Long-Term Mortality After Trauma Is Much Higher Than Expected

Long-term mortality for adult trauma patients is much higher than expected, given their age and health status before being injured, according to a report March 9 in JAMA.

In a retrospective cohort study of 124,421 patients, mortality was approximately 10% during the first year after hospital discharge, and 16% during the 3 years after hospital discharge. "These results suggest that in an adult trauma patient, acute injury is not just a brief physiological setback to a healthy life, but rather signals significant long-term mortality in a large number of patients," said Dr. Giana H. Davidson of Harborview Injury Prevention and Research Center, Seattle, and her associates.

Inpatient mortality declined steadily over time, both within emergency departments and within hospitals. In dramatic contrast, postdischarge mortality increased over time and "was sharply higher than that expected for the general Washington population at 1, 2, and 3 years," Dr. Davidson and her colleagues said (JAMA 2011;305:1001-7).

The researchers performed the study because "little is known about long-term outcomes following trauma admissions," and the information could be helpful in counseling patients and their families about prognosis.

The mean age of the study subjects was 53 years, and 59% were men. The study did not include burn patients, and injuries were categorized as being caused by blunt trauma (39%), penetrating trauma (11%), falls (47%), or other causes (3%). The patients were treated at 78 trauma centers throughout Washington State in 1995-2008.

"Washington State had a well-organized and mature statewide trauma system (established in 1990) during the study period," the investigators noted.

A total of 7,243 patients (6%) died during their initial hospitalization, leaving 117,178 for this analysis. The median length of stay was 4 days and the mean was 6 days.

Data were adjusted to account for patient age and sex; the presence and severity of head trauma; overall injury severity; the Glasgow Coma Scale score; the FIM (Functional Independence Measure) mobility score at discharge; mechanism of injury; hospital length of stay; ICU length of stay; need for tracheotomy; comorbidity index; and insurance status.

Several factors at admission were found to strongly predict risk of death after hospital discharge. Older patient age, a systolic blood pressure less than 90 mm Hg, a Glasgow Coma Scale score less than 9, male sex, blunt injury, and injury from falling all substantially raised the mortality risk (to 44%) for the first postdischarge year.

This information can help guide clinician and family decision making for the adult trauma patient, the researchers said.

Approximately 25% of patients were discharged to a skilled nursing facility. In the subgroup of patients older than 65 years at the time of their injury, more than half (54%) were discharged to a skilled nursing facility.

Discharge to a skilled nursing facility was associated with a higher risk of postdischarge death in every age group (34% cumulative mortality at 3 years), compared with discharge home (with or without assistance); discharge to a rehabilitation facility; discharge to jail; transfer to a psychiatric hospital; or transfer to another acute-care facility, including ventilator-weaning facilities.

"Due to the substantial difference between the expected and observed mortality rates for our trauma population, we conclude that trauma itself may be an indicator of higher long-term mortality or marker of patient decline," Dr. Davidson and her associates said.

"Interventions should be aimed at improving the care of the injured patient following discharge from the hospital and narrowing the gap in outcomes for those patients discharged to skilled nursing facilities," they said.

This study was supported by the National Institute of Child Health and Human Development. The authors reported having no financial conflicts of interest.

Long-term mortality for adult trauma patients is much higher than expected, given their age and health status before being injured, according to a report March 9 in JAMA.

In a retrospective cohort study of 124,421 patients, mortality was approximately 10% during the first year after hospital discharge, and 16% during the 3 years after hospital discharge. "These results suggest that in an adult trauma patient, acute injury is not just a brief physiological setback to a healthy life, but rather signals significant long-term mortality in a large number of patients," said Dr. Giana H. Davidson of Harborview Injury Prevention and Research Center, Seattle, and her associates.

Inpatient mortality declined steadily over time, both within emergency departments and within hospitals. In dramatic contrast, postdischarge mortality increased over time and "was sharply higher than that expected for the general Washington population at 1, 2, and 3 years," Dr. Davidson and her colleagues said (JAMA 2011;305:1001-7).

The researchers performed the study because "little is known about long-term outcomes following trauma admissions," and the information could be helpful in counseling patients and their families about prognosis.

The mean age of the study subjects was 53 years, and 59% were men. The study did not include burn patients, and injuries were categorized as being caused by blunt trauma (39%), penetrating trauma (11%), falls (47%), or other causes (3%). The patients were treated at 78 trauma centers throughout Washington State in 1995-2008.

"Washington State had a well-organized and mature statewide trauma system (established in 1990) during the study period," the investigators noted.

A total of 7,243 patients (6%) died during their initial hospitalization, leaving 117,178 for this analysis. The median length of stay was 4 days and the mean was 6 days.

Data were adjusted to account for patient age and sex; the presence and severity of head trauma; overall injury severity; the Glasgow Coma Scale score; the FIM (Functional Independence Measure) mobility score at discharge; mechanism of injury; hospital length of stay; ICU length of stay; need for tracheotomy; comorbidity index; and insurance status.

Several factors at admission were found to strongly predict risk of death after hospital discharge. Older patient age, a systolic blood pressure less than 90 mm Hg, a Glasgow Coma Scale score less than 9, male sex, blunt injury, and injury from falling all substantially raised the mortality risk (to 44%) for the first postdischarge year.

This information can help guide clinician and family decision making for the adult trauma patient, the researchers said.

Approximately 25% of patients were discharged to a skilled nursing facility. In the subgroup of patients older than 65 years at the time of their injury, more than half (54%) were discharged to a skilled nursing facility.

Discharge to a skilled nursing facility was associated with a higher risk of postdischarge death in every age group (34% cumulative mortality at 3 years), compared with discharge home (with or without assistance); discharge to a rehabilitation facility; discharge to jail; transfer to a psychiatric hospital; or transfer to another acute-care facility, including ventilator-weaning facilities.

"Due to the substantial difference between the expected and observed mortality rates for our trauma population, we conclude that trauma itself may be an indicator of higher long-term mortality or marker of patient decline," Dr. Davidson and her associates said.

"Interventions should be aimed at improving the care of the injured patient following discharge from the hospital and narrowing the gap in outcomes for those patients discharged to skilled nursing facilities," they said.

This study was supported by the National Institute of Child Health and Human Development. The authors reported having no financial conflicts of interest.

Long-term mortality for adult trauma patients is much higher than expected, given their age and health status before being injured, according to a report March 9 in JAMA.

In a retrospective cohort study of 124,421 patients, mortality was approximately 10% during the first year after hospital discharge, and 16% during the 3 years after hospital discharge. "These results suggest that in an adult trauma patient, acute injury is not just a brief physiological setback to a healthy life, but rather signals significant long-term mortality in a large number of patients," said Dr. Giana H. Davidson of Harborview Injury Prevention and Research Center, Seattle, and her associates.

Inpatient mortality declined steadily over time, both within emergency departments and within hospitals. In dramatic contrast, postdischarge mortality increased over time and "was sharply higher than that expected for the general Washington population at 1, 2, and 3 years," Dr. Davidson and her colleagues said (JAMA 2011;305:1001-7).

The researchers performed the study because "little is known about long-term outcomes following trauma admissions," and the information could be helpful in counseling patients and their families about prognosis.

The mean age of the study subjects was 53 years, and 59% were men. The study did not include burn patients, and injuries were categorized as being caused by blunt trauma (39%), penetrating trauma (11%), falls (47%), or other causes (3%). The patients were treated at 78 trauma centers throughout Washington State in 1995-2008.

"Washington State had a well-organized and mature statewide trauma system (established in 1990) during the study period," the investigators noted.

A total of 7,243 patients (6%) died during their initial hospitalization, leaving 117,178 for this analysis. The median length of stay was 4 days and the mean was 6 days.

Data were adjusted to account for patient age and sex; the presence and severity of head trauma; overall injury severity; the Glasgow Coma Scale score; the FIM (Functional Independence Measure) mobility score at discharge; mechanism of injury; hospital length of stay; ICU length of stay; need for tracheotomy; comorbidity index; and insurance status.

Several factors at admission were found to strongly predict risk of death after hospital discharge. Older patient age, a systolic blood pressure less than 90 mm Hg, a Glasgow Coma Scale score less than 9, male sex, blunt injury, and injury from falling all substantially raised the mortality risk (to 44%) for the first postdischarge year.

This information can help guide clinician and family decision making for the adult trauma patient, the researchers said.

Approximately 25% of patients were discharged to a skilled nursing facility. In the subgroup of patients older than 65 years at the time of their injury, more than half (54%) were discharged to a skilled nursing facility.

Discharge to a skilled nursing facility was associated with a higher risk of postdischarge death in every age group (34% cumulative mortality at 3 years), compared with discharge home (with or without assistance); discharge to a rehabilitation facility; discharge to jail; transfer to a psychiatric hospital; or transfer to another acute-care facility, including ventilator-weaning facilities.

"Due to the substantial difference between the expected and observed mortality rates for our trauma population, we conclude that trauma itself may be an indicator of higher long-term mortality or marker of patient decline," Dr. Davidson and her associates said.

"Interventions should be aimed at improving the care of the injured patient following discharge from the hospital and narrowing the gap in outcomes for those patients discharged to skilled nursing facilities," they said.

This study was supported by the National Institute of Child Health and Human Development. The authors reported having no financial conflicts of interest.