The road to recovery for vulnerable road users hospitalised for orthopaedic injury following an on-road crash

https://doi.org/10.1016/j.aap.2019.105279Get rights and content

Highlights

  • Of the 6186 vulnerable road users studied over the 8-year period, 43% were motorcyclists, 32% and 25% were pedestrians.

  • Problems with usual activities at 6 months, and pain/discomfort at 12 months, were most prevalent.

  • The adjusted odds of reporting problems on all EQ-5D-3 L items were lower for cyclists when compared to pedestrians.

  • An average cyclist had a greater odds of a good recovery and returning to work after injury, compared to an average pedestrian.

Abstract

Background

Pedestrians, cyclists and motorcyclists are vulnerable to serious injury due to limited external protective devices. Understanding the level of recovery, and differences between these road user groups, is an important step towards improved understanding of the burden of road trauma, and prioritisation of prevention efforts. This study aimed to characterise and describe patient-reported outcomes of vulnerable road users at 6 and 12 months following orthopaedic trauma.

Methods

A registry-based cohort study was conducted using data from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) and included pedestrians, cyclists and motorcyclists who were hospitalised for an orthopaedic injury following an on-road collision that occurred between January 2009 and December 2016. Outcomes were measured using the 3-level EuroQol 5 dimensions questionnaire (EQ-5D-3 L), Glasgow Outcome Scale – Extended (GOS-E) and return to work questions. Outcomes were collected at 6 and 12 months post-injury. Multivariable generalized estimating equations (GEE), adjusted for confounders, were used to compare outcomes between the road user groups over time.

Results

6186 orthopaedic trauma patients met the inclusion criteria during the 8-year period. Most patients were motorcyclists (42.8%) followed by cyclists (32.6%) and pedestrians (24.6%). Problems were most prevalent on the usual activities item of the EQ-5D-3 L at 6-months post-injury, and the pain/discomfort item of the EQ-5D-3 L at 12 months. The adjusted odds of reporting problems on all EQ-5D-3 L items were lower for cyclists when compared to pedestrians. Moreover, an average cyclist had a greater odds of a good recovery on the GOS-E, (AOR 2.75, 95% CI 2.33, 3.25) and a greater odds of returning to work (AOR = 3.13, 95% CI 2.46, 3.99) compared to an average pedestrian.

Conclusion

Pedestrians and motorcyclists involved in on-road collisions experienced poorer patient-reported outcomes at 6 and 12 months post-injury when compared to cyclists. A focus on both primary injury prevention strategies, and investment in ongoing support and treatment to maximise recovery, is necessary to reduce the burden of road trauma for vulnerable road users.

Introduction

Pedestrians, cyclists and motorcyclists are considered vulnerable road users, and according to the World Health Organization comprise more than half of all global road transport fatalities (World Health Organization, 2018). Vulnerable road users have limited external devices to protect them from mechanical force during a crash and are therefore more susceptible to sustaining serious trauma. The effects of road trauma on vulnerable road users extend well beyond the physical injuries. Traumatic road injuries can cause psychological distress, which may become prolonged in the form of mental illnesses such as post-traumatic stress disorder, and generalised anxiety disorder (Holbrook et al., 2005; Vincent et al., 2015). Involvement in a road transport crash also increases vulnerability to experiencing problems with social and physical functioning, and can negatively impact on health-related quality of life (Gabbe et al., 2017; Papadakaki et al., 2017). Furthermore, a proportion of people involved in a traumatic road-transport injury will go on to develop chronic pain that persists for greater than six months, which can significantly impact upon performing daily activities and working capacity (Rosenbloom et al., 2013). The societal burden of orthopaedic transport injury is borne through the high costs of hospitalisation and treatment (Beck et al., 2017a), loss of work productivity (Gabbe et al., 2007), involvement in adversarial aspects of compensation schemes (Ioannou et al., 2016) and misuse of prescription opioids to name a few (Hahn et al., 2018).

Previous studies have examined injury outcomes for vulnerable road users in the hospital setting, with a focus on length of stay and injury characteristics (Brockamp et al., 2017; Cevik et al., 2013; O’Hern et al., 2015). Others have investigated long-term outcomes such as return to work, function and quality of life (Dinh et al., 2016; Gabbe et al., 2017; Kenardy et al., 2017). Of the longitudinal studies conducted, the prevalence of people reporting problems up to two and three years post-injury from road trauma in Australia remains high, indicating that further research in this area is warranted to attenuate the burden of road trauma for our most vulnerable road users (Gabbe et al., 2017; Kenardy et al., 2017). Vulnerable road user groups included in studies to date are rarely considered separately, and pedestrians are often combined with cyclists (Gabbe et al., 2017; Heron-Delaney et al., 2017; Kenardy et al., 2017). Consequently, the rate of recovery and improvements in health-related quality of life for different types of vulnerable road users after orthopaedic injury remains unclear. Prior research has demonstrated that pedestrians sustain higher rates of severe head injury compared to motor vehicle drivers (Reith et al., 2015), and when compared to other vulnerable road users, comprise a larger proportion of older adults (Vanlaar et al., 2016). Unlike pedestrians and motorcyclists, cyclists generally have the best improvements in health status over time (Tournier et al., 2014; Vanlaar et al., 2016). The group most commonly admitted to hospital after a motorcycle-related injury comprise young males with low education (Papadakaki et al., 2018). Few longitudinal studies have investigated health outcomes of motorcyclists compared to other road users (Hours et al., 2010), however it has been reported that compared to other vulnerable road user groups a larger proportion of motorcyclists experience pain six months after the injury (Hours et al., 2010). There is a need for longitudinal studies to explore health outcomes of injured motorcyclists over longer periods of time.

Understanding and improving mental and physical health recovery specific to each vulnerable road user group after orthopaedic transport injury is an important step towards improving care post-discharge from hospital. Identifying factors that place an individual at risk of experiencing poor quality of life outcomes could assist with the delivery of targeted interventions and detection of financial resources to specific individuals at an appropriate time along the journey to recovery. The aim of the present study was to characterise and describe patient reported outcomes of vulnerable road users at 6 and 12 months post-injury for pedestrians, cyclists and motorcyclists who sustained an orthopaedic injury following an on-road collision.

Section snippets

Victorian Orthopaedic Trauma Outcomes Registry (VOTOR)

The VOTOR includes patients admitted with orthopaedic injury to four hospitals in Victoria, including two major trauma centres, one metropolitan trauma centre and one regional trauma centre. Patients are included in the registry if they are aged > 16 years, and have a length of hospital stay >24 h following orthopaedic trauma. Patients are excluded if they have a pathological fracture related to metastatic disease or an isolated soft tissue injury managed non-operatively. Patient outcomes are

Results

There were 8528 injury pedestrians, motorcyclists and cyclists during the study period of which 6186 (72.5%) were injured on a road, street or highway, and therefore met the inclusion criteria for the study (Table 1). One hundred and thirty-three patients (2.2%) died during their hospital stay including 27 motorcyclists, 16 cyclists and 90 pedestrians. A further 48 patients died post-discharge prior to the 12-month follow up time point (Fig. 1).

The follow-up rates at 12 months post-injury were

Discussion

We explored the demographic and injury characteristics, and longer term outcomes, of vulnerable road users who sustained orthopaedic injuries. To our knowledge, this is the first longitudinal study that has compared health-related quality of life, function and work outcomes between vulnerable road user groups. We found no differences in health-related quality of life between motorcyclists and pedestrians (with the exception of anxiety/depression). In contrast, the longer term outcomes of

Conclusion

This study demonstrated that health-related quality of life and return to work outcomes differed between vulnerable road user groups. In particular, pedestrians and motorcyclists experienced poorer health-related quality of life, function and return to work outcomes when compared to cyclists. Primary prevention efforts are the preferred method for reducing the burden of road trauma. Additional and targeted investment to protect these vulnerable road users is needed. Further, this study

Acknowledgements

The Victorian Orthopaedic Trauma Outcomes Registry is funded by the Transport Accident Commission. Ben Beck and Melita Giummarra were supported by Australian Research Council Discovery Early Career Researcher Award Fellowships (DE180100825; DE170100726). Belinda Gabbe was supported by an Australian Research Council Future Fellowship (FT170100048). CE was supported by a National Health and Medical Research Council of Australia (NHMRC) Early Career Fellowship (1106633).

References (37)

  • C.S. Palmer et al.

    Defining major trauma using the 2008 abbreviated injury scale

    Injury

    (2016)
  • M. Papadakaki et al.

    Psychological distress and physical disability in patients sustaining severe injuries in road traffic crashes: results from a one-year cohort study from three European countries

    Injury

    (2017)
  • M. Papadakaki et al.

    Physical, psychological and economic burden of two-wheel users after a road traffic injury: evidence from intensive care units of three EU countries

    J. Safety Res.

    (2018)
  • C. Tournier et al.

    A few seconds to have an accident, a long time to recover: consequences for road accident victims from the ESPARR cohort 2 years after the accident

    Accid. Anal. Prev.

    (2014)
  • W. Vanlaar et al.

    Fatal and serious injuries related to vulnerable road users in Canada

    J. Safety Res.

    (2016)
  • H.K. Vincent et al.

    Psychological distress after orthopedic trauma: prevalence in patients and implications for rehabilitation

    PM&R

    (2015)
  • B. Beck et al.

    Road safety: serious injuries remain a major unsolved problem

    Med. J. Aust.

    (2017)
  • T. Brockamp et al.

    Comparison of transportation related injury mechanisms and outcome of young road users and adult road users, a retrospective analysis on 24,373 patients derived from the TraumaRegister DGU®

    Scand. J. Trauma Resusc. Emerg. Med.

    (2017)
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