RESTORE: REcovery after Serious Trauma—Outcomes, Resource use and patient Experiences study protocol

Patients Lost to Follow-up After Injury: Who are They and What are Their Long-Term Outcomes?

INTRODUCTION

Trauma patients are at high risk for loss to follow-up (LTFU) after hospital discharge. We sought to identify risk factors for LTFU and investigate associations between LTFU and long-term health outcomes in the trauma population.

METHODS

Trauma patients with an Injury Severity Score ≥9 admitted to one of three Level-I trauma centers, 2015-2020, were surveyed via telephone 6 mo after injury. Univariate and multivariate analyses were performed to assess factors associated with LTFU and several long-term outcomes.

RESULTS

Of 3609 patients analyzed, 808 (22.4%) were LTFU. Patients LTFU were more likely to be male (71% versus 61%, P = 0.001), Black (22% versus 14%, P = 0.003), have high school or lower education (50% versus 42%, P = 0.003), be publicly insured (23% versus 13%, P < 0.001), have a penetrating injury (13% versus 8%, P = 0.006), have a shorter length of stay (3.64 d ± 4.09 versus 5.06 ± 5.99, P < 0.001), and be discharged home without assistance (79% versus 50%, P < 0.001). In multivariate analyses, patients who followed up were more likely to require assistance at home (6% versus 11%; odds ratio [OR] 2.23, 1.26-3.92, P = 0.005), have new functional limitations (11% versus 26%; OR 2.91, 1.97-4.31, P = < 0.001), have daily pain (30% versus 48%; OR 2.11, 1.54-2.88, P = < 0.001), and have more injury-related emergency department visits (7% versus 10%; OR 1.93, 1.15-3.22, P = 0.012).

CONCLUSIONS

Vulnerable populations are more likely to be LTFU after injury. Clinicians should be aware of potential racial and socioeconomic disparities in follow-up care after traumatic injury. Future studies investigating improvement strategies in follow-up care should be considered.

Perspectives of major traumatic injury survivors on accessibility and quality of rehabilitation services in rural Australia

PURPOSE

For the 30% of Australians who live in rural areas, access to rehabilitation services after sustaining a major traumatic injury can be challenging. This study aimed to explore the experience of rural major traumatic injury survivors accessing rehabilitation services.

MATERIALS AND METHODS

Semi-structured interviews were conducted with 21 rural major traumatic injury survivors (M_age = 47.86; SD = 11.35; Range: 21-61) who were an average of seven years post-injury (SD = 3.10; Range: 3.25-13.01). Transcribed interviews were thematically analysed.

RESULTS

Four themes were identified: (1) Managing the transition back to local services, (2) Independence and determination to get better, (3) Rehabilitation is an ongoing process, and (4) Limited service access and quality. While injury-related symptoms persisted for many participants, they expressed strong determination for independence and self-management of their recovery. Barriers to accessing rehabilitation services included poor knowledge of local services, travel burden, financial costs, and a lack of local practitioners experienced in major traumatic injury rehabilitation. Facilitating factors included financial, psychological, community, and informal supports.

CONCLUSIONS

To support recovery, future rural service models should improve consideration of factors resulting from living at a distance to services and harness independence to self-manage.IMPLICATIONS FOR REHABILITATIONRural major traumatic injury survivors need support to navigate numerous barriers to accessing rehabilitation services.Rural participants expressed their preference for greater involvement in planning their transition back home following hospitalisation and help to link with available services in their local area.Specialist training and support for rural rehabilitation practitioners is needed, to effectively treat impairments related to major traumatic injury, particularly psychological and cognitive difficulties.Future service delivery models should incorporate methods to locate rural services; facilitate telehealth access and client self-management; and provide financial and mental health support to both rural survivors of major traumatic injury and their carers.

"It's been a long hard road": challenges faced in the first three years following traumatic brain injury

PURPOSE

There is limited qualitative research exploring challenges experienced following severe traumatic brain injury (TBI). We investigated challenges to recovery identified by individuals who sustained severe TBI three years earlier or their close others (COs), as well as suggestions for managing these challenges.

MATERIALS AND METHODS

Nine participants with TBI and 16 COs completed semi-structured interviews. Using reflexive thematic analysis, challenges were identified across several timeframes (i.e., at the injury, acute care, inpatient rehabilitation, outpatient rehabilitation, and at home/other location).

RESULTS

Challenges experienced across all timeframes included: lack of information and poor communication, pre-existing conditions, missed injuries, and issues with medical staff, and continuity of care. From acute care onwards, there were TBI-related consequences, issues with coping and emotional adjustment, negative outlook, insufficient treatment, lack of support for COs, and issues with compensation and funding for rehabilitation needs. Some challenges were unique to a specific timeframe (e.g., over-stimulating ward setting during acute care, and limited or unsupportive families once injured individuals went home). Suggestions for managing some of the challenges were provided (e.g., information provision, having peer supports).

CONCLUSION

Suggestions should be considered to promote successful outcomes following severe TBI.IMPLICATIONS FOR REHABILITATIONRecovery following a severe traumatic brain injury can be hindered by challenges, such as poor communication, limited information provision, injury-related consequences, limited services and emotional support for the injured individual and their Close Others, and a need for education of the broader community about traumatic brain injury.Suggestions for managing these challenges (e.g., peer supports; services closer to home) could be used to inform clinical guidelines that could be used in a rehabilitation context.These suggestions ultimately aim to improve the post-injury experience and outcomes of individuals with traumatic brain injury and their Close Others.

Long-term health and mobility of older adults following traumatic injury: a qualitative longitudinal study

PURPOSE

The aim of this study was to explore older adults' experiences of and approaches to managing their long-term health and mobility after traumatic injury.

METHODS

A longitudinal qualitative study was undertaken with older adults following traumatic injury in Victoria, Australia. Fifteen participants (≥65 years) were interviewed at three years post-injury (n = 15), and re-interviewed at four (n = 14) and five years (n = 12) post-injury. Using a framework approach, a longitudinal thematic analysis was performed.

RESULTS

Older age at the time of injury was identified by participants as a key factor influencing their recovery. Many participants reported actively attempting to regain their strength and fitness in the first five years following injury. However, their age, injury impacts, other health conditions, and weight gain made it difficult to achieve recovery goals. Many older adults reported a decline in their physical function over time. While these experiences and persistent disability constrained or changed the quality of social relationships, community participation, and independence, several participants described adapting to their functional limitations, and managing their secondary conditions over time.

CONCLUSION

In our cohort, the intertwined combination of ageing, injury, and comorbid conditions negatively affected health and mobility, reinforcing the need for preventative strategies.Implications for rehabilitationOlder adults recovering from traumatic injury may benefit from specialised care pathways that offer long-term and tailored therapies, with programs and services specific to their needs and goals.An integrated service approach by injury insurers, health care, primary care, disability, and aged care could more clearly identify and effectively address the individual needs and goals of older adults with complex conditions.Health and social services that work with people with injuries to develop personalised coping strategies can reduce anxiety related to uncertainty about the future, promote well-being, and support participation in valued activities.

Health-related quality of life and functional outcome measures for pediatric multiple injury: A systematic review and narrative synthesis

BACKGROUND

Pediatric multiple injury is a major cause of mortality and morbidity worldwide, with varied long-term sequelae. To improve care, a better understanding of the outcome tools used following multiple injury is needed.

OBJECTIVES

This study aimed to (1) identify the outcome tools used to assess functional and health-related quality of life outcomes in pediatric multiple injury and to (2) describe the tool domains and validity.

METHODS

Eligible studies were those that included pediatric participants aged 0 to 17 years who experienced multiple injury or severe trauma based on Injury Severity Score/Abbreviated Injury Scale score and a functional outcome tool was used to assess outcomes (e.g., physical, psychological, quality of life). Excluded study designs were editorials, narrative, and systematic reviews.

RESULTS

Twenty-two papers were included encompassing 16,905 participants and 34 different outcome tools. Ten tools were validated in children of which 4 were multiple injury specific; 18 were validated in adults of which 8 were trauma specific, and 6 were previously unvalidated. The tools were a mixture of patient reported (7 of 10 validated in children and 13 of 18 validated in adults) and clinician reported (3 of 10 validated in children and 2 of 13 validated in adults). Pediatric tool domains assessed were function, mobility, activities of daily living, pain, school, cognition, emotional domains, mental health, behavior, and high-risk behaviors. Using adult-validated tools to assess children may not capture the children's true function and health-related quality of life.

CONCLUSION

There was a lack of consistency in the outcome tools used following multiple injury in children. Adult-validated measures may not accurately capture pediatric outcomes after multiple injury. To fully understand the impact of pediatric multiple injury and make comparisons between studies, development of a core outcome set is required.

LEVEL OF EVIDENCE

Quantitative observational studies, level III.

Follow-up of severely injured patients can be embedded in routine hospital care: results from a feasibility study

OBJECTIVE

Understanding the longitudinal patient experience outcomes following major trauma can promote successful recovery. A novel, hospital-led telephone follow-up program was implemented by a multi-disciplinary clinical trauma service team at a Level I trauma center. This process evaluation examined what factors promoted or impeded the program's implementation.

METHODS

A prospective convergent mixed methods process evaluation design was used. Quantitative data included patient and injury demographics and program feasibility data such number of telephone calls attempted/completed and call duration. Qualitative data consisted of semi-structured interviews with program participants (staff, patients, caregivers) who had participated in the program. Descriptive statistics and thematic analysis were applied to quantitative and qualitative data respectively. Data were collected concurrently and merged in the results to understand and describe the implementation and sustainability of the program.

RESULTS

274 major trauma patients (ISS ≥ 12) were eligible for follow-up. A response rate of over 75% was achieved, with nurses responsible for most of the calls. Limited time and competing clinical demands were identified as barriers to the timely completion of the calls.

Participants valued the pre-existing trauma service/patient relationship, and this facilitated program implementation. Clinicians were motivated to evaluate their patient's recovery, whilst patients felt 'cared for' and 'not forgotten' post-hospital discharge. Teamwork and leadership were highly valued by the clinical staff throughout the implementation period as ongoing source of motivation and support.

Staff spontaneously developed the program to incorporate clinical follow up processes by providing guidance, advice and referrals to patients who indicated ongoing issues such as pain or emotional problems.

CONCLUSION

Telephone follow-up within a clinical trauma service team is feasible, accepted by staff and valued by patients and families. Despite time constraints, the successful implementation of this program is reliant on existing clinical/patient relationships, staff teamwork and leadership support.

Urine-derived stem cells: applications in skin, bone and articular cartilage repair

As an emerging type of adult stem cell featuring non-invasive acquisition, urine-derived stem cells (USCs) have shown great potential for applications in tissue engineering and regenerative medicine. With a growing amount of research on the topic, the effectiveness of USCs in various disease models has been shown and the underlying mechanisms have also been explored, though many aspects still remain unclear. In this review, we aim to provide an up-to-date overview of the biological characteristics of USCs and their applications in skin, bone and articular cartilage repair. In addition to the identification procedure of USCs, we also summarize current knowledge of the underlying repair mechanisms and application modes of USCs. Potential concerns and perspectives have also been summarized.

Adaptation, self-motivation and support services are key to physical activity participation three to five years after major trauma: a qualitative study

QUESTIONS

What are the perceived long-term impacts of major trauma on physical activity participation over time? What factors influence physical activity participation in people recovering from major trauma?

DESIGN

Longitudinal qualitative study.

PARTICIPANTS

Sixty-six people aged ≥ 16 years with non-neurological major trauma.

METHODS

Participants were interviewed 3 years (n = 66), 4 years (n = 63) and 5 years (n = 57) after their injury. A thematic analysis was performed.

RESULTS

Despite wanting to be physically active, many participants experienced significant, long-term physical activity restriction after their injury, which persisted over time. Restrictions were often related to a fear of re-injury or of exacerbating pain and fatigue levels. These restrictions were a source of distress and frustration for many participants, given the perceived impacts on their social life, family roles and enjoyment of life. Participants were also concerned about weight gain, health decline and reduced physical fitness. Participants valued the support of insurers and specialised services in facilitating access to modified activities, such as clinical Pilates and hydrotherapy. Many participants also recognised the importance of adaptation, goal-setting, self-motivation and determination to be physically active despite limitations.

CONCLUSION

People recovering from major trauma experienced significant and persistent physical activity restriction after their injury. Given the high prevalence of activity restrictions, distress and health concerns that were reported, there is an urgent need to develop and evaluate support strategies to improve physical activity participation in this group.

What can trauma patients' experiences and perspectives tell us about the perceived quality of trauma care? a qualitative study set within the UK National Health Service

The global drive for improvements in the efficiency and quality of healthcare has led to the development of frameworks to assist in defining and measuring 'good quality care'. However, such frameworks lack a systematic or meaningful definition of what 'good quality care' means from the patients' perspective. The present research provides an in-depth analysis of patients' experiences in a hospital setting from a quality of care perspective. Forty-five adults (aged 16-70) hospitalised in one of four UK NHS trusts following an unintentional injury were interviewed about their experiences of care. The findings show variability in perceived quality of care within the same hospital episode which cannot be meaningfully captured by existing frameworks. The context of trauma care (e.g. distressing nature of injury, patient vulnerability, expectations of hospitalisation and participants' interaction with different service providers) defined the care experience and the value of being 'cared for'. Participants identified some aspects of good and care which related to holistic, person-centred and personalised care beyond the medical needs. Participants discussed the value of being understood, staff thinking of their needs beyond hospitalisation, staff trying 'their best' despite constrains of current care, having their emotional needs recognised and addressed and staff competence. Patients reported also poor quality of care and 'not being cared for' by specific staff groups which they expected to fulfil this role, rushed and unsympathetic care, lack of recognition for emotional impact of injury mapped onto existing quality frameworks e.g. safety, equity, accessibility and patient-centeredness as well as quality of interaction with providers, empathetic care which extended beyond medical needs, coordination of care, and the positivity of care delivery as important dimensions of quality care with implications for their recovery. The findings have implications for quality frameworks and theoretical definitions of quality of care; they demonstrate the importance of patient experience in addition to clinical effectiveness and safety as an essential dimension of quality care. In terms of practice, the findings support the need to incorporate knowledge and training of injured adults' psychological needs, and the value of interaction with professionals as a patient defined dimension of the quality of care.

Factors facilitating recovery following severe traumatic brain injury: A qualitative study

Given the significant impact of severe traumatic brain injury (TBI), understanding factors influencing recovery is critical to inform prognostication and treatment planning. Previous research has focussed primarily on factors negatively associated with outcome, with less focus on factors facilitating the recovery process. The current qualitative study examined positive factors identified for recovery by individuals who had sustained severe TBI three years earlier. Semi-structured interviews were conducted with nine participants with TBI and 16 close-others. Participants were asked to identify factors about themselves (or the injured individual), those around them, and the care they received that they felt were positive for recovery. Using reflexive thematic analysis, three themes were identified as positive for recovery after a TBI. Having a support network included social supports such as family and friends, and receiving other funded/non-funded assistance towards improving independence and participation. Being positive and engaged included being able to participate, being positive, using compensatory strategies, and becoming fit, healthy and happy. Getting good care included patients perceiving they had a comprehensive and good quality hospital experience, and access to multidisciplinary outpatient services. A focus on enhancing these positive environmental, personal and service factors in service provision may enhance outcomes following severe TBI.

Pre-injury health status of major trauma patients with orthopaedic injuries

BACKGROUND

Pre-injury health status is an important determining factor of long-term outcomes after orthopaedic major trauma. Determining pre-injury health status of major trauma patients with orthopaedic injuries is also important for evaluating the change from pre to post-injury health status.

OBJECTIVES

Describe pre-injury health statuses reported at three different time points (6, 12 and 24 months) after injury and compare these with Australian normative values; determine the agreement between pre-injury health status collected at multiple time points post-injury; and identify factors associated with reporting better pre-injury health status.

MATERIALS AND METHODS

A registry-based cohort study was conducted. Major trauma patients with orthopaedic injuries captured by the Victorian State Trauma Registry with a date of injury from January 2009 to December 2016 were included. Pre-injury health status (measured using the EuroQol-Visual Analogue Scale (EQ-VAS)), reported 6, 12 and 24 months post-injury, was compared against Australian population normative values. The Bland-Altman method of comparison was used to determine the agreement between pre-injury EQ-VAS scores reported 6 to 12 and 6 to 24 months post-injury. Mixed effects ordinal logistic regression was used to determine factors associated with reporting better pre-injury health status.

RESULTS

A total of 3,371 patients were eligible for the study. The median (IQR) pre-injury EQ-VAS score reported 6, 12 and 24 months post-injury was 90 (85-100) out of 100. Participants' pre-injury EQ-VAS scores reported 6, 12 and 24 months post-injury were significantly higher than Australian population normative values. Pre-injury EQ-VAS scores reported 6 months post-injury agreed with pre-injury EQ-VAS scores reported 12 and 24 months post-injury. A significant association exists between pre-injury health status and age, comorbidities, injury characteristics, socioeconomic status and pre-injury work status.

CONCLUSIONS

People with orthopaedic major trauma have better pre-injury health compared to the general Australian population. Therefore, population-specific values should be used as baseline measures to evaluate orthopaedic trauma outcomes. Pre-injury health status values reported at three different post-injury time points were comparable. If conducting a retrospective pre-injury health evaluation, researchers need be aware of factors that influence self-reporting of pre-injury health status and the response shift that may happen due to encountering injury.

Patterns and Predictors of Return to Work After Major Trauma: A Prospective, Population-based Registry Study

OBJECTIVE

To characterize patterns of engagement in work during the 4-year period after major traumatic injury, and to identify factors associated with those patterns.

BACKGROUND

Employment is an important marker of functional recovery from injury. There are few population-based studies of long-term employment outcomes, and limited data on the patterns of return to work (RTW) after injury.

METHODS

A population-based, prospective cohort study using the Victorian State Trauma Registry. A total of 1086 working age individuals, in paid employment or full-time education before injury, were followed-up through telephone interview at 6, 12, 24, 36, and 48 months post-injury. Responses to RTW questions were used to define 4 discrete patterns: early and sustained; delayed; failed; no RTW. Predictors of RTW patterns were assessed using multivariate multinomial logistic regression.

RESULTS

Slightly more than half of respondents (51.6%) recorded early sustained RTW. A further 15.5% had delayed and 13.3% failed RTW. One in 5 (19.7%) did not RTW. Compared with early sustained RTW, predictors of delayed and no RTW included being in a manual occupation and injury in a motor vehicle accident. Older age and receiving compensation predicted both failed and no RTW patterns. Preinjury disability was an additional predictor of failed RTW. Presence of comorbidity was an additional predictor of no RTW.

CONCLUSIONS

A range of personal, occupational, injury, health, and compensation system factors influence RTW patterns after serious injury. Early identification of people at risk for delayed, failed, or no RTW is needed so that targeted interventions can be delivered.

Care coordination experiences of people with traumatic brain injury and their family members in the 4-years after injury: a qualitative analysis

TITLE

Care coordination experiences of people with traumatic brain injury and their family members 4-years after injury: A qualitative analysis.

AIM

To explore experiences of care coordination in the first 4-years after severe traumatic brain injury (TBI).

METHODS

A qualitative study nested within a population-based longitudinal cohort study. Eighteen semi-structured telephone interviews were conducted 48-months post-injury with six adults living with severe TBI and the family members of 12 other adults living with severe TBI. Participants were identified through purposive sampling from the Victorian State Trauma Registry. A thematic analysis was undertaken.

RESULTS

No person with TBI or their family member reported a case manager or care coordinator were involved in assisting with all aspects of their care. Many people with severe TBI experienced ineffective care coordination resulting in difficulty accessing services, variable quality in the timing, efficiency and appropriateness of services, an absence of regular progress evaluations and collaboratively formulated long-term plans. Some family members attempted to fill gaps in care, often without success. In contrast, effective care coordination was reported by one family member who advocated for services, closely monitored their relative, and effectively facilitated communication between services providers.

CONCLUSION

Given the high cost, complexity and long-term nature of TBI recovery, more effective care coordination is required to consistently meet the needs of people with severe TBI.

Patient-identified information and communication needs in the context of major trauma

Background

Navigating complex health care systems during the multiple phases of recovery following major trauma entails many challenges for injured patients. Patients’ experiences communicating with health professionals are of particular importance in this context. The aim of this study was to explore seriously injured patients’ perceptions of communication with and information provided by health professionals in their first 3-years following injury.

Methods

A qualitative study designed was used, nested within a population-based longitudinal cohort study. Semi-structured telephone interviews were undertaken with 65 major trauma patients, aged 17 years and older at the time of injury, identified through purposive sampling from the Victorian State Trauma Registry. A detailed thematic analysis was undertaken using a framework approach.

Results

Many seriously injured patients faced barriers to communication with health professionals in the hospital, rehabilitation and in the community settings. Key themes related to limited contact with health professionals, insufficient information provision, and challenges with information coordination. Communication difficulties were particularly apparent when many health professionals were involved in patient care, or when patients transitioned from hospital to rehabilitation or to the community. Difficulties in patient-health professional engagement compromised communication and exchange of information particularly at transitions of care, e.g., discharge from hospital. Conversely, positive attributes displayed by health professionals such as active discussion, clear language, listening and an empathetic manner, all facilitated effective communication. Most patients preferred communication consistent with patient-centred approaches, and the use of multiple modes to communicate information.

Conclusions

The communication and information needs of seriously injured patients were inconsistently met over the course of their recovery continuum. To assist patients along their recovery trajectories, patient-centred communication approaches and considerations for environmental and patients’ health literacy are recommended. Additionally, assistance with information coordination and comprehensive multimodal information provision should be available for injured patients.

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.

Quantifying the hospitalised morbidity and mortality attributable to traumatic injury using a population-based matched cohort in Australia

OBJECTIVES

To quantify the 12-month hospitalised morbidity and mortality attributable to traumatic injury using a population-based matched cohort in Australia.

SETTING

New South Wales, Queensland and South Australia, Australia.

PARTICIPANTS

Individuals ≥18 years who had an injury-related hospital admission in 2009 formed the injured cohort. The non-injured comparison cohort was randomly selected from the electoral roll and was matched 1:1 on age, gender and postcode of residence at the date of the index injury admission of their matched counterpart.

PRIMARY OUTCOME MEASURES

Using linked emergency department presentation, hospital admission and mortality records from 1 January 2008 to 31 December 2010 for both the injured and non-injured cohorts, 12-month mortality and pre-index and post-index injury hospital service use was examined. Adjusted rate ratios and attributable risk were calculated.

RESULTS

There were 167 600 individuals injured in 2009 and admitted to hospital in New South Wales, South Australia or Queensland with a matched comparison. The injured cohort had 3 times higher proportion of having ≥1 comorbidity preinjury, higher preinjury hospital service use, and a higher 12-month mortality compared with a non-injured comparison group. The injured cohort had 2.20 (95% CI 2.12 to 2.28) times higher rate of hospital admissions in the 12 months post the index injury admission compared with the non-injured comparison cohort. Injury was a likely contributory factor in at least 55% of hospitalisations within 12 months of the index injury hospitalisation.

CONCLUSIONS

Individuals who had an injury-related hospitalisation had higher mortality and are hospitalised at increased rates for many months postinjury. While comorbid conditions are significant, they do not account for the differences in outcomes. This study contributes to informing research efforts on better quantifying the attributable burden of hospitalised injury-related disability and mortality in Australia.

Direct, indirect and intangible costs of acute hand and wrist injuries: A systematic review

BACKGROUND

Injuries sustained to the hand and wrist are common, accounting for 20% of all emergency presentations. The economic burden of these injuries, comprised of direct (medical expenses incurred), indirect (value of lost productivity) and intangible costs, can be extensive and rise sharply with the increase of severity.

OBJECTIVE

This paper systematically reviews cost-of-illness studies and health economic evaluations of acute hand and wrist injuries with a particular focus on direct, indirect and intangible costs. It aims to provide economic cost estimates of burden and discuss the cost components used in international literature.

MATERIALS AND METHODS

A search of cost-of-illness studies and health economic evaluations of acute hand and wrist injuries in various databases was conducted. Data extracted for each included study were: design, population, intervention, and estimates and measurement methodologies of direct, indirect and intangible costs. Reported costs were converted into US-dollars using historical exchange rates and then adjusted into 2015 US-dollars using an inflation calculator RESULTS: The search yielded 764 studies, of which 21 met the inclusion criteria. Twelve studies were cost-of-illness studies, and seven were health economic evaluations. The methodology used to derive direct, indirect and intangible costs differed markedly across all studies. Indirect costs represented a large portion of total cost in both cost-of-illness studies [64.5% (IQR 50.75-88.25)] and health economic evaluations [68% (IQR 49.25-73.5)]. The median total cost per case of all injury types was US$6951 (IQR $3357-$22,274) for cost-of-illness studies and US$8297 (IQR $3858-$33,939) for health economic evaluations. Few studies reported intangible cost data associated with acute hand and wrist injuries.

CONCLUSIONS

Several studies have attempted to estimate the direct, indirect and intangible costs associated with acute hand and wrist injuries in various countries using heterogeneous methodologies. Estimates of the economic costs of different acute hand and wrist injuries varied greatly depending on the study methodology, however, by any standards, these injuries should be considered a substantial burden on the individual and society. Further research using standardised methodologies could provide guidance to relevant policy makers on how to best distribute limited resources by identifying the major disorders and exposures resulting in the largest burden.

Caregiver Reports of Children's Activity Participation Following Serious Injury

Paediatric trauma can result in significant levels of on-going disability. The aim of this study was to explore the restrictions on activity participation that children experience following serious injury from the perspective of their caregivers. We performed a thematic analysis of transcripts of semi-structured in-depth interviews with the caregivers of 44 seriously injured children, conducted three-years after the injury, and purposively sampled from a population-based cohort study. Both temporary and on-going restrictions on school, sport, leisure and social activities were identified, some of which were imposed by caregivers, schools, or recommended by health providers. The perceived risk of further injury, physical restrictions, emotional state and fatigue levels were important influences on degrees of activity restriction. Children who were socially less engaged, especially those who were more severely injured, had difficulty making and retaining friends, and exhibited signs of depression or social withdrawal. The activities of pre-school children were strongly regulated by their caregivers, while school age children faced obstacles with participation in aspects such as study, sport, and peer and teacher relationships, affecting learning, school attendance and enjoyment. The findings highlight the need for primary prevention and reducing the impacts of serious injury throughout the continuum of care.

Prevalence, recovery patterns and predictors of quality of life and costs after non-fatal injury: the Brabant Injury Outcome Surveillance (BIOS) study

INTRODUCTION

Trauma is a major public health problem worldwide that leads to high medical and societal costs. Overall, improved understanding of the full spectrum of the societal impact and burden of injury is needed. The main purpose of the Brabant Injury Outcome Surveillance (BIOS) study is to provide insight into prevalence, predictors and recovery patterns of short-term and long-term health-related quality of life (HRQoL) and costs after injury.

MATERIALS AND METHODS

This is a prospective, observational, follow-up cohort study in which HRQoL, psychological, social and functional outcome, and costs after trauma will be assessed during 24 months follow-up within injured patients admitted in 1 of 10 hospitals in the county Noord-Brabant, the Netherlands. Data will be collected by self-reported questionnaires at 1 week (including preinjury assessment), and 1, 3, 6, 12 and 24 months after injury. If patients are not capable of filling out the questionnaires, proxies will be asked to participate. Also, information about mechanism and severity of injury, comorbidity and indirect and direct costs will be collected. Mixed models will be used to examine the course of HRQoL, functional and psychological outcome, costs over time and between different groups, and to identify predictors for poor or good outcome.

RELEVANCE

This study should make a substantial contribution to the international collaborative effort to assess the societal impact and burden of injuries more accurately. The BIOS results will also be used to develop an outcome prediction model for outcome evaluation including, besides the classic fatal, non-fatal outcome.

TRIAL REGISTRATION NUMBER

NCT02508675.