Beyond the hospital bed : studies of post-discharge socioeconomic and quality of life outcomes in trauma patients in urban India

Abstract

Background: Trauma contributes toone-tenth of the global morbidity, with low- and middle- income countries (LMICs) bearing a disproportionate burden. It is the biggest contributor of morbidity among young adults, and there is scope for substantial work to be done to address this global public health issue. Trauma morbidity has long-term social and economic consequences that extend beyond discharge from hospital, affecting the quality of life of trauma survivors though their recovery. Patient and trauma characteristics influence these outcomes and the healthcare system can play a role in improving these outcomes. However, most of the evidence on these post-discharge outcomes comes from high-income countries. Consequently, they remain poorly understood in LMIC settings. Building on evidence from these settings can help identify specific needs of post-discharge trauma patients and develop policies and practices to strengthen the existing healthcare system to meet the recovery needs of patients in LMICs.

Aim: The aim of this thesis was to study post-discharge outcomes and factors associated with such outcomes in adult trauma patients in urban areas in India, which contributes more than 20% of the global trauma morbidity.

Methods: Paper I assessed the current evidence on post-discharge socioeconomic and QOL outcomes in trauma patients by conducting a systematic review and meta-analysis of peer-reviewed scientific papers on key post-discharge socioeconomic and QOL outcomes among trauma patients. Paper II explored how post-discharge socioeconomic and QOL outcomes were experienced by trauma patients in urban India through thematic analysis of semi- structured interviews, in the city of Mumbai, India. Paper III developed and validated local trauma severity models to predict trauma outcomes in the context of India using machine learning techniques using data from a multi-center cohort of trauma patients. Paper IV determined the interaction of age and sex with post-discharge QOL outcomes in adult trauma patients from four cities in urban India.

Results: The findings indicate that even a year after the trauma, one-third of participants had not returned to work and QOL was less than the pre-trauma and general population levels [I]. Trauma patients in urban India experienced post-discharge socioeconomic and QOL outcomes as incomplete, expensive, and inter-social recovery and social support was an important factor in reducing the effect of the outcomes [II]. Paper III, shows that locally developed models have better discrimination and calibration in predicting trauma mortality than the widely used global gold-standard, Trauma Injury Severity Score (TRISS). Older adults, particularly females, have the lowest health status, while middle-aged females have the highest odds of having problems across different QOL domains. The inability to perform usual activities, the persistence of pain, and the presence of psychological morbidity were the main drivers of QOL among urban Indian trauma patients [IV].

Conclusions: Socioeconomic and quality-of-life outcomes continue to remain affected up to a year after discharge in trauma patients. Post-discharge socioeconomic and quality-of-life outcomes are unmet, costly to improve, and strongly shaped by social roles among trauma patients in urban India. Local models are better suited for prediction of outcomes in academic research and trauma quality improvement programs. Age and sex are associated with post- discharge QOL among trauma patients in urban India.