Suzanne Polinder

Posttraumatic stress symptoms and health-related quality of life: a two year follow up study of injury treated at the emergency department

BackgroundAmong injury victims relatively high prevalence rates of posttraumatic stress disorder (PTSD) have been found. PTSD is associated with functional impairments and decreased health-related quality of life (HRQoL). Previous studies that addressed the latter were restricted to injuries at the higher end of the severity spectrum. This study examined the association between PTSD symptoms and health-related quality of life (HRQoL) in a comprehensive population of injury patients of all severity levels and external causes.MethodsWe conducted a self-assessment survey which included items regarding demographics of the patient, accident type, sustained injuries, EuroQol health classification system (EQ-5D) and Health Utilities Index (HUI) to measure functional outcome and HRQoL, and the Impact of Event Scale (IES) to measure PTSD symptoms. An IES-score of 35 or higher was used as indication for the presence of PTSD. The survey was completed by 1,781 injury patients two years after they were treated at the Emergency Department (ED), followed by either hospital admission or direct discharge to the home environment.ResultsSymptoms indicative of PTSD were associated with more problems on all EQ-5D and HUI3 domains of functional outcome and a considerable utility loss in both hospitalized (0.23-0.24) and non-hospitalized (0.32-0.33) patients. Differences in reported problems between patients with IES scores higher or lower than 35 were largest for EQ-5D health domains pain/discomfort (82% versus 28%) and anxiety/depression (53% versus 11%) and HUI domains emotion (92% versus 33%) and pain (84% versus 38%). After adjusting for potential confounders, PTSD remained strongly associated with adverse HRQoL.ConclusionsAmong patients treated at an ED posttraumatic stress symptoms indicative of PTSD were associated with a considerable decrease in HRQoL in both hospitalized and non-hospitalized patients. PTSD symptoms may therefore raise a major barrier for full recovery of injury patients of even minor levels of severity.

The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study 2013

Background The Global Burden of Diseases (GBD), Injuries, and Risk Factors study used the disability-adjusted life year (DALY) to quantify the burden of diseases, injuries, and risk factors. This paper provides an overview of injury estimates from the 2013 update of GBD, with detailed information on incidence, mortality, DALYs and rates of change from 1990 to 2013 for 26 causes of injury, globally, by region and by country. Methods Injury mortality was estimated using the extensive GBD mortality database, corrections for ill-defined cause of death and the cause of death ensemble modelling tool. Morbidity estimation was based on inpatient and outpatient data sets, 26 cause-of-injury and 47 nature-of-injury categories, and seven follow-up studies with patient-reported long-term outcome measures. Results In 2013, 973 million (uncertainty interval (UI) 942 to 993) people sustained injuries that warranted some type of healthcare and 4.8 million (UI 4.5 to 5.1) people died from injuries. Between 1990 and 2013 the global age-standardised injury DALY rate decreased by 31% (UI 26% to 35%). The rate of decline in DALY rates was significant for 22 cause-of-injury categories, including all the major injuries. Conclusions Injuries continue to be an important cause of morbidity and mortality in the developed and developing world. The decline in rates for almost all injuries is so prominent that it warrants a general statement that the world is becoming a safer place to live in. However, the patterns vary widely by cause, age, sex, region and time and there are still large improvements that need to be made.

Societal consequences of falls in the older population: injuries, healthcare costs, and long-term reduced quality of life.

BACKGROUND Fall incidents are a major cause of morbidity and mortality in older adults. The aim of this cohort study was to determine the incidence, costs, and quality of life for fall-related injuries in the older Dutch population presenting at the emergency department. METHODS Data on fall-related injuries in persons aged 65 years or older were retrieved from the Dutch Injury Surveillance System, which records injuries treated at the emergency department, and a patient follow-up survey conducted between 2003 and 2007. Injury incidence, discharge rates, healthcare costs, and quality of life measures were calculated. RESULTS Fall-related injuries were to the upper or lower limb in 70% of cases and consisted mainly of fractures (60%), superficial injuries (21%), and open wounds (8%). Falls led to a total healthcare cost of €474.4 million, which represents 21% of total healthcare expenses due to injuries. Both admitted and nonadmitted patients reported a reduced quality of life up to 9 months after the injury. CONCLUSIONS Fall-related injuries in older adults are age and gender related, leading to high healthcare consumption, costs, and long-term reduced quality of life. Further implementation of falls prevention strategies is needed to control the burden of fall-related injuries in the aging population.

Disability weights for the Global Burden of Disease 2013 study

BACKGROUND The Global Burden of Disease (GBD) study assesses health losses from diseases, injuries, and risk factors using disability-adjusted life-years, which need a set of disability weights to quantify health levels associated with non-fatal outcomes. The objective of this study was to estimate disability weights for the GBD 2013 study. METHODS We analysed data from new web-based surveys of participants aged 18-65 years, completed in four European countries (Hungary, Italy, the Netherlands, and Sweden) between Sept 23, 2013, and Nov 11, 2013, combined with data previously collected in the GBD 2010 disability weights measurement study. Surveys used paired comparison questions for which respondents considered two hypothetical individuals with different health states and specified which person they deemed healthier than the other. These surveys covered 183 health states pertinent to GBD 2013; of these states, 30 were presented with descriptions revised from previous versions and 18 were new to GBD 2013. We analysed paired comparison data using probit regression analysis and rescaled results to disability weight units between 0 (no loss of health) and 1 (loss equivalent to death). We compared results with previous estimates, and an additional analysis examined sensitivity of paired comparison responses to duration of hypothetical health states. FINDINGS The total analysis sample consisted of 30 230 respondents from the GBD 2010 surveys and 30 660 from the new European surveys. For health states common to GBD 2010 and GBD 2013, results were highly correlated overall (Pearsons r 0·992 [95% uncertainty interval 0·989-0·994]). For health state descriptions that were revised for this study, resulting disability weights were substantially different for a subset of these weights, including those related to hearing loss (eg, complete hearing loss: GBD 2010 0·033 [0·020-0·052]; GBD 2013 0·215 [0·144-0·307]) and treated spinal cord lesions (below the neck: GBD 2010 0·047 [0·028-0·072]; GBD 2013 0·296 [0·198-0·414]; neck level: GBD 2010 0·369 [0·243-0·513]; GBD 2013 0·589 [0·415-0·748]). Survey responses to paired comparison questions were insensitive to whether the comparisons were framed in terms of temporary or chronic outcomes (Pearsons r 0·981 [0·973-0·987]). INTERPRETATION This study substantially expands the empirical basis for assessment of non-fatal outcomes in the GBD study. Findings from this study substantiate the notion that disability weights are sensitive to particular details in descriptions of health states, but robust to duration of outcomes. FUNDING European Centre for Disease Prevention and Control, Bill and Melinda Gates Foundation.

Epidemiology of traumatic brain injury in Europe

BackgroundTraumatic brain injury (TBI) is a critical public health and socio-economic problem throughout the world, making epidemiological monitoring of incidence, prevalence and outcome of TBI necessary. We aimed to describe the epidemiology of traumatic brain injury in Europe and to evaluate the methodology of incidence studies.MethodWe performed a systematic review and meta-analyses of articles describing the epidemiology of TBI in European countries. A search was conducted in the PubMed electronic database using the terms: epidemiology, incidence, brain injur*, head injur* and Europe. Only articles published in English and reporting on data collected in Europe between 1990 and 2014 were included.ResultsIn total, 28 epidemiological studies on TBI from 16 European countries were identified in the literature. A great variation was found in case definitions and case ascertainment between studies. Falls and road traffic accidents (RTA) were the two most frequent causes of TBI, with falls being reported more frequently than RTA. In most of the studies a peak TBI incidence was seen in the oldest age groups. In the meta-analysis, an overall incidence rate of 262 per 100,000 for admitted TBI was derived.ConclusionsInterpretation of published epidemiologic studies is confounded by differences in inclusion criteria and case ascertainment. Nevertheless, changes in epidemiological patterns are found: falls are now the most common cause of TBI, most notably in elderly patients. Improvement of the quality of standardised data collection for TBI is mandatory for reliable monitoring of epidemiological trends and to inform appropriate targeting of prevention campaigns.

Assessing the burden of injury in six European countries

OBJECTIVE To assess injury-related mortality, disability and disability-adjusted life years (DALYs) in six European countries. METHODS Epidemiological data (hospital discharge registers, emergency department registers, mortality databases) were obtained for Austria, Denmark, Ireland, Netherlands, Norway, and the United Kingdom (England and Wales). For each country, the burden of injury was estimated in years lost due to premature mortality (YLL), years lived with disability (YLD), and DALYs (per 1000 persons). FINDINGS We observed marked differences in the burden of injury between countries. Austria lost the largest number of DALYs (25 per 1000 persons), followed by Denmark, Norway and Ireland (17-20 per 1000 persons). In the Netherlands and United Kingdom, the total burden due to injuries was relatively low (12 per 1000 persons). The variation between countries was attributable to a high variation in premature mortality (YLL varied from 9-17 per 1000 persons) and disability (YLD varied from 2-8 per 1000 persons). In all countries, males aged 25-44 years represented one third of the total injury burden, mainly due to traffic and intentional injuries. Spinal cord injury and skull-brain injury resulted in the highest burden due to permanent disability. CONCLUSION The burden of injury varies considerably among the six participating European countries, but males aged 15-24 years are responsible for a disproportionate share of the assessed burden of injury in all countries. Consistent injury control policy is supported by high-quality summary measures of population health. There is an urgent need for standardized data on the incidence and functional consequences of injury.

Outcome and medical costs of patients with invasive aspergillosis and acute myelogenous leukemia-myelodysplastic syndrome treated with intensive chemotherapy: An observational study

BACKGROUND Invasive aspergillosis (IA) is a leading cause of mortality in patients with acute leukemia. Management of IA is expensive, which makes prevention desirable. Because hospital resources are limited, prevention costs have to be compared with treatment costs and outcome. METHODS In 269 patients treated for acute myelogenous leukemia-myelodysplastic syndrome (AML-MDS) during 2002-2007, evidence of IA was collected using high-resolution computed tomography and galactomannan measurement in bronchoalveolar lavage fluid specimens. IA was classified on the basis of updated European Organization for Research and Treatment of Cancer/Mycoses Study Group definitions. Outcome of infection was registered. Diagnostic and therapeutic IA-related costs, corrected for neutropenia duration, were comprehensively analyzed from a hospital perspective. Voriconazole treatment was given orally from day 1 if possible. RESULTS A total of 80 patients developed IA; 48 (18%) had probable or proven infection, and 32 (12%) had possible IA. Seventy-three patients were treated with voriconazole; 55 (75%) took oral voriconazole from day 1. In patients with IA, the mortality rate 12 weeks after starting antifungal therapy was 22% (16 of 73 patients). The overall mortality rate, registered 12 weeks after neutrophil recovery from the last dose of antileukemic treatment, was 26% in patients with IA versus 16% in patients without IA (P = .08), reflecting an IA-attributable mortality rate of 10%. In a Cox regression analysis, IA was associated with an increased mortality risk (hazard ratio, 2.4; 95% confidence interval, 1.3-4.4). Total IA-related costs increased to euro 8360 and euro 15,280 for patients with possible and probable or proven IA, respectively, compared with patients without IA (P<.001). CONCLUSIONS Early diagnosis and treatment of IA with oral voriconazole result in acceptable mortality rates. Nevertheless, IA continues to have substantial attributable mortality combined with a major impact on hospital resource use, so effective prevention in high-incidence populations has the potential to save lives and costs.

A systematic review of studies measuring health-related quality of life of general injury populations

BackgroundIt is important to obtain greater insight into health-related quality of life (HRQL) of injury patients in order to document peoples pathways to recovery and to quantify the impact of injury on population health over time. We performed a systematic review of studies measuring HRQL in general injury populations with a generic health state measure to summarize existing knowledge.MethodsInjury studies (1995-2009) were identified with main inclusion criteria being the use of a generic health status measure and not being restricted to one specific type of injury. Articles were collated by study design, HRQL instrument used, timing of assessment(s), predictive variables and ability to detect change over time.ResultsForty one studies met inclusion criteria, using 24 different generic HRQL and functional status measures (most used were SF-36, FIM, GOS, EQ-5D). The majority of the studies used a longitudinal design, but with different lengths and timings of follow-up (mostly 6, 12, and 24 months). Different generic health measures were able to discriminate between the health status of subgroups and picked up changes in health status between discharge and 12 month follow-up. Most studies reported high prevalences of health problems within the first year after injury. The twelve studies that reported HRQL utility scores showed considerable but incomplete recovery in the first year after discharge.ConclusionThis systematic review demonstrates large variation in use of HRQL instruments, study populations, and assessment time points used in studies measuring HRQL of general injury populations. This variability impedes comparison of HRQL summary scores between studies and prevented formal meta-analyses aiming to quantify and improve precision of the impact of injury on population health over time.

Prevalence and Prognostic Factors of Disability After Childhood Injury

Objective. To assess the prevalence and the prognostic factors of disabilities after minor and major childhood injuries and to analyze which sociodemographic and injury-related factors are predictive for suboptimal functioning in the long term. Method. We conducted a patient follow-up study in a stratified sample of 1221 injured children who were aged 5 to 14 years and had visited an emergency department in the Netherlands. Our study sample was stratified so that severe, less common injuries were overrepresented. Postal questionnaires were sent 2.5, 5, and 9 months after the injury. We gathered injury and external cause data, sociodemographic information, and data on functional outcome with a generic health status measure EuroQol (EQ-5D) with an additional cognitive dimension. A nonresponse analysis was performed by multivariate logistic regression, and the data were adjusted for nonresponse and the sample stratification. We performed bootstrap analysis to estimate the prevalence of disability in terms of the EQ-5D summary score and the occurrence of limitations in separate health domains: mobility, self-care, usual activities, pain/discomfort, anxiety/depression, and cognition. Respondents also rated their own health state on a visual analog scale, between 0 (worst imaginable health state) and 100 (best imaginable health state). We analyzed the relationship between functional outcome and sociodemographic (age and gender) and injury-related determinants (type of injury, external cause, multiple injury, admission to hospital, and length of stay) by logistic regression analysis. Results. Response rates with respect to the original sample were 43%, 31%, and 30%, respectively. A total of 37% of the children were admitted to the hospital. The mean age of the children was 9.6 years. In two thirds (65%) of the cases, the injury was attributed to a home and/or leisure injury. The health status of injured children improved from 0.92 (EQ-5D summary score) at 2.5 months to 0.96 at 5 months and 0.98 at 9 months. Of all injured children, 26% had at least 1 functional limitation after 2.5 months, 18% after 5 months, and 8% still experienced functional limitations after 9 months. After 2.5 months, lower extremity fractures and other injuries (eg, spinal cord injury, injury of the nerves) demonstrated the worst functional outcome. Independent of the type of injury, our sample of injured children generally showed good recovery between 2.5 and 9 months. The highest prevalence of dysfunction after 9 months existed for pain/discomfort (7%) and usual activities (5%). Hospital admission (odds ratio: 3.6–5.8) and female gender (odds ratio: 3.0) were predictive for long-term disability. Girls reported more problems for all health domains (except self-care) compared with boys after 9 months, which was also confirmed by the visual analog scale score for self-related health (89 for girls vs 95 for boys). Almost one fifth of injured children with a hospital stay of >3 days still had pain and problems with usual activities 9 months after the injury. Three quarters of all residual problems were caused by nonhospitalized injuries. Conclusion. Most children show quick and full recovery after injury, but a small subgroup of patients (8%) have residual disabilities after 9 months. Girls have a 3-fold risk compared with boys for long-term disability after childhood injury. Prognosis in the long-term is also negatively influenced by hospitalization, but in absolute terms, residual disabilities are frequently caused by injuries that are treated fully in the emergency department. The group of injured children with persistent health problems as identified in this study indicates the importance of health monitoring over a longer period in trauma care, whereas trauma care should be targeted at early identification and management of the particular needs of these patients.

Economic impact of hand and wrist injuries: Health-care costs and productivity costs in a population-based study

BACKGROUND Injuries to the hand and wrist account for approximately 20% of patient visits to emergency departments and may impose a large economic burden. The purpose of this study was to estimate the total health-care costs and productivity costs of injuries to the hand and wrist and to compare them with other important injury groups in a nationwide study. METHODS Data were retrieved from the Dutch Injury Surveillance System, from the National Hospital Discharge Registry, and from a patient follow-up survey conducted between 2007 and 2008. Injury incidence, health-care costs, and productivity costs (due to absenteeism) were calculated by age group, sex, and different subgroups of injuries. An incidence-based cost model was used to estimate the health-care costs of injuries. Follow-up data on return to work rates were incorporated into the absenteeism model for estimating the productivity costs. RESULTS Hand and wrist injuries annually account for