William J. Sieber

Outcome after major trauma: 12-month and 18-month follow-up results from the Trauma Recovery Project

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.

A prospective study of stress among women undergoing in vitro fertilization or gamete intrafallopian transfer

OBJECTIVE To evaluate whether baseline or procedural stress during in vitro fertilization (IVF) or gamete intrafallopian transfer (GIFT) affects pregnancy or live birth delivery rates. DESIGN Prospective study. SETTING Seven clinics in Southern California between 1993 and 1998. PATIENT(S) One hundred and fifty-one women completed two questionnaires. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) The number of oocytes aspirated and fertilized, the number of embryos transferred, the achievement of a pregnancy, live birth delivery, and infant outcomes. RESULT(S) Positive-affect negative-affect score at baseline negatively influenced the number of oocytes retrieved and embryos transferred. A higher expectation of pregnancy was associated with greater numbers of oocytes fertilized and embryos transferred. At baseline, the risk of no live birth was 93% lower for women who had the highest positive-affect score compared to those with the lowest score. Furthermore, the score on the Infertility Reaction Scale was related to negative outcomes in live birth delivery, infant birth weight, and multiple births. During the time of the procedure, the PANAS and Bipolar Profile of Moods States results were related to the number of oocytes fertilized and embryos transferred; stress did not affect pregnancy or delivery. CONCLUSION(S) Baseline (acute and chronic) stress affected biologic end points (i.e., number of oocytes retrieved and fertilized), as well as pregnancy, live birth delivery, birth weight, and multiple gestations, whereas (procedural) stress only influenced biologic end points.

Outcome after major trauma: discharge and 6-month follow-up results from the Trauma Recovery Project

BACKGROUND The study of both short-term and long-term outcomes after major trauma has become an increasingly important focus of injury research because of the improved survival rates attributable to the evolution of sophisticated trauma care systems. 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 discharge and 6-month follow-up time points 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, a more sensitive index to the well end of the functioning continuum (range, 0 = death to 1.000 = optimum functioning). Functional outcome was also measured using a standard activities of daily living (ADL) scale (range, 13 = full function to 47 = maximum dysfunction). Follow-up at 6 months after discharge was completed for 826 patients (79%). RESULTS The mean age was 36 +/- 14.8 years; 70% of the patients were male; 52% of the patients were white, 30% were Hispanic, and 18% were black or other. Less than 40% of study participants were married or living with a partner. 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). After major trauma, QWB scores at discharge showed a significant degree of functional limitation (mean, 0.401 +/- 0.045). At 6-month follow-up, QWB scores continued to show high levels of functional limitation (mean, 0.633 +/- 0.122). Limitation measured using the standard ADL scale found only moderate dysfunction at discharge (mean, 30.0 +/- 7.7) and at 6-month follow-up (mean, 15.0 +/- 4.2). Postinjury depression, PTSD, serious extremity injury, and length of stay were significant independent predictors of 6-month QWB outcome. CONCLUSION Postinjury functional limitation is a clinically significant complication in trauma patients at discharge and a 6-month follow-up. The QWB yields a more sensitive assessment of functional status than traditional ADL instruments. Postinjury depression, PTSD, serious extremity injury, and length of stay are significantly associated with 6-month QWB outcome.

Perceived threat to life predicts posttraumatic stress disorder after major trauma: risk factors and functional outcome.

BACKGROUND The importance of psychological morbidity after major trauma, such as posttraumatic stress disorder (PTSD), is continuing to gain attention in trauma outcomes research. The Trauma Recovery Project is a large prospective epidemiologic study designed to examine multiple outcomes after major trauma, including quality of life (QoL) and PTSD. The specific objectives of the present report are to examine risk factors for PTSD and to assess the impact on QoL at the 6-, 12-, and 18-month follow-up time points in the Trauma Recovery Project population. 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 study. The enrollment criteria for the study included age 18 years and older, admission Glasgow Coma Scale score of 12 or greater, and length of stay > 24 hours. QoL was measured after injury using the Quality of Well-being scale, a sensitive index to the well end of the functioning continuum (range, 0 = death to 1.000 = optimum functioning). Early symptoms of acute stress reaction (SASR) at discharge were assessed using the Impact of Events Scale (score > 30 = SASR). PTSD at 6-month follow-up was diagnosed using standardized Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, criteria. Patient outcomes were assessed at discharge and at 6, 12, and 18 months after discharge. RESULTS PTSD was diagnosed in 32% (261 of 824) patients at 6-month follow-up. Perceived threat to life predicted PTSD onset (odds ratio [OR], 1.6; p < 0.01) and early SASR (OR, 2.2; p < 0.001). PTSD was more frequent in women (39%) than in men (29%) and in younger low-income patients. Other major risk factors were penetrating trauma (OR, 2.3; p < 0.001) and assaults (OR, 1.5; p < 0.05). PTSD had a major impact on QoL at 6-, 12-, and 18-month follow-up (Quality of Well-being scale score: 6 months, 0.576 vs. 0.658; 12 months, 0.620 vs. 0.691; 18 months, 0.620 vs. 0.700; p < 0.0001). CONCLUSION These results provide new and provocative evidence that perceived threat to life and mechanism predict PTSD after major traumatic injury. PTSD had a prolonged and profound impact on short- and long-term outcome and QoL.

The quality of well-being scale: Comparison of the interviewer-administered version with a self-administered questionnaire

Abstract The Quality of Well-being Scale (QWB) is a general measure of health-related quality of life that has been used in a wide variety of population and clinical studies. One of the major disadvantages of the QWB is that it requires a trained interviewer. Recently, a self-administered version of the QWB was developed. The purpose of this study was to compare the self-administered QWB with the established interviewer-administered form. The respondents were 218 English speaking adults who attended primary care clinics. Each respondent was evaluated twice with an interval of one month in-between. At each session respondents were randomly assigned to complete either the interviewer-administered or self-administered QWB, resulting in a 2 × 2 factorial design. Data from the study demonstrated that the self-administered QWB yields scores equivalent to the interviewer-administered form. Further, QWB scores remain stable over the course of a one month interval. The results suggest that an inexpensive self-admi...

Mental health treatment preferences of older and younger primary care patients

Objective: To compare mental health treatment history and preferences in older and younger primary care patients. Method: We surveyed 77 older (60+) and 312 younger adult primary care patients from four outpatient medical clinics about their mental health treatment history and preferences. Results: Older adults were less likely than younger adults to report a history of mental health treatment (29% vs. 51%) or to be currently receiving treatment (11% vs. 23%). They were also less likely to indicate that they currently desire help with emotional problems (25% vs. 50%). Older adults were more likely to hold a belief in self-reliance that could limit their willingness to accept treatment for mental health problems, although they were less likely than younger adults to identify other barriers to treatment. Older adults reported that they were less likely to attend programs in primary care targeting mental health issues (counseling, stress management) than younger adults, although they were as willing as younger adults to attend programs targeting physical health issues (healthy living class, fitness program). Age remained a significant predictor of mental health treatment history and preferences even after controlling for other demographic variables. Conclusion: These results suggest that older adults in the primary care setting may be less willing to accept mental health services than younger adults. Results further suggest that perceived barriers may differ for older and younger patients, which may indicate the need for age-specific educational messages and services targeted to older adults in primary care.

Use of the quality of well-being self-administered version (QWB-SA) in assessing health-related quality of life in depressed patients.

BACKGROUND This study evaluated the cross-sectional and longitudinal relationship between depression severity and the Quality of Well-Being scale self-administered version (QWB-SA) in subjects diagnosed with current major depression. METHODS The research design was prospective and observational. Data were collected on a convenience sample of 58 subjects. Additional measures included the Quality of Well-Being scale interviewer-version (interviewer-QWB), Hamilton Rating Scale for Depression (HRSD-17), Beck Depression Inventory, and each were collected at baseline, 4 weeks, and 4 months postmedication treatment. RESULTS Cross-sectional and longitudinal QWB-SA scores were significantly correlated with depression severity and the interviewer-QWB. Treatment response, defined as 50% improvement in HRSD-17, was associated with 0.10 and 0.16 unit changes in the QWB-SA at 4 weeks and 4 months, respectively. The QWB-SA was significantly and negatively correlated with cross-sectional and longitudinal depression severity. LIMITATIONS The study design was observational and used a convenience sample of subjects. CONCLUSIONS The QWB-SA is less expensive to administer than the interviewer-QWB and is a useful alternative for determining the effectiveness and cost-effectiveness of treatments for depression relative to other physical and mental illness treatments.

Assessing the Impact of Migraine on Health-Related Quality of Life: An Additional Use of the Quality of Well-being Scale-Self-administered

Objectives.—To compare the interviewer‐administered Quality of Well‐being Scale (QWB) with a self‐administered form (QWB‐SA) for patients with migraine, and to compare the health status of migraineurs to other medical populations.

Spousal perpetuation of chronic pain behavior

The literature reviewed here demonstrates that spousal response to pain display can reinforce and thereby perpetuate the patients pain behavior. Relationships characterized as “sick-role homeostatis” reflect a nexus of behavioral contingencies which are highly resistant to treatment. Though such relationships could developde novo subsequent to accident or injury, modeling and familial effects in chronic pain suggest a rich personal and family history of chronic pain learning experiences. Spousal reinforcement of pain behavior is greater in satisfied relationships and tends to involve contingent attention and caring rather than assistance or taking over tasks and chores. As the vast majority of pain patients and spouses report being satisfied with their marriages, spousal involvement in chronic pain treatment is critical.

Are patients' initial experiences at the diagnosis of type 2 diabetes associated with attitudes and self-management over time?

Objective The purpose of this study was to investigate patients’ experiences when diagnosed with type 2 diabetes and diabetes-related distress and self-management years later. Method One hundred seventy-nine adults with type 2 diabetes, 1 to 5 years after diagnosis, completed a questionnaire assessing what they were told and what was recommended at diagnosis as well as current diet, physical activity, and diabetes distress. Results Most patients (60%) expressed confidence in their health care provider (HCP) at diagnosis, but 30% reported that a clear action plan was not communicated. Current diabetes distress was significantly lower among those who reported being reassured at diagnosis that diabetes could be managed successfully and had developed a clearer action plan with their HCP. Patients’ current dietary behaviors were significantly better among those receiving a clearer action plan at diagnosis. Conclusion Patients’ retrospective reports of reassuring HCP messages when diagnosed, along with the presentation of a clear action plan, are associated with less diabetes distress and better self-management at 1 to 5 years after diagnosis. Practical implications Findings suggest a long-lasting impact on patients’ attitudes and behaviors when the diagnosis of type 2 diabetes is delivered clearly, a sense of hope is provided, and a specific care plan is put forward.