Patient Perspectives: General Health, Work Status and Satisfaction One Year after Injury
Study of trauma care has frequently focused on physical recovery, complications, mortality, and cost. This study measured outcomes that are more nebulous, but are very important in evaluating the outcome after injury from the patient's perspective. Research in this study focused on outcomes related to overall satisfaction with recovery, function at work, and general wellness. The authors chose these measures because "…they have meaning for the patient and our community as well as trauma surgeons."
The researchers evaluated 247 patients with an interview upon admission to the trauma center, and by mailed self-reports at six and twelve months post trauma. Patients were excluded from the study if they suffered severe neurotrauma, had amputations, a history of psychosis, were mentally disabled, were in prison, or had self-inflicted injuries. The patients averaged 37 years of age, 73% were male and 27% female.
Factors identified as important for the patients' return to productivity included education level, occupational status, and the presence of insurance and compensation. The absence of litigation, chronic pain, and orthopedic injury also contributed to return to productivity. The authors also found that those patients with more education and better baseline measurements of general health had better work scores at the twelve-month follow-up. Work status was negatively correlated with pain, compromised mental health, overall satisfaction, financial difficulties, litigation, and compensation.
Mental health scores at twelve months after injury were, not surprisingly, related to baseline mental health. But, even after controlling for this the authors found prevalent and compromising levels of posttraumatic stress disorder (PTSD), depression, and increased abuse of drugs and alcohol. Previous research has found that in injured patients depression and PTSD interact and increase both dysfunction and distress after trauma. Given that the influence of alcohol and drugs is a significant factor in trauma epidemiology, this increased abuse of substances while patients are under the care of the trauma system is disturbing and impedes recovery. The authors state, "Clearly, further work could be done to provide treatment protocols for these psychological morbidities as an integrated component of our trauma system."
There are several limitations to keep in mind when evaluating this study. Fifty percent of patients that had begun the study, dropped out in the follow-up phase. Baseline measurements were based on patients' own reports of their pre-injury levels of functional status. Participants were treated at a single trauma center, (demographics for this population (i.e., educational and financial status) may differ from other trauma populations), and nearly all had moderate injury severity. Finally, in order to evaluate outcome from the patient's perspective, follow-up measures were self-reported.
Despite these limitations, "This study demonstrates that outcome can be assessed from the patients' perspective, and that in their eyes, mental health is an essential element of satisfaction, work function, and general health status after trauma. This association persists after controlling for measured baseline status, injury severity, and physical recovery. The mental distress after trauma is related to a lower level of baseline mental health symptoms of PTSD and depression, an increase in substance abuse, and pain. These symptoms persist and continue to compromise the patients for at least a year after injury."
The authors suggest that the trauma care system look beyond the hospital phase of trauma care and make greater efforts to provide patient support and care until the patient can return to optimal levels of function.
Michaels AJ, Michaels CE, Smith JS, Moon CH, Peterson C, Long WB. Outcome from injury: general health, work status, and satisfaction 12 months after trauma. The Journal of Trauma: Injury, Infection, and Critical Care 2000;45(5):841-850.