Abstract
Background:
Disability and impaired health-related quality may persist for months among injured children. Previous studies of long-term outcomes have focused mainly on children with specific injury types rather than those with multiple injured body regions. This study’s objective was to determine the long-term functional status and health-related quality of life after serious pediatric injury and to evaluate the associations of these outcomes with features available at hospital discharge.
Study Design:
We conducted a prospective observational study at seven level 1 pediatric trauma centers of children treated for at least one serious (Abbreviated Injury Scale ≥3) injury. Patients were sampled to increase the representation of less frequently injured body regions and multiple injured body regions. Six-month functional status was measured using the Functional Status Scale (FSS) and health-related quality of life using the Pediatric Quality of Life Inventory (PedsQL™).
Results:
Among 323 injured children with complete discharge and follow-up assessments, six-month FSS was abnormal in 33 patients (10.2%), 16 with persistent impairment and 17 previously normal at discharge. Increasing levels of impaired discharge FSS were associated with impaired FSS and lower PedsQL™ scores at six-month follow-up. Additional factors on multivariable analysis associated with six-month FSS impairment included older age, penetrating injury type, severe head injuries, and spine injuries and for lower six-month PedsQL™ scores included older age.
Conclusion:
Older age and discharge functional status are associated with long-term impairment of functional status and health-related quality of life. Although most seriously injured children return to normal, ongoing disability and reduced health-related quality of life remained six months after injury. Our findings support long-term assessments as standard practice for evaluating the health impact serious pediatric injury.
Keywords: wounds and injuries, infant, child, adolescent, functional status, quality of life
Graphical Abstract
Precis
Among seriously injured children, discharge functional impairment was associated with continued functional impairment and lower health-related quality of life at 6 months. Other factors related to long-term functional impairment included older age, penetrating injury, severe head injury, and spine injury.
INTRODUCTION
More than six million children are treated for an injury in an emergency department in the US each year,1 with over 150,000 requiring admission to a trauma center.2 Nearly 20% of injured children treated in an emergency department will have a residual functional limitation at four months, and 8% will have impairment at nine months.2 Children hospitalized for a serious injury have a several-fold higher risk of residual functional impairment, with functional limitations being observed in as many as 60%.2,3 Injuries have a similar impact on health-related quality of life (HRQoL), with decreases from normal observed in about 75% of hospitalized children at one month after injury and nearly 10% at 12 months.4
Although the long-term morbidity of pediatric injury has been established, measuring these outcomes is often challenging. These challenges include participant attrition, incomplete responses, and the lack of additional resources for measuring and tracking outcomes.5 Identifying factors available at discharge associated with long-term status can identify groups that should be prioritized for follow-up assessment or post-hospitalization interventions. Targeting resources toward evaluating those at risk would improve the efficiency of assessing long-term outcomes among injured children and partially address barriers to implementing these assessments.6 The association between discharge and follow-up functional status has been evaluated, but a consistent relationship has not been observed in adult trauma patients.7.8 Although these findings suggest the need for follow-up assessments, this association has not been previously evaluated in a cohort of injured children with diverse injury types.
We conducted a prospective observational two-year, multicenter study evaluating six-month functional status and HRQoL in a sample of children hospitalized for at least one serious injury at seven pediatric trauma centers. We hypothesized that patient demographics, injury characteristics, and discharge functional status would be associated with six-month impaired functional status and health-related quality of life.
METHODS
Study Design
The “Assessment of Functional Outcomes and Health-Related Quality of Life after Pediatric Trauma” was a prospective observational study performed from March 2018 to February 2020 at the seven pediatric trauma centers participating in the National Institutes of Health-funded Collaborative Pediatric Critical Care Research Network (CPCCRN). Using data from this study, we previously identified cohorts of injured children at the highest risk for discharge functional impairment based on injury patterns.9 This report describes outcome assessments at six months and the relationships of these outcomes with factors observed at discharge. The Institutional Review Board at the University of Utah approved this study through a central mechanism. Written consent was obtained for participation in this study. The parent or guardian received financial incentives for enrollment and follow-up participation.
The eligibility criteria, sampling strategy, and enrollment procedures have been previously described.9 In brief, children (<15 years old) who sustained a blunt or penetrating injury in one or more major body regions (head, thorax, abdomen, spine, or extremities [upper and lower]) were eligible for enrollment. We included only hospitalized patients who had an injury classified by the as serious, severe, or critical (severity 3 to 5). Eligibility was limited to patients whose parents or guardians spoke English or Spanish for ensuring completion of discharge survey and follow-up telephone and email assessments. We prioritized sampling of children with less commonly injured body regions (least to most common: spine, thorax, abdomen, extremity, and head) and multiple injured body regions. Eligible patients were approached for enrollment based on this sampling strategy. Enrollment targets at each site were set at 50 patients per year, with a goal of 70% of children with isolated injured body regions and 30% with multiple injured body regions. After enrollment, patients were categorized based on three factors: the presence of single or multiple injured body regions, the body region injured when isolated, and the severity of head injury when present. A severe head injury was defined as an initial Glasgow coma scale (GCS) of <9 or a GCS motor score of <5. Patients with a missing total GCS were classified as severe because missingness is associated with abnormal GCS and mortality.10
Data Collection
Self-reported race, ethnicity and insurance status were obtained from surveys completed by the parent or guardian. We used medical chart review to determine pre-injury medical conditions based on a prespecified classification. We obtained injury type (blunt versus penetrating), injury mechanism, and initial GCS from the institutional trauma registries. ‘Child physical abuse’ was based on a medical record diagnosis. Functional status was measured with the Functional Status Scale (FSS), a validated measure that assesses function in six domains: mental status, sensory, communication, motor, feeding, and respiratory status.11 Total FSS scores are calculated as a composite of the values in each domain and range from ‘good’ (6 or 7) to ‘very severely abnormal’ (>21). Because it is rapidly performed and easy to implement, FSS has been used in previous large-scale studies assessing the outcome of critically ill and injured children.12 HRQoL was assessed using the parent-proxy Pediatric Quality of Life Inventory (PedsQL™).13,14 PedsQL™ scores are on a 0-100 scale, with higher scores indicating better HRQoL. A change of 4.5 in PedsQL™ is the smallest change of clinical relevance.15
FSS at hospital discharge was obtained by interviews with clinical caretakers and the medical record. To ensure consistent outcome measurement, trained surveyors located at the University of Utah obtained six-month assessments using FSS and PedsQL™. We evaluated long-term outcomes at this interval based on evidence showing a recovery plateau at this time point.3,4,16 When initial contact could not be made by telephone, survey instruments were emailed for completion. FSS was obtained by electronic medical record review when possible if telephone and email contact were not successful.17 A data coordinating center monitored enrollment, validated collated data, and conducted the statistical analyses.
Statistical Analysis
The study’s primary outcomes were abnormal FSS (>7) and total PedsQL™ scores at six months. We assessed the univariable associations of demographic, injury-related variables, and discharge functional status with these two follow-up status measures using the Mantel-Haenszel chi-squared exact, Fisher’s exact, Kruskal-Wallis, or Wilcoxon rank-sum tests. Multivariable models were used to evaluate the associations of each primary outcome with discharge functional status, age, injury type, child physical abuse, injury category, and severe head injury. We selected covariates for multivariable modeling a priori based on the potential for influencing functional outcomes using a literature review and domain knowledge. Patients with missing data were excluded from these models using casewise deletion. Six-month FSS was modeled using multivariable logistic regression (normal/abnormal), and six-month PedsQL™ using multivariable linear regression. We used inverse probability weights in these regressions to adjust for the sampling strategy used at enrollment. To compare all possible pairs of injury categories as predictors of six-month functional impairment, we varied the injury category used as the reference group in the multivariable model. We reported these pairwise adjusted odds ratios using a matrix with different reference and comparison injury categories. Analyses were performed using SAS 9.4 (Cary, NC). We defined significance at p<0.05 with two-sided tests.
RESULTS
Study Population
Among 835 patients assessed for eligibility, 654 met inclusion criteria, 493 were approached for consent, and 428 consented. One patient without a qualifying injury was removed after consent. Among the 427 patients, 323 (75.6%) had complete discharge and six-month follow-up FSS assessments and were included in this report. Differences in follow-up were observed based on insurance status and ethnicity (eTable 1).
A similar proportion of the 323 patients were in each age category (Table 1). Most patients were male (n=207, 64.1%, Table 1). Race and ethnicity were most often white (n=215, 66.6%) and non-Hispanic (n=294, 91.0%). Most had either private insurance (n=180, 55.7%) or Medicaid/Medicare (n=130, 40.2%) as primary coverage. Preinjury comorbidities were observed in 52 children (16%). The pre-injury functional status of most patients was normal (n=312, 96.6%). Blunt trauma was the predominant injury type (n=288, 89.2%), with falls being the most frequent injury mechanism (n=93, 29%) (Table 2). Patients most commonly had a single body region injury (n=264, 81.7%), usually an isolated extremity or head injury. Thirty-two patients (10%) presented with a severe head injury based on initial GCS values.
Table 1.
Relationship Between Functional Status and Health-Related Quality of Life at 6-Month Follow-Up and Patient Characteristics
| Patient characteristic | Overall, n (%) n = 323 | FSS at follow-up | PedsQL at follow-up, median, [IQR] n = 279 | p Value | |||
|---|---|---|---|---|---|---|---|
| 6-7 (good), n (%) n = 290 | 8-9 (mildly abnormal), n (%) n = 22 | >9 (moderately to very severely abnormal), n (%) n = 11 | p Value | ||||
| Age category | 0.15* | 0.002† | |||||
| 0-4 y | 119 (37) | 109 (92) | 8 (7) | 2 (2) | 94.0 [89.3, 98.8] | ||
| 5-9 y | 89 (28) | 81 (91) | 5 (6) | 3 (3) | 91.3 [75.5, 97.8] | ||
| 10-14 y | 115 (36) | 100 (87) | 9 (8) | 6 (5) | 87.0 [75.0, 97.8] | ||
| Sex | 0.58‡ | 0.49§ | |||||
| Male | 207 (64) | 185 (89) | 16 (8) | 6 (3) | 92.4 [78.3, 97.9] | ||
| Female | 116 (36) | 105 (91) | 6 (5) | 5 (4) | 92.4 [83.7, 97.8] | ||
| Race | 0.70‡ | 0.66† | |||||
| White | 215 (67) | 195 (91) | 12 (6) | 8 (4) | 92.8 [81.5, 97.8] | ||
| Black | 68 (21) | 59 (87) | 7 (10) | 2 (3) | 92.4 [72.8, 98.4] | ||
| Other | 39 (12) | 35 (90) | 3 (8) | 1 (3) | 90.6 [81.5, 98.8] | ||
| Missing‖ | 1 (0) | 1 (100) | 0 (0) | 0 (0) | 90.2 [90.2, 90.2] | ||
| Ethnicity | 0.21‡ | 0.17§ | |||||
| Hispanic or Latino | 27 (8) | 22 (81) | 3 (11) | 2 (7) | 90.3 [67.9, 95.7] | ||
| Not Hispanic or Latino | 294 (91) | 266 (91) | 19 (6) | 9 (3) | 92.4 [81.5, 97.9] | ||
| Missing‖ | 2 (1) | 2 (100) | 0 (0) | 0 (0) | 85.9 [71.7, 100.0] | ||
| Insurance | 0.73‡ | 0.04† | |||||
| Private/commercial | 180 (56) | 161 (89) | 11 (6) | 8 (4) | 91.3 [81.0, 97.8] | ||
| Medicaid/Medicare | 130 (40) | 116 (89) | 11 (8) | 3 (2) | 92.4 [76.1, 97.8] | ||
| Self-pay/no insurance | 9 (3) | 9 (100) | 0 (0) | 0 (0) | 98.9 [97.3, 100.0] | ||
| Missing‖ | 4 (1) | 4 (100) | 0 (0) | 0 (0) | 95.7 [68.5, 100.0] | ||
| Chronic diagnosis | 0.04‡ | 0.002† | |||||
| None | 271 (84) | 248 (92) | 15 (6) | 8 (3) | 93.2 [83.7, 98.9] | ||
| Respiratory (asthma) | 12 (4) | 11 (92) | 1 (8) | 0 (0) | 85.9 [70.7, 93.5] | ||
| Cardiovascular disease (arrhythmia/congenital) | 2 (1) | 1 (50) | 1 (50) | 0 (0) | 88.9 [82.1, 95.7] | ||
| Neurological (seizure/other) | 5 (2) | 4 (80) | 0 (0) | 1 (20) | 93.5 [76.6, 99.5] | ||
| Other | 33 (10) | 26 (79) | 5 (15) | 2 (6) | 77.2 [69.6, 89.8] | ||
| Preinjury FSS | 0.31‡ | 0.02§ | |||||
| Normal (6-7) | 312 (97) | 281 (90) | 21 (7) | 10 (3) | 92.4 [81.5, 97.9] | ||
| Not normal (>7) | 11 (3) | 9 (82) | 1 (9) | 1 (9) | 72.8 [65.2, 79.3] | ||
Mantel-Haenszel chi-square exact test with Monte Carlo approximation
Kruskal-Wallis test
Fisher’s exact test with Monte Carlo approximation
Wilcoxon rank-sum test
Not included in p value calculation
FSS, Functional Status Scale; IQR, interquartile range; PedsQL, Pediatric Quality of Life Inventory
Table 2.
Relationships Between Functional and Health-Related Quality of Life at 6-Month Follow-Up and Injury Characteristics
| Injury characteristic | Overall, n (%) n = 323 | FSS at follow-up | PedsQL at follow-up, median [IQR] (n = 279) | p Value | |||
|---|---|---|---|---|---|---|---|
| 6-7 (good), n (%) n = 290 | 8-9 (mildly abnormal), n (%) n = 22 | >9 (moderately to very severely abnormal), n (%) n = 11 | p Value | ||||
| Injury category | <0.001* | 0.004† | |||||
| Multiple head (severe) | 19 (6) | 12 (63) | 4 (21) | 3 (16) | 72.8 [60.9, 95.7] | ||
| Multiple head (not severe) | 10 (3) | 10 (100) | 0 (0) | 0 (0) | 91.8 [86.5, 95.5] | ||
| Multiple excluding head | 30 (9) | 27 (90) | 3 (10) | 0 (0) | 94.0 [78.3, 98.9] | ||
| Isolated head (severe) | 13 (4) | 9 (69) | 3 (23) | 1 (8) | 85.0 [59.8, 93.5] | ||
| Isolated head (not severe) | 61 (19) | 58 (95) | 2 (3) | 1 (2) | 92.4 [87.2, 98.9] | ||
| Isolated thorax | 22 (7) | 20 (91) | 2 (9) | 0 (0) | 95.7 [85.3, 98.9] | ||
| Isolated abdomen | 58 (18) | 57 (98) | 1 (2) | 0 (0) | 96.7 [85.9, 98.9] | ||
| Isolated spine | 17 (5) | 13 (76) | 0 (0) | 4 (24) | 82.6 [71.7, 93.5] | ||
| Isolated extremity | 93 (29) | 84 (90) | 7 (8) | 2 (2) | 91.3 [77.2, 96.4] | ||
| No. of body regions with AIS ≥3 | 0.05‡ | 0.02† | |||||
| 1 | 264 (81.7) | 241 (91.3) | 15 (6) | 8 (3) | 92.4 [81.5, 97.9] | ||
| 2 | 37 (11) | 32 (86) | 4 (11) | 1 (3) | 93.8 [85.3, 98.9] | ||
| >2 | 22 (7) | 17 (77) | 3 (14) | 2 (9) | 77.2 [59.8, 95.7] | ||
| Injury type | 0.31* | 0.66§ | |||||
| Blunt | 288 (89.2) | 259 (89.9) | 18 (6) | 11 (4) | 92.4 [79.9, 98.4] | ||
| Penetrating | 14 (4) | 12 (86) | 2 (14) | 0 (0) | 91.5 [70.0, 97.3] | ||
| Missing‖ | 21 (7) | 19 (90) | 2 (10) | 0 (0) | 92.4 [83.7, 97.2] | ||
| Mechanism of injury | 0.23* | 0.09† | |||||
| Child abuse | 30 (9) | 27 (90) | 2 (7) | 1 (3) | 92.9 [88.9, 97.2] | ||
| Penetrating | 8 (2) | 7 (88) | 1 (13) | 0 (0) | 93.5 [52.2, 100.0] | ||
| Fall | 93 (29) | 88 (95) | 2 (2) | 3 (3) | 94.0 [85.7, 98.9] | ||
| Motor vehicle collision occupant | 62 (19) | 53 (85) | 5 (8) | 4 (6) | 84.8 [67.4, 97.6] | ||
| Pedestrian | 22 (7) | 15 (68) | 5 (23) | 2 (9) | 83.7 [65.2, 95.7] | ||
| Transport other/motorcycle | 16 (5) | 15 (94) | 1 (6) | 0 (0) | 93.5 [77.2, 98.9] | ||
| Cyclist | 19 (6) | 18 (95) | 1 (5) | 0 (0) | 95.7 [85.9, 100.0] | ||
| Struck by/against | 26 (8) | 24 (92) | 1 (4) | 1 (4) | 93.5 [80.4, 98.9] | ||
| Other | 10 (3) | 10 (100) | 0 (0) | 0 (0) | 88.6 [76.2, 97.7] | ||
| Missing‖ | 37 (11) | 33 (89) | 4 (11) | 0 (0) | 91.7 [83.7, 97.8] | ||
| Severe head injury | <0.001* | 0.004§ | |||||
| No | 291 (90) | 269 (92) | 15 (5) | 7 (2) | 92.8 [81.5, 98.8] | ||
| Yes | 32 (10) | 21 (66) | 7 (22) | 4 (13) | 84.5 [60.9, 93.5] | ||
| Discharge FSS | <0.001‡ | <0.001† | |||||
| 6-7 (good) | 242 (75) | 225 (93) | 13 (5) | 4 (2) | 93.2 [82.6, 98.9] | ||
| 8-9 (mildly abnormal) | 53 (16) | 48 (91) | 3 (6) | 2 (4) | 90.4 [79.3, 97.6] | ||
| >9 (moderately to very severely abnormal) | 28 (9) | 17 (61) | 6 (21) | 5 (18) | 67.9 [58.7, 91.3] | ||
Mantel-Haenszel chi-square exact test with Monte Carlo approximation
Kruskal-Wallis test
Fisher’s exact test with Monte Carlo approximation
Wilcoxon rank-sum test
Not included in p value calculation
AIS, Abbreviated Injury Scale; FSS, Functional Status Scale; IQR, interquartile range; PedsQL, Pediatric Quality of Life Inventory
Functional Status
Long-term follow-up FSS was abnormal in 33 patients (10%), 22 with a ‘mildly abnormal’ FSS and 11 with a more than ‘moderately abnormal’ FSS (Table 2). Seventeen of these 33 patients had no impairment at hospital discharge and 16 had persistent impairment at six months. Among the patients who were normal at discharge and became abnormal at follow-up, 13 changed to a ‘mildly abnormal’ FSS and four to a ‘moderately abnormal’ FSS. Eighty-one patients had hospital discharge FSS impairment, 65 (80%) who had a normal FSS at follow-up (Table 2).
Several factors at discharge were associated with six-month follow-up FSS impairment on univariable analysis, including the presence of preexisting chronic diagnoses, injury category, severe head injuries, and abnormal discharge FSS (Tables 1 and 2). The highest proportion of FSS follow-up impairment >9 was among those with multiple injured body regions with a severe head injury (3/19, 16%), isolated severe head injuries (1/13, 8%), and isolated spine injuries (4/17, 24%). Consistent with these proportions, patients with a severe head injury more often had a follow-up FSS >9 than those without (Table 2). Among the 17 patients with spinal injuries, four had cord injuries in addition to fractures or ligamentous injuries. Two patients with spinal cord injuries had residual functional impairment at follow-up.
Using multivariable analysis, we observed that follow-up functional impairment was associated with older age, injuries from a penetrating mechanism, and severe head injuries (Tables 3 and 4). Pairwise comparison of injuries by body region showed isolated abdominal and thorax injuries at low risk for long-term functional impairment and spinal injuries at highest risk among injury groups (Table 5). Isolated head and isolated extremity injuries had a higher risk of long-term impairment than abdomen injuries but lower risk than spinal injuries (Table 5). Patients with ‘moderate’ or greater FSS impairment (>9) more often had abnormal status at six-month follow-up than those with normal discharge status (Table 3).
Table 3.
Factors Associated with Abnormal Functional Status Scale (>7) at 6-Month Follow-Up Determined by Logistic Regression
| Variable | Multivariable | |
|---|---|---|
| Adjusted odds ratio (95% CI) | p Value | |
| FSS discharge | ||
| 6-7 (good) | Ref | |
| 8-9 (mildly abnormal) | 0.68 (0.45, 1.02) | 0.06 |
| >9 (moderately to very severely abnormal) | 3.37 (2.18, 5.22) | <0.001 |
| Age, y | 1.06 (1.02, 1.09) | 0.001 |
| Injury type | ||
| Blunt | Ref | |
| Penetrating | 3.08 (1.70, 5.58) | <0.001 |
| Child physical abuse | ||
| No | Ref | |
| Yes | 1.67 (1.00, 2.79) | 0.052 |
| Injury category | ||
| Multiple | 3.07 (0.95, 9.92) | 0.06 |
| Isolated head | 3.68 (1.26, 10.80) | 0.02 |
| Isolated thorax | 5.18 (1.50, 17.90) | 0.009 |
| Isolated abdomen | Ref | |
| Isolated spine | 18.20 (5.43, 60.92) | <0.001 |
| Isolated extremity | 6.53 (2.27, 18.81) | <0.001 |
| Severe head injury | ||
| No | Ref | |
| Yes | 4.94 (3.02, 8.09) | <0.001 |
Analysis based on 302 patients with complete data.
FSS, Functional Status Scale
Table 4.
Comparison of Abnormal Functional Status Scale at Follow-Up Between Injury Categories Using Logistic Regression.
| Comparison | Ref | ||||
|---|---|---|---|---|---|
| Isolated abdomen | Isolated thorax | Isolated spine | Isolated head | Multiple | |
| Isolated head | - | - | - | - | 1.20 (0.69, 2.09) |
| Isolated spine | - | - | - | 4.94 (2.45, 9.96)* | 5.93 (2.56, 13.78)* |
| Isolated thorax | - | - | 0.28 (0.11, 0.72)* | 1.41 (0.66, 3.00) | 1.69 (0.71, 4.05) |
| Isolated abdomen | - | 0.19 (0.06, 0.67)* | 0.05 (0.02, 0.18)* | 0.27 (0.09, 0.80)* | 0.33 (0.10, 1.06) |
| Isolated extremity | 6.53 (2.27, 18.81)* | 1.26 (0.61, 2.62) | 0.36 (0.19, 0.69)* | 1.77 (1.24, 2.54)* | 2.13 (1.17, 3.87)* |
Values represents the odds ratios and 95% CI of paired group comparisons in multivariable regression based on the model shown in Table 3.
p < 0.05
Table 5.
Factors Associated with Pediatric Quality of Life Inventory at 6-Month Follow-Up Determined by Multivariable Linear Regression
| Variable | Parameter estimate (95% CI) | p Value |
|---|---|---|
| FSS discharge | ||
| 6-7 (good) | Ref | |
| 8-9 (mildly abnormal) | −1.32 (−5.86, 3.22) | 0.57 |
| >9 (moderately to very severely abnormal) | −14.45 (−22.06, −6.84) | <0.001 |
| Age, y | −0.91 (−1.28, −0.53) | <0.001 |
| Injury type | ||
| Blunt | Ref | |
| Penetrating | −7.51 (−15.53, 0.51) | 0.07 |
| Child physical abuse | ||
| No | Ref | |
| Yes | −1.41 (−8.39, 5.56) | 0.69 |
| Injury category | ||
| Multiple | −2.17 (−10.92, 6.58) | 0.63 |
| Isolated head | −5.74 (−12.25, 0.77) | 0.08 |
| Isolated thorax | 0.54 (−9.65, 10.72) | 0.92 |
| Isolated abdomen | Ref | |
| Isolated spine | −9.19 (−21.58, 3.20) | 0.15 |
| Isolated extremity | −6.32 (−12.73, 0.10) | 0.054 |
| Severe head injury | ||
| No | Ref | |
| Yes | −3.13 (−10.29, 4.03) | 0.39 |
Analysis based on 264 patients with complete data.
FSS, Functional Status Scale
Health-related Quality of Life
Among those enrolled in the study, 279 (65.3%) had follow-up assessments of PedsQL™. The median six-month PedsQL™ score was 92.4 (interquartile range: 80.4, 97.9). Several discharge features were associated with lower PedsQL™ scores on univariable analysis, including older age, insurance status, preexisting diagnosis, preinjury functional status, injury body region, number of injured body regions, severe head injuries, and discharge FSS (Tables 1 and 2). PedsQL™ was lowest among patients with multiple injured body regions that included a severe head injury and those with isolated spine injuries (Table 2). In a multivariable analysis, older age and moderate to severe FSS impairment at discharge were associated with lower PedsQL™ scores (Table 5), while injury category and severe head injury were not.
DISCUSSION
In this study, we observed an association of six-month functional impairment with older age, injury category (including spine and severe head injuries), and lower discharge functional status. Patients at every level of discharge FSS had residual functional impairment at six months, including those with a normal FSS at discharge. A lower PedsQL™ was also associated with older age and lower discharge functional status, but not with injury category or the presence of a severe head injury. Despite an association with discharge functional status, normal status at discharge is not enough to rule out the need for follow-up functional or health-related quality of life evaluations. Our findings support performing six-month assessments to evaluate the long-term impact of serious pediatric injury.
Two previous studies have evaluated long-term functional status and HRQoL in a general population of injured children. In a study of 104 children hospitalized for treatment of serious injuries, functional status and HRQoL improved but remained lower than population norms at six-months after injury.4 Similar to our study, impaired functional status and HRQoL were frequent at six-months among children with head injuries. In another study focused on HRQoL, most of the 169 children who completed follow-up returned to normal HRQoL at four months after injury.18 As in our study, older age was associated with worse HRQoL at four months. Although hospitalized patients had a lower HRQoL at four months than those not hospitalized, no association with injury severity was observed using a triage acuity scale. The association between injured body region and long-term HRQoL was not considered in this study. In contrast to these previous studies, we used a strategy for sampling children with uncommon and multiple injuries, evaluated functional status and HRQoL in children of all ages, and applied multivariable modeling to adjust for confounders.
We observed an association between the presence of a spinal or severe head injury and follow-up functional impairment. We used initial GCS to define head injury severity because our study relied mainly on trauma registry data. Previous studies have found that other severity measures, including intracranial pressure and CT findings, may be more reliable than GCS as predictors of long-term functional status.19,20 Future studies should include these more accurate severity measures that rely on additional clinical data. In addition to identifying an association with severe head injuries, we observed that injuries to the spinal region were at higher risk for follow-up impairment. Our findings are consistent with a previous description of the dominance of head and spinal region injuries as causes of short- and long-term disability after pediatric injury.21
In our study, we observed an association between discharge functional status and six-month outcomes. Although not studied after pediatric injury, the association between discharge functional status and six-month status has been evaluated in injured adults showing inconsistent results. In a study of injured adults, discharge functional status correlated with status at six months when controlling for hospital length of stay, the number of days outside of the intensive care unit, and the Disability Rating Scale score at discharge.7 In contrast, an association between discharge and long-term functional status was not observed using the modified Functional Independence Measure (FIM) or Glasgow Outcome Scale (GOS) in adults hospitalized after a blunt injury.8
We identified a subset of children with normal status at discharge who had new impairment at follow-up. Although not previously studied in a general population of injured children, different recovery patterns have been described after adult injury, including improvement, persistent or worsening status, and new impairment.22,23 Children with traumatic brain injury show differences in recovery based on age and injury severity, with younger children and those with more severe injury most likely to decline after hospital discharge.24 The domains of functional impairment after traumatic brain injury also differ by age, suggesting a relationship between developmental phase and recovery trajectory.25 Using available data, we could not determine why a subset of patients who were normal at discharge became abnormal at follow-up. Potential explanations include new injury-related impairment, new injuries or disease, miscoding of discharge or follow-up status, or the accuracy of FSS for detecting impairment across injury cohorts. Given that recovery after critical illness and injury may not always move toward continued improvement,23,26 future studies are needed to explain new and persistent long-term impairment.
This study has several limitations. First, we used FSS as the main predictor of follow-up assessments and as the primary outcome measure. Although FSS is suitable for large-scale pediatric critical care and injury studies, other metrics are available that measure age-specific and injury-specific function that may be more sensitive or specific overall or for specific injury subgroups.19,20 For example, among children with isolated severe head injuries, most had no residual impairment at six months, a proportion that may be higher using measures other than FSS. Future studies that use injury-specific measures are needed to validate the long-term outcomes that we observed in each cohort. Second, we used body region for injury classification rather than specific injuries in these regions. Although the number of serious or greater injuries precluded analysis at the level of individual injuries, variations of the injuries occurring within each body region could impact outcomes. Third, we used proxy reporting of functional status and health-related quality of life. Although patient self-reports are standard for measuring outcomes for adults and older children, proxy measures are a practical approach for large-scale multicenter studies and those that include younger children. Fourth, 65 patients who were approached declined to participate in the study. It is not known whether demographic or other characteristics of this cohort may have influenced our conclusions. Finally, follow-up assessments were missing for many enrolled patients. Our study’s retention, however, exceeded that observed in similar reports of pediatric critical illness and injury.26,27 Strategies are needed to retain subjects for long-term evaluation, particularly for those among demographic groups at risk for dropout.
CONCLUSIONS
We identified several features associated with long-term functional impairment and decreased HRQoL. For six-month FSS, these factors included older age, penetrating injury, injured body region, and discharge functional impairment. For follow-up HRQoL, these included older age and discharge functional impairment. Although discharge functional status was associated with follow-up status, a subset of children was normal at discharge and developed later impairment, suggesting that new injury-related morbidity may occur after hospital discharge in some patients. Our findings support long-term assessments as standard practice for evaluating the health impact of serious pediatric injury.
Supplementary Material
ACKNOWLEDGEMENTS
We want to acknowledge the contribution of the research coordinators and trauma administrative teams at each site for assisting with the data acquisition.
Disclosures outside the scope of this work:
Dr Holubkov is a paid board member of Pfizer, Inc; Dr Hall is a paid consultant to LaJolla Pharmaceuticals; and Dr Pollack’s institute is supported by grants from Mallinckrodt Pharmaceuticals.
Support:
This work was supported by NIH grant numbers UG1HD049981, U01HD049934, UG1HD049983, UG1HD083170, UG1HD083166, UG1HD050096, and UG1HD083171. Disclaimer: The NIH had no role in the conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the manuscript.
ABBREVIATIONS
- AIS
Abbreviated Injury Scale
- CPCCRN
National Institutes of Health-funded Collaborative Pediatric Critical Care Research Network
- FIM
Functional Independence Measure
- FSS
Functional Status Scale
- GCS
Glasgow Coma Scale
- GOS
Glasgow Outcome Scale
- HRQoL
health-related quality of life
- PedsQL™
Pediatric Quality of Life Inventory
APPENDIX
Members of The Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network Assessment of Functional Outcomes and Health-Related Quality of Life After Pediatric Trauma Investigators: Joseph A Carcillo, MD, Department of Critical Care Medicine and Pediatrics, Children’s Hospital of Pittsburgh, Pittsburgh, PA; Todd C Carpenter, MD and Peter M Mourani, MD, Department of Pediatrics, Children’s Hospital Colorado and University of Colorado School of Medicine, Aurora, CO; J. Michael Dean, MD, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT; Mark W Hall, MD and Andrew R Yates, MD, Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH; Patrick S McQuillen, MD, Department of Pediatrics, Benioff Children’s Hospital, University of California San Francisco, San Francisco, CA; Kathleen L Meert, MD, Department of Pediatrics, Children’s Hospital of Michigan, Detroit, MI, Central Michigan University, Mt. Pleasant, MI; and Michael L Nance, MD, FACS, Division of Pediatric Trauma, Department of Surgery, Children’s Hospital of Philadelphia, Philadelphia, PA
Footnotes
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