Pam Simpson

Improved functional outcomes for major trauma patients in a regionalized, inclusive trauma system.

Objective:To describe outcomes of major trauma survivors managed in an organized trauma system, including the association between levels of care and outcomes over time. Background:Trauma care systems aim to reduce deaths and disability. Studies have found that regionalization of trauma care reduces mortality but the impact on quality of survival is unknown. Evaluation of a trauma system should include mortality and morbidity. Methods:Predictors of 12-month functional (Glasgow Outcome Scale—Extended) outcomes after blunt major trauma (Injury Severity Score >15) in an organized trauma system were explored using ordered logistic regression for the period October 2006 to June 2009. Data from the population-based Victorian State Trauma Registry were used. Results:There were 4986 patients older than 18 years. In-hospital mortality decreased from 11.9% in 2006–2007 to 9.9% in 2008–2009. The follow-up rate at 12 months was 86% (n = 3824). Eighty percent reported functional limitations. Odds of better functional outcome increased in the 2007–2008 [adjusted odds ratio (AOR): 1.22; 95% CI: 1.05, 1.41] and 2008–2009 (AOR: 1.16; 95% CI: 1.01, 1.34) years compared with 2006–2007. Cases managed at major trauma services (MTS) achieved better functional outcome (AOR: 1.22; 95% CI: 1.03, 1.45). Female gender, older age, and lower levels of education demonstrated lower adjusted odds of better outcome. Conclusions:Despite an annual decline in mortality, risk-adjusted functional outcomes improved over time, and cases managed at MTS (level-1 trauma centers) demonstrated better functional outcomes. The findings provide early evidence that this inclusive, regionalized trauma system is achieving its aims.

A classification system for hip disease in cerebral palsy

In population‐based studies, hip displacement affects approximately one‐third of children with cerebral palsy (CP). Given the extreme range of clinical phenotypes in the CP spectrum, it is unsurprising that hip development varies from normality, to dislocation and degenerative arthritis. Numerous radiological indices are available to measure hip displacement in children with CP; however, there is no grading system for assessing hip status in broad categorical terms. This makes it difficult to audit the incidence of hip displacement, determine the relationship between hip displacement and CP subtypes, assess the outcome of intervention studies, and to communicate hip status between health care professionals. We developed a categorical, radiographic classification of hip morphology based on qualitative indices and measurement of the key continuous variable, the migration percentage of Reimers. One hundred and thirty‐four radiographs were reviewed of 52 female and 82 male adolescents with CP who were at, or close to, skeletal maturity (mean age 16y 1mo [SD 1y 4mo] range 14y to 19y 1mo). Twenty‐nine were classified at Gross Motor Function Classification System level I, 25 at level II, 27 at level III, 24 at level IV, and 29 at level V. A classification system was developed to encapsulate the full spectrum of hip morphology in CP, with and without intervention.

Predictors of mortality, length of stay and discharge destination in blunt trauma

Background:u2003 The present study explored a range of variables to identify predictors of mortality and morbidity and to develop prediction models based on these variables.

Functional and health-related quality of life outcomes after pediatric trauma.

BACKGROUNDnPediatric trauma results in lower mortality than adults and a high potential for lifelong functional impairment and reduced health-related quality of life (HRQL). There is no consensus regarding the best approach to measuring outcomes in this group.nnnMETHODSnOne hundred and fifty injured children admitted to a pediatric trauma center participated in this study. The Pediatric Quality of Life Inventory (PedsQL), Child Health Questionnaire (CHQ-PF28), Kings Outcome Scale for Childhood Head Injury (KOSCHI), modified Glasgow Outcome Scale (mGOS), and the Functional Independence Measure (FIM) were administered at 1 month, 6 months, and 12 months after injury by telephone. Change in instrument scores was assessed using multilevel mixed effects models. Mean HRQL scores were compared with population norms for the CHQ-PF28 and with healthy children for the PedsQL.nnnRESULTSnFollow-up at all time points was completed for 144 (96%) cases. The median injury severity score was 10, and 65% of the patients enrolled were men. At 12 months, the percentage of cases with ongoing disability was 14% for the FIM, 61% using the mGOS, and 58% for the KOSCHI. CHQ-PF28 physical and PedsQL psychosocial health scores were below healthy child norms at 12 months. Improvement across all time points was demonstrated for the KOSCHI, mGOS, CHQ-PF28 physical, and PedsQL psychosocial summary scores.nnnCONCLUSIONSnSeriously injured children showed ongoing disability and reduced HRQL 12 months after injury. The CHQ-PF28 and PedsQL, and the mGOS and KOSCHI, performed comparably. The FIM demonstrated considerable ceiling effects, and improvement over time was not shown. The results inform the methodology of pediatric outcomes studies and protocol development for the routine follow-up of pediatric trauma patients.

Evaluating Time Points for Measuring Recovery After Major Trauma in Adults

Objective:To evaluate recovery after major trauma over a 24-month time frame. Background:Measuring disability after injury is seen as increasingly important but requires knowledge not only of the measures that should be implemented but also of the critical time points for follow-up. Methods:Six hundred sixty-two adult major trauma patients from 2 level 1 trauma centers (October 2006 to March 2007) were followed up by telephone at 6-, 12-, 18-, and 24 months after injury. SF-12, Glasgow Outcome Scale-Extended (GOS-E), pain scores, and return to work (RTW) were collected. Multilevel mixed-effects regression models were fitted to analyze change in outcomes over time. Results:Six hundred seventeen (93%) were followed up for at least 1 time point. Functional recovery (GOS-E = 8) [odds ratio (OR) 3.1, 95% CI: 1.9, 5.0] and RTW (OR 2.4, 95% CI: 1.4, 4.0) improved, and physical health (PCS-12) scores were better (mean difference 1.9, 95% CI: 0.9, 2.9), from 6 to 12 months after injury, but changed little from 12 months. Pain scores were unchanged from 6 to 12 months but were higher at 18 months than at 12 months (OR 1.8, 95% CI: 1.2, 2.8). SF-12 mental health (MCS-12) scores decreased until 18 months but improved from 18 to 24 months (mean difference 1.5, 95% CI: 0.2, 2.8). The rate of recovery differed by injury group and age. Conclusions:Different patterns of recovery were evident for each outcome, and there was a variation in the rate of recovery for some subgroups. The selection of time points for follow-up requires consideration of the outcome measurements of interest and the population being studied.

Agreement between parent and child report of health-related quality of life: impact of time postinjury.

BACKGROUNDnHealth-related quality of life (HRQL) is subjective concept and, therefore, should be captured directly from the patient. However, proxy reporting of HRQL is widespread, particularly in pediatric studies where children have been considered unreliable respondents. This study assessed the level of agreement between proxy (parent) and child reports of HRQL at key time points after injury.nnnMETHODSnThirty-seven seriously injured children aged 13 years to 16 years participated in this study. The Pediatric Quality of Life inventory was administered to the parent and child at 1 month, 6 months, and 12 months after injury by telephone interview. Agreement between child and parent responses was compared using Bland-Altman plots, and Pediatric Quality of Life inventory physical and psychosocial summary scales were compared using paired t tests or Wilcoxon signed-rank tests, respectively.nnnRESULTSnAt 1-month (psychosocial t = -4.6, p < 0.001; physical t = -6.5 p < 0.001) and 6-month (psychosocial z = -2.5, p = 0.01; physical z = -2.6, p = 0.01) postinjury there was a significant difference between the parent and child reports, with children rating their HRQL higher than their parents. At 12-months, there was no difference between the scores reported by parents and their children (psychosocial z = -0.3, p = 0.76; physical t = -0.7, p = 0.51).nnnCONCLUSIONSnAgreement between parent and child ratings of HRQL improved with time postinjury. The findings have implications for the design of pediatric trauma outcomes studies and the routine collection of pediatric HRQL data. Parent and child reports should be considered separate but important information, particularly in the early stages following injury. Where collection of both is not feasible, parent or child report should be chosen, and interchangeable use of parent and child reports limited.

Injection frequency of botulinum toxin A for spastic equinus: a randomized clinical trial.

We compared two botulinum toxin A (BoNT‐A) injection frequency regimens, 12‐monthly versus 4‐monthly, for spastic equinus in a randomized clinical trial. The primary outcome measure was passive ankle dorsiflexion.

Effect of spirometry and medical review on asthma control in patients in general practice: A randomized controlled trial

Background and objective:u2003 Although guidelines for asthma emphasize the importance of spirometry for continuity and evaluation of care, it is underused in general practice. The objective of this study was to investigate the effect of spirometry and medical review on asthma control in general practice over 12u2003months.

Long-term health status and trajectories of seriously injured patients: a population-based longitudinal study

Background Improved understanding of the quality of survival of patients is crucial in evaluating trauma care, understanding recovery patterns and timeframes, and informing healthcare, social, and disability service provision. We aimed to describe the longer-term health status of seriously injured patients, identify predictors of outcome, and establish recovery trajectories by population characteristics. Methods and findings A population-based, prospective cohort study using the Victorian State Trauma Registry (VSTR) was undertaken. We followed up 2,757 adult patients, injured between July 2011 and June 2012, through deaths registry linkage and telephone interview at 6-, 12-, 24-, and 36-months postinjury. The 3-level EuroQol 5 dimensions questionnaire (EQ-5D-3L) was collected, and mixed-effects regression modelling was used to identify predictors of outcome, and recovery trajectories, for the EQ-5D-3L items and summary score. Mean (SD) age of participants was 50.8 (21.6) years, and 72% were male. Twelve percent (n = 333) died during their hospital stay, 8.1% (n = 222) of patients died postdischarge, and 155 (7.0%) were known to have survived to 36-months postinjury but were lost to follow-up at all time points. The prevalence of reporting problems at 36-months postinjury was 37% for mobility, 21% for self-care, 47% for usual activities, 50% for pain/discomfort, and 41% for anxiety/depression. Continued improvement to 36-months postinjury was only present for the usual activities item; the adjusted relative risk (ARR) of reporting problems decreased from 6 to 12 (ARR 0.87, 95% CI: 0.83–0.90), 12 to 24 (ARR 0.94, 95% CI: 0.90–0.98), and 24 to 36 months (ARR 0.95, 95% CI: 0.95–0.99). The risk of reporting problems with pain or discomfort increased from 24- to 36-months postinjury (ARR 1.06, 95% CI: 1.01, 1.12). While loss to follow-up was low, there was responder bias with patients injured in intentional events, younger, and less seriously injured patients less likely to participate; therefore, these patient subgroups were underrepresented in the study findings. Conclusions The prevalence of ongoing problems at 3-years postinjury is high, confirming that serious injury is frequently a chronic disorder. These findings have implications for trauma system design. Investment in interventions to reduce the longer-term impact of injuries is needed, and greater investment in primary prevention is needed.

Spirometry and regular follow-up do not improve quality of life in children or adolescents with asthma: cluster randomized controlled trials

To determine whether spirometry and regular medical review improved quality of life or other outcomes in children and adolescents with asthma.