The impact of trauma-center care on mortality and function following pelvic ring and acetabular injuries

ABSTRACT Background: Lower mortality and improved physical function following major polytrauma have been associated with treatment at level-1 trauma centers (TC) compared with that at non-trauma centers (NTC). This study investigates the impact of TC care on outcomes after pelvic and acetabular injuries. Methods: Mortality and quality of life-related measures were compared among patients treated in 18 hospitals with level-1 trauma centers and 51 hospitals without trauma centers in 14 U.S. states. Complete data were obtained on 829 adult trauma patients (18-84 years old) with at least one pelvic ring or acetabular injury (OTA 61 or 62). We used inverse probability of treatment weighting to adjust for observable confounding. Results: After adjustment for case mix, in-hospital mortality was significantly lower at TC versus NTC (RR 0.10, 95% CI 0.02-0.47), as was death by 90 days (RR 0.10, 95% CI 0.02-0.47), and one year (RR 0.21, 95% CI 0.06-0.76) for patients with more severe acetabular injuries (OTA 62-B or 62-C). Patients with combined pelvic ring and acetabular injuries treated at TC had lower mortality by 90 days (RR 0.34, 95% CI 0.14-0.82) and one year (RR 0.30 95% CI 0.14-0.68). Care at TC was also associated with mortality risk reduction for those with unstable pelvic ring injuries (OTA 61-B or 61-C) at one year (RR 0.21, 95%CI 0.06-0.76). Seventy-eight percent of included subjects discharged alive was available for interview at twelve months. Average absolute differences in SF-36 physical functioning and Musculoskeletal Functional Assessment at one year were 11.4 (95%CI 5.3 – 17.4) and 13.2 (1.7 – 24.7) respectively, indicating statistically and clinically significant improved outcomes with TC treatment for more severe acetabular injuries. Conclusions: Mortality is reduced for patients with unstable pelvic and severe acetabular injuries when care is provided in a TC compared to NTC. Moreover, those with severe acetabular fractures experience improved physical function at one year. Patients with these injuries represent a well-defined subset of trauma patients that should be preferentially triaged or transferred to a Level-1 trauma center

Disability weights based on patient-reported data from a multinational injury cohort

textabstractObjective To create patient-based disability weights for individual injury diagnosis codes and nature-of-injury classifications, for use, as an alternative to panel-based weights, in studies on the burden of disease. Methods Self-reported data based on the EQ-5D standardized measure of health status were collected from 29 770 participants in the Injury-VIBES injury cohort study, which covered Australia, the Netherlands, New Zealand, the United Kingdom of Great Britain and Northern Ireland and the United States of America. The data were combined to calculate new disability weights for each common injury classification and for each type of diagnosis covered by the 10th revision of the International statistical classification of diseases and related health problems. Weights were calculated separately for hospital admissions and presentations confined to emergency departments. Findings There were 29 770 injury cases with at least one EQ-5D score. The mean age of the participants providing data was 51 years. Most participants were male and almost a third had road traffic injuries. The new disability weights were higher for admitted cases than for cases confined to emergency departments and higher than the corresponding weights used by the Global Burden of Disease 2013 study. Long-term disability was common in most categories of injuries. Conclusion Injury is often a chronic disorder and burden of disease estimates should reflect this. Application of the new weights to burden studies would substantially increase estimates of disability-adjusted life-years and provide a more accurate reflection of the impact of injuries on peoples’ lives

Level of agreement between patient-reported EQ-5D responses and EQ-5D responses mapped from the SF-12 in an injury population

Background: Comparing health-related quality of life (HRQL) outcomes between studies is difficult due to the wide variety of instruments used. Comparing study outcomes and facilitating pooled data analyses requires valid "crosswalks" between HRQL instruments. Algorithms exist to map 12-item Short Form Health Survey (SF-12) responses to EQ-5D item responses and preference weights, but none have been validated in populations where disability is prevalent, such as injury. Methods: Data were extracted from the Validating and Improving injury Burden Estimates Study (Injury-VIBES) for 10,166 adult, hospitalized trauma patients, with both the three-level EQ-5D (EQ-5D-3L) and SF-12 data responses at six and 12-months postinjury. Agreement between actual (patient-reported) and estimated (mapped from SF-12) EQ-5D-3L item responses and preference weights was assessed using Kappa, Prevalence-Adjusted Bias-Adjusted Kappa statistics and Bland-Altman plots. Results: Moderate agreement was observed for usual activities, pain/discomfort, and anxiety/depression. Agreement was substantial for mobility and self-care items. The mean differences in preference weights were -0.024 and -0.012 at six and 12 months (p < 0.001), respectively. The Bland-Altman plot limits of agreement were large compared to the range of valid preference weight values (-0.56 to 1.00). Estimated EQ-5D-3L responses under-reported disability for all items except pain/discomfort. Conclusions: Caution should be taken when using EQ-5D-3L responses mapped from the SF-12 to describe patient outcomes or when undertaking economic evaluation, due to the underestimation of disability associated with mapped values. The findings from this study could be used to adjust expected EQ-5D-3L preference weights when estimated from SF-12 item responses when combining data from studies that use either instrument