Implementation of a care-pathway at the emergency department for older people presenting with nonspecific complaints; a protocol for a multicenter parallel cohort study.

BACKGROUND: Older adults frequently attend the Emergency Department (ED) with poorly defined symptoms, often called nonspecific complaints (NSC). NSC such as 'weakness' and 'not feeling well', often lead to an extensive differential diagnosis. Patients with NSC experience a prolonged length of stay at the ED and are prone to adverse outcomes. Currently, a care pathway for patients with NSC does not exist. A special structured care pathway for patients with NSC was designed to improve the efficiency and quality of care at the ED. METHOD: A multicenter parallel cohort study, organized in different hospitals in the Noord-Brabant area, the Netherlands, in which general practitioners (GP), elderly care physicians (ECP), Emergency Physicians (EP), geriatricians and internists will collaborate. Patients ≥ 70 years presenting with NSC and in need of ED admission as indicated by their own GP or ECP are eligible for inclusion. Before implementation each hospital will retrospectively include their own control-group. After implementation, patients will prospectively be included. The care-pathway exists of risk stratification by the APOP-screener, in-depth history taking, i.e. limited comprehensive geriatric assessment (CGA) and a standard set of diagnostics, and a dedicated ED-nurse (if possible) present to ensure the care-pathway is followed. The primary outcome is length of stay at the ED (LOS-ED) and perceived quality of care. Secondary outcomes are hospital length of stay, revisits, readmissions and mortality at 30- and 90-day follow-up. DISCUSSION: This study proposes a structured care pathway for older patients presenting at the ED with NSCs and considering effectiveness and perceived quality this may improve acute care for these patients. TRIAL REGISTRATION: Dutch Trial register, number NL8960.

Comparing health status after major trauma across different levels of trauma care.

INTRODUCTION: Mortality due to trauma has reduced the past decades. Trauma network implementations have been an important contributor to this achievement. Besides mortality, patient reported outcome parameters should be included in evaluation of trauma care. While concentrating major trauma care, hospitals are designated with a certain level of trauma care following specific criteria. OBJECTIVE: Comparing health status of major trauma patients after two years across different levels of trauma care in trauma networks. METHODS: Multicentre observational study comprising a secondary longitudinal multilevel analysis on prospective cohorts from two neighbouring trauma regions in the Netherlands. INCLUSION CRITERIA: patient aged ≥ 18 with an ISS > 15 surviving their injuries at least one year after trauma. Health status was measured one and two years after trauma by EQ-5D-5 L, added with a sixth health dimension on cognition. Level I trauma centres were considered as reference in uni- and multivariate analysis. RESULTS: Respondents admitted to a level I trauma centre scored less favourable EQ-US and EQ-VAS in both years (0.81-0.81, 71-75) than respondents admitted to a level II (0.88-0.87, 78-85) or level III (0.89-0.88, 75-80) facility. Level II facilities scored significantly higher EQ-US and EQ-VAS in time for univariate analysis (ß 0.095, 95% CI 0.038-0.153, p = 0.001, and ß 7.887, 95% CI 3.035-12.740, p = 0.002), not in multivariate analysis (ß 0.052, 95% CI -0.010-0.115, p = 0.102, and ß 3.714, 95% CI -1.893-9.321, p = 0.193). Fewer limitations in mobility (OR 0.344, 95% CI 0.156-0.760), self-care (OR 0.219, 95% CI 0.077-0.618), and pain and discomfort (OR 0.421, 95% CI 0.214-0.831) remained significant for level II facilities in multivariate analysis, whereas significant differences with level III facilities disappeared. CONCLUSION: Major trauma patients admitted to level I trauma centres reported a less favourable general health status and more limitations compared to level II and III facilities scoring populations norms one to two years after trauma. Differences on general health status and limitations in specific health domains disappeared in adjusted analysis. Well-coordinated trauma networks offer homogeneous results for all major trauma patients when they are distributed in different centres according to their need of care.

Concepts, utilization, and perspectives on the Dutch Nationwide Trauma registry: a position paper.

Over the last decades, the Dutch trauma care have seen major improvements. To assess the performance of the Dutch trauma system, in 2007, the Dutch Nationwide Trauma Registry (DNTR) was established, which developed into rich source of information for quality assessment, quality improvement of the trauma system, and for research purposes. The DNTR is one of the most comprehensive trauma registries in the world as it includes 100% of all trauma patients admitted to the hospital through the emergency department. This inclusive trauma registry has shown its benefit over less inclusive systems; however, it comes with a high workload for high-quality data collection and thus more expenses. The comprehensive prospectively collected data in the DNTR allows multiple types of studies to be performed. Recent changes in legislation allow the DNTR to include the citizen service numbers, which enables new possibilities and eases patient follow-up. However, in order to maximally exploit the possibilities of the DNTR, further development is required, for example, regarding data quality improvement and routine incorporation of health-related quality of life questionnaires. This would improve the quality assessment and scientific output from the DNTR. Finally, the DNTR and all other (European) trauma registries should strive to ensure that the trauma registries are eligible for comparisons between countries and healthcare systems, with the goal to improve trauma patient care worldwide.

Funnel plots a graphical instrument for the evaluation of population performance and quality of trauma care: a blueprint of implementation.

BACKGROUND: Using patient outcomes to monitor medical centre performance has become an essential part of modern health care. However, classic league tables generally inflict stigmatization on centres rated as "poor performers", which has a negative effect on public trust and professional morale. In the present study, we aim to illustrate that funnel plots, including trends over time, can be used as a method to control the quality of data and to monitor and assure the quality of trauma care. Moreover, we aimed to present a set of regulations on how to interpret and act on underperformance or overperformance trends presented in funnel plots. METHODS: A retrospective observational cohort study was performed using the Dutch National Trauma Registry (DNTR). Two separate datasets were created to assess the effects of healthy and multiple imputations to cope with missing values. Funnel plots displaying the performance of all trauma-receiving hospitals in 2020 were generated, and in-hospital mortality was used as the main indicator of centre performance. Indirect standardization was used to correct for differences in the types of cases. Comet plots were generated displaying the performance trends of two level-I trauma centres since 2017 and 2018. RESULTS: Funnel plots based on data using healthy imputation for missing values can highlight centres lacking good data quality. A comet plot illustrates the performance trend over multiple years, which is more indicative of a centre's performance compared to a single measurement. Trends analysis offers the opportunity to closely monitor an individual centres' performance and direct evaluation of initiated improvement strategies. CONCLUSION: This study describes the use of funnel and comet plots as a method to monitor and assure high-quality data and to evaluate trauma centre performance over multiple years. Moreover, this is the first study to provide a regulatory blueprint on how to interpret and act on the under- or overperformance of trauma centres. Further evaluations are needed to assess its functionality. LEVEL OF EVIDENCE: Retrospective study, level III.

The prevalence and prognostic factors of psychological distress in older patients with a hip fracture: A longitudinal cohort study.

INTRODUCTION: A hip fracture can be experienced as a traumatic event that can induce psychological distress. The aim of this study is to give more insight into the prevalence of symptoms of psychological distress in older patients following the first year after a hip fracture. In addition, prognostic factors were determined for psychological distress after hip fracture. MATERIALS AND METHODS: This hip fracture cohort data was derived from the Brabant Injury Outcome Surveillance, a multicenter longitudinal prospective cohort study. Hip fracture patients (≥65years) admitted to a hospital between August 2015 and November 2016 were asked to complete a questionnaire at 1 week, and 1, 3, 6 and 12 months. The Hospital Anxiety and Depression Scale (HADS) was used to assess symptoms of anxiety and depression and the Impact of Event Scale (IES) was used to assess symptoms of posttraumatic stress (PTS). Prognostic factors were assessed with multivariable logistic mixed models. RESULTS: In total 570 patients (inclusion rate: 69.7%) were included. The prevalence of psychological distress ranged from 36% at 1 week to 31% at 1 year after hip fracture. Frailty at onset of hip fracture was the most important prognostic factor of symptoms of depression (Odds ratio (OR), 2.74; 95% Confidence interval (CI) 1.41 to 5.34) and anxiety (OR, 2.60; 95% CI 1.15 to 5.85) on average in the year following hip fracture. Frailty was not a prognostic factor of symptoms of PTS (OR, 1.97; 95% CI 0.42 to 9.23). CONCLUSIONS: The prevalence of psychological distress is high in the first year after a hip fracture. Frailty at onset of a hip fracture is the most important prognostic factor of symptoms of depression and anxiety. These findings have important implications for strategies with early identification of frail patients with a hip fracture at high risk of psychological distress.

The Dutch nationwide trauma registry: The value of capturing all acute trauma admissions.

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 für 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 criteria CONCLUSION: The DNTR has evolved into a comprehensive well-structured nationwide population-based trauma register. With 80,000 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.

Prognostic factors and quality of life after pelvic fractures. The Brabant Injury Outcome Surveillance (BIOS) study.

INTRODUCTION: Pelvic 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. METHODS: This 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. RESULTS: A 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 ß = 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. DISCUSSION: Patients 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.

Burden of illness of hip fractures in elderly Dutch patients.

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.

Correspondence of directly reported and recalled health-related quality of life in a large heterogeneous sample of trauma patients.

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 < 0.05) at T2 and 0.363 (p < 0.001) at T3. Directly reported mean T2 EQ-5D summary score was 0.737 and mean recalled T2 EQ-5D summary score was 0.713 (p < 0.05) at T3. Directly reported mean T1 EQ-VAS was 56.3, whereas mean recalled T1 EQ-VAS at T2 and T3 was 55.4 (p = 0.304) and 53.3 (p < 0.05), respectively. Directly reported mean T2 EQ-VAS was 72.5 and recalled T2 EQ-VAS at T3 was 68.0 (p < 0.001). The correspondence between all directly reported and recalled HRQL (both EQ-5D summary and EQ-VAS) was fair (ICC = 0.518-0.598). Lowest correspondence was seen in patients with major trauma (injury severity score ≥ 16) and in patients with middle-level education. CONCLUSIONS: Recalled HRQL measured by the EQ-5D-3L and EQ-VAS was systematically lower compared to the directly reported HRQL. Patient characteristics, injury severity, subjectivity of the dimension, and time interval appear to influence correspondence between directly reported and recalled HRQL.

Quality of life after pelvic ring fractures: Long-term outcomes. A multicentre study.

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.

Predicting health status in the first year after trauma.

BACKGROUND: Although 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. METHODS: The 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 ). RESULTS: In 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. CONCLUSION: The most important predictors of health status in the first year after trauma in this population appeared to be preinjury health status and frailty.

Validation and reliability of the Abbreviated World Health Organization Quality of Life Instrument (WHOQOL-BREF) in the hospitalized trauma population.

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.

Quality of life after pelvic ring fractures: A cross-sectional study.

BACKGROUND: 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). METHODS: 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. RESULTS: 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 the <65 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 the <65 group, significant differences in MPS results between the Tile groups regarding pain (P < 0.01) and the total MPS score (P = 0.04) were seen. Neither significant regression coefficients nor clinically relevant differences were found in the ≥65 group. CONCLUSIONS: 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.

Follow-up in patients with a burn-related emergency department visit: a feasibility study.

BACKGROUND: Data on epidemiology, costs, and outcomes of burn-related injuries presenting at emergency departments (EDs) are scarce. To obtain such information, a questionnaire study with an adequate response rate is imperative. There is evidence that optimized strategies can increase patient participation. However, it is unclear whether this applies to burn patients in an ED setting. The objective of this feasibility study was to optimize and evaluate patient recruitment strategy and follow-up methods in patients with burn injuries presenting at EDs. METHODS: In a prospective cohort study with a 6-month follow-up, patients with burn-related injuries attending two large EDs during a 3-month study period were included. Eligible patients were quasi-randomly allocated to a standard or optimized recruitment strategy by week of the ED visit. The standard recruitment strategy consisted of an invitation letter to participate, an informed consent form, a questionnaire, and a franked return envelope. The optimized recruitment strategy was complemented by a stamped returned envelope, monetary incentive, sending a second copy of the questionnaire, and a reminder by telephone in non-responders. Response rates were calculated, and questionnaires were used to assess treatment, costs, and health-related quality of life. RESULTS: A total of 87 patients were included of which 85 were eligible for the follow-up study. There was a higher response rate at 2 months in the optimized versus the standard recruitment strategy (43.6% vs. 20.0%; OR = 3.1 (95% CI 1.1-8.8)), although overall response is low. Non-response analyses showed no significant differences in patient, burn injury or treatment characteristics between responders versus non-responders. CONCLUSIONS: This study demonstrated that response rates can be increased with an optimized, but more labor-intensive recruitment strategy, although further optimization of recruitment and follow-up is needed. It is feasible to assess epidemiology, treatment, and costs after burn-related ED contacts.

The relationship between physical and psychological complaints and quality of life in severely injured patients.

PURPOSE: The purpose of this study was two-fold. The first goal was to investigate which variables were associated with the remaining physical limitations of severely injured patients after the initial rehabilitation phase. Second, we investigated whether physical limitations were attributable to the association between psychological complaints and quality of life in this patient group. METHODS: Patients who were 18 years or older and who had an injury severity score (ISS)>15 completed a set of questionnaires at one time-point after their rehabilitation phase (15-53 months after their trauma). The Short Musculoskeletal Function Assessment (SMFA) questionnaire was used to determine physical limitations. The Hospital Anxiety and Depression Scale, the Dutch Impact of Event Scale and the Cognitive Failure Questionnaire were used to determine psychological complaints, and the World Health Organization Quality of Life assessment instrument-BREF was used to measure general Quality of Life (QOL). Differences in physical limitations were investigated for several trauma- and patient-related variables using non-parametric independent-sample Mann-Whitney U tests. Multiple linear regression was performed to investigate whether the decreased QOL of severely injured patients with psychological complaints could be explained by their physical limitations. RESULTS: Older patients, patients with physical complaints before the injury, patients with higher ISS scores, and patients who had an injury of the spine or of the lower extremities reported significantly more physical problems. Additionally, patients with a low education level, patients who were living alone, and those who were unemployed reported significantly more long-term physical problems. Severely injured patients without psychological complaints reported significantly less physical limitations than those with psychological complaints. The SMFA factor of Lower extremity dysfunction was a confounder of the association between psychological complaints and QOL in all QOL domains. CONCLUSIONS: Long-term physical limitations were mainly reported by patients with psychological complaints. The decreased QOL of severely injured patients with psychological complaints can partially be explained by physical limitations, particularly those involving lower extremity function. Experienced physical limitations were significantly different for some trauma and patient characteristics. These characteristics may be used to select patients for whom a rehabilitation programme would be useful.

The effect of socio-economic status on non-fatal outcome after injury: A systematic review.

BACKGROUND: Over the past decades, the number of survivors of injuries has rapidly grown. It has become important to focus more on the determinants of non-fatal outcome. Although socio-economic status (SES) is considered to be a fundamental determinant of health in general, the role of SES as a determinant of non-fatal outcome after injury is largely unknown. METHODS: An online search was conducted in November 2015 using Embase, Medline, Web of Science, Cinahl, Cochrane, Google scholar and PubMed. Studies examining the relation between SES and a physical or psychological outcome measure, or using SES as a confounder in a general trauma population were included. There were no restrictions regarding study design. The 'Quality in Prognostic Studies tool' was used to assess the methodological quality of the included studies. RESULTS: The 24 included studies showed large variations in methodological quality. The number of participants ranged from 56 to 4639, and assessments of the measures ranged from immediately to 6year post-injury. Studies used a large number of variables as indicators of SES. Participant's educational level was used most frequently. The majority of the studies used a multivariable technique to analyse the relation between SES and non-fatal outcome after injury. All studies found a positive association (80% of studies significant, n=19) between increased SES and better non-fatal outcome after injury. CONCLUSION: Although an adequate and valid measure of SES is lacking, the results of this review showed that SES is an important determinant of non-fatal outcome after injury. Future research should focus on the definition and measurement of SES and should further underpin the effect of SES on non-fatal outcome after injury.

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

INTRODUCTION: Trauma is a major public health problem worldwide that leads to high medical and societal costs. Overall, improved understanding of the full spectrum of the societal impact and burden of injury is needed. The main purpose of the Brabant Injury Outcome Surveillance (BIOS) study is to provide insight into prevalence, predictors and recovery patterns of short-term and long-term health-related quality of life (HRQoL) and costs after injury. MATERIALS AND METHODS: This is a prospective, observational, follow-up cohort study in which HRQoL, psychological, social and functional outcome, and costs after trauma will be assessed during 24 months follow-up within injured patients admitted in 1 of 10 hospitals in the county Noord-Brabant, the Netherlands. Data will be collected by self-reported questionnaires at 1 week (including preinjury assessment), and 1, 3, 6, 12 and 24 months after injury. If patients are not capable of filling out the questionnaires, proxies will be asked to participate. Also, information about mechanism and severity of injury, comorbidity and indirect and direct costs will be collected. Mixed models will be used to examine the course of HRQoL, functional and psychological outcome, costs over time and between different groups, and to identify predictors for poor or good outcome. RELEVANCE: This study should make a substantial contribution to the international collaborative effort to assess the societal impact and burden of injuries more accurately. The BIOS results will also be used to develop an outcome prediction model for outcome evaluation including, besides the classic fatal, non-fatal outcome. TRIAL REGISTRATION NUMBER: NCT02508675.

Psychometric properties of the Dutch Short Musculoskeletal Function Assessment (SMFA) questionnaire in severely injured patients.

UNLABELLED: 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.

Technical errors and complications in orthopaedic trauma surgery.

INTRODUCTION: Adverse events and associated morbidity and subsequent costs receive increasing attention in clinical practice and research. As opposed to complications, errors are not described or analysed in literature on fracture surgery. The aim of this study was to provide a description of errors and complications in relation to fracture surgery, as well as the circumstances in which they occur, for example urgency, type of surgeon, and type of fracture. METHODS: All errors and complications were recorded prospectively in our hospital's complication registry, which forms an integral part of the electronic medical patient file. All recorded errors and complications in the complication registry linked to fracture surgery between 1 January, 2000 and 31 December, 2010 were analysed. RESULTS: During the study period 4310 osteosynthesis procedures were performed. In 78 (1.8 %) procedures an error in osteosynthesis was registered. The number of procedures in which an error occurred was significantly lower (OR = 0.53; p = 0.007) when an orthopaedic trauma surgeon was part of the operating team. Of all 3758 patients who were admitted to the surgical ward for osteosynthesis, 745 (19.8 %) had one or more postoperative complications registered. There was no significant difference in the number of postoperative complications after osteosynthesis procedures in which an orthopaedic trauma surgeon was present or absent (16.7 vs. 19.1 %; p = 0.088; OR 0.85). DISCUSSION: In the present study the true error rate after osteosynthesis may have been higher than the rate found. Errors that had no significant consequence may be especially susceptible to underreporting. CONCLUSION: The present study suggests that an osteosynthesis procedure performed by or actively assisted by an orthopaedic trauma surgeon decreases the probability of an error in osteosynthesis. Apart from errors in osteosynthesis, the involvement of an orthopaedic trauma surgeon did not lead to a significant reduction in the number of postoperative complications.

A cross-sectional study of psychological complaints and quality of life in severely injured patients.

PURPOSE: The purpose of this study was to examine the incidence of psychological complaints and the relationship of these complaints with the quality of life (QOL) and accident- and patient-related factors among severely injured patients after the rehabilitation phase. METHODS: Patients of 18 years or older with an injury severity score above 15 were included 15-53 months after their accident. Accident and patient characteristics were obtained from questionnaires and the trauma registry. Several questionnaires (Hospital Anxiety and Depression Scale, Impact of Events Scale, and Cognitive Failure Questionnaire) were used to determine the symptoms of psychological problems (anxiety or depression, post-traumatic stress disorder, or subjective cognitive complaints, respectively). The World Health Organization Quality of Life-Bref was used to determine QOL. A reference group of the Dutch general population was used for comparison of QOL scores. RESULTS: The participation rate was 62 % (n = 173). At the time of the study, 30.1 % (n = 52) of the investigated patients had psychological complaints. No relation between psychological complaints and somatic severity or type of injury was found. Patients who were employed before the accident or resumed working reported less psychological complaints. Use of any medication before the accident and treatment for pre-accidental psychological problems were positively related to psychological complaints afterwards. QOL of severely injured patients was impaired in comparison with the general Dutch population, but only for those with psychological complaints. CONCLUSIONS: Psychological complaints seem to be an important and underestimated factor for a decreased QOL among severely injured patients.