Treatment of Patients With Severe Burns—Costs and Health-Related Quality of Life Outcome:

Recovery in patients undergoing ablative fractional carbon dioxide laser for adult hypertrophic burn scars: A longitudinal cohort study

INTRODUCTION

Ablative fractional carbon dioxide laser (AFCO2L) is widely used as a treatment for hypertrophic burn scars. This study aimed to evaluate clinician and patient-reported outcomes after AFCO2L treatment, safety, and identify factors influencing outcomes.

METHODS

This longitudinal study recruited adult patients with hypertrophic burn scars treated with AFCO2L at a single Australian burn unit. Patients received up to four AFCO2L treatments over approximately 12 months. Outcomes were ultrasound scar thickness, the Patient and Observer Scar Assessment Scale (POSAS), and the Brisbane Burn Scar Impact Scale (BBSIP), measured at baseline and 3, 6, and 12 months after the first AFCO2L treatment. Analysis used mixed effects linear models.

RESULTS

47 patients were included with median age 32 years (IQR: 24, 53) and median burn TBSA of 35 % (IQR: 7.5 %, 48 %). Statistically significant improvements between baseline and 12-month follow-up occurred in scar thickness, and all POSAS and BBSIP subscores. Most improvements remained when accounting for TBSA, Fitzpatrick skin type, scar maturity, and body area treated. Patients reported transient symptoms after 61 of 89 (69 %) AFCO2L treatments, but infection or delayed wound healing occurred after only 4 of 89 (4 %) treatments.

CONCLUSION

This study supports safety and improved clinician and patient-reported outcomes in patients undergoing AFCO2L for hypertrophic burn scars.

The impact of an open-label design on human amniotic membranes vs. silver sulfadiazine dressings for second-degree burns: a randomized controlled clinical trial

BACKGROUND

Burn wounds require optimal medical management due to associated psycho-emotional and socioeconomic impacts and severe pain. The use of synthetic and biological dressings improves healing and reduces burn wound complications. The present study aimed to compare the outcomes of using human amniotic membrane (hAM) dressings and conventional silver sulfadiazine (SSDZ) ointment dressings in the management of second-degree burn wounds.

METHODS

Fifty patients who participated in this clinical trial were divided into two groups via simple randomization. All the enrolled patients, who had burnt in the last 24 h, had thermal damage mechanisms and were suffering from less than 20% second-degree heat-burn wounds on the skin surface. The target group (n = 25) was treated with hAM, and the control group (n = 25) was treated with SSDZ ointment. The researcher-designed checklist was used to determine the clinical performance in the follow-up assessments on days 7, 14, and 30.

RESULTS

No significant differences were detected in terms of sex, age, or percentage of burn wounds (p > 0.05). Wound epithelialization at days 7, 14, and 30, scar formation, wound pigmentation, pain severity, analgesia requirements, and hospital stay length (on day 30) were significantly lower in the target group (treated with hAM) than in the control group (treated with SSDZ ointment) (p < 0.05). However, treatment costs in the target group ($170) were significantly higher than those in the control group ($71) (p < 0.001).

CONCLUSION

Despite its higher cost, hAM, as a technology-based therapy dressing, demonstrates superiority over SSDZ ointment in terms of wound healing and pain management.

Recovery of functional independence following major burn: A systematic review

BACKGROUND

Major burn injury, despite advancements in care and prevention, can have a profound impact on long-term morbidity, affecting quality of life and socioeconomic standing. We aim to explore factors predicting recovery of independence, the expected rate and time in majorly burned patients, and the measures of progress used.

METHOD

A systematic search of four databases (MEDLINE, EMBASE, COCHRANE, CINAHL) was conducted for studies reporting outcomes pertaining to physical ability indicative of independent function in adult (>15 y) cohorts who had suffered a major burn (>20% TBSA) up to 30 years after treatment in a developed specialised burn service. Data extracted included factors affecting rate of and time to achievement of function in five independence domains, as well as the outcome measures used.

RESULTS

21 eligible studies were included comprising 1298 major burns survivors with a combined mean age of 39.6 y and a mean TBSA of 25.8%. The most significant recurring factors impacting recovery of independent function were older age, female gender, burn severity, prolonged ICU and hospital admission, preceding mental health conditions, and post-acute psychological issues. Exercise-based rehabilitation conferred benefits on major burn patients even over 2 years following injury. Discharge to independent living from hospital occurred in 27% to 97% of patients, while reported return to work rates varied from 52% to 80%. Burns Specific Health Scale-Brief, Functional Independence Measure, and Physical Composite Score (SF-36) were the most widely used outcome scoring systems.

CONCLUSION

Major burn survivors have protracted recovery with potential for persistent chronic impairments, remaining consistently below baseline levels of function. Non-modifiable factors such as age and gender, and disease characteristics such as burn size with associated physical, physiological and psychosocial sequelae are contributory. Further research is required to explore achievement of specific milestones of major burn and polytrauma critical care patients, while early targeted rehabilitation addressing physical, psychological, and vocational needs has promising potential benefit.

Application of fractional carbon dioxide laser monotherapy in keloids: A meta-analysis

BACKGROUND

There is no evidence-based guidance on the use of fractional CO2 laser in the excision of scars.

AIM

To explore the effectiveness and safety of fractional CO2 laser in the treatment of keloids.

METHODS

In this meta-analysis, we searched the PubMed, Embase, and Cochrane databases from inception to April 2023. We only included studies reporting fractional CO2 laser treatment of keloids. We excluded duplicate published studies, incomplete studies, those with incomplete data, animal experiments, literature reviews, and systematic studies.

RESULTS

The pooled results showed that the Vancouver Scar Scale (VSS) parameters of height weighted mean difference (WMD) = -1.10, 95% confidence interval (CI): -1.46 to -0.74), pigmentation (WMD = -0.61, 95% CI: -1.00 to -0.21), and pliability (WMD = -0.90, 95% CI: -1.17 to -0.63) were significantly improved after fractional CO2 laser treatment of keloids. However, vascularity did not significantly change. Additionally, the total VSS was significantly improved after treatment (WMD = -4.01, 95% CI: -6.22 to -1.79). The Patient Scars Assessment Scale was significantly improved after treatment (WMD = -15.31, 95% CI: -18.31 to -12.31). Regarding safety, the incidences of hyperpigmentation, hypopigmentation, pain, telangiectasia, and atrophy were 5%, 0%, 11%, 2% (95% CI: 0%-6%), and 0% (95% CI: 0%-4%), respectively.

CONCLUSIONS

Fractional CO2 laser is effective in the treatment of keloids and can effectively improve the height, pigmentation, and pliability of scars, and patients are satisfied with this treatment. Further studies should explore the role of combination therapy.

Health systems research in burn care: an evidence gap map

BACKGROUND

Burn injury is associated with significant mortality and disability. Resilient and responsive health systems are needed for optimal response and care for people who sustain burn injuries. However, the extent of health systems research (HSR) in burn care is unknown. This review aimed to systematically map the global HSR related to burn care.

METHODS

An evidence gap map (EGM) was developed based on the World Health Organization health systems framework. All major medical, health and injury databases were searched. A standard method was used to develop the EGM.

RESULTS

A total of 6586 articles were screened, and the full text of 206 articles was reviewed, of which 106 met the inclusion criteria. Most included studies were cross-sectional (61%) and were conducted in hospitals (71%) with patients (48%) or healthcare providers (29%) as participants. Most studies were conducted in high-income countries, while only 13% were conducted in low-and middle-income countries, accounting for 60% of burns mortality burden globally. The most common health systems areas of focus were service delivery (53%), health workforce (33%) and technology (19%). Studies on health policy, governance and leadership were absent, and there were only 14 qualitative studies.

CONCLUSIONS

Major evidence gaps exist for an integrated health systems response to burns care. There is an inequity between the burden of burn injuries and HSR. Strengthening research capacity will facilitate evidence-informed health systems and policy reforms to sustainably improve access to affordable, equitable and optimal burn care and outcomes.

Association of age with perioperative morbidity among patients undergoing surgical management of minor burns

Introduction

Burn injuries are associated with significant morbidity, often necessitating surgical management. Older patients are more prone to burns and more vulnerable to complications following major burns. While the relationship between senescence and major burns has already been thoroughly investigated, the role of age in minor burns remains unclear. To better understand differences between elderly and younger patients with predominantly minor burns, we analyzed a multi-institutional database.

Methods

We reviewed the 2008-2020 ACS-NSQIP database to identify patients who had suffered burns according to ICD coding and underwent initial burn surgery.

Results

We found 460 patients, of which 283 (62%) were male and 177 (38%) were female. The mean age of the study cohort was 46 ± 17 years, with nearly one-fourth (n = 108; 23%) of all patients being aged ≥60 years. While the majority (n = 293; 64%) suffered from third-degree burns, 22% (n = 99) and 15% (n = 68) were diagnosed with second-degree burns and unspecified burns, respectively. An average operation time of 46 min, a low mortality rate of 0.2% (n = 1), a short mean length of hospital stay (1 day), and an equal distribution of in- and outpatient care (51%, n = 234 and 49%, n = 226, respectively) indicated that the vast majority of patients suffered from minor burns. Patients aged ≥60 years showed a significantly prolonged length of hospital stay (p<0.0001) and were significantly more prone to non-home discharge (p<0.0001). In univariate analysis, advanced age was found to be a predictor of surgical complications (p = 0.001) and medical complications (p = 0.0007). Elevated levels of blood urea nitrogen (p>0.0001), creatinine (p>0.0001), white blood cell count (p=0.02), partial thromboplastin time (p = 0.004), and lower levels of albumin (p = 0.0009) and hematocrit (p>0.0001) were identified as risk factors for the occurrence of any complication. Further, complications were more frequent among patients with lower body burns.

Discussion

In conclusion, patients ≥60 years undergoing surgery for predominantly minor burns experienced significantly more complications. Minor lower body burns correlated with worse outcomes and a higher incidence of adverse events. Decreased levels of serum albumin and hematocrit and elevated values of blood urea nitrogen, creatinine, white blood count, and partial thromboplastin time were identified as predictive risk factors for complications.

Translation and psychometric validation of the Finnish version of the Patient Scar Assessment Scale for use in patients with burn scars

BACKGROUND

The aim of this study was to create a Finnish scar assessment scale by translating and evaluating the psychometric properties of the Patient Scar Assessment Scale (PSAS), a part of the Patient and Observer Scar Assessment Scale (POSAS), with burn patients to enable its use in burn care.

METHODS

The translation process followed international guidelines with forward and backward translations and cognitive debriefing with patients. Psychometric validation was performed with adult patients with burns who had been treated at the Helsinki Burn Centre between 2006 and 2017 with skin grafting following the excision of deep second- or third-degree burns. To ensure reproducibility, the PSAS was sent to the study participants twice. The correlation between the PSAS and health-related quality of life (HRQL) was also tested.

RESULTS

In total, 192 patients, of whom 71 % were male, participated in this study. The mean (SD) age of the participants was 57 (17) years. The internal consistency of the PSAS was good, Cronbach's α 0.89 (95 % CI: 0.86-0.91). The reproducibility was also good concerning all items and the total score, ICC from 0.77 to 0.89. As expected, the total PSAS score correlated negatively with HRQL.

CONCLUSION

The PSAS was successfully translated and culturally adapted into Finnish and the newly translated version has good validity and reproducibility for assessing mature burn scars.

The association between out of hours burn centre admission and in-hospital outcomes in patients with severe burns

INTRODUCTION

Patients with severe burns (≥20 % total body surface area [TBSA]) have specific and time sensitive needs on arrival to the burn centre. Burn care systems in Australia and New Zealand are organised differently during weekday business hours compared to overnight and weekends. The aims of this study were to compare the profile of adult patients with severe burns admitted during business hours with patients admitted out of hours and to quantify the association between time of admission and in-hospital outcomes in the Australian and New Zealand context.

METHODS

Data were extracted from the Burns Registry of Australia and New Zealand for adults (≥18 years) with severe burns admitted to Australian or New Zealand burn centres between July 2016 and June 2020. Differences in patient profiles, clinical management, and in-hospital outcomes were investigated. Univariable and multivariable logistic and linear regression models were used to quantify associations between time of admission and in-hospital outcomes of interest.

RESULTS

We found 623 patients eligible for inclusion. Most patients were admitted out of hours (69.2 %), their median age was 42 years, and most were male (78 %). The median size burn was 30 % TBSA and 32 % of patients had an inhalation injury. A greater proportion of patients admitted out of hours had alcohol and/or drugs involved with injury compared to patients admitted during business hours. No other differences between groups were observed. Patients in both groups had similar odds of dying in hospital (Odds Ratio [OR], 95 % Confidence Interval [95 %CI] 1.49 [0.64, 3.48]), developing acute kidney injury within 72 h (OR, 95 %CI 0.58 [0.32, 1.07]), or sepsis (OR, 95 %CI 1.04 [0.46, 2.35]). No association was found between time of admission and hospital (%, 95 %CI 1.00 [0.82, 1.23]) nor intensive care length of stay (%, 95 %CI 0.97 [0.73, 1.27]).

DISCUSSION

In this first Australian and/or New Zealand study to explore the association between time of admission and burn patient in-hospital outcomes, out of hours admission was not associated with patient outcomes of interest.

CONCLUSION

These findings support current models of care in Australian and New Zealand burn centres, however further investigation is required. Nonetheless, given most severe burns patients arrive out of hours to burn the centre, it is plausible that out of hours availability of senior burn clinicians will improve patient care and safety resilience within burn care systems.

Burden and Costs of Severe Burn Injury in Victoria, Australia

This study examines the costs of severe burn injury in Victoria, Australia. It quantifies the funding generated through an activity-based case-mix system for hospital treatment of acute injury and presentations in the subsequent two years and costs of the longer-term burden of burn injury due to premature burn-related deaths and disability. Severe adult burns cases in Victoria from 2007-2016 were identified using the Victorian State Trauma Registry (VSTR). Cases were linked with the Victorian Admitted Episodes Dataset (VAED), Victoria Emergency Minimum Dataset (VEMD), and the National Coronial Information System (NCIS). Hospital re-imbursements and costs of Disability-Adjusted Life Years (DALYs) were calculated using disability weights derived from the EQ-5D-3L questionnaire responses at 24 months post injury. There were 331 patients hospitalised with a burn ≥20% total body surface area (TBSA) from 2007-2016. Total mean re-imbursement (SD) for the acute treatment episode per patient in Australian dollars (AUD) was $87,570 ($97,913). There was significant variation in the number of cases by year and re-imbursement per patient, with high outliers common. Excluding 2009, when 173 people died in bushfires, there were 7749 DALYs which cost $991,872,000. Severe burns are uncommon and variable. Economic treatment costs of severe burns are high, and among survivors there is high incidence of long-term disability and overall burden of injury.

Health utilities in burn injury survivors: A systematic review

BACKGROUND

An estimated 11 million burn injuries with medical attention occur every year worldwide. Although potentially deadly, burn injuries are now considered a chronic disease with multiple lifetime physical and psychological sequelae. However, it remains unclear how these events affect patients' utility scores. We aimed to conduct a systematic review to summarize the utility scores of burn injury survivors.

METHODS

We conducted on March 18^th, 2020 a systematic review of the published literature using a search strategy designed in collaboration with a research librarian. Our search strategy aimed to identify studies that provided burn injury survivors' utility scores via a standardized indirect instrument.

RESULTS

We identified 15 studies that reported burn injury survivors' utility scores. Most studies used the EQ-5D instruments to assess patients' utility scores. Results varied substantially between studies, ranging from a low of 0.06 to a high of 0.972. Our review identified two key trends. First, utility scores seem to be negatively correlated with the severity of the burn injury. Second, utility scores in adults tend to increase in function of the time since injury.

CONCLUSION

Unfortunately, due to differences in study design and settings, patient populations and instruments used to assess patients' utility scores, we were unable to combine all study results into a single value. In spite of this limit, results we identified support previous trends identified by others regarding the relationship between utility scores and the burn injury severity and/or the time since injury.

Poly(lactide-co-ε-caprolactone) scaffold promotes equivalent tissue integration and supports skin grafts compared to a predicate collagen scaffold

Dermal scarring from motor vehicle accidents, severe burns, military blasts, etc. is a major problem affecting over 80 million people worldwide annually, many of whom suffer from debilitating hypertrophic scar contractures. These stiff, shrunken scars limit mobility, impact quality of life, and cost millions of dollars each year in surgical treatment and physical therapy. Current tissue engineered scaffolds have mechanical properties akin to unwounded skin, but these collagen-based scaffolds rapidly degrade over 2 months, premature to dampen contracture occurring 6-12 months after injury. This study demonstrates a tissue engineered scaffold can be manufactured from a slow-degrading viscoelastic copolymer, poly(ι-lactide-co-ε-caprolactone), with physical and mechanical characteristics to promote tissue ingrowth and support skin-grafts. Copolymers were synthesized via ring-opening polymerization. Solvent casting/particulate leaching was used to manufacture 3D porous scaffolds by mixing copolymers with particles in an organic solvent followed by casting into molds and subsequent particle leaching with water. Scaffolds characterized through SEM, micro-CT, and tensile testing confirmed the required thickness, pore size, porosity, modulus, and strength for promoting skin-graft bioincorporation and dampening fibrosis in vivo. Scaffolds were Oxygen Plasma Treatment and collagen coated to encourage cellular proliferation. Porosity ranging from 70% to 90% was investigated in a subcutaneous murine model and found to have no clinical effect on tissue ingrowth. A swine full-thickness skin wound model confirmed through histology and Computer Planimetry that scaffolds promote skin-graft survival, with or without collagen coating, with equal safety and efficacy as a commercially available tissue engineered scaffold. This study validates a scalable method to create poly(ι-lactide-co-ε-caprolactone) scaffolds with appropriate characteristics and confirms in mouse and swine wound models that the scaffolds are safe and effective at supporting skin-grafts. The results of this study have brought us closer towards developing an alternative technology that supports skin grafts with the potential to investigate long-term hypertrophic scar contractures.

The Costs of Burn Victim Hospital Care around the World: A Systematic Review

BACKGROUND

Burn injuries are very common and fire-related burns account for over 300,000 deaths per year globally. The costs of the treatment of these patients change around the world. The aim of the present study was to conduct a systematic literature review to identify the costs related to hospital stays of burn victims in countries with different Human Development Index (HDIs).

METHODS

PubMed, CINAHL and BVIS databases were searched using the following terms: "burn," treatment" and "costs". The review included articles that presented cost studies or economic assessments of burn victims in which the costs were reported, and published between 2012 and 2019. The quality of the evidence was assessed using the Consensus on Health Economic Criteria. This review presents register in Prospero (CRD42019137580).

RESULTS

The review included 19 economic studies conducted in 13 countries, most with a very high HDIs. Most studies estimated direct acute burn care costs through bottom-up costing and institutional data. Total hospital care costs ranged from US$ 10.58 to US$ 125,597.86 per patient, the cost of 1% of total body surface area burned ranged from US$ 2.65 to US$ 11,245.04, and the cost of hospital care per day, from US$ 24.23 to US$ 4,125.50.

CONCLUSION

The costs are high and show wide discrepancies among countries. Medical costs and other losses caused by fatal and non-fatal burn injuries differ considerably among demographic groups, care protocols, and country HDIs.

Health related quality of life in adults after burn injuries: A systematic review

OBJECTIVES

Measurement of health-related quality of life (HRQL) is essential to qualify the subjective burden of burns in survivors. We performed a systematic review of HRQL studies in adult burn patients to evaluate study design, instruments used, methodological quality, and recovery patterns.

METHODS

A systematic review was performed. Relevant databases were searched from the earliest record until October 2016. Studies examining HRQL in adults after burn injuries were included. Risk of bias was scored using the Quality in Prognostic Studies tool.

RESULTS

Twenty different HRQL instruments were used among the 94 included studies. The Burn Specific Health Scale-Brief (BSHS-B) (46%), the Short Form-36 (SF-36) (42%) and the EuroQol questionnaire (EQ-5D) (9%) were most often applied. Most domains, both mentally and physically orientated, were affected shortly after burns but improved over time. The lowest scores were reported for the domains 'work' and 'heat sensitivity' (BSHS-B), 'bodily pain', 'physical role limitations' (SF-36), and 'pain/discomfort' (EQ-5D) in the short-term and for 'work' and 'heat sensitivity', 'emotional functioning' (SF-36), 'physical functioning' and 'pain/discomfort' in the long-term. Risk of bias was generally low in outcome measurement and high in study attrition.

CONCLUSION

Consensus on preferred validated methodologies of HRQL measurement in burn patients would facilitate comparability across studies, resulting in improved insights in recovery patterns and better estimates of HRQL after burns. We recommend to develop a guideline on the measurement of HRQL in burns. Five domains representing a variety of topics had low scores in the long-term and require special attention in the aftermath of burns.

Burns: Pathophysiology of Systemic Complications and Current Management

As a result of many years of research, the intricate cellular mechanisms of burn injury are slowly becoming clear. Yet, knowledge of these cellular mechanisms and a multitude of resulting studies have often failed to translate into improved clinical treatment for burn injuries. Perhaps the most valuable information to date is the years of clinical experience and observations in the management and treatment of patients, which has contributed to a gradual improvement in reported outcomes of mortality. This review provides a discussion of the cellular mechanisms and pathways involved in burn injury, resultant systemic effects on organ systems, current management and treatment, and potential therapies that we may see implemented in the future.

Scar massage for hypertrophic burns scarring-A systematic review

BACKGROUND

Scar massage is used in burn units globally to improve functional and cosmetic outcomes of hypertrophic scarring following a burn, however, the evidence to support this therapy is unknown.

OBJECTIVE

To review the literature and assess the efficacy of scar massage in hypertrophic burn scars.

METHODS

MEDLINE, PubMed, Embase, CINAHL and the Cochrane Library were searched using the key words "burn", "burn injury", "thermal injury" and "scar", "hypertrophic scar" and "massage", "manipulation", "soft tissue mobilisation", "soft tissue manipulation". The articles were scored by the assessors using the Physiotherapy Evidence Database (PEDro) scale and outcome measures on range of motion (ROM), cosmesis (vascularity, pliability, height), pain scores, pruritus, and psychological measures of depression and anxiety were extracted.

RESULTS

Eight publications were included in the review with 258 human participants and 15 animal subjects who received scar massage following a thermal injury resulting in hypertrophic scarring. Outcome measures that demonstrated that scar massage was effective included scar thickness as measured with ultrasonography (p=0.001; g=-0.512); depression (Centre for Epidemiologic Studies - Depression [CES-D]) (p=0.031; g=-0.555); pain as measured with Visual Analogue Scale (VAS) (p=0.000; g=-1.133) and scar characteristics including vascularity (p=0.000; g=-1.837), pliability (p=0.000; g=-1.270) and scar height (p=0.000; g=-2.054). Outcome measures that trended towards significance included a decrease in pruritus (p=0.095; g=-1.157).

CONCLUSIONS

It appears that there is preliminary evidence to suggest that scar massage may be effective to decrease scar height, vascularity, pliability, pain, pruritus and depression in hypertrophic burns scaring. This review reflects the poor quality of evidence and lack of consistent and valid scar assessment tools. Controlled, clinical trials are needed to develop evidence-based guidelines for scar massage in hypertrophic burns scarring.

Treatment costs of burn victims in a university hospital

OBJECTIVES

To analyze the direct costs of treating critically ill patients in the intensive care unit of a center specializing in treating burns.

METHODS

This is a prospective cohort study of 180 patients from May 2011 to May 2013. Clinical and demographic data were collected in addition to data for the calculation of severity scores. The costs related to daily clinical and surgical treatment were evaluated until hospital outcome. The costs were grouped into five blocks: Clinical support, Drugs and blood products, Medical procedures, Specific burn procedures and Hospital fees. The level of significance was set at 5%.

RESULTS

There was a predominance of males, 131 (72.8%). The mean age of the patients was 42.0±15.3years and the mean burned body surface area was 27.9±17%. The median length of stay in intensive care beds was 15.0 (interquartile range IQR: 7.0-24.8) days and the median hospital stay was 23.0 (IQR: 14.0-34.0) days. The mean daily cost was US$ 1330.48 (standard error of the mean SE=38.36) and the mean total cost of hospitalization was US$ 39,594.90 (SE: 2813.11). The drugs and blood products block accounted for the largest fraction of the total costs (US$ 18,086.09; SE 1444.55). There was a difference in the daily costs of survivors and non survivors (US$ 1012.89; SE: 29.38 and US$ 1866.11, SE: 36.43, respectively, P<0.001).

CONCLUSION

The direct costs of the treatment of burn patients at the study center were high. The drugs and blood products block presented the highest mean total and daily costs. Non surviving patients presented higher costs.

Return to work after specialised burn care: A two-year prospective follow-up study of the prevalence, predictors and related costs

BACKGROUND

Burn injuries may cause long-term disability and work absence, and therefore result in high healthcare and productivity costs. Up to now, detailed information on return to work (RTW) and productivity costs after burns is lacking.

AIMS

The aim of this study was to accurately assess RTW after burn injuries, to identify predictors of absenteeism and to calculate healthcare and productivity costs from a societal perspective.

METHODS

A prospective cohort study was conducted in the burn centre of Rotterdam, the Netherlands, including all admitted working-age patients from 1 August 2011 to 31 July 2012. At 3, 12 and 24 months post-burn, patients were sent a questionnaire: including the Work and Medical Consumption questionnaire for the assessment of work absence and medical consumption and the EQ-5D-3L plus a cognitive dimension to assess post-burn and pre-burn quality of life (QOL). Cost analyses were from a societal perspective according the micro-costing method and the friction cost method was applied for the calculation of productivity loss. Univariate logistic regression was used to identify predictors of absenteeism at three months.

RESULTS

A total of 104 patients were included in the study with a mean total body surface area (TBSA) burned of 8% (median 4%). 66 respondents were pre-employed, at 3 months 70% was back at work, at 12 months 92% and 8% had not returned to work at time of final follow-up at 24 months. Predictors of absenteeism at 3 months were: TBSA, length of stay, ICU-admission and surgery. Mean costs related to loss in productivity were €11.916 [95% CI 8.930-14.902] and accounted for 30% of total costs in pre-employed respondents in the first two years.

CONCLUSION

This two-year follow-up study demonstrates that burn injuries cause substantial and prolonged productivity loss amongst burn survivors with mixed burn severity. This absenteeism contributes to already high societal costs of burn injuries. Predictors of absenteeism found in this study were primarily fixed patient and treatment related factors, future studies should focus on modifiable factors, in order to improve RTW outcomes. Also, more attention in the rehabilitation trajectory is needed to optimally support RTW in burn survivors.

Two-year follow-up of outcomes related to scarring and distress in children with severe burns

PURPOSE

We assessed the perception of scarring and distress by pediatric burn survivors with burns covering more than one-third of total body surface area (TBSA) for up to 2 years post-burn.

METHODS

Children with severe burns were admitted to our hospital between 2004 and 2012, and consented to this IRB-approved-study. Subjects completed at least one Scars Problems and/or Distress questionnaire between discharge and 24 months post burn. Outcomes were modeled with generalized estimating equations or using mixed linear models. Significance was accepted at p < 0.01.

RESULTS

Responses of 167 children with a mean age of 7 ± 5 years and burns covering an average 54 ± 14% of TBSA were analyzed. Significant improvements over the 2-year period were seen in reduction of pain, itching, sleeping disturbance, tightness, range of motion, and strength (p < 0.01). There was a significantly increased persistent desire to hide the scarred body areas over time (p < 0.01). The perception of mouth scarring, inability to portray accurate facial expressions, and skin coloration did not improve over the follow-up period.

CONCLUSIONS

According to self-assessment questionnaires, severely burned children exhibit significant improvements in their overall perception of scarring and distress. However, these patients remain self-conscious with respect to their body image even 2 years after burn injury. Implications for Rehabilitation According to self-assessment questionnaires, severely burned children perceive significant improvements in scarring and distress during the first 2 years post burn. Significant improvements were seen in reduction of pain, itching, sleeping disturbances, tightness, range of motion, and strength (p < 0.01). Burn care providers should improve the treatment of burns surrounding the mouth that with result in scarring, and develop strategies to prevent skin discoloration. Careful evaluation of pain and sleeping disorders during the first year post burn are warranted to improve the patient rehabilitation. Overall, significantly more female patients expressed a persistent desire to hide their scarred body areas. The rehabilitation team should provide access to wigs or other aids to pediatric burn survivors to address these needs.

Long term outcomes data for the Burns Registry of Australia and New Zealand: Is it feasible?

BACKGROUND

Incorporating routine and standardised collection of long term outcomes following burn into burn registries would improve the capacity to quantify burn burden and evaluate care.

AIMS

To evaluate methods for collecting the long term functional and quality of life outcomes of burns patients and establish the feasibility of implementing these outcomes into a multi-centre burns registry.

METHODS

Five Burns Registry of Australia and New Zealand (BRANZ) centres participated in this prospective, longitudinal study. Patients admitted to the centres between November 2009 and November 2010 were followed-up at 1, 6, 12 and 24-months after injury using measures of burn specific health, health status, fatigue, itch and return to work. Participants in the study were compared to BRANZ registered patients at the centres over the study timeframe to identify participation bias, predictors of successful follow-up were established using a Generalised Estimating Equation model, and the completion rates by mode of administration were assessed.

RESULTS

463 patients participated in the study, representing 24% of all BRANZ admissions in the same timeframe. Compared to all BRANZ patients in the same timeframe, the median %TBSA and hospital length of stay was greater in the study participants. The follow-up rates were 63% at 1-month, 47% at 6-months; 40% at 12-months, and 21% at 24-months after injury, and there was marked variation in follow-up rates between the centres. Increasing age, greater %TBSA and opt-in centres were associated with greater follow-up. Centres which predominantly used one mode of administration experienced better follow-up rates.

CONCLUSIONS

The low participation rates, high loss to follow-up and responder bias observed indicate that greater consideration needs to be given to alternative models for follow-up, including tailoring the follow-up protocol to burn severity or type.

Measuring the impact of burn scarring on health-related quality of life: Development and preliminary content validation of the Brisbane Burn Scar Impact Profile (BBSIP) for children and adults

INTRODUCTION

No burn-scar specific, health-related quality of life (HRQOL) measure exists. This study aimed to develop a patient-reported, evaluative HRQOL measure to assess the impact of burn scarring in children and adults.

METHOD

Semi-structured interviews, content validation surveys, and cognitive interviews were used to develop and test content validity of a new measure - the Brisbane Burn Scar Impact Profile (BBSIP).

RESULTS

Participants comprised Australian adults (n=23) and children (n=19) with burn scarring; caregivers of children with burn scarring (n=28); and international scar management experts (n=14). Items distinct from other burn scar measures emerged. Four versions of the BBSIP were developed; one for children aged 8-18 years, one for adults, one for caregivers (as proxies for children aged less than 8-years), and one for caregivers of children aged 8-18 years. Preliminary content validity of the BBSIP was supported. Final items covered physical and sensory symptoms; emotional reactions; impact on social functioning and daily activities; impact of treatment; and environmental factors.

CONCLUSION

The BBSIP was developed to assess burn-scar specific HRQOL and will be available at http://www.coolburns.com.au under a creative commons license. Further testing is underway.