Trauma Outcomes Should Include Patient-Reported Outcome Measures, Group Says

By Will Boggs MD

April 22, 2020

NEW YORK (Reuters Health) - Follow-up of trauma survivors should include evaluation of patient-reported outcome measures (PROMs), according to the The Patient Reported Outcome Consortium.

"There is a great recognition of the longer-term impact of injury on functional outcomes and quality of life," Dr. Joseph V. Sakran from Johns Hopkins University School of Medicine, in Baltimore, Maryland, told Reuters Health by email. "It's important to remember that collecting patient-reported outcomes data across the system will allow us to identify strategies that are more likely to reduce the disability, return patients to their families, and, in the words of many patients, 'get their life back.'"

Most studies of trauma care have been limited to the acute phase, while the patient is still in the trauma center, and data relevant to outcomes after discharge are limited to small-scale studies.

Dr. Sakran and colleagues organized a conference with representatives from major medical organizations, trauma survivors and experts in PROMs to identify a small number of PROMs to incorporate into the American College of Surgeons National Trauma Data Standard (NTDS) database.

They focused on patients with an Abbreviated Injury Scale (AIS) of 3 or higher, representing severe injury in at least one body region and accounting for half of adult trauma survivors.

The Consortium recommends using the Patient-Reported Outcomes Measurement Information System (PROMIS)-Physical Function scale to assess physical function for adults and the EuroQol-5D (EQ-5D) youth version for children and adolescents.

For cognitive assessment, they recommend PROMIS-Applied Cognition as a slight preference over Neuro-QoL (Quality of Life in Neurological Disorders), they note in their report in the Journal of the American College of Surgeons.

Recommendations for assessing mental health included the PTSD Checklist for DSM-5 Criteria (PCL-5) as the optimal tool for screening for posttraumatic stress disorder in adults, the Child Trauma Screening Questionnaire (CSTQ) for PTSD screening in children, the Personal Health Questionnaire (PHQ-9) as the most practical means of screening for depression, and AUDIT-C to identify patients with possible alcohol abuse.

How best to define and measure quality of life following injury remains unclear, but conference participants felt that life satisfaction and participation in life events made critical contributions to quality of life. Accordingly, they recommended the use of the PROMIS tool "Ability to Participate in Social Roles and Activities" along with the Satisfaction With Life Scale.

The group agreed that much work remains to be done to pilot the feasibility and optimal data collection strategy among U.S. trauma centers.

"The main obstacle is that most trauma centers currently function at a limited capacity," Dr. Sakran said. "In order to capture PROMs type data, there needs to be support at both the state and federal level in order to ensure the necessary investment to fund the research and development required to build the infrastructure and capture the needed data."

"There are numerous instruments that currently exist for collection of patient-reported outcome measures," he said. "As we continue to collect data and learn about the impact patients face post-discharge, I would not be surprised to see a shift in both the type of tools we are using to collect the data as well as the duration of time they are used post-injury."

Dr. Heather K. Vincent of the University of Florida, in Gainesville, who recently evaluated PROMs in orthopedic-trauma patients during early recovery, told Reuters Health by email, "It is critical to use a combination of self-reported emotional well-being and physical functioning when tracking patient recovery after trauma, as we have found that the time course for emotional and functional health are different based on patient characteristics and injuries."

"First, we have found that when people are discharged home after the hospital stay, there is a realization period that occurs in which patients see all the functional things they can't do and the emotional state changes," said Dr. Vincent, who was not involved in the new report. "Second, we sometimes see that there can be a disjunction between how people feel they are doing compared to what they can actually do. Having both sets of measures can help patients see actual progress in specific functional gains that may positively impact the emotional state."

"Physicians can help shape the patient engagement in PROMs and maintaining participation in these measures," Dr. Vincent said. "The bottom line is that a culture of personal investment in care by patients is truly needed if success with PROMs can occur. The first step is for physicians to help make sure that patients understand the value of these measures and how it can shape care pathways for people like them."

"Finally, we must put PROM in context of socioeconomic status and patient characteristics - not just PROM related to injury or surgery," she said. "For example, a person with low socioeconomic status and obesity might not have the same emotional and wellbeing recovery after a severe car accident as a patient who has plenty of resources and is otherwise healthy."

SOURCE: Journal of the American College of Surgeons, online March 19, 2020.