Outcome after major trauma: 12-month and 18-month follow-up results from the Trauma Recovery Project

Background: The importance of outcome after major injury has continued to g ain attention in light of the ongoing development of sophisticated trauma c are systems in the United States. The Trauma Recovery Project (TRP) is a la rge prospective epidemiologic study designed to examine multiple outcomes a fter major trauma in adults aged 18 years and older, including quality of l ife, functional outcome, and psychologic sequelae such as depression and po sttraumatic stress disorder (PTSD). Patient outcomes were assessed at disch arge and at 6, 12, and 18 months after discharge. The specific objectives o f the present report are to describe functional outcomes at the 12-month an d 18-month follow-ups in the TRP population and to examine the association of putative risk factors with functional outcome. Methods: Between December 1, 1993, and September 1, 1996, 1,048 eligible tr auma patients triaged to four participating trauma center hospitals in the San Diego Regionalized Trauma System were enrolled in the TRP study. The ad mission criteria for patients were as follows: (1) age 18 years or older; ( 2) Glasgow Coma Scale score on admission of 12 or greater; and (3) length o f stay greater than 24 hours. Functional outcome after trauma was measured before and after injury using the Quality of Well-Being (QWB) Scale, an ind ex sensitive to the well end of the functioning continuum (0 = death, 1.000 = optimum functioning). Follow-up at 12 months after discharge was complet ed for 806 patients (79%), and follow-up at 18 months was completed for 780 patients (74%). Follow-up contact at any of the study time points (6, 12, or 18 months) was achieved for 926 (88%) patients. Results: The mean age was 36 +/- 14.8 years, and 70% of the patients were m ale; 52% were white, 30% were Hispanic, and 18% were black or other. Less t han 40% of study participants were married or living together. The mean Inj ury Severity Score was 13 +/- 8.5, with 85% blunt injuries and a mean lengt h of stay of 7 +/- 9.2 days. QWB scores before injury reflected the norm fo r a healthy adult population (mean, 0.810 +/- 0.171). At the 12-month follo w-up, there were very high levels of functional limitation (QWB mean score, 0.670 +/- 0.137). Only 18% of patients followed at 12 months had scores ab ove 0.800, the norm for a healthy population. There was no improvement in f unctional limitation at the 18-month follow-up (QWB mean score, 0.678 +/- 0 .130). The majority of patients (80%) at the 18-month follow-up continued t o have QWB scores below the healthy norm of 0.800. Postinjury depression, P TSD, serious extremity injury, and intensive care unit days were significan t independent predictors of 12-month and 18-month QWB outcome. Conclusion: This study demonstrates a prolonged and profound level of funct ional limitation after major trauma at 12-month and 18-month follow-up. Thi s is the first report of longterm outcome based on the QWB Scale, a standar dized quality-of-life measure, and provides new and provocative evidence th at the magnitude of dysfunction after major injury has been underestimated. Postinjury depression, PTSD, serious extremity injury, and intensive care unit days are significantly associated with 12-month and 18-month QWB outco me.