Callcut RA, Wakam G, Conroy AS, Kornblith LZ, Howard BM, Campion EM, Nelson MF, Mell MW, Cohen MJ. J. Trauma Acute Care Surg. 2015; 80(2): 210-217.
Affiliation
1Department of Surgery, San Francisco General Hospital, University of California, San Francisco 2Department of Surgery, Denver Health Medical Center and the University of Colorado School of Medicine, Denver, CO 3Department of Surgery, Stanford University, Stanford, California.
INTRODUCTION: Outcome after traumatic injury has typically been limited to determination at time of discharge or brief follow-up. This study investigates the natural history of long-term survival after trauma.
METHODS: All highest level activation patients prospectively enrolled in an on-going cohort study from 2005-2012 were selected. To allow for long-term follow-up, patients had to be enrolled at least 1 year prior to the latest available data from the National Death Index (NDI 2013). Time and cause of mortality was determined based upon death certificates. Survival status was determined by the latest date of either care in our institution or NDI query. Kaplan-Meier curves were created stratified for injury severity (ISS). Survival was compared with estimated actuarial survival based on age, gender, and race.
RESULTS: 908 highest level activation patients (median ISS 18) were followed for a median 1.7 years (IQR 1.0 - 2.9; maximum 9.8 years). Survival data was available on 99.8%. Overall survival was 73% (663/908). For those with at least 2 year follow-up, survival was only 62% (317/509). Severity of injury predicted long-term survival (p<.0001) with those having ISS>=25 with the poorest outcome (57% survival at 5 years). For all ISS groups, survival was worse than predicted actuarial survival [p<0.001]. Excluding early deaths (<=30 days), observed survival was still significantly lower than estimated actuarial survival [p<0.002]. 18% (44/245 deaths) of all deaths occurred after 30 days. Amongst late deaths, 53% occurred between 31 days to 1 year post trauma. Trauma related mortality was the leading cause of post-discharge death accounting for 43% of the late deaths.
CONCLUSION: Post-discharge deaths represent a significant percentage of total trauma related mortality. Despite having 'survived' to leave the hospital, long term survival was worse than predicted actuarial survival suggesting that the mortality from injury does not end at 'successful' hospital discharge. LEVEL OF EVIDENCE: Level 3, prognostic.