Validating the Functional Capacity Index as a measure of outcome following blunt multiple trauma

BACKGROUND

The validity of the Functional Capacity Index (FCI) is evaluated by examining its distributional characteristics, its correlation with other well-known measures of outcome and its ability to discriminate among persons with injuries of varying type and severity.

METHODS

A telephone survey which included the FCI and the SF-36 was administered 1 year post-injury to 1240 blunt trauma patients discharged from 12 trauma centers. A subsample of 656 patients also completed the Sickness Impact Profile (SIP) by mail.

RESULTS

FCI scores correlated well with the physical health subscores of the SIP and SF-36. They also correlated well with self-reported change in health status and return to work. The FCI, when compared to either the SF-36 or the SIP, however, appears to discriminate better among patients according to the presence and severity of head trauma.

CONCLUSIONS

While further testing of the FCI is needed, it holds promise as a preference based measure for assessing the physical impact of trauma.

Predicting ambulatory function following lower extremity trauma using the functional capacity index

This study evaluated the accuracy of experts' predictions of ambulatory function following lower extremity trauma using the Functional capacity index (FCI). Data from three orthopedic trauma studies designed to determine long-term function following specific types of lower extremity injuries were used to examine the extent of agreement between the reported and predicted ambulatory function of 921 subjects. Functional limitations reported by the cohort using a generalized health status measure and more detailed questions on lower extremity function were compared with those predicted by experts based on the injuries sustained. The overall agreement between predicted and self-reported FCI function for ambulation was relatively low (31%). In the majority of cases (80%), the disagreement differed by one functional level. Subjects were more likely to report worse function than predicted by the experts. Multivariate modeling identified different injuries, combinations of injuries, and patient characteristics that significantly influenced agreement. For example, subjects who sustained both a tibia and a femur fracture were three times more likely than subjects who did not sustain either fracture type to report poorer ambulatory function than predicted. Many challenges are faced in predicting long-term function following trauma. More empirical data are needed to inform the process. These data suggest that until the FCI can more accurately predict long-term ambulatory function following different lower extremity injuries, it should not be used for this purpose.

Use and satisfaction with prosthetic devices among persons with trauma-related amputations: a long-term outcome study

OBJECTIVE

To document and examine the use, satisfaction, and problems with prosthetic devices among persons who suffered a trauma-related lower limb amputation.

DESIGN

Abstracted medical records and follow-up interview data were collected for a retrospective cohort of persons with a lower limb trauma-related amputation who received their acute care at the University of Maryland R. Adams Cowley Shock Trauma Center, Baltimore, MD, between 1984 and 1994. Patients with spinal cord injury, traumatic brain injury, or only toe amputations were excluded.

RESULTS

There were 146 patients identified. Of those, 9% died during the acute admission and 3.5% died after discharge. Seventy-eight amputees were available for interview (68% response rate). The majority of those interviewed were male (87%), and two-thirds had undergone amputation before age 40 yr. Nearly 95% had a prosthesis and wore it an average of 80 hr (SD = 33) per week. Despite high use, only 43% reported being satisfied with the comfort of their prosthesis. About one-quarter of all users reported problems with wounds, skin irritation, or pain. Traumatic amputees used an average of four prostheses since injury, about one new prosthesis every 2 yr. Statistical analyses revealed that males reported higher prosthetic use (P < 0.01). Higher Injury Severity Score negatively impacted on prosthetic use (P < 0.01). Phantom pain negatively influenced reported satisfaction with the prosthesis (P < 0.03)

CONCLUSIONS

Although almost all persons living with trauma-related amputations use prosthetic devices, the majority are not satisfied with prosthetic comfort. Phantom pain and residual limb skin problems are also common afflictions in this population.

Validation of the ICD/AIS MAP for pediatric use

OBJECTIVE

To determine the performance of the ICD/AIS MAP (EJ MacKenzie et al) as a method of classifying injury severity for children.

METHODS

Data on all children less than 16 years of age admitted to all designated trauma centers in Pennsylvania from January 1994 through October 1996 were obtained from the state trauma registry. The ICD/AIS MAP was used to convert all injury related ICD-9-CM diagnosis codes into abbreviated injury scale (AIS) score and injury severity score (ISS). Agreement between trauma registry AIS and ISS scores and MAP generated scores was assessed using the weighted kappa (kappaw) coefficient for ordered data and the intraclass correlation coefficient for continuous data.

RESULTS

Agreement in ISS scores was excellent, both overall (intraclass correlation coefficient = 0.86, 95% confidence interval (CI) 0.84 to 0.89)), and when grouped into three levels of severity (kappaw= 0.86, 95% CI 0.85 to 0.87). Agreement in AIS scores across all body regions and ages was also excellent, (kappaw= 0.86 (95% CI 0.83 to 0.87). Agreement increased with age (kappaw= 0.78 for children <2 years; kappaw= 0.86 for older children) and varied by body region, though was excellent across all regions.

CONCLUSIONS

The performance of the ICD/AIS MAP in assessing severity of pediatric injuries was equal to or better than previous assessments of its performance on primarily adult patients. Its performance was excellent across the pediatric age range and across nearly all body regions of injury.

Relationship between trauma center volume and outcomes

CONTEXT

The premise underlying regionalization of trauma care is that larger volumes of trauma patients cared for in fewer institutions will lead to improved outcomes. However, whether a relationship exists between institutional volume and trauma outcomes remains unknown.

OBJECTIVE

To evaluate the association between trauma center volume and outcomes of trauma patients.

DESIGN

Retrospective cohort study.

SETTING

Thirty-one academic level I or level II trauma centers across the United States participating in the University Healthsystem Consortium Trauma Benchmarking Study.

PATIENTS

Consecutive patients with penetrating abdominal injury (PAI; n = 478) discharged between November 1, 1997, and July 31, 1998, or with multisystem blunt trauma (minimum of head injury and lower-extremity long-bone fractures; n = 541) discharged between June 1 and December 31, 1998.

MAIN OUTCOME MEASURES

Inpatient mortality and hospital length of stay (LOS), comparing high-volume (>650 trauma admissions/y) and low-volume (</=650 admissions/y) centers.

RESULTS

After multivariate adjustment for patient characteristics and injury severity, the relative odds of death was 0.02 (95% confidence interval [CI], 0.002-0.25) for patients with PAI admitted with shock to high-volume centers compared with low-volume centers. No benefit was evident in patients without shock (P =.50). The adjusted odds of death in patients with multisystem blunt trauma who presented with coma to a high-volume center was 0.49 (95% CI, 0.26-0.93) vs low-volume centers. No benefit was observed in patients without coma (P =.05). Additionally, a shorter LOS was observed in patients with PAI and New Injury Severity Scores of 16 or higher (difference in adjusted mean LOS, 1.6 days [95% CI, -1.5 to 4.7 days]) and in all patients with multisystem blunt trauma admitted to higher-volume centers (difference in adjusted mean LOS, 3.3 days [95% CI, 0.91-5.70 days]).

CONCLUSIONS

Our results indicate that a strong association exists between trauma center volume and outcomes, with significant improvements in mortality and LOS when volume exceeds 650 cases per year. These benefits are only evident in patients at high risk for adverse outcomes.

Epidemiology of injuries: current trends and future challenges

For the above challenges to be met, it will be important for the field of injury epidemiology to move from the largely descriptive studies that have predominated in the literature to the application of more rigorous analytical methods for defining the underlying casual patterns of injury. Studies focusing on the descriptive epidemiology of injury have and will continue to serve the field well, perhaps even more so than in other fields, since the proximal etiology of injuries (i.e., acute exposure to physical agents such as mechanical energy) is well known. However, major new advances in the prevention of injuries will continue to require a more analytical approach to understanding the complex array of factors that influence the incidence, severity, and outcomes of injury. At the same time, it will be important for investigators in this field to conduct rigorous evaluations of new interventions to better inform the establishment of programs and policies. These evaluations must include assessments of both the effectiveness and the costs of the intervention. For example, in a recently published systematic review of 10 different strategies for preventing motor vehicle injuries, 54,708 papers and reports were identified in the literature but only 161 met the initial screening criteria for inclusion in the published review (44). Of these, a much smaller number were randomized controlled trials or well executed controlled time series trials. Major advancements in the prevention and control of injuries will continue to rely on effective collaborations between epidemiologists and scientists from other disciplines, including the behavioral sciences, sociology, criminology, law, engineering, and biomechanics. Only through truly collaborative efforts across these disciplines will we be able to establish a foundation for cost-effective interventions. For example, understanding the principles of injury mechanics and the physical and physiologic responses of the human body to the impact of injury is fundamental to the study of injury causation (6). While significant advances have been made in this regard, more work needs to be done. The biomechanics of head injury are still not well understood, yet head injuries account for nearly 50 percent of all injury deaths and remain the leading cause of both injury death and disability among children and young adults. Animal and human cadaver research combined with rapidly evolving techniques of computerized modeling will continue to play a critical role in increasing our understanding of injury mechanisms. At the same time, the development of effective interventions is dependent on a better understanding of the role of behavior in injury causation and prevention (45). We know, for example, that the use of personal protective devices such as seat belts, car seats, and bicycle helmets reduces injury risk and that these behaviors can be influenced through educational, behavioral, and legislative strategies (46-49). Interventions addressing individuals at risk can be enhanced by additional research into risk perception, risk-taking, and behavioral responses to safety improvements. However, behavioral strategies may also be used effectively with key decision-makers who design and manufacture products and who pass and implement laws that affect the injury risk of entire populations; more research is needed to understand and influence the process of behavior change in these groups (50). The importance of injury as a major public health problem worldwide was highlighted in the seminal report "The Global Burden of Disease" (25). Worldwide, injuries account for approximately one in eight deaths among males and one in 14 deaths among females (51). Motor vehicle injuries alone constitute the ninth leading cause of disease burden as measured by the number of associated disability-adjusted life years (25). By the year 2020, motor vehicle injuries are projected to increase in rank to third. (ABSTRACT TRUNCATED)

A prospective evaluation of the clinical utility of the lower-extremity injury-severity scores

BACKGROUND

High-energy trauma to the lower extremity presents challenges with regard to reconstruction and rehabilitation. Failed efforts at limb salvage are associated with increased patient mortality and high hospital costs. Lower-extremity injury-severity scoring systems were developed to assist the surgical team with the initial decision to amputate or salvage a limb. The purpose of the present study was to prospectively evaluate the clinical utility of five lower-extremity injury-severity scoring systems.

METHODS

Five hundred and fifty-six high-energy lower-extremity injuries were prospectively evaluated with use of five injury-severity scoring systems for lower-extremity trauma designed to assist in the decision-making process for the care of patients with such injuries. Four hundred and seven limbs remained in the salvage pathway six months after the injury. The sensitivity, specificity, and area under the receiver operating characteristic curve were calculated for the Mangled Extremity Severity Score (MESS); the Limb Salvage Index (LSI); the Predictive Salvage Index (PSI); the Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and Age of Patient Score (NISSSA); and the Hannover Fracture Scale-97 (HFS-97) for ischemic and nonischemic limbs. The scores were analyzed in two ways: including and excluding limbs that required immediate amputation.

RESULTS

The analysis did not validate the clinical utility of any of the lower-extremity injury-severity scores. The high specificity of the scores in all of the patient subgroups did confirm that low scores could be used to predict limb-salvage potential. The converse, however, was not true. The low sensitivity of the indices failed to support the validity of the scores as predictors of amputation.

CONCLUSIONS

Lower-extremity injury-severity scores at or above the amputation threshold should be cautiously used by a surgeon who must decide the fate of a lower extremity with a high-energy injury.

Trends in incidence of pediatric injury hospitalizations in Pennsylvania

OBJECTIVES

This study analyzed short-term trends in pediatric injury hospitalizations.

METHODS

We used a population-based retrospective cohort design to study all children 15 years or younger who were admitted to all acute care hospitals in Pennsylvania with traumatic injuries between 1991 and 1995.

RESULTS

Injuries accounted for 9% of all acute hospitalizations for children. Between 1991 and 1995, admissions of children with minor injuries decreased by 29% (P < .001). However, admissions for children with moderate (P = .69) or serious (P = .41) injuries did not change.

CONCLUSIONS

Significant declines in pediatric admissions for minor injuries were noted and may reflect both real reductions in injury incidence and changes in admission practices over the period of the study.

Outcome validation of the AO/OTA fracture classification system

OBJECTIVES

To determine whether a greater severity of injury as documented by the AO/OTA code would correlate with poor scores of impairment, functional performance, and self-reported health status.

DESIGN

Prospective, functional outcome.

SETTING

Three Level One Trauma Centers.

PATIENTS/PARTICIPANTS

Two hundred patients with unilateral and isolated lower extremity fractures.

MAIN OUTCOME MEASUREMENTS

Six- and twelve-month SIP, AMA impairment, and functional performance measures of self-selected walking speed, stair climbing, heel raises, rising from a chair, balance work.

RESULTS

At six months post injury, overall impairment was significantly (p < 0.05) higher for patients with Type C versus Type B fractures. A significant difference was found among the A, B, C types and the ROM impairment rating at six months (p = 0.004). Using the Scheffe method, the significant difference was determined to be between the B- and C-type fractures. Overall functional performance scores at six months were shown to have significant (p = 0.01) variation using an ANOVA with the significant variation being between the B and C type. At twelve months, the overall functional performance was significant (p = 0.05).

CONCLUSION

Patients with C-type fractures had significantly worse functional performance and impairment compared with patients with B-type fractures but were not significantly different from patients with A-type fractures. AO/OTA code may not be a good predictor of six- and twelve-month functional performance and impairment for patients with isolated unilateral lower extremity fractures.

To the rescue: optimally locating trauma hospitals and helicopters

Injury (trauma) is the leading cause of death in the United States for people younger than 45 years of age. Each day, more than 170,000 men, women, and children are injured severely enough to seek medical care. About 400 of these people will die and another 200 will sustain a long-term disability as a result of their injuries. An estimated 20-40% of trauma-related deaths could be prevented if all Americans lived in communities that were served by a well-organized system of trauma care. This Issue Brief describes a new computer model that can help State and regional policymakers decide where to place designated trauma hospitals and helicopter depots to maximize their residents' access to trauma care.

Characterization of patients with high-energy lower extremity trauma

PURPOSE

(a) to report the demographic, socioeconomic, behavioral, social, and vocational characteristics of patients enrolled in a study to examine outcomes after high-energy lower extremity trauma (HELET) and to compare them with the general population; (b) to determine whether characteristics of patients undergoing limb salvage versus amputation after HELET are significantly different from each other.

DESIGN AND STUDY POPULATION

A prospective study of 601 patients admitted with high-energy lower extremity trauma to eight Level I trauma centers.

PROCEDURES

Patients were evaluated during the initial hospitalization. They are being followed up for 24 months postinjury. Study patients are compared with the general population by using census information, population survey data, and published norms. Characteristics of patients undergoing limb salvage versus amputation are also compared.

RESULTS

Most patients were male (77 percent), white (72 percent), and between the ages of twenty and forty-five years (71 percent). Seventy percent graduated from high school (compared with 86 percent nationally) (p < 0.05). One fourth lived in households with incomes below the federal poverty line, compared with 16 percent nationally (p < 0.05). The percentage with no health insurance (38 percent) was also higher than in the general population (20 percent) (p < .05). The percentage of heavy drinkers was over two times higher than reported nationally (p < 0.01). Study patients were slightly more neurotic and extroverted and less open to new experiences. When patient characteristics were compared for those undergoing amputation versus limb salvage, no significant differences were found among any of the variables (p > 0.05).

CONCLUSION

In conclusion, LEAP patients differ in important ways from the general population. However, the decision to amputate verus reconstruct does not appear to be significantly influenced by patient characteristics.

A trauma resource allocation model for ambulances and hospitals

OBJECTIVE

To develop a mathematical model for the location of trauma care resources.

DATA SOURCES/STUDY SETTING

Severely injured patients queried from Maryland hospital discharge and vital statistics data. A spatial injury profile was created by parsing these patients into ZIP codes.

STUDY DESIGN

The Trauma Resource Allocation Model for Ambulances and Hospitals (TRAMAH) was formulated using integer and heuristic programming. To maximize coverage of severely injured patients, trauma centers and aeromedical depots were simultaneously sited using TRAMAH. A severe injury was considered covered if at least one trauma center was sited within a time standard by ground, or if an aeromedical depot-trauma center pair was sited in such a way that the sum of the flying time from the aeromedical depot to the scene of injury plus the flying time from the scene of injury to the trauma center was within the same time standard.

PRINCIPAL FINDINGS

From 1992 to 1994, 26,774 severe injuries were considered for coverage. Across Maryland, 94.8 percent of severely injured residents had access to trauma system resources within 30 minutes and 70.3 percent had access within 15 minutes. For the same number of resources as the existing Maryland Trauma System, TRAMAH achieved a coverage objective of 99.97 percent within 30 minutes. This translated into an additional 461 severely injured people covered each year. Holding in place the trauma centers of the existing system, approximately the same percentage of coverage as that of the existing system was achieved within 15 minutes by optimally locating six fewer aeromedical depots.

CONCLUSIONS

TRAMAH will allow trauma systems planners to better locate their resources with respect to spatial needs and response times.

Use and need for post-acute services following paediatric head injury

This paper aims to document the types of inpatient and outpatient post-acute services children receive after discharge from an acute care hospital for head injury and to better understand the extent to which children fail to receive services and the reasons for not receiving needed services. A follow-up was conducted on 95 children (aged 5-15) 1 year after they were hospitalized for head injury. Parents were interviewed by phone concerning their child's use of and need for medical, rehabilitation, and social services since the injury. Questions were also asked regarding the child's current health status and behaviour. Inpatient records were reviewed to obtain information on the characteristics of the injury. Overall use of outpatient rehabilitation and social services was low during the year following injury, ranging from 0-18% of the study sample. Although need for and use of services was positively correlated with head injury severity, it appears that unmet need was highest for children with the least severe head injuries. Finally, need for physical or occupational therapy and mental health services was unrecognized for one third of children with physical limitations and 40% of children with at least 14 identified behaviour problems. These findings underscore the need for physicians and other health care professionals to thoroughly evaluate children during follow-up visits as well as during the initial hospitalization for head injury-related deficits. Identification of functional deficits or behavioural problems should be followed-up by evaluation and treatment by qualified rehabilitation professionals.

Rehabilitation and the long-term outcomes of persons with trauma-related amputations

OBJECTIVE

To examine the long-term outcomes of persons undergoing trauma-related amputations, and to explore factors affecting their physical, social, and mental health and the role of inpatient rehabilitation in improving such outcomes.

DESIGN

Abstracted medical records and interview data sought for a retrospective cohort of persons who had undergone a lower-limb trauma-related amputation.

PARTICIPANTS

Patients identified with a principal or secondary diagnosis of a trauma-related amputation to the lower extremity at the University of Maryland Shock Trauma Center between 1984 and 1994. Patients with spinal cord injury or traumatic brain injury were excluded.

RESULTS

Of 146 patients who had trauma-related amputations to the lower limb at the University of Maryland Shock Trauma Center during the study period, nearly 9% died during the acute admission and 3.5% died after discharge. About 87% of all trauma-related amputations involved males, and roughly three quarters involved white persons. About 80% of all amputations occurred before age 40. The health profile of traumatic amputee subjects interviewed in the study (n = 78, 68% response rate) was systematically lower than that of the general US population for all SF-36 scores. The differences in profiles were largest among SF-36 scales sensitive to differences in physical health status, particularly physical functioning, role limitations due to physical health, and bodily pain. About one fourth of persons with a trauma-related amputation reported ongoing severe problems with the residual limb, including phantom pain, wounds, and sores. The number of inpatient rehabilitation nights significantly improved the ability of patients with amputation to function in their physical roles, increased vitality, and reduced bodily pain. Inpatient rehabilitation was also significantly correlated with improved vocational outcomes.

CONCLUSIONS

These findings suggest a substantial effect of inpatient rehabilitation in improving long-term outcomes of persons with trauma-related amputations.

Systematic review of published evidence regarding trauma system effectiveness

OBJECTIVE

Provide a systematic review of the published literature assessing the affect of trauma center/system implementation on patient outcomes.

DATA SOURCES

A bibliographic search of MEDLINE (1966-May of 1998), HealthSTAR (1995-May of 1998), and CINAHL (1982-May of 1998). Additional manuscripts were identified in the references of reviewed manuscripts. Literature was limited to English language reports on trauma systems in the United States and Canada.

STUDY SELECTION

Initial inclusion criteria were based on methodologic criteria (i.e., a comparative [controlled] study). Authors independently assessed the strength of evidence demonstrated by each article.

DATA EXTRACTION

Included articles were classified into three groups based on study design: panel review studies, trauma registry comparison studies, and population-based studies. Key demographic, sampling frame, study design, and outcome variables were tabulated for each included study. Potential sources of bias were also identified and tabled.

DATA SYNTHESIS

A total of 12, 11, and 17 studies were incorporated into individual evidence tables for panel review, registry comparison, and population-based studies, respectively. Included studies rely on weak evidence (Class III) to assess the impact of trauma systems on patient care and outcome.

CONCLUSIONS

To date, studies assessing trauma system efficacy rely on hospital deaths as the primary indicator of effectiveness. Future research should use more sophisticated study designs (Class II) and expand available outcome measures to assess the entire continuum of care, including prehospital, rehabilitation outcomes, and long-term quality of life.

Comparison of alternative methods for assessing injury severity based on anatomic descriptors

BACKGROUND

There is mounting confusion as to which anatomic scoring systems can be used to adequately control for trauma case mix when predicting patient survival.

METHODS

Several Abbreviated Injury Scale (AIS) and International Classification of Disease Clinical (ICD-9CM)-based methods of scoring severity were compared by using data from the Pennsylvania Trauma Outcome Study. By using a design dataset, the probability of survival was modeled as a function of each score or profile. Resulting coefficients were used to derive expected probabilities in a test dataset; expected and observed probabilities were then compared by using standard measures of discrimination and calibration.

RESULTS

The modified Anatomic Profile, Anatomic Profile, and New Injury Severity Score outperformed the International Classification of Disease-based Injury Severity Score. This finding remains true when AIS values are obtained by means of a conversion from International Classification of Disease to AIS.

CONCLUSION

Results support the integrity of the AIS and argue for its continued use in research and evaluation. The modified Anatomic Profile, Anatomic Profile, and New Injury Severity Score, however, should be used in preference to the Injury Severity Score as an overall measure of severity.

Review of evidence regarding trauma system effectiveness resulting from panel studies

OBJECTIVE

The objectives this study are to elucidate the advantages and disadvantages of the panel method for evaluating the quality of trauma care and to review the individual and collective evidence in support of regionalized trauma care derived from these studies.

METHOD

A review of the published literature was conducted and identified 10 panel studies that compared appropriateness of care and/or the preventability of deaths occurring either across hospitals in a trauma system versus non-trauma system, in a defined region before and after implementation of a trauma system, between trauma center and non-trauma center hospitals within a defined region, or across hospitals of varying levels of care presystem.

RESULTS

Panel studies vary widely in the approaches used to elicit judgments; low rates of inter-rater reliability have been reported. The strength of the evidence derived from panel studies in support of trauma system effectiveness must be reviewed in this context.

CONCLUSION

All panel studies are classified as providing weak, Class III evidence. Yet, collectively they provide some face validity in support of the hypothesis that treatment at a trauma versus non-trauma center may be associated with less inappropriate care and fewer preventable deaths among the seriously injured.

Emergency medical services outcomes project I (EMSOP I): prioritizing conditions for outcomes research

Over the past several years, out-of-hospital EMS have come under increased scrutiny regarding the value of the range of EMS as currently provided. We used frequency data and expert opinion to rank-order EMS conditions for children and adults based on their potential value for the study of effectiveness of EMS care. Relief of discomfort was the outcome parameter EMS professionals identified as having the most potential impact for the majority of children and adults in the top quartile conditions. Future work from this project will identify appropriate severity and outcome measures that can be used to study these priority conditions. The results from the first year of this project will assist those interested in EMS outcomes research to focus their efforts. Furthermore, the results suggest that nonmortality out-come measures, such as relief of discomfort, may be important parameters in determining EMS effectiveness.

Compliance with prehospital triage protocols for major trauma patients

BACKGROUND

The extent to which severely injured patients receive definitive care at trauma centers is determined by the accuracy of prehospital major trauma criteria in predicting severe injuries and by the level of compliance with these triage instructions by prehospital providers. This study was conducted to evaluate the level of compliance with triage criteria in an established trauma system.

METHODS

The study involved a retrospective analysis of the 1995 Maryland statewide prehospital ambulance data. Prehospital providers in Maryland are instructed to consider transporting patients meeting any of the three nonexclusive major trauma criteria-physiology, injury, and mechanism-to designated trauma centers. Compliance with these criteria was defined as the proportion of patients transported to designated trauma centers among those meeting prehospital triage criteria as documented on the ambulance trip report. Special emphasis was placed on differences in the levels of compliance by age of the trauma patients.

RESULTS

A total of 32,950 transports were analyzed. Patients meeting injury criteria were most likely to be transported to trauma centers (86%), followed by those meeting mechanism criteria (46%), and physiology criteria (34%). When the level of compliance was stratified by age, there was no age difference in the level of compliance for patients meeting injury criteria (90.5% for patients aged 0-54 years vs. 88.7% for patients aged 55+ years; p = 0.197). For older patients meeting physiology criteria only or for those meeting mechanism criteria only, however, compliance was differentially low. For patients meeting physiology criteria only, the compliance was 40.3% for patients aged 0 to 54 years and 23.9% for patients aged 55 years and older (p = 0.0001); for patients meeting mechanism criteria only, compliance was 47.0% for patients aged 0 to 54 years and 39.7% for patients aged 55+ years (p = 0.002).

CONCLUSION

The majority of patients meeting prehospital major trauma criteria were transported to designated trauma centers. Patients meeting only physiology criteria, however, were much less likely to be transported to trauma centers, and there was a differentially low compliance for elderly trauma patients meeting physiology criteria alone. The causes and consequences of lower compliance with triage instructions for the elderly population deserve further investigation.

Effects of high school driver education on motor vehicle crashes, violations, and licensure

OBJECTIVE

We sought evidence in the research literature to determine if (1) high school-aged persons who enroll in a driver education course have fewer motor vehicle-related crashes or violations, or are more likely to obtain a drivers license, than those who do not enroll in driver education courses, and (2) the availability of high school driver education courses is associated with lower community rates of motor vehicle crashes among young drivers.

METHODS

To be included, a study must: (1) assess the effects of driver education courses or legislation for high school-aged persons; (2) present non-self-reported data for at least one of the following outcome measures: driver licensure rates, motor vehicle-related violations, or crashes; (3) include some form of no intervention comparison group; (4) adequately control for potentially confounding variables; (5) randomly assign participants to control or treatment groups, if a controlled trial.

RESULTS

Nine studies met our inclusion criteria. Based on these studies, there is no convincing evidence that high school driver education reduces motor vehicle crash involvement rates for young drivers, either at the individual or community level. In fact, by providing an opportunity for early licensure, there is evidence that these courses are associated with higher crash involvement rates for young drivers.

CONCLUSIONS

Although few driver education curricula have been carefully evaluated, in the absence of evidence that driver education reduces crash involvement rates for young persons, schools and communities should consider other ways to reduce motor vehicle-related deaths in this population, such as graduated licensing.

Systematic reviews of strategies to prevent motor vehicle injuries

BACKGROUND

Information on which strategies have been shown to be effective, which are ineffective, and which strategies have been inadequately evaluated is important for both public policy and future research.

OBJECTIVE

To provide systematic reviews of the literature on important strategies to prevent motor vehicle injuries.

METHODS

The Injury Control Research Centers (ICRCs) funded by the Centers for Disease Control and Prevention identified 9 important motor vehicle injury prevention strategies. A systematic review of the literature in 9 different computerized databases was conducted to identify relevant controlled trials. These were critically reviewed and summarized.

RESULTS

A total of 54,078 citations were reviewed; 1,111 met initial screening criteria. The reports for these citations were obtained and critically reviewed by the ICRCs. Standard criteria for inclusion of articles in the review and for evaluating the methodological quality of the articles were applied. Few randomized controlled trials were found; most controlled studies were either comparisons over time and/or across different populations. Nevertheless, these studies were able to be summarized to provide meaningful conclusions about the effectiveness of various interventions to decrease morbidity and mortality from motor vehicle crashes.

CONCLUSIONS

A large body of literature on motor vehicle injury interventions exists. The summary of this literature will provide useful information to direct policy and future research efforts.

Return to work following injury: the role of economic, social, and job-related factors

OBJECTIVES

This study examined factors influencing return to work (RTW) following severe fracture to a lower extremity.

METHODS

This prospective cohort study followed 312 individuals treated for a lower extremity fracture at 3 level-1 trauma centers. Kaplan-Meier estimates of the proportion of RTW were computed, and a Cox proportional hazards model was used to examine the contribution of multiple risk factors on RTW.

RESULTS

Cumulative proportions of RTW at 3, 6, 9, and 12 months post-injury were 0.26, 0.49, 0.60, and 0.72. After accounting for the extent of impairment, characteristics of the patient that correlated with higher rates of RTW included younger age, higher education, higher income, the presence of strong social support, and employment in a white-collar job that was not physically demanding. Receipt of disability compensation had a strong negative effect on RTW.

CONCLUSIONS

Despite relatively high rates of recovery, one quarter of persons with lower extremity fractures did not return to work by the end of 1 year. The analysis points to subgroups of individuals who are at high risk of delayed RTW, with implications for interventions at the patient, employer, and policy levels.

Correlation between the measures of impairment, according to the modified system of the American Medical Association, and function

We performed a prospective study of 302 patients who had a fracture of the lower extremity. Our purpose was to determine whether there was any association between impairment ratings of the lower extremity, derived with use of the Guides to the Evaluation of Permanent Impairment by the American Medical Association, and measurements of task performance based on direct observation as well as the patient's own assessment of activity limitation and disability as recorded on the Sickness Impact Profile. The mean residual impairment of the lower extremity according to the Guides was 27 per cent one year after the injury. Only 130 subjects (43 per cent) could perform all five functional tasks without difficulty. Eighty-four subjects (28 per cent) reported functional limitations that resulted in a score on the Sickness Impact Profile that was more than one standard deviation from the preinjury norm for the sample. Impairment ratings according to a modification of the system of the American Medical Association correlated strongly with the performance of functional tasks (r = 0.57) as well as the patients' reported activity limitations as recorded on the Sickness Impact Profile (r = 0.55). Correlations were highest when measures of impairment were based on strength rather than on range of motion. The relationship between the impairment rating and function (as observed by an examiner and as reported by the patient) was not influenced by the location of the fracture or the receipt of disability compensation. Our results suggest that the American Medical Association developed a valid approach for the measurement of physical impairment after a fracture of the lower extremity. In our study, the anatomical approach of evaluation based on muscle strength that was described in the Guides to the Evaluation of Permanent Impairment was the most sensitive measure of impairment compared with the anatomical measure based on range of motion and compared with the functional and diagnostic methods for the rating of impairment. Until the diagnostic and functional approaches for the measurement of musculoskeletal impairment are refined, we recommend use of the anatomical approach when evaluating impairment after a fracture of the lower extremity.

Determinants of use of outpatient rehabilitation services following upper extremity injury

This study documents the utilization of outpatient therapy services following upper extremity injury and identifies factors that influence the use of services. One hundred twelve patients admitted to a hand center for treatment of upper extremity injury were followed prospectively for 7 months to determine their utilization of therapy services and their perceptions of unmet need. Eighty percent of the patients used therapy services following their injury Those who were more severely injured, were female, had health insurance, or obtained disability compensation made more visits than other subjects. One third of the patients reported that they did not have an adequate number of therapy visits. Subjects cited various reasons (e.g., lack of insurance, transportation difficulties) for unmet need. These findings suggest that the variation in utilization of rehabilitation services depends on not only the severity of the injury but other patient characteristics and resources as well.

Incidence, acute care length of stay, and discharge to rehabilitation of traumatic amputee patients: an epidemiologic study

OBJECTIVE

To examine patterns of trauma-related amputations over time by age and gender of the patient and by level and type of amputation, and to explore factors affecting acute care length of stay and discharge to inpatient rehabilitation.

DESIGN

Population-based hospital discharge data for Maryland from 1979 through 1993.

PARTICIPANTS

Patients (N = 6,069) discharged with either (1) a principal or secondary diagnosis of a trauma-related amputation to the upper or lower extremity or (2) a procedure code for a lower or upper limb amputation in combination with a principal diagnosis of an extremity injury or injury-related complication.

RESULTS

Incidence of major amputations declined 3.4% (p < .05) annually from 1.88 per 100,000 in 1979 to 1.07 per 100,000 in 1993. Incidence of minor amputations declined 4.8% (p < .05) annually from 10.8 per 100,000 in 1979 to 4.7 per 100,000 in 1993. Acute care length of stay for trauma-related amputations declined 40% over the study period and was significantly affected by the patient's payer source, amputation level, and injury characteristics. Of the patients with a major amputation, 15% were discharged to inpatient rehabilitation; 60% were discharged directly home. More proximal amputation levels, presence of severe injuries to other body systems, and acute care at a designated trauma center significantly increased the likelihood of disposition to inpatient rehabilitation. The leading causes of trauma-related amputation were injuries involving machinery (40.1%), powered tools and appliances (27.8%), firearms (8.5%), and motor vehicle crashes (8%).

CONCLUSIONS

Findings suggest a substantial decline in incidence rates of both major and minor amputations over the 15-year study period, a low rate of disposition to inpatient rehabilitation services of patients sustaining major amputations, and an apparent role of firearms as a cause of trauma-related amputations in patients younger than 25 years of age. The consequences of increasingly shorter acute care hospital stays and low rates of discharge to inpatient rehabilitation on the long-term outcomes of persons who have had traumatic amputation should be examined.

Geographic variation in serious nonfatal firearm injuries in Pennsylvania

OBJECTIVE

The purpose of this study was to characterize the geographic epidemiology of serious nonfatal firearm injuries (NFFI) within Pennsylvania during a 6-year period.

METHODS

A historical review of data from the Pennsylvania Trauma System Foundation trauma registry was completed using county-level data. Based on a format adapted from the United States Department of Agriculture, NFFI in Pennsylvania were classified by their county of occurrence: central city counties, metropolitan counties, nonmetropolitan counties, or rural counties. Population-based rates of NFFI were then calculated, as were NFFI as a proportion of the number of injuries within each region. These rates were stratified by intent of injury, scene of injury, and type of firearm.

RESULTS

A total of 100,703 trauma cases were reported to the Pennsylvania Trauma System Foundation from 1988 through 1993, of which 5,847 were serious NFFI. Nonfatal firearm assaults increased from rural counties to central city counties, whereas unintentional NFFI decreased (p < 0.05). A 225% increase in the number of NFFI, from 445 cases in 1988 to 1,004 cases in 1993, was noted in the central city counties. Comparatively, the increase in the noncity regions was 145%, from 182 cases in 1988 to 263 in 1993. Nonfatal firearm injuries occurred most often at home in noncity counties (rural, nonmetropolitan, and metropolitan counties) (47.9%). This is in contrast to central city counties, where NFFI occurred significantly more often in the street (53.5%) (p < 0.05). Handgun NFFI increased, whereas rifle NFFI decreased, from rural counties to central city counties (p < 0.05). Relative to population size, the risk of shotgun injuries was greatest in central city counties and lowest in rural counties. Shotgun injuries also accounted for a significantly longer hospital stay (15.06 days) compared with handgun injuries (10.38 days) and rifle injuries (11.81 days) (p < 0.05).

CONCLUSION

Significant variation in NFFI was observed across population-based regions in Pennsylvania. Rural areas demonstrated relatively high risks of NFFI committed unintentionally, in the home, and with rifles. As regional populations increase, relatively high risks of NFFI, committed as assaults, in the street, and by handguns, are highlighted. Although handguns were the most prominent firearm associated with NFFI, nonfatal shotgun injuries produced substantially longer hospital stays and may be an underappreciated cause of nonfatal firearm assaults in the urban setting.

Adult respiratory distress syndrome, pneumonia, and mortality following thoracic injury and a femoral fracture treated either with intramedullary nailing with reaming or with a plate. A comparative study

Multiply injured patients (an Injury Severity Score of 17 points or more) who were admitted to one of two level-I regional trauma centers between 1983 and 1994 because of a fracture of the femoral shaft with a thoracic injury (an Abbreviated Injury Scale score of 2 points or more) or without a thoracic injury were studied retrospectively. The patient populations and the protocols for the treatment of trauma were similar at the two centers; however, the centers differed with regard to the technique that was used for acute stabilization of the fracture of the femoral shaft. At Center I intramedullary nailing with reaming was used in 217 (95 per cent) of the 229 patients, whereas at Center II a plate was used in 206 (92 per cent) of the 224 patients. This difference was used to investigate the effect of acute femoral reaming on the occurrence of adult respiratory distress syndrome in multiply injured patients who had a chest injury. Three groups of patients were evaluated: those who had both a fracture of the femur and a thoracic injury, those who had a fracture of the femur but no thoracic injury, and those who had a thoracic injury without a fracture of the femur or the tibia. The third group was studied at each center to determine if there was a difference between the institutions with regard to the rate of adult respiratory distress syndrome. Patients who had diabetes, chronic obstructive pulmonary disease, asthma, hepatic or renal failure, or an immunosuppressive condition were excluded from the study. The records were abstracted to determine the Injury Severity Score, Abbreviated Injury Scale score, and Glasgow Coma Score for each patient. Requirements for fluid resuscitation were calculated for the first twenty-four hours; these included the number of units of packed red blood cells, fresh-frozen plasma, and platelets that were transfused and the volume of crystalloid that was used. The duration of intubation, the duration of hospitalization, and the occurence of adverse outcomes (death, multiple organ failure, adult respiratory distress syndrome, pneumonia, and pulmonary embolism) were determined for each patient. The groups of patients were analyzed as a whole and then were stratified into subgroups (according to whether or not they had a thoracic injury and whether the Injury Severity Score was less than 30 points or 30 points or more) to determine if the type of fixation of the femoral fracture affected the rate of adult respiratory distress syndrome or mortality. Logistic regression models were used to analyze the data. The over-all occurrence of adult respiratory distress syndrome in the 453 patients who had a femoral fracture was only 2 per cent (ten patients). The rates of adult respiratory distress syndrome for the patients who had a thoracic injury but no femoral fracture (eight [6 per cent] of 129 patients at Center I, compared with ten [8 per cent] of 125 patients at Center II) did not differ between centers, suggesting that the institutions were comparable in their treatment of multiply injured patients. The occurrence of adult respiratory distress syndrome in the patients who had a femoral fracture without a thoracic injury did not differ substantially according to whether the fracture had been treated with a nail (118 patients) or a plate (114 patients). Likewise, the frequency of adult respiratory distress syndrome, pneumonia, pulmonary embolism, failure of multiple organs, or death for the patients who had a femoral fracture and a thoracic injury was similar regardless of whether nailing with reaming (117 patients) or a plate (104 patients) had been used. The use of intramedullary nailing with reaming for acute stabilization of fractures of the femur in multiply injured patients who have a thoracic injury without a major comorbid disease does not appear to increase the occurrence of adult respiratory distress syndrome, pulmonary embolism, failure of multiple organs, pneumonia, or death.

Effect of trauma and pelvic fracture on female genitourinary, sexual, and reproductive function

OBJECTIVES/HYPOTHESIS

To evaluate the impact of a pelvic fracture on a woman's physical, sexual, and reproductive functioning.

DESIGN

Retrospective review.

SETTING

Level one trauma center.

PATIENTS

Two groups of female multitrauma patients: those with pelvic fractures (subjects) and those with extremity fractures but no pelvic fracture (controls).

MAIN OUTCOME MEASUREMENTS

Of the 302 women eligible for participation in this study, 255 (80%; 123 subjects, 118 controls) were interviewed by blinded professional interviewers regarding genitourinary symptoms, sexual function, and reproductive history.

RESULTS

Urinary complaints occurred significantly more frequently in subjects than in controls (21 versus 7%, respectively; p = 0.003), in subjects with residual pelvic fracture displacement > or = 5 mm than in those without displacement (33 versus 14%, respectively; p = 0.018), and in subjects with residual lateral (60%) or vertical (67%) displacement than in those with medially displaced fractures (21.4%) (p = 0.04). Although both groups reported increased rates of cesarean section, this increase was statistically significant only in the subject group: 14.5% preinjury versus 48% postinjury (p < 0.0001). Adjusting for previous cesarean sections, cesarean section was significantly more frequent in subjects with fractures initially displaced > or = 5 mm (80%) than in those with fractures initially displaced < 5 mm (15%) (p = 0.02). There was no difference in the incidence of miscarriage or infertility between the groups. Problems with physiologic arousal or orgasm were rare. Pain during sex (dyspareunia) was more common in subjects with fractures displaced > or = 5 mm than in those with nondisplaced fractures (43 versus 25%, respectively; p = 0.04).

CONCLUSIONS

We found that pelvic trauma negatively affected the genitourinary and reproductive function of female patients. The increased rate of cesarean section in women after pelvic trauma may be multifactorial in origin and warrants further investigation.

The development of the Functional Capacity Index

OBJECTIVE

This paper describes the development of the Functional Capacity Index (FCI) and compares it to the Abbreviated Injury Scale (AIS) and the Injury Impairment Scale (IIS).

METHODS

The FCI maps 1990 AIS injury descriptions into scores that reflect expected levels of reduced functional capacity at 1 year after injury. Its development involved three steps. First, an expert clinical panel identified 10 relevant dimensions of function and defined levels of capacity within each dimension. A group of 114 individuals then rated the relative severity of different levels of function in terms of their impact on daily living. The third step involved clinical experts assigning FCI scores to AIS '90 injury descriptions based on their knowledge of the likely 1-year consequences associated with each injury. As a first step in validating the FCI, 1 year postinjury levels of impairment (based on range of motion and strength) were correlated with FCI, IIS, and AIS scores derived for 301 patients with severe lower extremity fractures.

RESULTS

Consistency of FCI scores derived within and across dimensions of function argue for the conceptual integrity of the index. Non-zero FCI scores were assigned to only 26% of the 1,272 AIS injury descriptions, indicating that, for most of the injuries in the AIS dictionary, very little or no residual impairment is expected for the average person at 1 year. FCI scores derived for 301 patients with lower extremity fractures ranged from 0 to 63 (out of a possible 100 points). A modest correlation was found between FCI scores and actual levels of impairment observed at 1 year. Compared with the AIS and the IIS, the FCI appeared to discriminate somewhat better among different levels of function.

CONCLUSIONS

Although further empirical validation of the FCI is essential before it can be broadly applied, its development represents an important first step in the generation of an AIS-based measure of expected functional outcome. Its validation is encouraged across a variety of settings and injury types.

Long-term outcomes after lower extremity trauma

Previous studies have shown that over one-quarter of patients who were working before a severe lower extremity fracture had not returned to work by 12 months after injury. Disabilities also persisted in household management, recreation, and social interaction. The objective of this study was to determine whether recovery extended beyond 12 months. Three hundred nineteen patients who were previously working and were treated at three level I trauma centers for a severe lower extremity fracture were prospectively followed at 3, 6, and 12 months after injury. Patients were queried at each follow-up about their work status and completed the Sickness Impact Profile (SIP) at 6 and 12 months. The SIP is a widely used and well validated measure of general health status; it was used in this study to measure functional recovery across several domains of daily living. Patients who had not recovered by 12 months (i.e., 204 who were not working, working with limitations, or had limitations in performing other daily activities as measured by elevated scores on the SIP) were contacted again at 30 months and asked to complete an interview and the SIP. At 30 months, an estimated 82% of the study patients had returned to work (compared to 72% at 12 months). SIP scores improved only slightly from 6.4 at 12 months to 5.7 at 30 months. At 30 months, 64% of the patients had no disability (SIP scores less than 4), 17% had mild disability (SIP scores of 4 to 9), 12% had moderate disability (SIP scores of 10 to 19), and 7% had severe disability (SIP scores of 20 or higher). Although the majority of patients with persistent disabilities at 30 months had residual physical impairments at 12 months, the extent of impairment did not fully explain why some people had and had not recovered at 30 months after injury. The results confirm those of other studies that conclude that overall, outcomes after serious trauma are good when appropriate trauma and rehabilitation care are rendered. However, a minority of patients still report limitations at 30 months after injury, with one-fifth not returning to work.

Functional status following orthopedic trauma in young women

OBJECTIVE

To evaluate the general health status and sexual function of women following serious orthopedic injury.

METHODS

Women aged 16-44 who were treated at a level I trauma center between 1986 and 1992 for a fracture to the pelvis or lower extremity were interviewed by telephone. The interview included the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) supplemented by questions about sexual function. The SF-36 is a measure of outcome from the respondent's point of view and consists of 36 items representing eight health concepts.

RESULTS

Of 289 eligible women, 233 (81%) were interviewed (123 pelvic fracture; 110 lower extremity fracture). Their mean Injury Severity Score was 17.9. Compared to age- and gender-standardized norms, study patients as a group scored significantly worse (lower scores) on all dimensions of the SF-36 except mental health (p < 0.05). Of the women interviewed, 45% reported feeling less sexually attractive due to their injury, and 39% reported a decrease in sexual pleasure. Women who reported arthritis that was attributed to their fracture had significantly poorer health outcomes than study subjects who did not. The most significant predictor of deviations from SF-36 norms was the presence of one or more comorbid chronic conditions.

CONCLUSION

The results underscore the importance of considering comorbidities when evaluating health outcomes following major trauma. In addition, the relatively high rates of reported change in sexual function after injury argue for more attention to these issues in both clinical practice and outcomes research.

A new model for category-scaling data with an application to the development of health-status measures

Category rating is used to assess patient, family-member, provider, and societal preferences for health outcomes. Often, it is of interest to compare ratings obtained from different groups. Standard methods for making comparisons, such as regressions, correlations, and multiple t-tests, do not account for the dependency among ratings. The authors propose a new model for category ratings that does consider their relative dependency. This model provides a profile of ratings for a single group and facilitates comparisons across groups. It was applied to category ratings for four levels of Bending and Lifting function as defined by the recently developed Functional Capacity Index (FCI). Differences in ratings were observed across groups with different personal experiences of functional limitations and across groups with different degrees of clinical knowledge. These differences were not observed when standard methods were used. Thus, ignoring the relative nature of category ratings can lead to different conclusions about group preferences for health outcomes. When the ratings are being used to scale a health-status measure, this discrepancy has implications for the application of the measure in resource allocation.

Progress in the development of trauma systems in the United States. Results of a national survey

OBJECTIVE

To examine the status of trauma system development and key structural and operational characteristics of these systems.

DESIGN AND SETTING

National survey of trauma systems with enabling state statute, regulation, or executive orders and for which designated trauma centers were present.

PARTICIPANTS

Trauma system administrators and directors of 37 state and regional organizations that had legal authority to administer trauma systems, which represented a response rate of 90.2%.

MAIN OUTCOME MEASURES

Trauma system components that had been implemented or were under development.

RESULTS

From 1988 to 1993, the number of states meeting one set of criteria for a complete trauma system criteria increased from two to five. The most common deficiency in establishing trauma systems was failure to limit the number of designated trauma centers based on community need. Although most existing trauma systems have developed formal processes for designating trauma centers, prehospital triage protocols to allow hospital bypass, and centralized trauma registries, several systems lack standardized policies for interhospital transfer and systemwide evaluation.

CONCLUSION

State and regional organizations have accomplished a great deal but still have substantial work ahead in developing comprehensive trauma systems. Research is needed to better understand the relationship between trauma volume and outcomes of care as well as the impact of trauma system structure and operational characteristics on care delivery. Improved measures of patient outcome are also needed so that effective system evaluation can take place.

Trauma centers in the United States: identification and examination of key characteristics

OBJECTIVES

To identify all hospitals in the United States that operated a trauma center between 1980 and 1991 and to contrast their organizational, service, and medical staff characteristics.

DESIGN

Trauma centers were identified through a series of surveys and follow-up discussions with state emergency medical service directors. Data on hospital characteristics were obtained through the American Hospital Association's 1990 Annual Survey of Hospitals.

MATERIALS AND METHODS

Hospital characteristics were compared across: (1) hospitals with and without trauma centers; (2) operational and closed trauma centers; and (3) trauma centers-based on trauma level and source of designation.

MEASUREMENTS AND MAIN RESULTS

Overall, 471 operational trauma centers and 58 hospitals that dropped this service were identified. Several differences were found in hospital operational, service, and medical staff characteristics across hospitals with and without trauma centers and across trauma centers distinguished by trauma level and by whether they continued to provide the service through 1991. Few differences were present across formally designated and self-designated centers.

CONCLUSIONS

The study provides structural and organizational profiles of trauma centers that should help trauma system planners identify strong candidates for trauma center designation.

Functional outcome after pediatric head injury

OBJECTIVES

To examine the consequences of head injury and the medical, economic, and sociodemographic factors affecting functional status 1 year after injury.

METHODS

A follow-up was conducted on 95 children (aged 5 to 15) 1 year after they were hospitalized for head injury. Parents were interviewed by phone concerning their child's preinjury and current health status, and the family's economic and social resources during the 1 year postinjury. Inpatient medical records were reviewed to obtain information regarding the characteristics of the injury.

RESULTS

We found that study children were more likely than children from the general population to have limitations in physical health, behavioral problems, and to be enrolled in a special education program. These findings were true for all levels of head injury severity, although children with severe head injuries (Abbreviated Injury Scale 5) were more likely to demonstrate these functional limitations than were children with less severe injuries (Abbreviated Injury Scale 2, 3, 4). After controlling for head injury severity, we found that the poorer outcomes were associated with poverty, preinjury chronic health problems, and lower extremity injuries.

CONCLUSIONS

The large proportion of children who demonstrated functional limitations underscores the importance of evaluating all children hospitalized with head injuries for functional limitations and providing rehabilitation and social services when needed.

Effect of preinjury illness on trauma patient survival outcome

Data from 11,156 patients treated at the four Major Trauma Outcome Study controlled sites were used to estimate the effect on survival of each APACHE II preinjury illness condition (PIC). A case-control methodology was applied; 544 patients (4.8%) had one or more PICs. For each patient with a specific PIC we identified a set of matching patients with no PICs. A patient matches a PIC patient if both have the same mechanism of injury, the same coding of Revised Trauma Score variables (Glascow Coma Scale score, systolic blood pressure, respiratory rate), the same coded age per A Severity Characterization of Trauma) (ASCOT), and if they differ by no more than 0.5 for A, B, and C (the ASCOT components for serious injuries). The estimated survival probability for a PIC patient is either the survival rate for the patient's matched set or, if there are no matches, the patient's ASCOT survival probability. The survival probabilities were used to compare the actual and predicted numbers of survivors for each PIC, using z and W statistics. Computations of z and W were also made using ASCOT survival probabilities for each PIC patient. The results indicate profound effects of five PICs (hepatic, cardiovascular, respiratory, renal, diabetes) on trauma patient outcomes.

CONCLUSION

Pre-existing organ dysfunction has a profound effect on patient outcome even after controlling for age, anatomic and physiologic severity, and mechanism of injury. But, because of their relatively low incidence in this sample, PICs did not strongly influence institutional outcome performance as measured by z and W values.

Patient-oriented functional outcome after unilateral lower extremity fracture

To determine patient-perceived functional outcome after lower extremity fracture (LEF), a prospective, follow-up study of patients managed at three level I trauma centers was conducted. Patients with unilateral LEF involving the acetabulum and distally were eligible for the study. A total of 444 patients were enrolled. Of these, 363 (82%) were interviewed at 6 months postdischarge. Study patients were predominantly young (mean age 34 years), white (72%) men (71%) who had been working preinjury (78%). Their injuries resulted primarily from motor vehicle crashes (73%); 30% had more than one fracture to the same extremity. Functional status was measured using the Sickness Impact Profile (SIP), a well-validated, general health status instrument. Mean 6-month SIP scores were significantly worse (higher) than those based on preinjury activities (9.8 vs. 2.5) (p < 0.01). Overall disability levels were moderate compared with other health conditions. Analysis of the 12 subscores comprising the SIP indicated particularly high scores in ambulation (16.2 postdischarge vs. 1.1 preinjury), sleep/rest (13.1 vs. 5.1), household management (14.5 vs. 2.6), recreation (17.6 vs. 4.2), emotional well-being (9.9 vs. 2.1), and most significantly work (33.2 vs. 8.8). Of those working preinjury, only 49% had returned by 6 months. SIP scores were highest for persons with three or more fractures to the same extremity and for fracture patterns typical of high-energy forces.

Physical impairment and functional outcomes six months after severe lower extremity fractures

To determine functional outcomes after lower extremity fracture (LEF), a prospective follow-up study of patients admitted to three level I trauma centers for treatment of unilateral LEFs was conducted. In this paper we describe outcomes at 6 months after discharge from the initial hospitalization and examine the relationship between impairment and disability. A total of 444 patients met the entry criteria for the study. Of these 376 (85%) were successfully located and interviewed at 6 months; 302 (68%) returned to the trauma center at 6 months for a clinical assessment by a physical therapist. Study patients were predominantly young (mean age = 32.4), white (72%) men (70%) who were working before the injury (77%). The fractures resulted primarily from motor vehicle crashes (71%); mean hospital LOS was 12 days. Disability was measured using the Sickness Impact Profile (SIP), a well validated patient assessment of health status. The overall SIP score averaged for all patients was 10.2, denoting a moderate level of dysfunction or disability. Analysis of the 12 subscores that constitute the SIP indicate particularly high scores for ambulation (16.7 postdischarge vs. 1.2 preinjury), sleep and rest (14.0 vs. 5.1), emotional behavior (10.5 vs. 2.2), home management (15.1 vs. 2.6), recreation and pastimes (19.0 vs. 4.4), and most notably, work (33.2 vs. 8.3). Further analysis of the subgroup of patients working before the injury shows that 48% had returned to work at 6 months. Correlations between lower extremity impairment (range of motion, muscle strength, and pain) and the ambulation subscore of the SIP were high. However, correlations between impairment and more global areas of activity such as home management, work, and recreation were considerably lower. These results suggest that other factors, over and above the extent of physical impairment, significantly influence broader disability outcomes such as return to work. Further research is needed to define these factors so that effective interventions after acute care can be identified and appropriately targeted.

Inter-rater reliability of preventable death judgments. The Preventable Death Study Group

This study examined the inter-rater reliability of preventable death judgments for trauma. A total of 130 deaths were reviewed for potential preventability by multiple panels of nationally chosen experts. Deaths involving a central nervous system (CNS) injury were reviewed by three panels, each consisting of a trauma surgeon, a neurosurgeon, and an emergency physician. Deaths not involving the CNS were reviewed by three panels, each consisting of two trauma surgeons and an emergency physician. Cases for review were sampled from all hospital trauma deaths occurring in Maryland during 1986. Panels were given prehospital and hospital records, medical examiner reports, and autopsy reports, and asked to independently classify deaths as not preventable (NP), possibly preventable (POSS), probably preventable (PROB), or definitely preventable (DEF). Cases in which there was disagreement about preventability were discussed by the panel as a group (via conference call). Results indicated that overall reliability was low. All three panels reviewing non-CNS deaths agreed in only 36% of the cases (kappa = 0.21). Agreement among panels reviewing CNS deaths was somewhat higher at 56% (kappa = 0.40). Most of the disagreements, however, were in judging whether deaths were NP or POSS. Agreement was higher for early deaths and less severely injured patients. For non-CNS deaths agreement was also higher for younger patients. When both autopsy results and prehospital care reports were available reliability increased across panels. A variety of approaches have been used to elicit judgments of preventability. This study provides information to guide recommendations for future studies involving implicit judgments of preventable death.

Hospitalizations for traumatic injuries among children in Maryland: trends in incidence and severity: 1979 through 1988

Trends in incidence and severity of hospitalized injury among children aged 0 through 13 years in the state of Maryland from 1979 through 1988 (n = 35,746) were examined using routinely reported hospital discharge data. Hospital discharge rates declined over the study period from 509 per 100,000 population in 1979 to 320 in 1988. There was a decline in incidence trends for both races. However, the decrease in the nonwhite population was smaller than in whites. Analysis of incidence rates for specific Injury Severity Score groups revealed a declining trend in all Injury Severity Score groups, although the mildest group (Injury Severity Score 1 through 4) had the most notable decline of 44% compared with an average decline of 20% in the other severity groups. These data suggest a change in admission practices of mildly injured children as a major cause for the observed overall decline in hospitalization rates. The smaller decrease in the hospitalization rates of non-white children compared with white children requires further study to determine the cause.

Effect of associated injuries and blood volume replacement on death, rehabilitation needs, and disability in blunt traumatic brain injury

OBJECTIVE

To examine the effects of associated injuries on death, disability, rehabilitation needs, and cost in patients with blunt traumatic brain injury.

DESIGN

A retrospective case series analysis of 1,709 patients with blunt traumatic brain injury, or 37.2% of 4,590 consecutive blunt trauma patients, was combined with a prospective study of a subset of 202 of the 1,709 brain-injured patients obtained during the same time period with regard to need for rehabilitation services, residual disability, and costs at 1 yr after discharge from the acute trauma center.

SETTING

A level I regional trauma center that is also the statewide neurotrauma and multiple trauma unit serving a population of more than 3 million persons.

RESULTS

Contingency table analysis showed the Glasgow Coma Scale to be highly predictive (p less than .0001) of likelihood of mortality, need for postacute inpatient rehabilitation, or discharge home. Of the blunt traumatic brain injury patients, 40.4% (691) had an isolated brain injury and 59.6% (1,018) had brain plus at least one other systemic injury. The mortality rate of the isolated brain injury group was 11.1% compared with 21.8% in all brain plus systemic injury groups (p less than .0001). Spine, lung, visceral, pelvis, or extremity injuries in blunt traumatic brain injury all increased mortality rate to greater than 25% (all simultaneously significant, p less than .0001). Analysis of the interaction of brain injury (quantified by Glasgow Coma Scale) with blood replacement in the initial 24 hrs showed that at any Glasgow Coma Scale range, percent mortality increased as the volume of blood increased. Hypovolemic shock increased the mortality rate from 12.8% to 62.1% (p less than .0001). The need for postacute inpatient rehabilitation in survivors also increased as blood replacement increased, and shock increased the percent of patients requiring post-acute inpatient rehabilitation from 39.7% to 60.3%. In 202 consecutive surviving brain trauma patients followed for 1 yr, isolated brain-injured patients with moderate brain injuries had a 4% need for posttrauma, postacute inpatient rehabilitation with a total cost per case of $12,489 compared with the brain plus extremity injury group, who had a 23% postacute inpatient rehabilitation rate and a total cost per case of $36,177 at 1 yr. With severe brain injury, isolated brain injury increased postacute inpatient rehabilitation to 29% and 1-yr cost to $59,274, but with the brain plus extremity injury group, postacute inpatient rehabilitation increased to 49% and cost to $84,950.

CONCLUSIONS

In blunt traumatic brain injury, the addition of major visceral or extremity injuries, with need for blood replacement or shock, increases the risk of death, the need for rehabilitation, and the costs of disability.

Trauma patients return to productivity

Economic issues threaten the development of a national trauma system. Much work has focused on the cost of trauma care; little has been done to define society's long-term economic return. We asked three questions about high cost trauma patients: (1) Do they survive?, (2) Do they continue to require expensive care?, and (3) Do they return to productivity? Of 6,129 consecutive trauma admissions, 114 had hospital charges over $100,000 (mean = $143,000), 102 (89.5%) were discharged alive, and 10 (8.8%) were lost to followup. Ninety-two patients or families were interviewed at least 1 year (mean = 2.6 year) after discharge. There were 88 survivors and 4 deaths (3.5%). Of the 88 survivors 73% had no limitation of ADLs, 67% received rehabilitation, 58% were still improving, and 37% were involved in litigation. Five survivors (5.7%) were confined to a nursing home, 48 (54.5%) had returned to productivity (RTP), 35 (39.8%) were unemployed, and five of these still require medical therapy. We conclude: (1) The majority of high cost patients survive (89.5%) and return to productivity (54.5%); (2) the severity of injury predicts survival but not return to productivity; and (3) the RTP rate may be increased by addressing nonmedical need.

Evaluating quality, cost-effective health care. Vascular database predicated on hospital discharge abstracts

This population-based study examines all carotid endarterectomies (CE) performed by all surgeons in a single state over a 10-year period. The methodology is designed to determine morbidity rate, mortality rate, cost, and length of stay, as well as to understand the effect of pre-existing chronic disease, physician, and hospital volume on these outcome variables. The data source consisted of hospital discharge abstract data uniformly collected on all admissions (N = 5.9 million) to acute care hospitals in the state. In the decade 1979 to 1988, 11,199 patients underwent CE. Mortality rate from CE was 2.1%, and the postoperative stroke rate was 3.7% over this period. High physician volume decreased the mortality rate (p less than 0.05) and stroke rate (p less than 0.01) by 50% and significantly (p less than 0.001) reduced hospital cost and length of stay independent of patient complexity. Examination of cost data, adjusted for inflation, showed a decrease in mean cost for CE over the decade. Thus physicians are providing better care for less hospital dollars. Both patient and payor outcome is improved by concentrating CE patients in the hands of high-volume surgeons. Although the data suggests this trend is already evolving, the pace of this evolution can be expected to increase as payors recognize that regionalization of this procedure lowers costs.

Trauma case mix and hospital payment: the potential for refining DRGs

Uniform hospital discharge abstract data from Maryland were used to examine the homogeneity of trauma-related DRGs with respect to a well-established measure of injury severity, the Injury Severity Score (ISS). Thirty DRGs were identified as including trauma cases with a wide range of severity; for each of these DRGs, ISS explains a significant amount of variation in length of stay. By applying statistical techniques similar to those used to create the original DRG groupings, these 30 DRGs were subdivided by severity and age categories to create a new set of severity-modified DRGs. The potential effects of using DRGs and modified DRGs to pay for inpatient care within the Maryland state regionalized system of trauma care were examined. Payments based on regional averages per DRG and per modified DRG were compared to actual hospital charges regulated by the state's Health Services Cost Review Commission. Using average charges per DRG as a basis of payment, approximately !1.4 million (11 percent of total hospital charges) would be shifted from trauma centers to nontrauma centers. This shift represents an 18 percent loss in revenues to trauma centers and a 30 percent gain in revenues to nontrauma centers. Using a payment system based on severity-modified DRGs, trauma centers would still experience a net loss in revenues and the nontrauma centers a net gain, but the total amount of the shift would be reduced from $11.4 million to $9.8 million. The results argue for the need to explore alternative payment systems not strictly based on current DRGs. Because of DRGs do not adequately reflect severity differences, using them to pay hospitals will create financial incentives that discourage regionalization of trauma care.

Trauma care reimbursement: comparison of DRGs to an injury severity-based payment system

Concern exists that per case payment using Diagnosis Related Groups (DRGs) inadequately pays trauma centers. In this study, 45 Trauma Resource Groups (TRGs), an alternative patient classification system based on the Injury Severity Score and patient age, is developed and compared to 172 Diagnosis Related Groups (DRGs) that include trauma diagnoses. TRGs were developed using 1983 Maryland trauma patient hospital discharge abstracts (n= 34,702), the same source used to assign a DRG. We compared estimated TRG and DRG payments to actual charges for 17,398 trauma cases treated during 1986 at five trauma centers and 18 community hospitals in the Central Maryland Metropolitan Statistical Area. The unexpected findings of this study are that an anatomic severity-based classification of hospital trauma discharges (TRGs) does not perform as well as DRGs in: 1) explaining variations in length of stay for trauma cases, or 2) assuring an appropriate distribution of revenues to regional trauma centers and community hospitals. Solutions discussed include segregating community hospital and trauma center costs in computation of average per case rate setting, and inclusion of physiologic and mechanism of injury parameters in prospective payment classification systems to increase explained variance of resource use.

Coding external causes of injury (E-codes) in Maryland hospital discharges 1979-88: a statewide study to explore the uncoded population

We examined the trends in hospital discharge E-coding in Maryland over a 10-year period. The overall proportion of E-coded discharges has increased from 40 percent in 1979 to 55 percent in 1988. E-coding was lower in the severely injured, the elderly, and patients with long hospital stays. Our findings demonstrate that E-code reporting varies because of the limited number of data fields available for coding of discharge diagnoses. Universal, systematic reporting of E-codes in hospital discharge data is essential if these data are to provide critically needed information about nonfatal injuries. Hospital discharge data formats should contain separate fields for E-codes and the use of these codes, we believe, should be mandated.

Mortality in trauma patients: the interaction between host factors and severity

Data on host factors influencing mortality in trauma patients is sparse and contradictory. To develop a model for health policy decisions, we examined all trauma admissions to acute care hospitals in the state of California in the year 1986. We looked at the influence of the following host factors: age, gender, and preinjury medical conditions, on mortality stratified by injury severity. The study group (N = 199,737) had an overall mortality rate of 1.9%. Mortality increased starting at age 40 years and was independently influenced by gender, the presence of pre-existing disease, and the body region injured. In patients with minor injury, mortality rates became higher in the elderly at age 65+. However, in patients with injuries of moderate severity, mortality increased in both middle age (40-64) and elderly groups (65+). Male gender was also a risk factor, present in both the elderly and middle age groups. While the presence of both pre-existing medical disease or injury to head or abdomen was related to increased mortality in middle-aged patients at all severity levels, neither accounted for the effect of gender. Conclusion. Age and gender influence mortality in trauma patients. These effects are not explained by documented pre-existing disease or region of injury. Age and gender serve only as observable markers for subgroups of patients with impaired response to injury. Middle-aged males comprise a previously unrecognized high-risk subgroup for this impaired response.

Acute hospital costs of pediatric trauma in the United States: how much and who pays?

National estimates of the numbers and expenditures associated with hospitalization due to injury among children (aged 0 to 14) were derived using data from the 1984, 1985, and 1986 National Hospital Discharge Surveys (NHDS) and the 1980 National Medical Care Utilization and Expenditures Study (NMCUES). In this report, age- and sex-specific estimates of the numbers of hospital admissions and expenditures are reported for subgroup of patients defined by external cause of the injury and by nature and severity of the injury. In 1985, over 266,000 children sustained a traumatic injury resulting in hospitalization (rate of 51 per 10,000 children). Expenditures totaled nearly $1 billion. Over 80% of the hospitalizations and two thirds of total expenditures were for minor (Maximum AIS = 1.2) trauma. Moderate (Maximum AIS = 3) and severe (Maximum AIS = 4,5) trauma accounted for 18% and 2% of admissions and 31% and 8% of expenditures, respectively. Falls ranked first in expenditures and admissions (36% of the total). Motor vehicle-related injuries accounted for 19% of trauma admissions and 24% of expenditures. Other less common causes included bicycle injuries, penetrating injuries and injuries caused by the child being hit by an object or person. An estimated 28% of the total hospital charges were paid for by public sources (15% from federal government programs, 13% from state and local programs). An additional 63% of total expenditures were paid for by private sources, with the remaining 9% considered uninsured care.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute hospital costs of trauma in the United States: implications for regionalized systems of care

As part of a larger effort to determine total direct and indirect costs of injury in the United States, national estimates of the numbers and expenditures associated with acute hospitalization due to traumatic injury were derived using data from the 1984, 1985, and 1986 National Hospital Discharge Surveys (NHDS). Estimates of the numbers of hospital episodes and total expenditures are reported in this paper for subgroups of patients defined by age, sex, and body region and AIS severity of the injuries sustained. In 1985 2.1 million individuals sustained a traumatic injury which resulted in hospitalization. Hospital expenditures totaled $11.4 billion inclusive of professional fees. Adolescents and young adults aged 15-44 years accounted for nearly one half of all discharges and total hospital costs. The elderly, who represent only 12% of the population, accounted for an additional one quarter of total discharges and hospital costs. Nearly three quarters of the hospitalizations and one half of total expenditures were for minor (ICD/AIS = 1, 2) injuries. Moderate (ICD/AIS = 3) and severe (ICD/AIS = 4, 5), injuries respectively accounted for 23% and 3% of total episodes and 37% and 11% of total expenditures. Only 12% of patients and 25% of trauma care dollars involved injuries sufficiently severe to require treatment at a trauma center.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluating performance of statewide regionalized systems of trauma care

A new methodology is presented for evaluating the extent to which patients within regionalized systems of trauma care are treated at the appropriate hospitals. Criteria are proposed for retrospectively classifying trauma patients as to whether they should have been treated at a trauma center. The criteria were developed by a panel of nationally recognized trauma experts and are based on the age of the patient and the type and AIS severity of injuries sustained. The criteria were then applied to uniformly collected data available for all trauma discharges in 1988 from acute care hospitals in a state with a well developed system of regionalized trauma care. According to the criteria, 19% of all trauma discharges in 1988 should have been treated at a trauma centers. Of those who should have been treated at a trauma center according to criteria, 66% actually received treatment at a center. Of those who were classified not to have required care at a trauma center, 62% actually were treated at non-trauma center hospitals. The congruence between where patients should have been treated and the actual level of hospital care received varied by the type and severity of the traumatic injuries sustained. The results of the analysis provide insights into the characteristics of trauma patients at higher risk of not getting the appropriate level of trauma care and should assist in improving guidelines for triage and transfer within a regionalized system of care.