Health related quality of life in trauma patients. Data from a one-year follow up study compared with the general population

As trauma care has improved substantially during recent decades and has led to higher survival rates [1], there has also been an increasing focus on the patients' perceived health-related quality of life (HRQOL) as an outcome after trauma [2]. There is growing evidence that trauma patients have impaired HRQOL after trauma [3–6] compared with reported pre-injury levels and with HRQOL in general populations [5–7]; however, the majority of this evidence stems from patients with serious injuries (Injury Severity Score (ISS) > 15) [4, 8–15]. Although patients with minor injuries (ISS < 9) contribute to a large part of the health burden among adults [16], there is less documentation regarding the impact of minor injuries on HRQOL and, in particular, few studies have been performed in populations with the whole range of injury severity [5, 17–19]. Studying a mixed trauma population with different levels of injury severity provides an opportunity to investigate the impact of the relative contribution of physical and mental factors to HRQOL.

Increased knowledge of HRQOL predictors after trauma may enable us to optimize and individually tailor interventions at an early stage in treatment and rehabilitaiton. The predictors of good HRQOL after trauma previously reported include lower age [4, 9, 20], male gender [21, 22], absence of pre-existing disease [3, 6, 20], lower ISS [15, 20, 23–25], lower number of injuries [17], absence of hip/lower extremity fracture or spine injury [18], short hospital stay [17], not having been admitted to an ICU [17] and absence of head injury [6, 15, 20]. Other reported predictors are low post-traumatic stress [4, 26] and depression scores [4]. Only three studies examined the impact of psychological distress on HRQOL after injury and hospital stay in a mixed-trauma population [5, 19, 27]. Two of them reported that psychiatric morbidity (mainly post-traumatic stress disorder (PTSD) and depression) predicted worse HRQOL after injury [5, 27]. In contrast, one study [19] reported that anxiety shortly after injury was a predictor of better physical health. To assess the relative contribution of physical and mental factors after trauma to HRQOL, it is also important to investigate the impact of psychological distress in these patients.

Although several studies have shown that ICU patients have reduced quality of life after the ICU stay [28, 29], it is not clear whether the ICU stay adds to the burden of trauma and whether the trauma ICU patients consequently report lower HRQOL than the non ICU-patients. To the best of our knowledge, few previous studies have investigated whether trauma patients who required ICU treatment had poorer HRQOL compared to hospitalized patients who did not require it.

General life orientation (pessimism vs. optimism) has in previous studies shown to be a predictor of HRQOL in ICU patients [29], depression in trauma ICU patients [30], and psychological morbidity in breast cancer patients [31]. We are not aware of any previous studies that have investigated the impact of general life orientation on HRQOL in trauma patients.

To fill in these gaps in knowledge, we performed a study with the following aims.

A prospective cohort study of hospitalized trauma patients with different levels of injury was performed. Trauma patients were consecutively enrolled at the Oslo University Hospital, Ulleval, from June 2005 to December 2006. This hospital is a trauma referral centre for Eastern and Southern Norway and serves a population of approximately 2.5 million people. Patients are transferred to local hospitals when specialized trauma care is no longer needed.

All patients aged between 18 and 75 years who were admitted to the hospital and received by the trauma team were eligible for inclusion. The following patients were excluded from the study: Patients visiting from abroad, patients with self-inflicted injuries, severe head injury causing cognitive impairment influencing the ability to answer a questionnaire, inability to read or understand Norwegian, unknown address or previous diagnosed serious psychiatric disorders. The ability to answer the questionnaire was assessed by a nurse at the ward or rehabilitation institution the patient was transferred to after the ICU stay. If the patient was assessed unable to answer within two months after the injury the patient was excluded from the study.

Data were recorded concerning which units the patients were admitted to and the duration of their stay. Patients with a more than 24 hour stay in ICU or recovery unit were categorized as ICU patients in the study.

After transfer from the emergency department/ICU to a ward or discharge from the hospital, eligible patients received written information regarding the study and were asked to participate. Patients provided written consent and answered a questionnaire by mail after discharge. For the ICU patients the median time from injury to first assessment was 44 days (interquartile range43 days), and for the non-ICU patients 17 days (interquartile range 20 days). Assessments were also performed 3 and 12 months later. Patients who were mailed a request about participation in the study were contacted later by telephone, to confirm that they had received the letter and to inquire whether they had questions regarding the project. One reminder was sent by mail.

The main findings in this study of trauma patients with different degrees of injury severity were that the mean scores for all subscales of HRQOL, with the exception of social functioning, were significantly lower than those observed in the Norwegian general population. Significant improvement between three and twelve months was only seen in physical functioning, role physical, pain and social functioning. Significant differences between ICU and non-ICU patients at 12 months were observed only for physical functioning and role physical subscales. Optimism was an independent predictor of good HRQOL at 12 months, in all dimensions. Other main predictors of good HRQOL were absence of depression and absence of PTS symptoms.

It might have been expected that there had been more improvement in other domains than physical functioning, role physical, pain and social functioning. On the other hand, the physical and pain domains were those most impaired, compared to the general population. Although we identified a significantly lower score in seven of eight domains at 12 months compared with that of the general Norwegian population; only physical functioning, role physical and pain had z-scores that were indicative of clinically significant differences compared with the general population.

We have identified six previous studies that compared HRQOL in trauma patients with the general population [4, 7, 50–52] or a healthy control group [19]; all of these studies reported significantly lower scores for the patients compared with the general population/control group but none of them presented z-scores for this difference. These six studies covered patients with pelvic ring fracture [51], mixed trauma [7, 52, 53], major trauma [4] and orthopaedic conditions [19] and might partly be comparable with our study.

Our patients' HRQOL scores 3 and 12 months post-trauma were significantly lower than in the general Norwegian population. In addition, our patients reported significantly higher pre-trauma HRQOL. It may therefore be argued that our patients had a greater drop in HRQOL than revealed by comparing with the general population. However, the high score before injury may well have been caused by recall bias. Watson et al. [52] also found a higher pre-injury level of HRQOL in trauma patients compared with that observed in the Australian general population. These authors compared the pre-injury level with that reported after 12 months in patients who had recovered completely from the injuries. As these two measures were similar, the authors argue that retrospectively measured pre-injury HRQOL is a valid measure of HRQOL. This might support the contention that the higher pre-injury levels of physical functioning, role physical and pain found in our study were not caused by a recall bias. One might assume that, at least for the physical dimensions, it is possible to recall these levels quite accurately. But it is also possible that our patients recall their physical and role physical functioning as better than it really was.

It might be discussed how relevant it is to compare trauma patients with the general population. The trauma population is known to have a greater proportion of people from lower social classes, with more substance abuse and criminality than the general population. Using a control group matched for income, education and occupation in addition to age and gender might have given less difference between SF-36 scores in patients and the comparing group.

Significant differences between ICU and non-ICU patients were seen only regarding physical functioning and role physical functioning at 12-months. One might have expected that ICU patients would also have lower scores in other dimensions, e.g., mental health, as it has previously been shown that ICU patients suffer from anxiety, depression and PTS symptoms after ICU stay [54, 55]. We are not aware of other studies that have compared HRQOL in ICU and non-ICU patients.

Optimism was an independent predictor of good HRQOL in all dimensions. To the best of our knowledge, this is the first study to demonstrate this in a mixed-trauma population. Previous studies showed that this is a predictor of HRQOL in ICU patients [29] and coronary artery bypass patients [56]. In a study of women with breast cancer, Schou et al. found that optimistic women reported better HRQOL and that this effect was mediated by coping strategy [57]. Optimistic women used a strategy of fighting spirit, whereas pessimistic women responded with a hopeless/helpless strategy to a greater degree. Survivors of trauma have the challenge of coping with both the physical and emotional consequences of the injury. It might be that the association between life orientation and HRQOL in trauma patients is also mediated by coping strategy. To improve HRQOL, patients with a pessimistic life orientation should be identified and interventions targeting better coping should be offered. A helpless/hopeless strategy can be improved using cognitive behavioural therapy [58].

Depression at baseline was a predictor of lower HRQOL in four dimensions: physical functioning, mental health, bodily pain and vitality. As depression is a psychological symptom, it is not surprising that it predicts mental health. Lack of energy is a symptom of depression and may explain why depression at baseline predicted vitality at 12 months. More surprisingly, depression also predicted physical functioning. This might be because depressed patients have little energy, which influences their ability to exercise and to regain their previous level of function after the injury. This means that patients could be screened for depression after trauma and that depressed patients could be offered treatment for this condition. They might benefit from being taught coping strategies to manage physical training, despite the depression. We identified only two studies that investigated the association between depression and HRQOL in trauma patients. Holbrook et al.[4] reported depression as a predictor of overall lower HRQOL in major trauma patients after 12 and 18 months. Ponsford et al.[19] found that depression was a predictor of worse physical health (as measured using SF-36) in orthopaedic trauma patients with a mean ISS of 13.1. They measured depression at the same time as the outcome; therefore, it can be argued that in that study, depression was associated with physical health but was not its predictor. The injury severity score was only an independent predictor of general health. One might have expected that the severity of injury would also have an impact on other dimensions, e.g., physical functioning and role physical. It has differed between studies whether ISS has been found to be a predictor of the different dimensions in HRQOL or not. MacKenzie et al [59] and Bull [60] did not find that ISS was a significant predictor of physical functioning after injury. Vles et al.[24] found that ISS score predicted all dimensions--with the exception of anxiety and depression--of HRQOL in severely injured patients, as measured using EuroQol. Harris et al [20] also found that ISS score independently predicted the physical component score measured by SF-36 in severely injured patients, and this was also found in a mixed-trauma sample [7]. Ringdal et al.[3] and Kiely et al [61] did not find a similar result in severely injured patients and in patients with moderate-to-severe injuries, respectively. Ringdal et al. found that the APACHE II score (a measure of the seriousness of illness), which was entered into the multivariate analysis together with ISS, was an independent predictor of physical functioning. Kiely et al. used the Functional Independence Measure as an independent variable in their multivariate analysis, together with ISS, and found that it was a predictor of physical functioning. It might be that these two variables also reflect the seriousness of the injury and crowd out ISS as an independent predictor.

The HRQOL improved significantly from the three to the twelve months follow up in five of eight dimensions of SF-36 in the trauma patients in our sample. However their scores were significantly lower for most subscales of SF-36 compared to the general population.

Significant differences between ICU and non-ICU patients were observed for only two physical subscales. Better HRQOL at 12 months was predicted mainly by optimism, low score for depression and PTS symptoms at baseline. High ISS predicted low general health exclusively.