Long-term Outcomes Poor for Trauma Patients

In a study that included more than 120,000 adults who were treated for trauma, 16% of these patients died within three years of their injury, compared to an expected population mortality rate of about 6%, according to a study published in the Journal of the American Medical Association. The researchers also found that trauma patients who were discharged to a skilled nursing facility had a significantly increased risk of death compared with patients discharged home without assistance.

According to the authors, few studies have evaluated long-term mortality in trauma patients and assessed predictors that increase the risk of death following hospital discharge. Information on the immediate and long-term causes of death following discharge can help “identify gaps in care amenable to improvement, and allow for counseling of patients and their families about prognosis following traumatic injuries, wrote Giana H. Davidson, MD, MPH, of the Harborview Injury Prevention and Research Center, Seattle, and colleagues.

The authors sought to identify risk factors for death following hospital discharge. They examined the long-term mortality of 124,421 adult trauma patients admitted to Washington State facilities from January 1995 to December 2008, and used the Washington State Trauma Registry linked to death certificate data. The average age of the patients was 53 years; 59% were male.

Of the patients in the study, 7,243 died (5.8%) during their trauma hospitalization, and 21,045 died following hospital discharge. The proportion of patients who died while in the hospital declined each year of the study, from 8% in 1995 to approximately 4.9% in 2008, whereas long-term cumulative mortality increased from 4.7% to 7.4%. Analysis indicated that cumulative mortality following injury was 9.8% at 1 year and 16% at 3 years. Age was shown to strongly predict risk of death during the follow-up period and time to death following injury.

Other significant predictors of death after discharge included a maximum score for head injury on an injury scale, a measure of functional independence, the mechanism for injury being a fall, and having Medicare or other government insurance.

Among patients discharged from the hospital, more than half were discharged home without assistance and nearly one-quarter were discharged to a skilled nursing facility. "Overall, cumulative mortality was significantly lower for those patients discharged home with or without assistance and patients discharged to rehabilitation facilities than for patients discharged to a skilled nursing facility, who had a 34% cumulative mortality by 3 years postdischarge," the authors wrote.

These results “indicate that skilled nursing facility discharge status may at least be a marker for significantly higher risk of subsequent mortality and may be the focus for future research and intervention,” especially among adults between the ages of 31 and 80. “There are significant differences in physical therapy and occupational therapy for patients in rehabilitation programs compared with patients at skilled nursing facilities, even when comparing similar demographic characteristics and medical complexity,” they added.

Davidson and colleagues believe that future research in surgical patients should focus on outcomes longer than the standard reporting of 30-day mortality, because a downwind shift in mortality may be resulting from improvements in the acute care period.

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