Outcome Measurement in Major Trauma Karen Hoffman Clinical Specialist Occupational Therapist – Neurosciences and Critical Care Objectives 1. 2. 3. 4. 5. 6. Why measure outcome What do we need to measure When do we need to measure What’s out there Patient perspective Provider perspictive In the context of clinical outcome and ‘rehabilitation’ 1. Why measure outcome? 1. Why measure outcome? • Severe trauma remains the leading cause of death in people under the age of 30 due to incidental death (Mackenzie, et al., 1998) • Trauma patients occupy more hospital beds then all patients from heart diseases, and four times more than patients with cancer’ (Pickering et al., 1999) • World Health Organisation (WHO) predicts that trauma will rank third among he causes of disability in 2020 worldwide and has a significant global disease burden 1. Why measure outcome? • Measure the efficacy and effectiveness of acute care interventions, therefore, justifying healthcare expenditure (Halcomb et al., 2005) • Holistic view of patient recovery and experience after trauma (Richmond, 1997) • To prove the value and benefits of the services we provide • Establish preferred practice patterns and improve quality of services • Benchmarking - provide a standard of care/performance • Quality control measure for the government and the patient • Predict outcome • Marketing tool 2. What do we need to measure? World Health Organisation Health Condition (disorder/disease) Body function&structure (Impairment) Environmental Factors Activities (Limitation) Participation (Restriction) Personal Factors Soberg et al, 2007. J Trauma,62:471– 481. Using the ICF as a framework Impairment Activity (Limitation) / function Participation (Restriction) ISS TRISS APACHE II ASIA Barthel Index FIM SF-36 EQ-5D AusTOMs GOS GAS Life satisfaction Index COPM London Handicap Scale Life Habits Assessment (LIFE-H) Craig Handicap Assessment Reporting Technique (CHART) AusTOMs Fatigue Impact Scale HADS BDI McGill Pain questionnaire Grip strength CAM Davidson Trauma Scale World Health Organisation Disability Schedule ll (WHO-DAS ll) Personal Care Participation Assessment & Resource Tool (PC-PART) 2. What do we need to measure? • Baseline assessment • Treatment – which interventions are the most effective with resources available (rehabilitation programs) • The processes, pathways and systems – to ensure optimal outcome • The overall socio-economic cost – effectiveness and efficacy of rehabilitation, measured against the patient outcome and the impact on the society 3. When do we need to measure? 3. When do we need to measure? • Throughout the patient pathway, e.g. on admission once stable, 2 weeks, 4 weeks, before discharge, 3 months, 12 months, 2 years (Baldry Currens & Coats 1999) • ICU, ward, discharge, in patient rehab, community, later • Consider pre-injury co-morbidities, socioeconomic and demographic detail • Longitudinal – lost to follow up 4. What’s out there? (Horwitz et al 2008) 4. What’s out there…? • Trauma rehabilitation outcome scoring (Horwitz et al 2008) • Nottingham Health Profile and Rosser Disability Scale (Dimopoulou et al, 2004) • Kosar et al, (2009) • Hannover Score for Polytrauma Outcome (HASPOC) • Functional Capacity Index • AO/ASIF classification of fractures • Manual and the soft-tissue injury - Gustilo7 • Closed fractures - Tscheme and Oestems. Seekamp Injury 1996;27:133-138 4. What’s out there…? • Brief Symptoms Inventory to assess Post Traumatic Stress Disorder (PTSD) • Davidson Trauma Scale – Posttraumatic psychopathology • HADS • World Health Organisation Disability Assessment Schedule (WHODAS II ) • SF-36 • EQ-5D • PROductivity and DISbility questionnaire (PRODISQ ) 4. What’s out there…? • Multidimensional Health Locus of Control (MHLC) – people’s beliefs about their health as being determined by their own behaviours or not • The Brief Approach/Avoidance Coping Questionnaire (BACQ) – general coping strategies of approach/avoidance Cognition • Head Injury Symptom Checklist (HISC) • FIM – cognitive • COG – self-assessed cognitive functioning • CAM Cognition.. The majority of trauma survivors without intracranial haemorrhage display persistent cognitive impairment, which is nearly twice as likely in those with skull fractures or concussions. This cognitive impairment was associated with functional defects, poor quality of life, and an inability to return to work. Future research must delineate modifiable risk factors for these poor outcomes, especially in patients with skull fractures and concussions, to help improve long-term cognitive and functional status. Jackson et al, 2007. Long-Term Cognitive, Emotional, and Functional Outcomes in Trauma Intensive Care Unit Survivors Without Intracranial haemorrhage. J Trauma, 62:80–88. 5. Patient perspective • Zatzick et al, (2001) – Of all the things that have happened to you since you were injured, what concerns you the most? – What about this worries you? – How concerning is this to you? Rated: Physical health, psychological, work and finance, social, legal, medical • Anke & Fugl-Meyer (2003) Life satisfaction several years after trauma • Satisfaction with leisure, family life and vocation 5. Patient perspective • Stineman et al (2007) and Kurtz et al (2008) Recovery Preference Exploration (RPE) • Focus on a person’s qualities to promote positive adjustment rather than negative aspects of disability djustment 6. Provider perspective • Northwick Park Dependency Scale Research Priority Recommendations - Clohan et al, 2007 1. Development of cognitive and psychosocial outcome measures, that are low in respondent burden and valid across patient populations 2. Development of measures of long-term outcomes that reflect participation, activity, and support system stability that can be obtained efficiently 3. Development of robust severity and selection criteria across different patient populations in PAC rehabilitation Research Priority Recommendations - Clohan et al, 2007 4. Evaluation of the reliability and validity of instruments across settings, diagnostic groups, and time points during the rehabilitation process 5. Assessment of environmental factors to allow adjustment of outcomes related to supportive resources 6. Development of evidence-based treatment guidelines and measurement systems to capture processes of care and outcomes to support quality improvement efforts and process- related payment systems Clohan et al, 2007. Post acute Rehabilitation Research and Policy Recommendations. Arch Phys Med Rehabil, 88: 1535-1541 In summary • Measure across the pathway • Consider the ICF as framework • Injury specific measurements and generic measurements • Patient perspective • Dependency “To Care for Him Who Shall Have Borne the Battle and for His Widow and His Orphan” (Abraham Lincoln) References • Seekamp A, Regel G, Tscherne H: Rehabilitation and reintegration of multiple injured patients: an oucome study with special reference to multiple limb fractures. Injury 1996;27:133-138 • Zelle B, Stalp M, Weihs Ch, Müller F, Reiter FO, Krettek Ch, Pape HC; Arbeitsgemeinschaft "Polytrauma" der Deutschen Gesellschaft für Unfallchirurgie. (Validation of the Hannover Score for Polytrauma Outcome (HASPOC) in a sample of 170 polytrauma patients and a comparison with the 12-Item Short-Form Health Survey) Chirurg. 2003 Apr;74(4):361-9.