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BackgroundAlthough mortality rates following major trauma are continuing to decline, a growing number of patients are experiencing long-term disability. The aim of this study was to identify factors associated with health status in the first year following trauma and develop prediction models based on a defined trauma population.MethodsThe Brabant Injury Outcome Surveillance (BIOS) study was a multicentre prospective observational cohort study. Adult patients with traumatic injury were included from August 2015 to November 2016 if admitted to one of the hospitals of the Noord-Brabant region in the Netherlands. Outcome measures were EuroQol Five Dimensions 5D-3L (EQ-5D™ utility and visual analogue scale (VAS)) and Health Utilities Index (HUI) 2 and 3 scores 1 week and 1, 3, 6 and 12 months after injury. Prediction models were developed using linear mixed models, with patient characteristics, preinjury health status, injury severity and frailty as possible predictors. Predictors that were significant (P < 0·050) for one of the outcome measures were included in all models. Performance was assessed using explained variance (R2).ResultsIn total, 4883 patients participated in the BIOS study (50·0 per cent of the total), of whom 3366 completed the preinjury questionnaires. Preinjury health status and frailty were the strongest predictors of health status during follow-up. Age, sex, educational level, severe head or face injury, severe torso injury, injury severity, Functional Capacity Index score, co-morbidity and duration of hospital stay were also relevant in the multivariable models predicting health status. R2 ranged from 35 per cent for EQ-VAS to 48 per cent for HUI 3.ConclusionThe most important predictors of health status in the first year after trauma in this population appeared to be preinjury health status and frailty.

Introduction: Twenty years ago the Dutch trauma care system was reformed by the designating 11 level one Regional trauma centres (RTCs) to organise trauma care. The RTCs set up the Dutch National Trauma Registry (DNTR) to evaluate epidemiology, patient distribution, resource use and quality of care. In this study we describe the DNTR, the incidence and main characteristics of Dutch acutely admitted trauma patients, and evaluate the value of including all acute trauma admissions compared to more stringent criteria applied by the national trauma registries of the United Kingdom and Germany.Methods: The DNTR includes all injured patients treated at the ED within 48 hours after trauma and consecutively followed by direct admission, transfers to another hospital or death at the ED. DNTR data on admission years 2007-2018 were extracted to describe the maturation of the registry. Data from 2018 was used to describe the incidence rate and patient characteristics. Inclusion criteria of the Trauma Audit and Research (TARN) and the Deutsche Gesellschaft fur Unfallchirurgie (DGU) were applied on 2018 DNTR data.Results: Since its start in 2007 a total of 865,460 trauma cases have been registered in the DNTR. Hospital participation increased from 64% to 98%. In 2018, a total of 77,529 patients were included, the median age was 64 years, 50% males. Severely injured patients with an ISS=16, accounted for 6% of all admissions, of which 70% was treated at designated RTCs. Patients with an ISS= 15were treated at non-RTCs in 80% of cases.Application of DGU or TARN inclusion criteria, resulted in inclusion of respectively 5% and 32% of the DNTR patients. Particularly children, elderly and patients admitted at non-RTCs are left out. Moreover, 50% of ISS >= 16 and 68% of the fatal cases did not meet DGU inclusion criteriaConclusion: The DNTR has evolved into a comprehensive well-structured nationwide population-based trauma register. With 80,0 00 inclusions annually, the DNTR has become one of the largest trauma databases in Europe The registries strength lies in the broad inclusion criteria which enables studies on the burden of injury and the quality and efficiency of the entire trauma care system, encompassing all trauma-receiving hospitals. (C) 2020 Elsevier Ltd. All rights reserved.

Summary Patients with hip fractures experience reduced health-related quality of life and have a reduced life expectancy. Patients’ utilization of healthcare leads to costs to society. The results of the study can be used in future economic evaluations of treatments for hip fractures. Purpose Hip fractures are associated with high mortality, reduced quality of life, and increased healthcare utilization, leading to an economic burden to society. The purpose of this study is to determine the burden of illness of hip fractures in elderly Dutch patients for specific time periods after surgery. Methods Patients with a hip fracture above the age of 65 were included in the study. In the 1-year period after surgery, patients were asked to complete a set of questionnaires pre-injury (retrospectively), and 1 week, 1 month, 3 months, 6 months and 12 months after surgery. The set of questionnaires included the Euroqol 5D (EQ-5D-3L), the iMTA Medical Consumption Questionnaire (iMCQ) and iMTA Productivity Cost Questionnaire (iPCQ). Health-related quality of life was calculated using Dutch tariffs. Costs were calculated using the methodology described in the Dutch costing manual. Results Approximately 20% of patients with a hip fracture died within 1 year. Health-related quality of life was significantly reduced compared to pre-injury values, and patients did not recover to their pre-injury values within 1 year. Total costs in the first year after injury were €27,573, of which 10% were due to costs of the procedure (€2706). Total follow-up costs (€24,876) were predominantly consisting of healthcare costs. Monthly costs decreased over time. Conclusions Hip fractures lead to a burden to patients, resulting from mortality and health-related quality of life reductions, and to society, due to (healthcare) costs. The results of this study can be used in future economic evaluations.

IntroductionPelvic fractures can have long-term consequences for health-related quality of life (HRQoL). The main purpose of this study is to provide insight into short-term HRQoL in the first year after pelvic injury and to identify short-term prognostic factors of decreased outcome.MethodsThis is a prospective, observational, multicenter, follow-up cohort study in which HRQoL and functional outcomes were assessed during 12-month follow-up of injured adult patients admitted to 1 of 10 hospitals in the county of Noord-Brabant, the Netherlands. The data were collected by self-reported questionnaires at 1 week (including preinjury assessment) and 1, 3, 6 and 12 months after injury. The EuroQoL-5D (EQ-5D), visual analog scale (VAS), Merle d'Aubigné Hip Score (MAHS) and Majeed Pelvic Score (MPS) were used. Multivariable mixed models were used to examine the course of the HRQoL and the prognostic factors for decreased HRQoL and functional outcomes over time.ResultsA total of 184 patients with pelvic fractures were identified between September 2015-September 2016; the fractures included 71 Tile A, 44 Tile B and 10 Tile C fractures and 59 acetabular fractures. At the pre-injury, 1 week, and 1, 3, 6 and 12 months after injury time points, the mean EQ-5D Index values were 0.90, 0.26, 0.45, 0.66, 0.77 and 0.80, respectively, and the mean EQ-VAS values were 83, 45, 57, 69, 75 and 75, respectively. At 6 and 12 months after injury, 22 and 25% of the MPS < 65 year group, 38 and 47% of the MPS ≥ 65 year group and 34 and 51% of the MAHS group, respectively, reached the maximum score. Pre-injury score, female gender and high Injury Severity Score (ISS) were important prognostic factors for a decreased HRQoL, and the EQ-5D VAS β = 0.43 (95% CI: 0.31 - 0.57), -6.66 (95% CI: -10.90 - -0.43) and -7.09 (95% CI: -6.11 - -5.67), respectively.DiscussionPatients with pelvic fractures experience a reduction in their HRQoL. Most patients do not achieve the HRQoL of their pre-injury state within 1 year after trauma. Prognostic factors for decreased HRQoL are a low pre-injury score, high ISS and female gender. We do not recommend using the MAHS and MPS in mid- or long-term follow-up of pelvic fractures because of ceiling effects. Trial registration number NCT02508675.

Introduction While the number of trauma patients surviving their injury increase, it is important to measure Quality of Life (QoL). The Abbreviated World Health Organization Quality of Life (WHOQOL-BREF) questionnaire can be used to assess QoL. However, its psychometric properties in trauma patients are unknown and therefore, we aimed to investigate the validity and reliability of the WHOQOL-BREF for the hospitalized trauma population. Methods Data were derived from the Brabant Injury Outcome Surveillance. Floor and ceiling effects and missing values of the WHOQOL-BREF were examined. Confirmatory factor analysis (CFA) was performed to examine the underlying 4 dimensions (i.e. physical, psychological, social and environmental) of the questionnaire. Cronbach’s alpha (CA) was calculated to determine internal consistency. In total, 42 hypotheses were formulated to determine construct validity and 6 hypotheses were created to determine discriminant validity. To determine construct validity, Spearman’s correlations were calculated between the WHOQOL-BREF and the EuroQol-five-dimension-3-level questionnaire, the Health Utility Index Mark 2 and 3, the Hospital Anxiety and Depression Scale and the Impact of Event Scale. Discriminant validity between patients with minor injuries (i.e. Injury Severity Score (ISS)≤8) and moderate/severe injuries (i.e. ISS ≥ 9) was examined by conducting Mann-Whitney-U-tests. Results In total, 202 patients (median 63y) participated in this study with a median of 32 days (interquartile range 29–37) post-trauma. The WHOQOL-BREF showed no problematic floor and ceiling effects. The CFA revealed a moderate model fit. The domains showed good internal consistency, with the exception of the social domain. All individual items and domain scores of the WHOQOL-BREF showed nearly symmetrical distributions since mean scores were close to median scores, except of the ‘general health’ item. The highest percentage of missing values was found on the ‘sexual activity’ item (i.e. 19.3%). The WHOQOL-BREF showed moderate construct and discriminant validity since in both cases, 67% of the hypotheses were confirmed. Conclusion The present study provides support for using the WHOQOL-BREF for the hospitalized trauma population since the questionnaire appears to be valid and reliable. The WHOQOL-BREF can be used to assess QoL in a heterogeneous group of hospitalized trauma patients accurately. Trail registration ClinicalTrials.gov identifier: NCT02508675

Background Well-advised priority setting in prevention and treatment of injuries relies on detailed insight into costs of injury. This study aimed to provide a detailed overview of medical and productivity costs due to injury up to two years post-injury and compare these costs across subgroups for injury severity and age. Methods A prospective longitudinal cohort study followed all adult (≥18 years) injury patients admitted to a hospital in Noord-Brabant, the Netherlands. Patients filled out questionnaires 1 week, 1, 3, 6, 12 and 24 months after trauma, including items on health care consumption from the medical consumption questionnaire (iMCQ) and productivity loss from the productivity cost questionnaire (PCQ). Furthermore, injury severity was defined by Injury Severity Score (ISS). Data on diagnostics was retrieved from hospital registries. We calculated medical costs, consisting of in-hospital costs and post-hospital medical costs, and productivity costs due to injury up to two years post-injury. Results Approximately 50% (N = 4883) of registered patients provided informed consent, and 3785 filled out at least one questionnaire. In total, the average costs per patient were €12,190. In-hospital costs, post-hospital medical costs and productivity costs contributed €4810, €5110 and €5830, respectively. Total costs per patient increased with injury severity, from €7030 in ISS1-3 to €23,750 in ISS16+ and were lowest for age category 18-24y (€7980), highest for age category 85 years and over (€15,580), and fluctuated over age groups in between. Conclusion Both medical costs and productivity costs generally increased with injury severity. Furthermore, productivity costs were found to be a large component of total costs of injury in ISS1-8 and are therefore a potentially interesting area with regard to reducing costs.

Purpose This study investigated the psychometric gain, if any, from the extension of the EQ-5D with a cognition bolt-on (EQ-5D + C) in a large cohort injury patients with and without traumatic brain injury (TBI). Methods Hospitalized adult injury patients filled out a survey 1 month after initial admission. The survey included the EQ-5D-3L, the cognition bolt-on item in EQ-5D format, and the visual analogue scale (EQ-VAS). We compared ceiling and other distributional effects between EQ-5D and EQ-5D + C and TBI and non-TBI group, and assessed convergent validity using the predictive association with EQ-VAS. Also, we assessed explanatory power using regression analysis, and classification efficiency using Shannon indices. Results In total, 715 TBI patients and 1978 non-TBI patients filled out the EQ-5D + C and EQ-VAS. Perfect health was reported by 7.9% (N = 214) on the EQ-5D, and 7.3% (N = 197) on the EQ-5D + C. Convergent validity was highest for EQ-5D + C in the TBI group (Spearman’s rank correlation coefficient = − 0.736) and lowest for EQ-5D in the non-TBI group (Spearman’s rank correlation coefficient = − 0.652). For both TBI and non-TBI groups, the explanatory power of EQ-5D + C was slightly higher than of EQ-5D (R2 = 0.56 vs. 0.53 for TBI; R2 = 0.47 vs. 0.45 for non-TBI). Absolute classification efficiency was higher for EQ-5D + C than for EQ-5D in both TBI groups, whereas relative classification efficiency was similar. Conclusions Psychometric performance in general of both the EQ-5D and EQ-5D + C was better in TBI patients. Adding a cognitive bolt-on slightly improved the psychometric performance of the EQ-5D-3L.

Purpose To evaluate the correspondence of directly reported and recalled health-related quality of life (HRQL) in a heterogeneous sample of trauma patients. Methods Adult trauma patients who attended the Emergency Department and were admitted between 03/2016 and 11/2016 were invited to participate. Postal surveys were sent 1 week (T1), 3 months (T2), and 12 months (T3) post-trauma. The EQ-5D-3L and Visual Analogue Scale (EQ-VAS) were used to assess directly reported and recalled HRQL. Results The EQ-5D was completed by 446 patients at T1, T2, and T3. Directly reported mean T1 EQ-5D summary score was 0.482, whereas recalled T1 EQ-5D summary score was 0.453 (p

Item does not contain fulltext AIMS: This study was conducted to determine long-term (5-10 years) health-related quality of life (HRQOL) and ceiling effects in patients with a pelvic ring fracture. PATIENTS AND METHODS: We identified all patients with pelvic ring fractures after high-energy trauma admitted at two level 1 trauma centres in the Netherlands from 2006 to 2011. Patients were asked to complete the Majeed Pelvic Score (MPS), EuroQol-5D (EQ-5D) and Short Musculoskeletal Function Assessment (SMFA) questionnaires. HRQOL analysis used a multiple linear regression model. RESULTS: In total, 136 patients returned the questionnaires. The median follow-up period was 8.7 years. The mean MPS and EQ-5D-VAS scores were 85.1 and 74, respectively. The mean EQ-5D index scores were 0.87, 0.81 and 0.82 in Tile B, A and C patients, respectively. The mean SMFA index was 24. A ceiling effect was observed for 1/3 of the patients. After multiple linear regression analysis, no differences were identified among the various fracture types for each questionnaire, with the exception of 2 subscales of the MPS. CONCLUSION: Patients who suffer pelvic ring fractures generally have good HRQOL outcomes after 5-10 years. No significant differences were found among different fracture types. Long-term follow-up of patients with Tile C fractures is warranted.

Pelvic ring fractures might have consequences for health-related quality of life (HrQoL). The main purpose of this study was to evaluate patients' HrQoL after a pelvic ring fracture, considering the patients' characteristics. A cross-sectional study was conducted using the EuroQoL-5D (EQ-5D) and the Majeed pelvic score (MPS).One hundred ninety-five patients (86%) with pelvic ring fractures who were conservatively or surgically treated in a level 1 trauma centre between 2011 and 2015 were included in this study (mean follow up: 29 months, range 6-61). A telephone survey of all patients was conducted. Multiple logistic and linear regression analyses were used for statistical assessment with the EQ-5D and the MPS. The MPS results were split into two age groups with a cut-off point of 65 years.EQ-5D: The mean EQ-5D Visual Analogue Scale (VAS) for Tiles A-C was, respectively, 74 (SD 18), 74 (SD 19) and 67 (SD 21), and the mean EQ-5D index score was, respectively, 0.81 (SD 0.23), 0.77 (SD 0.30) and 0.71 (SD 0.26). Compared with Tile A, patients in Tile C experienced significantly more pain (odds ratio 6.28 (1.73-22.82 95% CI), P 0.01). Clinically relevant differences in EQ-5D scores between Tile A and Tile C were seen in the domains of usual activities and anxiety and in the index score. MPS: The mean MPS of Tiles A-C patients in the65 group was, respectively, 86 (SD 15), 81 (SD 17), and 74 (SD 16), and in the ≥65 group, it was, respectively, 69 (SD 15), 68 (SD 15) and 66 (SD 9). In the65 group, significant differences in MPS results between the Tile groups regarding pain (P0.01) and the total MPS score (P = 0.04) were seen. Neither significant regression coefficients nor clinically relevant differences were found in the ≥65 group.In conclusion, our study showed that pain was increased in patients with Tile C fractures, compared with Tiles A and B. Furthermore, Tile C patients had significantly lower EQ-5D index and total MPS scores. However, these problems were not seen in the ≥65 group.

BackgroundFormer studies have demonstrated that health-related quality of life is decreased in severely injured patients. However, in those studies patients were asked about their functioning and not about their (dis)contentment concerning their functioning. Little is known about how severely injured patients experience their quality of life (QOL). The objective of this cross-sectional study was to measure this subjective QOL of severely injured patients after their rehabilitation phase and to examine which accident- and patient-related factors affect the QOL of these patients.MethodsPatients of 18 years or older with an injury severity score (ISS) above 15 were included 15–53 months after their accident. Comorbidity before the accident, accident and sociodemographic characteristics, and QOL were obtained from the trauma registry and questionnaires. The WHOQOL-BREF was used to measure QOL. A reference group of the Dutch general population was used for comparison.ResultsThe participation rate was 61% (n = 173). Compared with the reference data, severely injured patients experienced a significantly worse QOL in all domains except social relations. The QOL scores were significantly decreased in all domains for patients with intracranial injury in combination with other injuries. Patients with a severe intracranial injury (AIS > 3) only reported significantly impaired QOL in the general and physical domains. Patients who resumed working or lived with others had significantly higher scores in all domains of QOL than patients who did not work anymore or were living alone. Significantly lower QOL scores were obtained from patients with comorbidity before the accident and from patients with longer durations of intensive care unit (ICU) treatment or hospitalisation. Gender, accident characteristics and time since the accident did not appear to be important for experienced QOL.ConclusionsThe experience of impaired QOL appears to depend on living alone, inability to return to work and pre-accidental comorbidity rather than on the injured body area or the severity of the injury. Duration of hospital or ICU stay is important to subsequent QOL, even if ISS or body region is not.Keywords: Quality of life, Injury, Trauma

In this cross-sectional study the psychometric properties are examined of the adapted Dutch translation of the Short Musculoskeletal Function Assessment (SMFA) questionnaire in severely injured patients (ISS > 15). Patients and methods Patients (N = 173) completed the SMFA, the World Health Organization Quality of Life assessment instrument-BREF (WHOQOL-BREF), the Dutch Impact of Event Scale (IES), the Hospital Anxiety and Depression Scale (HADS) and the Cognitive Failure Questionnaire (CFQ). The Abbreviated Injury Score and the Injury Severity Score were established to determine the injured body area and the severity of the injuries. Exploratory factor analysis (method: PAF) was performed. Correlations were calculated between our SMFA factors and scores on the WHOQOL-BREF, IES, HADS and CFQ. The SMFA scores of the factors Upper extremity dysfunction and Lower extremity dysfunction were compared between subgroups of patients with and without injuries in respectively the upper extremities and the lower extremities. For responsiveness analysis, data were compared with the baseline SMFA measurement of a reference group. Results A three-factor structure was found: Lower extremity dysfunction, Upper extremity dysfunction, and Emotion. Strong correlations between the SMFA and the other questionnaires were found. Patients with injury of the lower extremities had significantly higher scores on the factor Lower extremity dysfunction than patients without injury of the lower extremities (p = 0.017). In none of the factors, a significant difference in mean scores was found between patients with and without injury of the upper extremities. Severely injured patients had significantly higher SMFA scores than the reference group (p < 0.001). Conclusion The adapted Dutch translation of the SMFA showed good psychometric properties in severely injured patients. It appeared to be useful to get a general overview of patients’ Health Status as well as patients’ Health Related Quality Of Life. Keywords SMFA, Injury, Psychometrics, Factor structure, Validity, Responsiveness

Background Because the death rate among the total trauma population is low, other performance indicators in addition to the classical dependent variable mortality are required to assess the overall quality of trauma care. The aim of this study was to develop and validate a prediction model for the occurrence of complications that can be used to adjust a measure of quality of trauma care for case mix. Methods Complications recorded in a trauma registry between 1997 and 2008 were analysed. Formulas for different types of complication (institution- or diagnosis-related) derived from logistic regression models were used to calculate the probability of absence of complications (PAC). Discriminative power was tested by calculating the area under the receiver operating characteristic curve (AUC) in test and validation samples. Calibration was tested using Hosmer and Lemeshow methodology. Results Some 5944 surgical trauma admissions were included in the analysis. A significant association between both institution- and diagnosis-related complications and Injury Severity Score was found. Diagnosis-related complications were also associated with Glasgow Coma Score and age. The AUCs of the PACs for institution- and diagnosis-related complications were 0·64 and 0·75 respectively in the test sample, and 0·66 and 0·76 in the validation sample. The AUCs increased when the outcomes of the models were divided into subcategories of complications. Hosmer and Lemeshow tests were not significant for all models, except that for institutional complications. Conclusion To predict complications, a distinction should be made between institution- and diagnosis-related complications. The development of more detailed diagnosis-related prediction models is preferable because of better performance. The formulas predicting the PAC can be used to compare expected and observed complications.

Background There is growing demand for a simple accurate scoring model to evaluate the quality of trauma care. This study compared different trauma survival prediction models with regard to their performance in different trauma populations. Methods The probability of survival for 10 777 trauma patients admitted to hospital was calculated using the formulas of the following models: the Major Trauma Outcome Study (MTOS), the Trauma Audit and Research Network (TARN) and the Base Excess Injury Severity Scale (BISS). Updated coefficients were calculated by logistic regression analysis based on a Dutch data set. Different models were compared for several subsets of patients, according to age and injury type and severity, using the area under the receiver operating characteristic (ROC) curve (AUC). Calibration for the updated models was presented graphically. Results Most of the models had an AUC exceeding 0·8. For the total population, the TARN Ps07 model with updated coefficients had the highest AUC (0·924); for the subset of patients in whom all parameters were available, the BISS model including the Glasgow Coma Scale had the highest AUC (0·909). All of the models had high discriminative power for patients aged less than 55 years. However, in older or intubated patients and in those with severe head injuries the discriminative power of the models dropped. The TARN model showed the best accuracy. Conclusion The investigated models predict mortality fairly accurately in a Dutch trauma population. However, the accuracy of the models depends greatly on the patients included. Severe head injuries and greater age are likely to lead to a decrease in the accuracy of survival prediction.

This retrospective cohort study was conducted to investigate whether operative treatment of patients with a pertrochanteric femoral fracture outside working hours is associated with an increased risk of complications and higher mortality. During the study period 165 patients were operated on outside working hours and 123 were operated on during working hours (08.00 to 17.00). There was no difference in the rate of early complications (outside working hours 33% versus working hours 33%, p = 0.91) or total complications during follow-up (outside working hours 40% versus working hours 41%, p = 0.91). Both in-hospital mortality (outside working hours 12% versus working hours 11%, p = 0.97) and mortality after one year (outside working hours 29% versus working hours 27%, p = 0.67) were comparable. Adjustment for possible confounders by multivariate logistic regression analysis revealed no increased risk of complications when patients were operated on outside working hours. On the basis of these data, there is no medical reason to postpone operative reduction and fixation in patients with a proximal femoral fracture until working hours.