Exploring the similarities and differences of burn registers globally: Results from a data dictionary comparison study

INTRODUCTION

Pooling and comparing data from the existing global network of burn registers represents a powerful, yet untapped, opportunity to improve burn prevention and care. There have been no studies investigating whether registers are sufficiently similar to allow data comparisons. It is also not known what differences exist that could bias analyses. Understanding this information is essential prior to any future data sharing. The aim of this project was to compare the variables collected in countrywide and intercountry burn registers to understand their similarities and differences.

METHODS

Register custodians were invited to participate and share their data dictionaries. Inclusion and exclusion criteria were compared to understand each register population. Descriptive statistics were calculated for the number of unique variables. Variables were classified into themes. Definition, method, timing of measurement, and response options were compared for a sample of register concepts.

RESULTS

13 burn registries participated in the study. Inclusion criteria varied between registers. Median number of variables per register was 94 (range 28 - 890), of which 24% (range 4.8 - 100%) were required to be collected. Six themes (patient information, admission details, injury, inpatient, outpatient, other) and 41 subthemes were identified. Register concepts of age and timing of injury show similarities in data collection. Intent, mechanism, inhalational injury, infection, and patient death show greater variation in measurement.

CONCLUSIONS

We found some commonalities between registers and some differences. Commonalities would assist in any future efforts to pool and compare data between registers. Differences between registers could introduce selection and measurement bias, which needs to be addressed in any strategy aiming to facilitate burn register data sharing. We recommend the development of common data elements used in an international minimum data set for burn injuries, including standard definitions and methods of measurement, as the next step in achieving burn register data sharing.

Aetiology of bioethanol related burn accidents: A qualitative study

BACKGROUND

Since insight into the motivation of behaviour in bioethanol related burn accidents is lacking, this study aimed to qualitatively examine influencing factors in bioethanol related burn accidents. In order to identify target points for effective burn prevention.

METHODS

Patients previously admitted with bioethanol related acute non-intentional burn injury to the three Dutch burn centres were eligible. One interviewer conducted fourteen semi-structured interviews. Interviews were transcribed and coded by two independent researchers. Conclusions were drawn based on generalised statements on the concerned topics.

RESULTS

Four overall themes in influencing factors were found, namely 1) motivation; including non-designated use and impaired judgement, 2) knowledge and education; including unknown product and properties and information overload, 3) risk perception; including poor recognisability of risks and preferred trial and error and 4) thresholds; including easy availability and unclear liability.

CONCLUSION

Trust in consumers may be over-estimated, as proper use cannot be expected. To prevent future bioethanol related burn incidents, thresholds for obtaining and using bioethanol should be increased, safe alternatives to ignite open fires and wood stoves should be provided and knowledge and warnings should be improved.

Timing of surgery in acute deep partial-thickness burns: A study protocol

For deep partial-thickness burns no consensus on the optimal treatment has been reached due to conflicting study outcomes with low quality evidence. Treatment options in high- and middle-income countries include conservative treatment with delayed excision and grafting if needed; and early excision and grafting. The majority of timing of surgery studies focus on survival rather than on quality of life. This study protocol describes a study that aims to compare long-term scar quality, clinical outcomes, and patient-reported outcomes between the treatment options. A multicentre prospective study will be conducted in the three Dutch burn centres (Rotterdam, Beverwijk, and Groningen). All adult patients with acute deep-partial thickness burns, based on healing potential with Laser Doppler Imaging, are eligible for inclusion. During a nine-month baseline period, standard practice will be monitored. This includes conservative treatment with dressings and topical agents, and excision and grafting of residual defects if needed 14-21 days post-burn. The subsequent nine months, early surgery is advocated, involving excision and grafting in the first week to ten days post-burn. The primary outcome compared between the two groups is long-term scar quality assessed by the Patient and Observer Scar Assessment Scale 3.0 twelve months after discharge. Secondary outcomes include clinical outcomes and patient-reported outcomes like quality of life and return to work. The aim of the study is to assess long-term scar quality in deep partial-thickness burns after conservative treatment with delayed excision and grafting if needed, compared to early excision and grafting. Adding to the ongoing debate on the optimal treatment of these burns. The broad range of studied outcomes will be used for the development of a decision aid for deep partial-thickness burns, to fully inform patients at the point of consent to surgery and support optimal person-centred care.

Effectiveness of tranexamic acid in burn patients undergoing surgery - a systematic review and meta-analysis

BACKGROUND

Reducing blood loss during excisional surgery in burn patients remains a challenge. Tranexamic acid during surgery can potentially reduce blood loss. The use of tranexamic acid during excisional surgery in burn patients has recently been described in a review and meta-analysis. However, quality assessment on studies included was not performed and this review did not apply independent reviewers. Quality assessment of studies investigating the effectiveness of tranexamic acid in burn patients is crucial before concusions can be drawn. Therefore, we conducted a systematic review and meta-analysis of the literature investigating the effectiveness of tranexamic acid in burn patients undergoing surgery.

METHODS

A systematic review and meta-analysis of the literature was conducted. The study was pre-registered in PROSPERO database (CRD42023396183).

RESULTS

Five studies including two randomised controlled trials (RCTs) with a total of 303 patients were included. Risk of bias of the included studies was moderate to high. Individual results of the studies were heterogeneous. In three studies of moderate quality the administration of tranexamic acid resulted in a reduction of blood loss per unit excised area, accounting as moderate level of evidence. In two low-quality studies and one moderate quality study the administration of tranexamic acid resulted in a reduction of transfused packed Red Blood Cells (pRBC's), accounting for moderate level of evidence. Postoperative haemoglobin levels were higher after tranexamic acid administration in one study, accounting for insufficient evidence. Meta-analysis pooling overall blood loss from two separate RCTs failed to detect a statistically significant reduction. Substantial heterogeneity was observed.

CONCLUSIONS

Moderate level of evidence indicates that tranexamic acid reduces blood loss per unit of excised area and transfusion of packed Red Blood Cells. Results indicate that tranexamic acid can be beneficial in burn patients undergoing surgery. More high-quality research is needed to confirm these results. Future studies should focus on the dosing of tranexamic acid, the administration approaches, and even consider combining these approaches.

TRIAL REGISTRATION

PROSPERO: CRD42023396183.

Laser speckle contrast imaging, an alternative to laser doppler imaging in clinical practice of burn wound care derivation of a color code

OBJECTIVE

To develop a color code and to investigate the validity of Laser Speckle Contrast Imaging (LSCI) for measuring burn wound healing potential (HP) in burn patients as compared to the reference standard Laser Doppler Imaging (LDI).

METHOD

A prospective, observational, cohort study was conducted in adult patients with acute burn wounds. The relationship between mean flux measured with LDI and mean perfusion units (PU) measured with LSCI was expressed in a regression formula. Measurements were performed between 2 and 5 days after the burn wound. The creation of a LSCI color code was done by mapping the clinically validated color code of the LDI to the corresponding values on the LSCI scale. To assess validity of the LSCI, the ability of the LSCI to discriminate between HP < 14 and ≥ 14 days and HP < 21 and original ≥ 21 days according to the LDI reference standard was evaluated, with calculation of receiver operating characteristics (ROC) curves.

RESULTS

A total of 50 patients were included with a median age of 40 years and total body surface area burned of 6%. LSCI values of 143 PU and 113 PU were derived as the cut-off values for the need of conservative treatment (HP < 14 and ≥ 14 days) resp. surgical closure (HP < 21 and ≥ 21 days). These LSCI cut off values showed a good discrimination between HP 14 days versus ≥ 14 days (Area Under Curve (AUC)= 0.89; sensitivity 85% and specificity = 82%) and a good discrimination between HP 21 days versus ≥ 21 days (AUC of 0.89, sensitivity 81% and specificity 88%).

CONCLUSION

This is the first study in which a color code for the LSCI in adult clinical burn patients has been developed. Our study reconfirms the good performance of the LSCI for prediction of burn wound healing potential. This provides additional evidence for the potential value of the LSCI in specialized burn care.

Reliability and validity of a frailty assessment tool in specialized burn care, a retrospective multicentre cohort study

BACKGROUND

Frailty is a predictor of adverse outcomes in elderly patients. The Canadian Study of Health and Aging Clinical Frailty Scale (CFS) is an often-used frailty assessment instrument. However, the CFS's reliability and validity in patients with burn injuries are unknown. This study aimed to assess the CFS's inter-rater reliability and validity (predictive validity, known group validity and convergent validity) in patients with burn injuries treated to specialized burn care.

METHODS

A retrospective multicentre cohort study was conducted in all three Dutch burn centres. Patients aged ≥ 50 years with burn injuries, with a primary admission in 2015-2018, were included. Based on information in the electronic patient files, a research team member scored the CFS retrospectively. Inter-rater reliability was calculated using Krippendorff's α. Validity was assessed using logistic regression analysis. Patients with a CFS ≥ 5 were considered frail.

RESULTS

In total, 540 patients were included, with a mean age of 65.8 years (SD 11.5) and a Total Body Surface Area (TBSA) burned of 8.5%. The CFS was used to assess frailty in 540 patients and the reliability of the CFS was scored for 212 patients. Mean CFS was 3.4(SD 2.0). Inter-rater reliability was adequate, Krippendorff's α 0.69 (95%CI 0.62-0.74). A positive frailty screening was predictive of a non-home discharge location (OR 3.57, 95%CI 2.16-5.93), a higher in-hospital mortality rate (OR 1.06-8.77), and a higher mortality rate within 12 months after discharge (OR 4.61, 95%CI 1.99-10.65) after adjustment for age, TBSA, and inhalation injury. Frail patients were more likely to be older (for<70 vs. ≥70 years odds ratio 2.88, 95%CI 1.95-4.25) and their comorbidities were more severe (ASA ≥3 vs 1-2 OR 6.43, 95%CI 4.26-9.70) (known group validity). The CFS was significantly related (rSpearman=0.55) to the Dutch Safety Management System (DSMS) frailty screening, reflecting a fair-good correlation between the CFS and DSMS frailty screening outcomes.

CONCLUSION

The Clinical Frailty scale is reliable and has shown its validity, including its association with adverse outcomes in patients with burn injury admitted to specialized burn care. Early frailty assessment with the CFS must be considered, to optimize early recognition and treatment of frailty.

Short-term and long-term increased mortality in elderly patients with burn injury: a national longitudinal cohort study

BACKGROUND

The population of elderly patients with burn injuries is growing. Insight into long-term mortality rates of elderly after burn injury and predictors affecting outcome is limited. This study aimed to provide this information.

METHODS

A multicentre observational retrospective cohort study was conducted in all three Dutch burn centres. Patients aged ≥65 years, admitted with burn injuries between 2009 and 2018, were included. Data were retrieved from electronic patient records and the Dutch Burn Repository R3. Mortality rates and standardized mortality ratios (SMRs) were calculated. Multivariable logistic regression was used to assess predictors for in-hospital mortality and mortality after discharge at 1 year and five-year. Survival analysis was used to assess predictors of five-year mortality.

RESULTS

In total, 682/771 admitted patients were discharged. One-year and five-year mortality rates were 8.1 and 23.4%. The SMRs were 1.9(95%CI 1.5-2.5) and 1.4(95%CI 1.2-1.6), respectively. The SMRs were highest in patients aged 75-80 years at 1 year (SMRs 2.7, 95%CI 1.82-3.87) and five-year in patients aged 65-74 years (SMRs 10.1, 95%CI 7.7-13.0). Independent predictors for mortality at 1 year after discharge were higher age (OR 1.1, 95%CI 1.0-1.1), severe comorbidity, (ASA-score ≥ 3) (OR 4.8, 95%CI 2.3-9.7), and a non-home discharge location (OR 2.0, 95%CI 1.1-3.8). The relative risk of dying up to five-year was increased by age (HR 1.1, 95%CI 1.0-1.1), severe comorbidity (HR 2.3, 95%CI 1.6-3.5), and non-home discharge location (HR 2.1, 95%CI 1.4-3.2).

CONCLUSION

Long-term mortality until five-year after burn injury was higher than the age and sex-matched general Dutch population, and predicted by higher age, severe comorbidity, and a non-home discharge destination. Next to pre-injury characteristics, potential long-lasting systemic consequences on biological mechanisms following burn injuries probably play a role in increased mortality. Decreased health status makes patients more prone to burn injuries, leading to early death.

The burden of disease of fatal and non-fatal burn injuries for the full spectrum of care in the Netherlands

BACKGROUND

A comprehensive overview of the burden of disease of burns for the full spectrum of care is not available. Therefore, we estimated the burden of disease of burns for the full spectrum in the Netherlands in 2018, and explored whether the burden of disease changed over the past 5 years (2014-2018).

METHODS

Data were collected at four levels: general practice, emergency department, hospital, and mortality data. For each level, years lived with disability (YLD), years of life lost (YLL), and disability-adjusted life-years (DALY) were estimated using a tailored methodology.

RESULTS

Burns resulted in a total of 9278 DALYs in the Netherlands in 2018, comprising of 7385 YLDs (80%) and 1892 YLLs (20%). Burn patients who visited the general practice contributed most DALYs (64%), followed by deceased burn patients (20%), burn patients admitted to hospital (14%) and those treated at the emergency department (2%). The burden of disease was comparable in both sexes (4734 DALYs (51%) for females; 4544 DALYs (49%) for males), though the distribution of DALYs by level of care varied; females contributed more DALYs at the general practice level, and males at all other levels of care. Among children boys 0-4 years had the highest burden of disease (784 DALYs (9%)), and among adults, females 18-34 years old (1319 DALYs (14.2%)) had the highest burden of disease. Between 2014 and 2018 there was a marginal increase of 0.8% in the number of DALYs.

CONCLUSIONS

Burns cause a substantial burden of disease, with burns requiring care at the general practice level contributing most DALYs. Information on burden of burns by the full level of care as well as by subgroup is important for the development of tailored burn prevention strategies, and the updated figures are recommended to be used for priority setting and resource allocation.

Hydrosurgical and conventional debridement of burns: randomized clinical trial

BACKGROUND

Tangential excision of burned tissue followed by skin grafting is the cornerstone of burn surgery. Hydrosurgery has become popular for tangential excision, with the hypothesis that enhanced preservation of vital dermal tissue reduces scarring. The aim of this trial was to compare scar quality after hydrosurgical versus conventional debridement before split-skin grafting.

METHODS

A double-blind randomized within-patient multicentre controlled trial was conducted in patients with burns that required split-skin grafting. One wound area was randomized to hydrosurgical debridement and the other to Weck knife debridement. The primary outcome was scar quality at 12 months, assessed with the observer part of the Patient and Observer Scar Assessment Scale (POSAS). Secondary outcomes included complications, scar quality, colour, pliability, and histological dermal preservation.

RESULTS

Some 137 patients were randomized. At 12 months, scars of the hydrosurgical debrided wounds had a lower POSAS observer total item score (mean 2.42 (95 per cent c.i. 2.26 to 2.59) versus 2.54 (95 per cent c.i. 2.36 to 2.72; P = 0.023)) and overall opinion score (mean 3.08 (95 per cent c.i. 2.88 to 3.28) versus 3.30 (95 per cent c.i. 3.09-3.51); P = 0.006). Patient-reported scar quality and pliability measurements were significantly better for the hydrosurgically debrided wounds. Complication rates did not differ between both treatments. Histologically, significantly more dermis was preserved with hydrosurgery (P < 0.001).

CONCLUSION

One year after surgery scar quality and pliability was better for hydrosurgically debrided burns, probably owing to enhanced histological preservation of dermis.

REGISTRATION NUMBER

Trial NL6085 (NTR6232 (http://www.trialregister.nl)).

The feasibility and reliability of frailty assessment tools applicable in acute in-hospital trauma patients: A systematic review

BACKGROUND

Assessing frailty in patients with an acute trauma can be challenging. To provide trustworthy results, tools should be feasible and reliable. This systematic review evaluated existing evidence on the feasibility and reliability of frailty assessment tools applied in acute in-hospital trauma patients.

METHODS

A systematic search was conducted in relevant databases until February 2020. Studies evaluating the feasibility and/or reliability of a multidimensional frailty assessment tool used to identify frail trauma patients were identified. The feasibility and reliability results and the risk of bias of included studies were assessed. This study was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and registered in Prospective Register of Systematic Reviews (ID: CRD42020175003).

RESULTS

Nineteen studies evaluating 12 frailty assessment tools were included. The risk of bias of the included studies was fair to good. The most frequently evaluated tool was the Clinical Frailty Scale (CFS) (n = 5). All studies evaluated feasibility in terms of the percentage of patients for whom frailty could be assessed; feasibility was high (median, 97%; range, 49-100%). Other feasibility aspects, including time needed for completion, tool availability and costs, availability of instructions, and necessity of training for users, were hardly reported. Reliability was only assessed in three studies, all evaluating the CFS. The interrater reliability varied between 42% and >90% agreement, with a Krippendorff α of 0.27 to 0.41.

CONCLUSION

Feasibility of most instruments was generally high. Other aspects were hardly reported. Reliability was only evaluated for the CFS with results varying from poor to good. The reliability of frailty assessment tools for acute trauma patients needs further critical evaluation to conclude whether assessment leads to trustworthy results that are useful in clinical practice.

LEVEL OF EVIDENCE

Systematic review, Level II.

Burn injuries in primary care in the Netherlands: Risk factors and trends

BACKGROUND

Research to date has mainly focused on burn injuries treated in secondary care. This study aims to provide knowledge on the epidemiology of burn injuries in primary care, to give directions for burn prevention.

METHODS

Data were derived from routine electronic health records of general practices and their out-of-hours service organisations in the Netherlands that participated in the Nivel Primary Care Database 2010-2015. We studied risk factors and trends.

RESULTS

The average burn injury prevalence rate was 4.40 (95% CI 4.27-4.53) per 1000 person-years in daytime general practice care and 1.47 (95% CI 1.46-1.49) per 1000 inhabitants in out-of-hours care. Children of 0-4 years old, especially boys, and young adult women had a higher risk. Burn injury risk was higher during the summer months and around New Year's Eve. Living in low socioeconomic and strongly urbanised neighbourhoods was associated with a higher risk of burn injury than living in other neighbourhoods.

CONCLUSION

Dutch general practitioners have a large share in burn care and therefore can play a significant role in burn prevention. Prevention may be most effective in the summer and around New Year's Eve, and specific attention seems to be warranted for low socioeconomic groups and strongly urbanised neighbourhoods.

Activity impairment, work status, and work productivity loss in adults 5-7 years after burn injuries

An important aspect of the rehabilitation of burn patients is social participation, including daily activities and work. Detailed information on long-term activity impairment and employment is scarce. Therefore, we investigated activity impairment, work status, and work productivity loss in adults 5–7 years following burn injuries, and investigated associations with burn-specific health-related quality of life (HRQL) domains. Adult participants completed the Work Productivity and Activity Impairment General Health questionnaire and the Burn Specific Health Scale-brief (BSHS-B) 5–7 years post-burn. Outcomes were compared between participants with mild/intermediate and severe burns (>20% total body surface area burned). Seventy-six (36%) of the 213 participants experienced some degree of activity impairment due to burn-related problems 5–7 years post-burn. Seventy percent of the population was employed; 12% of them experienced work productivity loss due to burn-related problems. Nineteen percent reported changes in their work situation (partly) because of the burn injury. A higher proportion of participants with severe burns had activity impairments (56% vs 29%; P = .001) and work productivity loss (26% vs 8%; P < .001) compared to participants with mild/intermediate burns. Activity impairment and work productivity loss were both associated with burn-related work problems and lower mood, measured with the BSHS-B. In conclusion, a substantial part of the study population experienced activity impairment and work productivity loss, was unemployed, and/or reported changes in their work situation due to their injury. Particularly patients with severe burns reported productivity loss and had lower employment rates. This subscribes the importance of addressing work-related functioning in the rehabilitation of burn patients.

Patient-reported scar quality of donor-sites following split-skin grafting in burn patients: Long-term results of a prospective cohort study

BACKGROUND

Skin grafting is the current gold standard for treatment of deeper burns. How patients appraise the donor-site scar is poorly investigated. The aim of this study was to evaluate long-term patient-reported quality of donor-site scars after split skin grafting and identify possible predictors.

METHODS

A prospective cohort study was conducted. Patients were included in a Dutch burn centre during one year. Patient-reported quality of donor-site scars and their worst burn scar was assessed at 12 months using the Patient and Observer Scar Assessment Scale (POSAS). Mixed model analyses were used to identify predictors of scar quality.

RESULTS

This study included 115 donor-site scars of 72 patients with a mean TBSA burned of 11.2%. The vast majority of the donor-site scars (84.4%) were rated as having at least minor differences with normal skin (POSAS item score ≥2) on one or more scar characteristics and the overall opinion on 80.9% of the donor-site scars was that they deviated from normal skin 12 months after surgery. The overall opinion on the donor-site scar was 3.2 ± 2.1 vs. 5.1 ± 2.4 on the burn scar. A younger age, female gender, a darker skin type, and location on the lower leg were predictors of reduced donor-site scar quality. In addition, time to re-epithelization was associated with scar quality.

CONCLUSION

This study provided new insights in long-term scar quality of donor-sites. Donor-site scars differed from normal skin in a large part of the population 12 months after surgery. Results of this study can be used to inform patients on the long-term outcomes of their scars and to tailor preventive or therapeutic treatment options.

Burns in the elderly: a nationwide study on management and clinical outcomes

Background

In modern-day burn care, advanced age remains an important predictor for mortality among burn victims. In this study, we compared the complete treatment trajectory (including pre-hospital and surgical treatment) and the outcomes between an elderly burn population and a younger adult burn population.

Methods

In this nationwide study, data from the Dutch Burn Repository were used. This is a uniform national registration for Dutch specialized burn care. All adult patients that were admitted to one of the three Dutch burn centres from the period 2009 to 2015 were included in the analysis. Burn patients were considered as elderly when ≥65 years of age, and were then further subdivided into three age categories: 65-74, 75-85 and 85+ years. Younger adults in the age category 18-64 years were used as the reference group.Surgical management was studied comprehensively and included timing of surgery, the number of procedures and details on the surgical technique, especially the technique used for debridement and the grafting technique that was applied.For the comparison of clinical outcome, the following parameters were included: mortality, wound infections, length of stay/TBSA (total body surface area) burned, discharge disposition and secondary reconstructions.

Results

During the study period, 3155 adult patients were included (elderly, n = 505). Burn severity, reflected by the median TBSA, varied between 3.2-4.0% and was comparable, but aetiology and pre-hospital care were different between elderly and the younger adult reference group.Surgical treatment was initiated significantly faster in elderly burn patients (p < 0.001). Less selective techniques for surgical debridement were used in the elderly burns patients (hydrosurgery, 42.0% vs 23.5-22.6%), and on the other hand more avulsion (5.3% vs 7.3-17.6%) and primary wound closure (6.7% vs 24.5%). The most frequently used grafting technique was meshed skin grafts (79.2-88.6%); this was not related to age.Mortality increased rapidly with a higher age and showed a high peak in the 85+ category (23.8%). Furthermore, considerable differences were found in hospital discharge disposition between the elderly and the reference group.

Conclusions

In conclusion, elderly burn patients who require specialized burn care are vulnerable and medically challenging. Differences in aetiology, comorbidity, physiology and the management prior to admission possibly affect the initial surgical management and result in significantly worse outcomes in elderly. Elderly patients need optimal, timely and specialized burn care to enhance survival after burn injuries.

Comparison of three different methods to estimate the burden of disease of burn injuries in Western Australia in 2011-2018

BACKGROUND

Priority setting and resource allocation in health care, surveillance and interventions is based increasingly on burden of disease. Several methods exist to calculate the non-fatal burden of disease of burns expressed in years lived with disability (YLDs). The aim of this study was to assess the burden of disease due to burns in Western Australia 2011-2018 and compare YLD outcomes between three existing methods.

METHODS

Data from the Burns Service of Western Australia was used. Three existing methods to assess YLDs were compared: the Global Burden of Disease (GBD) method, a method dedicated to assess injury YLDs (Injury-VIBES), and a method dedicated to assess burns YLDs (INTEGRIS-burns).

RESULTS

Incidence data from 2,866 burn patients were used. Non-fatal burden of disease estimates differed substantially between the different methods. Estimates for 2011-2018 ranged between 610 and 1,085 YLDs per 100.000 based on the Injury-VIBES method; between 209 and 324 YLDs based on the INTEGRIS-burns method; and between 89 and 120 YLDs based on the GBD method. YLDs per case were three to nine times higher when the Injury-VIBES method was applied compared to the other methods. Also trends in time differed widely through application of the different methods. There was a strong increase in YLDs over the years when the Injury-VIBES method was applied, a slight increase when the INTEGRIS-burns method was applied and a stable pattern when the GBD method was applied.

CONCLUSION

This study showed that the choice for a specific method heavily influences the non-fatal burden of disease expressed in YLDs, both in terms of annual estimates as well as in trends over time. By addressing the methodological limitations evident in previously published calculations of the non-fatal burden of disease, the INTEGRIS-burns seems to present a method to provide the most robust estimates to date, as it is the only method adapted to the nature of burn injuries and their recovery.

Long-term quality of life and cost-effectiveness of treatment of partial thickness burns: A randomized controlled trial comparing enzyme alginogel vs silver sulfadiazine (FLAM study)

The clinical effectiveness and scar quality of the randomized controlled trial comparing enzyme alginogel with silver sulfadiazine (SSD) for treatment of partial thickness burns were previously reported. Enzyme alginogel did not lead to faster wound healing (primary outcome) or less scar formation. In the current study, the health-related quality of life (HRQoL), costs, and cost-effectiveness of enzyme alginogel compared with SSD in the treatment of partial thickness burns were studied. HRQoL was evaluated using the Burn Specific Health Scale-Brief (BSHS-B) and the EQ-5D-5L questionnaire 1 week before discharge and at 3, 6, and 12 months postburn. Costs were studied from a societal perspective (health care and nonhealth-care costs) for a follow-up period of 1 year. A cost-effectiveness analysis was performed using cost-effectiveness acceptability curves and comparing differences in societal costs and Quality Adjusted Life Years (QALYs) at 1 year postburn. Forty-one patients were analyzed in the enzyme alginogel group and 48 patients in the SSD group. None of the domains of BSHS-B showed a statistically significant difference between the treatment groups. Also, no statistically significant difference in QALYs was found between enzyme alginogel and SSD (difference -0.03; 95% confidence interval [CI], -0.09 to 0.03; P = .30). From both the health care and the societal perspective, the difference in costs between enzyme alginogel and SSD was not statistically significant: the difference in health-care costs was €3210 (95% CI, €-1247 to €7667; P = .47) and in societal costs was €3377 (95% CI €-6229 to €12 982; P = .49). The nonsignificant differences in costs and quality-adjusted life-years in favor of SSD resulted in a low probability (<25%) that enzyme alginogel is cost-effective compared to SSD. In conclusion, there were no significant differences in quality of life between both treatment groups. Enzyme alginogel is unlikely to be cost-effective compared with SSD in the treatment of partial thickness burns.

Prevalence and Risk Factors for Delirium in Elderly Patients With Severe Burns: A Retrospective Cohort Study

Little is known about delirium in elderly burn center patients. The aim of this study is to provide information on the prevalence of delirium and risk factors contributing to the onset of delirium. All patients aged 70 years or older admitted with burn injuries to the Burn Center, Maasstad Hospital, in 2011 to 2017 were eligible for inclusion. We retrospectively collected data regarding the presence of delirium, potential risk factors contributing to the onset of delirium and outcome after delirium. We included elderly 90 patients in this study. The prevalence of delirium in our population was 13% (N = 12). Risk factors for delirium were advanced age, increased American Society for Anesthesiologists score, physical impairment and the use of anticholinergic drugs during admission. Patients with delirium had a poorer outcome, with prolonged hospital stay and increased mortality 6 and 12 months after discharge. Delirium is diagnosed in 13% of the elderly patients admitted to our burn center. Risk factors for delirium found in this study are advanced age, poor physical health status, physical impairment, and the use of anticholinergic drugs. Delirium is related to poor outcomes, including prolonged hospital stay and mortality after discharge.

Burn injury

Burn injuries are under-appreciated injuries that are associated with substantial morbidity and mortality. Burn injuries, particularly severe burns, are accompanied by an immune and inflammatory response, metabolic changes and distributive shock that can be challenging to manage and can lead to multiple organ failure. Of great importance is that the injury affects not only the physical health, but also the mental health and quality of life of the patient. Accordingly, patients with burn injury cannot be considered recovered when the wounds have healed; instead, burn injury leads to long-term profound alterations that must be addressed to optimize quality of life. Burn care providers are, therefore, faced with a plethora of challenges including acute and critical care management, long-term care and rehabilitation. The aim of this Primer is not only to give an overview and update about burn care, but also to raise awareness of the ongoing challenges and stigmata associated with burn injuries.

Improved and standardized method for assessing years lived with disability after burns and its application to estimate the non-fatal burden of disease of burn injuries in Australia, New Zealand and the Netherlands

Background

Burden of disease estimates are an important resource in public health. Currently, robust estimates are not available for the burn population. Our objectives are to adapt a refined methodology (INTEGRIS method) to burns and to apply this new INTEGRIS-burns method to estimate, and compare, the burden of disease of burn injuries in Australia, New Zealand and the Netherlands.

Methods

Existing European and Western-Australian health-related quality of life (HRQL) datasets were combined to derive disability weights for three homogenous burn injury groups based on percentage total body surface area (%TBSA) burned. Subsequently, incidence data from Australia, New Zealand, and the Netherlands from 2010 to 2017 were used to compute annual non-fatal burden of disease estimates for each of these three countries. Non-fatal burden of disease was measured by years lived with disability (YLD).

Results

The combined dataset included 7159 HRQL (EQ-5D-3 L) outcomes from 3401 patients. Disability weights ranged from 0.046 (subgroup < 5% TBSA burned > 24 months post-burn) to 0.497 (subgroup > 20% TBSA burned 0–1 months post-burn). In 2017 the non-fatal burden of disease of burns for the three countries (YLDs/100,000 inhabitants) was 281 for Australia, 279 for New Zealand and 133 for the Netherlands.

Conclusions

This project established a method for more precise estimates of the YLDs of burns, as it is the only method adapted to the nature of burn injuries and their recovery. Compared to previous used methods, the INTEGRIS-burns method includes improved disability weights based on severity categorization of burn patients; a better substantiated proportion of patients with lifelong disability based; and, the application of burn specific recovery timeframes. Information derived from the adapted method can be used as input for health decision making at both the national and international level. Future studies should investigate whether the application is valid in low- and middle- income countries.

Recovery of health-related quality of life after burn injuries: An individual participant data meta-analysis

Background

A prominent outcome measure within burn care is health related quality of life (HRQL). Until now, no model for long-term recovery of HRQL exists for adult burn patients which requires large samples with repeated measurements. Re-use and the combination of existing data is a way to achieve larger data samples that enable the estimation of long-term recovery models. The aim of this secondary data analysis was to assess the recovery of HRQL after a burn injury over time.

Methods and findings

Data from ten European studies on generic HRQL assessed in adult burn patients (either with the EQ-5D or SF-36) from five different countries were merged into one dataset. SF-36 outcomes were transformed into EQ-5D outcomes. A 24-month recovery of HRQL (EQ-5D utility) was modeled using a linear mixed-effects model and adjusted for important patient and burn characteristics. Subgroups of patients with mild and intermediate burns (≤20% total body surface area (TBSA) burned) and with major burns (>20% TBSA burned) were compared. The combined database included 1687 patients with a mean age of 43 (SD 15) years and a median %TBSA burned of 9% (IQR 4–18). There was large improvement in HRQL up to six months after burns, and HRQL remained relatively stable afterwards (studied up to 24 months post burn). However, the estimated EQ-5D utility scores remained below the norm scores of the general population. In this large sample, females, patients with a long hospital stay and patients with major burns had a delayed and worse recovery. The proportion of patients that reported problems for the EQ-5D dimensions ranged from 100% (pain/discomfort at baseline in patients with major burns) to 10% (self-care ≥3 months after injury in patients with mild and intermediate burns). After 24 months, both subgroups of burn patients did not reach the level of the general population in the dimensions pain/discomfort and anxiety/depression, and patients with major burns in the dimension usual activities. A main limitation of the study includes that the variables in the model were limited to age, gender, %TBSA, LOS and time since burn as these were the only variables available in all datasets.

Conclusions

The 24-month recovery model can be used in clinical practice to inform patients on expected HRQL outcomes and provide clinicians insights into the expected recovery of HRQL. In this way, a delayed recovery can be recognized in an early stage and timely interventions can be started in order to improve patient outcomes. However, external validation of the developed model is needed before implementation into clinical practice. Furthermore, our study showed the benefit of secondary data usage within the field of burns.

Predictability of exercise capacity following pediatric burns: a preliminary investigation

PURPOSE

Describe the course of exercise capacity in pediatric burn patients during the initial 6 months after hospital discharge, and examine whether its recovery can be predicted from burn characteristics, sociodemographic characteristics, and/or prior assessment.

MATERIALS AND METHODS

Exercise capacity was assessed at discharge, and 6 weeks, 3 months, and 6 months after discharge using the Steep Ramp Test (SRT).

RESULTS

Twenty-four pediatric patients with burns affecting 0.1-34% of total body surface area were included. At group level, exercise capacity was low at discharge and did not reach healthy reference values within 6 months, despite significant improvement over time. At individual level, the course of exercise capacity varied widely. Six months after discharge, 48% of participants scored more than one standard deviation below healthy age- and sex-specific reference values. SRT outcomes at 6 weeks and 3 months were the best predictors of exercise capacity 6 months after discharge, explaining, respectively, 76% and 93% of variance.

CONCLUSIONS

Forty-eight percent of participants did not achieve healthy reference values of exercise capacity and were therefore considered "at risk" for diminished functioning. Our preliminary conclusion that early assessment of exercise capacity with the SRT can timely identify those patients, needs to be strengthened by further research.IMPLICATIONS FOR REHABILITATIONPediatric burns can be considered as a chronic medical condition because of the lifelong consequences.Exercise capacity is reduced following- even minor -pediatric burns.Recovery patterns vary widely: some pediatric burn patients achieve healthy levels of exercise capacity without specific intervention, while others do not.The Steep Ramp Test can be used to assess exercise capacity, identifying those "at risk" for adverse outcomes at an early stage.Patients "at risk" should be encouraged to play sports and adopt an active lifestyle.

Patient-reported scar quality of adults after burn injuries: A five-year multicenter follow-up study

Scar formation is an important adverse consequence of burns. How patients appraise their scar quality is often studied shortly after sustaining the injury, but information in the long‐term is scarce. Our aim was, therefore, to evaluate long‐term patient‐reported quality of burn scars. Adults with a burn center admission of ≥1 day between August 2011 and September 2012 were invited to complete a questionnaire on long‐term consequences of burns. We enriched this sample with patients with severe burns (>20% total body surface area [TBSA] burned or TBSA full thickness >5%) treated between January 2010 and March 2013. Self‐reported scar quality was assessed with the Patient Scale of the Patient and Observer Scar Assessment Scale (POSAS). Patients completed this scale for their—in their opinion—most severe scar ≥5 years after burns. This study included 251 patients with a mean %TBSA burned of 10%. The vast majority (91.4%) reported at least minor differences with normal skin (POSAS item score ≥2) on one or more scar characteristics and 78.9% of the patients’ overall opinion was that their scar deviated from normal skin. Patients with severe burns had higher POSAS scores, representing worse scar quality, than patients with mild/intermediate burns, except for color, which was high in both groups. A longer hospital stay predicted reduced scar quality (both mean POSAS and mean overall opinion of the scar) in multivariate analyses. In addition, female gender was also associated with a poorer overall opinion of the scar. In conclusion, this study provides new insights in long‐term scar quality. Scars differed from normal skin in a large part of the burn population more than 5 years after burns, especially in those with severe burns. Female gender is associated with a poorer patients’ overall opinion of their scar, which may be an indication of gender differences in perception of scar quality after burns.

Burn intensive care treatment over the last 30 years: Improved survival and shift in case-mix

PURPOSE

Mortality in burn intensive care unit (ICU) has been decreasing and treatment appears to be changing. The aims of this study: (1) examine outcome in burn patients, (2) examine changes in ICU indication and (3) explore the influence of a changing case-mix.

METHODS

Retrospective study in patients admitted to ICU (1987-2016). Four groups were specified: major burns (≥15% TBSA), inhalation injury with small injury (<15% TBSA, inhalation injury), watchful waiting (<15% TBSA, without inhalation injury), tender loving care (patients withheld from treatment). Logistic regression was performed to evaluate the relation between case-mix and outcome.

RESULTS

Overall mortality decreased to 7%. Mortality of major burns decreased by 15%. The major burn group decreased by 36%. The inhalation injury and watchful waiting group increased by 9% and 21%. The percentage of ventilated patients increased by 14% in the major burn group. 40% of patients were ventilated in the watchful waiting group.

CONCLUSIONS

After correction for case-mix, survival improved, mainly in the major burn group. Case-mix shifted towards inhalation injury and watchful waiting. Growth of the watchful waiting group is not necessarily harmful. However, the increase of mechanical ventilation could be. We suggest raising awareness for risks and consequences of mechanical ventilation.

Long-term scar quality after hydrosurgical versus conventional debridement of deep dermal burns (HyCon trial): study protocol for a randomized controlled trial

Background

Deep dermal burns require tangential excision of non-viable tissue and skin grafting to improve wound healing and burn-scar quality. Tangential excision is conventionally performed with a knife, but during the last decade hydrosurgery has become popular as a new tool for tangential excision. Hydrosurgery is generally thought to be a more precise and controlled manner of burn debridement leading to preservation of viable tissue and, therefore, better scar quality. Although scar quality is considered to be one of the most important outcomes in burn surgery today, no randomized controlled study has compared the effect of these two common treatment modalities with scar quality as a primary outcome. The aim of this study is, therefore, to compare long-term scar quality after hydrosurgical versus conventional tangential excision in deep dermal burns.

Methods/design

A multicenter, randomized, intra-patient, controlled trial will be conducted in the Dutch burn centers of Rotterdam, Beverwijk, and Groningen. All patients with deep dermal burns that require excision and grafting are eligible. Exclusion criteria are: a burn wound < 50 cm², total body surface area (TBSA) burned > 30%, full-thickness burns, chemical or electrical burns, infected wounds (clinical symptoms in combination with positive wound swabs), insufficient knowledge of the Dutch or English language, patients that are unlikely to comply with requirements of the study protocol and follow-up, and patients who are (temporarily) incompetent because of sedation and/or intubation. A total of 137 patients will be included. Comparable wound areas A and B will be appointed, randomized and either excised conventionally with a knife or with the hydrosurgery system. The primary outcome is scar quality measured by the observer score of the Patient and Observer Scar Assessment Scale (POSAS); a subjective scar-assessment instrument, consisting of two separate six-item scales (observer and patient) that are both scored on a 10-point rating scale.

Discussion

This study will contribute to the optimal surgical treatment of patients with deep dermal burn wounds.

Trial registration

Dutch Trial Register, NTR6232. Registered on 23 January 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2599-2) contains supplementary material, which is available to authorized users.

Long-term scar quality in burns with three distinct healing potentials: A multicenter prospective cohort study

The laser Doppler imager is used in cases of indeterminate burn depth to accurately predict wound healing time at an early stage. The laser Doppler imager classifies burns into three estimated healing potentials as follows: high, <14 days; intermediate, 14-21 days; and low, >21 days. At this time, the relationship between these healing potentials and long-term scar quality is unknown. The objective of this study was to determine the long-term scar quality of burns with three distinct healing potentials. The secondary objectives were to compare treatment strategies in intermediate wounds, to study the effect of the timing of surgery on low healing potential wounds and to identify predictors of reduced scar quality. Hence, in a prospective cohort study, scar quality was determined in patients whose burns were assessed with laser Doppler imaging. Scar Quality was assessed with objective and subjective measurement tools, including overall scar quality (Patient and Observer Scar Assessment Scale) as a primary outcome and color and elasticity parameters. A total of 141 patients (>19 months postburn) with 216 scars were included. Wounds with high and intermediate healing potential did not significantly differ regarding scar quality. Wounds with a low healing potential had a significantly lower scar quality. Analysis of 76 surgically treated low healing potential wounds showed no significant differences in the primary outcome regarding the timing of surgery (≤14 days vs. >14). Predictors of reduced long-term scar quality were darker skin type and multiple surgeries. In conclusion, scar quality was strongly related to the healing potential category. Scar quality was very similar in high and intermediate healing potential wounds. No positive effects were found on scar quality or on healing time in surgically treated wounds with intermediate healing potential, advocating a conservative approach. Further studies should focus on the optimal timing of surgery in low healing potential wounds.

Clinical effectiveness, quality of life and cost-effectiveness of Flaminal® versus Flamazine® in the treatment of partial thickness burns: study protocol for a randomized controlled trial

Background

Partial thickness burns are painful, difficult to manage and can have a negative effect on quality of life through scarring, permanent disfigurement and loss of function. The aim of burn treatment in partial thickness burns is to save lives, stimulate wound healing by creating an optimumly moist wound environment, to have debriding and analgesic effects, protect the wound from infection and be convenient for the patient and caregivers. However, there is no consensus on the optimal treatment of partial thickness wounds. Flaminal® and Flamazine® are two standard treatment options that provide the above mentioned properties in burn treatment. Nevertheless, no randomized controlled study has yet compared these two common treatment modalities in partial thickness burns. Thus, the aim of this study is to evaluate the clinical effectiveness, quality of life and cost-effectiveness of Flaminal® versus Flamazine® in the treatment of partial thickness burns.

Methods/Design

In this two-arm open multi-center randomized controlled trial, 90 patients will be randomized between Flaminal® and Flamazine® and followed for 12 months. The study population will consist of competent or temporarily non-competent (because of sedation and/or intubation) patients, 18 years of age or older, with acute partial thickness burns and a total body surface area (TBSA) of less than 30 %. The main study outcome is time to complete re-epithelialization (greater than 95 %). Secondary outcome measures include need for grafting, wound colonization/infection, number of dressing changes, pain and anxiety, scar formation, health-related quality of life (HRQoL), and costs.

Discussion

This study will contribute to the optimal treatment of patients with partial thickness burn wounds and will provide evidence on the (cost-)effectiveness and quality of life of Flaminal® versus Flamazine® in the treatment of partial thickness burns.

Trial registration

Netherlands Trial Register NTR4486, registered on 2 April 2014.

Economic burden of burn injuries in the Netherlands: A 3 months follow-up study

INTRODUCTION

Burn care has rapidly improved in the past decades. However, healthcare innovations can be expensive, demanding careful choices on their implementation. Obtaining knowledge on the extent of the costs of burn injuries is an essential first step for economic evaluations within burn care. The objective of this study was to determine the economic burden of patients with burns admitted to a burn centre and to identify important cost categories until 3 months post-burn.

PATIENTS AND METHODS

A prospective cohort study was conducted in the burn centre of Maasstad Hospital Rotterdam, the Netherlands, including all patients with acute burn related injuries from August 2011 until July 2012. Total costs were calculated from a societal perspective, until 3 months post injury. Subgroup analyses were performed to examine whether the mean total costs per patient differed by age, aetiology or percentage total body surface area (TBSA) burned.

RESULTS

In our population, with a mean burn size of 8%, mean total costs were €26,540 per patient varying from €742 to €235,557. Most important cost categories were burn centre days (62%), surgical interventions (5%) and work absence (20%). Flame burns were significantly more costly than other types of burns, adult patients were significantly more costly than children and adolescents and a higher percentage TBSA burned also corresponded to significantly higher costs.

DISCUSSION AND CONCLUSION

Mean total costs of burn care in the first 3 months post injury were estimated at €26,540 and depended on age, aetiology and TBSA. Mean total costs in our population probably apply to other high-income countries as well, although we should realise that patients with burn injuries are diverse and represent a broad range of total costs. To reduce costs of burn care, future intervention studies should focus on a timely wound healing, reducing length of stay and enabling an early return to work.

Patient reported facial scar assessment: directions for the professional

BACKGROUND

The face is central to our identity and provides our most expressive means of communication. Currently, the role of facial scarring in relation to self-esteem is unclear and the value of self-reported scar assessment is insufficiently understood. The aim of this study was twofold: (1) to assess the extent of agreement between patients' ratings and observers' ratings of facial scar characteristics; and (2) to examine if patients' and observers' scar characteristics ratings, or the differences, are associated with the patients' self-esteem.

METHODS

A prospective study was conducted including patients with facial burns. Patients completed the Patient and Observer Scar Assessment Scale (POSAS) and the Rosenberg Self-Esteem Scale 3 months post-burn.

RESULTS

Ninety-four subjects were included, 76 (81%) men and mean percentage TBSA burned was 12.4 (SD 10.4; range 1-50). Subject's and observer's assessment were significantly positively correlated and were identical in 53% of the cases. Subjects' assessments and discrepancy scores on the scar characteristic surface roughness were associated with self-esteem in multiple regression analysis.

CONCLUSIONS

The majority of the patients scored the quality of facial scars in a similar way as the professionals. Furthermore, facial scarring appeared only moderately associated with self-esteem. However, our study suggests that using both patients' and professionals' scar assessments provides more useful information regarding the patients' well-being relative to focussing on the separate assessments only. In particular a discrepancy between the patients' and professionals' view on surface roughness might be an early indication of psychological difficulties and a call for further clinical attention.

Cost study of dermal substitutes and topical negative pressure in the surgical treatment of burns

BACKGROUND

A recently performed randomised controlled trial investigated the clinical effectiveness of dermal substitutes (DS) and split skin grafts (SSG) in combination with topical negative pressure (TNP) in the surgical treatment of burn wounds. In the current study, medical and non-medical costs were investigated, to comprehensively assess the benefits of this new treatment.

METHODS

The primary outcome was mean total costs of the four treatment strategies: SSG with or without DS, and with or without TNP. Costs were studied from a societal perspective. Findings were evaluated in light of the clinical effects on scar elasticity.

RESULTS

Eighty-six patients were included. Twelve months post-operatively, highest elasticity was measured in scars treated with DS and TNP (p=0.027). The initial cost price of treatment with DS and TNP was €2912 compared to treatment with SSG alone €1703 (p<0.001). However, mean total costs per patient did not differ significantly between groups (range €29097-€43774).

DISCUSSION

Costs of the interventional treatment contributed maximal 7% to the total costs and total costs varied widely within and between groups, but were not significantly different. Therefore, in the selection of the most optimal type of surgical intervention, cost considerations should not play an important role.

Cost-effectiveness of laser Doppler imaging in burn care in the Netherlands

Background

Early accurate assessment of burn depth is important to determine the optimal treatment of burns. The method most used to determine burn depth is clinical assessment, which is the least expensive, but not the most accurate.

Laser Doppler imaging (LDI) is a technique with which a more accurate (>95%) estimate of burn depth can be made by measuring the dermal perfusion. The actual effect on therapeutic decisions, clinical outcomes and the costs of the introduction of this device, however, are unknown. Before we decide to implement LDI in Dutch burn care, a study on the effectiveness and cost-effectiveness of LDI is necessary.

Methods/design

A multicenter randomised controlled trial will be conducted in the Dutch burn centres: Beverwijk, Groningen and Rotterdam. All patients treated as outpatient or admitted to a burn centre within 5 days post burn, with burns of indeterminate depth (burns not obviously superficial or full thickness) and a total body surface area burned of ≤ 20% are eligible. A total of 200 patients will be included. Burn depth will be diagnosed by both clinical assessment and laser Doppler imaging between 2–5 days post burn in all patients. Subsequently, patients are randomly divided in two groups: ‘new diagnostic strategy’ versus ‘current diagnostic strategy’. The results of the LDI-scan will only be provided to the treating clinician in the ‘new diagnostic strategy’ group. The main endpoint is the effect of LDI on wound healing time.

In addition we measure: a) the effect of LDI on other patient outcomes (quality of life, scar quality), b) the effect of LDI on diagnostic and therapeutic decisions, and c) the effect of LDI on total (medical and non-medical) costs and cost-effectiveness.

Discussion

This trial will contribute to our current knowledge on the use of LDI in burn care and will provide evidence on its cost-effectiveness.

Trial registration

NCT01489540

Clinical effectiveness of dermal substitution in burns by topical negative pressure: a multicenter randomized controlled trial

Previous research has shown clinical effectiveness of dermal substitution; however, in burn wounds, only limited effect has been shown. A problem in burn wounds is the reduced take of the autograft, when the substitute and graft are applied in one procedure. Recently, application of topical negative pressure (TNP) was shown to improve graft take. The aim of this study was to investigate if application of a dermal substitute in combination with TNP improves scar quality after burns. In a four-armed multicenter randomized controlled trial, a split-skin graft with or without a dermal substitute and with or without TNP was compared in patients with deep dermal or full-thickness burns requiring skin transplantation. Graft take and rate of wound epithelialization were evaluated. Three and 12 months postoperatively, scar parameters were measured. The results of 86 patients showed that graft take and epithelialization did not reveal significant differences. Significantly fewer wounds in the TNP group showed postoperative contamination, compared to other groups. Highest elasticity was measured in scars treated with the substitute and TNP, which was significantly better compared to scars treated with the substitute alone. Concluding, this randomized controlled trial shows the effectiveness of dermal substitution combined with TNP in burns, based on extensive wound and scar measurements.

Parent-reported health outcomes in infants/toddlers: measurement properties and clinical validity of the ITQOL-SF47

PURPOSE

To derive and evaluate a shorter infant/toddler quality of life questionnaire (ITQOL) for use in clinical care.

METHODS

Stepwise regression, factor analysis, and item-scaling principles were used to derive and guide item selection using data from a large general sample in the Netherlands (n = 5,211) and a "wheezing illness" sample (n = 138). Item internal consistency, discriminant validity, and floor and ceiling effects were evaluated using a general Dutch sample (Salland Region n = 410) and two clinical samples: Functional abdominal pain (FAP, n = 81) and Burn (n = 194). Reliabilities were estimated using Cronbach's alpha. Relative precision (RP), the ability to distinguish between clinical subgroups, was computed by comparing the proportion of variance explained by the short-form scales versus respective full-length scales.

RESULTS

The ITQOL was reduced from 97 to 47 items. Median alpha coefficients were 0.77 Salland sample, 0.76 (FAP), and 0.84 (Burn). Ninety-one to 100 % scaling successes for item discriminant validity were observed for 21 of 24 tests (8 scales, 3 samples). Floor effects were not observed; some ceiling effects were detected. RP estimates in the Salland sample ranged from 2.40 (physical abilities) to 0.58 (temperament and moods). RP estimates in the FAP sample were 0.85 (bodily pain), 1.36 (temperament and moods) and 1.62 (parental-impact emotional) and for Burn, 1.51 (temperament and moods) and 0.59 (general health perceptions).

CONCLUSION

The ITQOL-SF47 is reliable and valid and exceeds item-level scaling criteria.

[Determining burn depth: clinical assessment and laser Doppler imaging]

Early accurate determination of burn depth is important to determine the optimal treatment of burns. The method most used to determine burn depth is clinical assessment. This is a cheap method, but not the most accurate. Laser Doppler imaging (LDI) is a technique with which a more accurate (>95%) estimate of burn depth can be made by measuring the dermal perfusion. It is hypothesised that the introduction of LDI will lead to quicker decisions as to whether or not to operate, possibly leading to a shorter length of hospital stay and lower medical costs. To test this hypothesis, a multicentre randomized controlled trial is presently being conducted in the Dutch burn centres.

Evaluation of trauma care by comparing mortality risks and admission policy in a Dutch trauma region

OBJECTIVE

To evaluate the effectiveness of trauma care in the Netherlands compared to UK norms and in terms of mortality risks in three groups of patients. The hypothesis was that there is no difference in risk of hospital death between major trauma patients transferred from another hospital to the trauma centre and patients directly admitted to the trauma centre.

METHODS

Trauma admissions (n=17,023) during the period 2000-2006 in 12 emergency departments were selected from a regional trauma registry database. In the analysis, the dependent variable was death within 30 days of admission. W-Statistics (W(s)) was used to compare outcomes of the total Dutch trauma population and the population admitted to the trauma centre, with norms for England and Wales. The effect of direct admission to a non-trauma centre and immediate admission to a trauma centre for major trauma patients versus indirect admission was tested in a logistic model and adjusted for confounding.

RESULTS

444 (2.6%) patients died within 30 days of admission. 6.1% of all patients were major trauma patients. W(s) resulted in 1.39 (95% CI 1.08-1.70) more observed survivors per 100 admitted trauma patients standardised for case mix using UK norms. W(s) of trauma patients in the trauma centre resulted in 0.85 (95% CI 0.44-1.27) more survivors than expected. Patients directly admitted to a trauma centre or a non-trauma centre without transfer were found to have a non-significant increasing risk of mortality (OR 1.5 (95% CI 0.7-3.4) and 1.9 (95% CI 0.9-4.1), respectively) compared to patients transferred from another hospital to a trauma centre.

CONCLUSION

Trauma care in this Dutch province is performing better than expected comparing to the norms for the England and Wales. The admission policy of transporting major trauma patients to the nearest hospital and, if necessary, then transferring them to the trauma centre, seems legitimate in Dutch trauma care.

Reliability and Validity of the Dutch Version of the American Burn Association/Shriners Hospital for Children Burn Outcomes Questionnaire (5–18 Years of Age)

The American Burn Association/Shriners Hospital for Children Burn Outcomes Questionnaire (BOQ) is a self-administered questionnaire to monitor functional outcome after burns in children and adolescents. This study aimed to assess feasibility, reliability, and validity of the Dutch BOQ. The BOQ was adapted into Dutch and tested in a population of children and adolescents aged 5 to 15 years who were primary admissions to a Dutch or Belgian burn center (n = 6) during the period of March 2001 through February 2004. To assess validity, the Child Health Questionnaire (CHQ) and the EuroQol-5D (EQ-5D) were included. Response rate was 53% among parents (n = 145) and 48% among adolescents (n = 52). Internal consistency of the BOQ scales was good (Cronbach's alpha >0.7 in all but one scale). Test and retest results were similar; there were no significant differences between parents and adolescents in this respect. Expected high correlations between BOQ scales and conceptually equivalent CHQ and EQ-5D scales were found in eight of 12 comparisons. Eleven scales showed significant differences in the expected direction between children with a long length of stay versus those with a short length of stay. The Dutch BOQ can be used to evaluate functional outcome after burns in children aged 5 years and older. Our study showed that the Dutch BOQ is a feasible instrument with good reliability and validity.

Cost estimation of injury-related hospital admissions in 10 European countries

BACKGROUND

Injuries are a major cause of total health care costs. Cost estimations may help identify injuries and high risk-groups to be considered for potential intervention.

METHODS

Hospital discharge registers of 10 European countries were used to estimate injury incidence. Consensus was reached between the participating countries about methodology, definition, classification, cost measurements, and valuation to maximize cross-national comparability of outcomes. The data of the countries were also used to give an estimate of the costs per capita by age, sex, type of injury, and external cause in Europe.

RESULTS

Large international differences were observed in injury incidence and associated costs related to hospital admissions, with relatively high costs per capita for Austria, followed by Denmark and Norway. In Greece, Italy, Ireland, and Wales, intermediate costs per capita were found, but these costs were relatively low for Spain, England, and the Netherlands. The patterns of costs by age, sex, injury type, and external cause are quite similar between the countries. For all countries, costs per capita increase exponentially in older age groups (age > or =65 years), due to the combined effect of high incidence and high costs per patient. The elderly females account for almost triple costs compared with same age males. Young children and male adolescents are also high-cost groups. Highest costs were found for hip fractures, fractures of the knee/lower leg, superficial injuries, skull-brain injuries, and spinal cord injuries. Home and leisure injuries (including sport injuries) and occupational injuries combined make a major contribution (86%) to the hospital costs of injury.

CONCLUSION

Elderly patients aged 65 years and older, especially women, consume a disproportionate share of hospital resources for trauma care, mainly caused by hip fractures and fractures of the knee/lower leg, which indicates the importance of prevention and investing in trauma care for this specific patient group.

Effectiveness of exercise therapy: a best-evidence summary of systematic reviews

The purpose of this project was to summarise the available evidence on the effectiveness of exercise therapy for patients with disorders of the musculoskeletal, nervous, respiratory, and cardiovascular systems. Systematic reviews were identified by means of a comprehensive search strategy in 11 bibliographic databases (08/2002), in combination with reference tracking. Reviews that included (i) at least one randomised controlled trial investigating the effectiveness of exercise therapy, (ii) clinically relevant outcome measures, and (iii) full text written in English, German or Dutch, were selected by two reviewers. Thirteen independent and blinded reviewers participated in the selection, quality assessment and data-extraction of the systematic reviews. Conclusions about the effectiveness of exercise therapy were based on the results presented in reasonable or good quality systematic reviews (quality score > or = 60 out of 100 points). A total of 104 systematic reviews were selected, 45 of which were of reasonable or good quality. Exercise therapy is effective for patients with knee osteoarthritis, sub-acute (6 to 12 weeks) and chronic (> or = 12 weeks) low back pain, cystic fibrosis, chronic obstructive pulmonary disease, and intermittent claudication. Furthermore, there are indications that exercise therapy is effective for patients with ankylosing spondylitis, hip osteoarthritis, Parkinson's disease, and for patients who have suffered a stroke. There is insufficient evidence to support or refute the effectiveness of exercise therapy for patients with neck pain, shoulder pain, repetitive strain injury, rheumatoid arthritis, asthma, and bronchiectasis. Exercise therapy is not effective for patients with acute low back pain. It is concluded that exercise therapy is effective for a wide range of chronic disorders.