treated there have better survival than those treated at all other levels of ATC.

Trauma centre outcome performance: A comparison of young adults and geriatric patients in an inclusive trauma system

BACKGROUND Elderly trauma patients represent a unique clientele requiring specialised care but they rarely benefit from standardised care strategies within trauma systems. We aimed to evaluate whether trauma centres with lower/higher than expected mortality amongst patients <65 years of age have similar results for geriatric patients. A secondary objective was to compare transfer to level I/II trauma centres across age groups. METHODS The study was based on data from a Canadian provincial trauma registry (1999-2006). Outcome performance was evaluated with estimates of risk-adjusted 30-day mortality generated for each of the systems 57 adult trauma centres. Agreement in performance results was evaluated with correlation coefficients. RESULTS The study sample comprised 55,283 young adults (3.5% mortality) and 30,960 geriatric patients (8.2% mortality). The two age groups only had one out of six outliers in common. Hospital ranks amongst young adults were not correlated to those assigned amongst geriatric patients (r = 0.01, 95%CI -0.25;0.27). Correlation was also low for patients with major trauma (r = 0.20, 95%CI -0.06;0.44). Amongst patients with severe head injuries initially received in a level III/IV centre, 81% of young adults versus 71% of geriatric patients were transferred to a level I/II centre (p<0.0001). CONCLUSIONS Trauma centres that have low risk-adjusted mortality for young adults do not necessarily do so for geriatric patients. In addition, geriatric patients with severe head injuries are less likely to be treated in neurosurgical trauma centres. Further research is needed to identify determinants of inter-hospital variation in outcome for geriatric trauma patients.

Decline in activities of daily living after a visit to a Canadian emergency department for minor injuries in independent older adults: are frail older adults with cognitive impairment at greater risk?

To compare functional decline in activities of daily living (ADLs) of older adults visiting emergency departments (EDs) for minor injuries according to frailty and cognitive status.

Measuring Frailty Can Help Emergency Departments Identify Independent Seniors at Risk of Functional Decline After Minor Injuries

Background. This study aims to (i) describe frailty in the subgroup of independent community-dwelling seniors consulting emergency departments (EDs) for minor injuries, (ii) examine the association between frailty and functional decline 3 months postinjury, (iii) ascertain the predictive accuracy of frailty measures and emergency physicians’ for functional decline. Method. Prospective cohort in 2011–2013 among 1,072 seniors aged 65 years or older, independent in basic daily activities, evaluated in Canadian EDs for minor injuries. Frailty was assessed at EDs using the Canadian Study of Health and Aging-Clinical Frailty scale (CSHA-CFS) and the Study of Osteoporotic Fracture frailty index (SOF). Functional decline was defined as a loss ≥2/28 on the Older American Resources Services scale 3 months postinjury. Generalized mixed models were used to explore differences in functional decline across frailty levels. Areas under the receiver operating characteristic curve were used to ascertain the predictive accuracy of frailty measures and emergency physicians’ clinical judgment. Results. The SOF and CSHA-CFS were available in 342 and 1,058 participants, respectively. The SOF identified 55.6%, 32.7%, 11.7% patients as robust, prefrail, and frail. These CSHA-CFS (n = 1,058) proportions were 51.9%, 38.3%, and 9.9%. The 3-month incidence of functional decline was 12.1% (10.0%−14.6%). The Areas under the receiver operating characteristic curves of the CSHA-CFS and the emergency physicians’ were similar (0.548–0.777), while the SOF was somewhat higher (0.704–0.859). Conclusion. Measuring frailty in community-dwelling seniors with minor injuries in EDs may enhance current risk screening for functional decline. However, before implementation in usual care, feasibility issues such as inter-rater reliability and acceptability of frailty tools in the EDs have to be addressed.

A comparison of methods to obtain a composite performance indicator for evaluating clinical processes in trauma care.

BACKGROUND: Process performance indicators that evaluate trauma centers in clinical case management provide information essential to the improvement of trauma care. However, multiple indicators are needed to adequately evaluate process performance, which renders comparisons cumbersome. Several methods are available for generating composite indicators that measure global performance. The goal of this study was to compare three composite methods that are widely used in other health care domains to identify the most appropriate for trauma care process performance evaluation. METHODS: In this retrospective, multicenter cohort study, 15 process performance indicators were implemented using data from a Canadian provincial trauma registry (19,853 patients; 59 centers) on patients with an Injury Severity Score (ISS) greater than 15. Composite scores were derived using three methods as follows: the indicator average, the opportunity model, and a latent variable model. Composite scores were evaluated in terms of discrimination, construct validity (association with an indicator of trauma center structural performance), criterion predictive validity (association with clinical outcomes), and forecasting (correlation over time). RESULTS: All composite scores discriminated well between trauma centers. Only the average indicator score was correlated with improved structure (r = 0.29; 95% confidence interval [CI], 0.07–0.53), lower risk‐adjusted mortality (r = ‐0.22; 95% CI, ‐0.46 to 0.04), and lower risk‐adjusted complication rate (r = ‐0.48; 95% CI, ‐0.65 to ‐0.25). Composite scores calculated with 1999 to 2002 data all correlated with those calculated with 2003 to 2006 data (r = 0.49, 0.87, and 0.84 for the indicator average, the opportunity model, and the latent variable model, respectively). CONCLUSION: Results suggest that of the three composite scores evaluated, only the indicator average demonstrates content and predictive criterion validity, discriminates between centers, and has good forecasting properties. In addition, this score is simple and intuitive and not subject to variation in weights over trauma systems and time. The observed association between higher indicator average scores and lower risk‐adjusted mortality and complication rates suggests that improving process performance may improve patient outcome. LEVEL OF EVIDENCE: Epidemiologic and prognostic study, level III.

Long-term functional outcome of older adults after a traumatic brain injury.

Purpose:To identify factors associated with long-term independence in mobility and self-care activities of daily living of older adults after traumatic brain injury (TBI). Participants:One hundred thirty-six TBI survivors 55 years or older were assessed 2 to 4 years postinjury (mean of 3.2 years). Setting:Level I or level II trauma centers in Quebec, Canada. Main measures:Personal, injury-related, and environmental factors were gathered from hospital records or by telephone interview; a telephone version of the Functional Independence Measure motor scale was collapsed to 4 levels. Analysis:Logistic regression analyses identified factors associated with independence in mobility and self-care. Results:The strongest and most consistent factors associated with independence in mobility and self-care were fewer comorbid conditions, no difficulty of access to home modification services and home support services, male gender, younger age at time of injury, and shorter acute care length of stay. Conclusion:Factors associated with long-term functional outcome should be considered in the development of practice guidelines for rehabilitation of older adults who sustained a TBI.

Is Cognitive Function a Concern in Independent Elderly Adults Discharged Home from the Emergency Department in Canada After a Minor Injury

To describe the cognitive functioning of independent community‐dwelling elderly adults visiting the emergency department (ED) for minor injuries and at 3‐ and 6‐month follow‐up assessments and to document the occurrence of falls, return to the ED, and hospital visits over time according to cognitive level.

Perceived mental health and needs for mental health services following trauma with and without brain injury.

OBJECTIVES To compare self-reported mental health in trauma survivors with and without brain injury; to describe factors associated with lower mental health; and to compare needs in terms of mental health services and perceived access limitations to such services. DESIGN Cross-sectional community survey. PATIENTS A total of 405 trauma survivors (239 with traumatic brain injury and 166 without) interviewed 2-4 years post-injury. METHODS Short Form-12 mental health scales and a survey measuring perceived needs for mental health services, and access limitations. RESULTS Injury survivors with and without traumatic brain injury are similarly affected on subjective reports of global mental health, vitality, role changes, and social functioning except for cognitive complaints. Variables associated with lower mental health in trauma survivors include younger age, being a woman, shorter time since injury, higher pain, lower social support, and presence of cognitive problems. Although individuals with traumatic brain injury report slightly more mental health problems and more need for mental health services, proportionally to their needs, more individuals without traumatic brain injury report access limitations to mental health services. CONCLUSION Mental health problems affect important proportions of trauma survivors, either with or without traumatic brain injury. More effort should be made to facilitate access to mental health services for all trauma survivors.

National survey of physicians to determine the effect of unconditional incentives on response rates of physician postal surveys

Objectives Physicians are a commonly targeted group in health research surveys, but their response rates are often relatively low. The goal of this paper was to evaluate the effect of unconditional incentives in the form of a coffee card on physician postal survey response rates. Design Following 13 key informant interviews and eight cognitive interviews a survey questionnaire was developed. Participants A random sample of 534 physicians, stratified by physician group (geriatricians, family physicians, emergency physicians) was selected from a national medical directory. Setting Using computer generated random numbers; half of the physicians in each stratum were allocated to receive a coffee card to a popular national coffee chain together with the first survey mailout. Interventions The intervention was a