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Female risk-adjusted survival advantage after injuries caused by falls, traffic or assault: a nationwide 11-year study
Linköping University, Department of Clinical and Experimental Medicine, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Anaesthesiology and Intensive Care in Linköping. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Hand and Plastic Surgery. Linköping University, Department of Medical and Health Sciences, Division of Drug Research.
Linköping University, Department of Clinical and Experimental Medicine, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Anaesthesiology and Intensive Care in Norrköping. Life Regiment Hussars, K3 Karlsborg, Sweden.ORCID iD: 0000-0003-4075-4600
Linköping University, Department of Clinical and Experimental Medicine, Division of Neuro and Inflammation Science. Linköping University, Faculty of Medicine and Health Sciences.
Linköping University, Department of Clinical and Experimental Medicine, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Hand and Plastic Surgery.
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2019 (English)In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, ISSN 1757-7241, E-ISSN 1757-7241, Vol. 27, no 1, article id 24Article in journal (Refereed) Published
Abstract [en]

Background: A female survival advantage after injury has been observed, and animal models of trauma have suggested either hormonal or genetic mechanisms as component causes. Our aim was to compare age and riskadjusted sex-related mortality in hospital for the three most common mechanisms of injury in relation to hormonal effects as seen by age.

Methods: All hospital admissions for injury in Sweden during the period 2001–2011 were retrieved from the National Patient Registry and linked to the Cause of Death Registry. The International Classification of Diseases Injury Severity Score (ICISS) was used to adjust for injury severity, and the Charlson Comorbidity Index to adjust for comorbidity. Age categories (0–14, 15–50, and ≥ 51 years) were used to represent pre-menarche, reproductive and post- menopausal women.

Results: Women had overall a survival benefit (OR 0.51; 95% CI 0.50 to 0.53) after adjustment for injury severity and comorbidity. A similar pattern was seen across the age categories (0–14 years OR 0.56 (95% CI 0.25 to 1.25), 15–50 years OR 0.70 (95% CI 0.57 to 0.87), and ≥ 51 years OR 0.49 (95% CI 0.48 to 0.51)).

Conclusion: In this 11-year population-based study we found no support for an oestrogen-related mechanism to explain the survival advantage for females compared to males following hospitalisation for injury.

Place, publisher, year, edition, pages
BioMed Central, 2019. Vol. 27, no 1, article id 24
Keywords [en]
Risk-adjusted mortality; ICISS; Trauma; injury; Nationwide; Epidemiological
National Category
Surgery
Identifiers
URN: urn:nbn:se:liu:diva-155087DOI: 10.1186/s13049-019-0597-3ISI: 000461309000001PubMedID: 30871611OAI: oai:DiVA.org:liu-155087DiVA, id: diva2:1296412
Note

Funding agencies: Linkoping University, Linkoping, Sweden; Burn Centre, Department of Plastic Surgery, Hand Surgery, and Burns

Available from: 2019-03-15 Created: 2019-03-15 Last updated: 2019-04-17Bibliographically approved
In thesis
1. Risk-Adjustment for Swedish In-Hospital Trauma Mortality using International Classification of disease Injury Severity Score (ICISS): issues with description and methods
Open this publication in new window or tab >>Risk-Adjustment for Swedish In-Hospital Trauma Mortality using International Classification of disease Injury Severity Score (ICISS): issues with description and methods
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Introduction

Different methods have been used to describe the epidemiology of trauma with varying results. Crude mortality outcome data differ significantly from risk-adjusted information. A previous standard method for risk-adjustment in trauma was the Injury Severity Score (ISS), although it has several shortcomings. In this thesis I examine Swedish injury statistics from an epidemiological perspective using crude and risk-adjusted mortality, and to adjust for injury I used the International Classification of disease Injury Severity Score (ICISS). The groups of most lethal injuries (fall, traffic, and assault) were examined separately using an ICISS mortality prediction model that focused particularly on the effects on the prediction of mortality by adding coexisting conditions (comorbidity) to it. Differences in mortality between the sexes and changes over time were tested separately.

Material and Methods

Data from all patients with ICD-10 based diagnoses of injury (ICD-10: V01 to Y36) in the Swedish National Patient Registry and Cause of Death Registry were collected from 1999 to 2012 and used for assessment of mortality and comorbidity. A subgroup (patients in hospital) from 2001-2011 were selected as the study group. Their injuries were in the subgroups of falls, traffic, and assaults, and are the focus of this thesis. Mortality within 30 days of injury was used as the endpoint. The severity of injury was adjusted for using the ICISS, which was first described by Osler et al. The model was also adjusted for age, sex, and comorbidities.

Results

The study group comprised 815 846 patients (of whom 17 721 died). There was a decrease over time in injuries caused by falls and traffic (coefficient -4.71, p=0.047 and coefficient -5.37, p<0.001), whereas there was no change in assault-related injuries/100 000 inhabitants. The risk-adjusted 30-day mortality showed a decrease in injuries related to traffic and assault (OR 0.95, p<0.001 and OR 0.93, p=0.022) whereas for falls it remained unchanged. There was also a risk-adjusted survival benefit for women, which increased with increasing age. Adjusting for comorbidities made the prediction of 30-day mortality by the ICISS model better (accuracy, calibration, and discrimination). However, most of this effect was found to be the result of the other characteristics of the fall related injury group (they were older, and had more coexisting conditions).

Conclusion

During a 10-year period, there has been a significant overall decrease in crude as well as risk-adjusted mortality for these three injury groups combined. Within these groups there is a clear, risk-adjusted, female survival advantage. The ICISS model for the prediction of mortality improves when comorbidities are added, but this effect is minor and seen mainly among the injuries caused by falls, where comorbidity is significant. The ICISS method was a valuable adjunct in the investigation of data on Swedish mortality after injury that has been gathered from health care registry data.

Abstract [sv]

Introduktion

Olika metoder har använts för att beskriva trauma, alla med varierande resultat. Riskjusterad respektive icke-justerad data skiljer sig markant åt. En metod som oftast används för riskjustering i traumasammanhang är Injury Severity Score (ISS) som tyvärr är belastad med ett antal praktiska tillkortakommande. I denna avhandling har jag undersökt de skadade i Sverige från ett epidemiologiskt perspektiv med både justerad och icke riskjusterad mortalitet. För att kunna justera för skadan använde jag International Classification of disease Injury Severity Score (ICISS). De dödligaste skademekanismerna i Sverige (fall, trafik och övergrepp) analyserades för sig med hjälp av en mortalitetsjusterad modell baserad på ICISS som fokuserade särskilt på mortalitetseffekterna av att lägga till tidigare sjukdomar (komorbiditet) i modellen. Skillnader i dödlighet mellan de olika könen samt förändringar över tid undersöktes.

Material och Metod

Information om alla patienter med en skadekod från ICD-10 systemet (ICD10: V01-Y36) i slutenvårdsregistret eller dödsorsaksregistrets under åren 1999–2012 samlades in för att användas för att kunna utvärdera mortalitet och komorbiditet. En undergrupp av sjukhusinlagda patienter från 2001–2011 valdes sedan som primär studiegrupp. De som i denna grupp hade drabbats av fall-, trafik- eller övergrepps-relaterade skador är det denna avhandling fokuserar på. Som mätpunkt (endpoint) användes avliden inom 30 dagar från skadan. Skadans allvarlighetsgrad bedömdes med ICISS som Osler var först att beskriva. Modellen justerades även för ålder, kön och komorbiditet.

Resultat

Studiegruppen innehöll 815 846 patienter (av vilka 17 721 avled). I gruppen med falloch trafik-relaterade skador var det en ren minskning över studietiden (koefficienten -4,71 med ett p=0,047 och med en koefficient på -5,37 med ett p <0,001), medans i övergreppsrelaterade skador kunde jag inte hitta någon minskning per 100 000 invånare. Den riskjusterade 30-dagars dödligheten hade en minskning i trafik- och övergreppsrelaterade skador (OR 0,95 med ett p <0,001 respektive OR 0,93 med ett p=0,022) men ingen minskning i fallrelaterade skador sågs. Riskjusterat gick det också att hitta en överlevnadsfördel för kvinnor, vilken ökade med ålder. När jag justerade för komorbiditeter blev prediktionsmodellen för ICISS med 30-dagars dödlighet bättre (detta gällde både precision, kalibrering och diskriminering). Det bör dock nämnas att det mesta av förbättringen vid eftergranskning var beroende på fall gruppens demografi (högre ålder och mer komorbiditeter).

Konklusion

Under denna tio-årsperiod har dödligheten minskat för dessa grupper, både riskjusterat och icke justerat. Inom dessa grupper finns en tydlig riskjusterad överlevnadsfördel för kvinnor. ICISS-modellen blir bättre på att förutspå 30-dagars dödlighet när man lägger till komorbiditet, men effekten är att betrakta som en mindre effekt och ses tydligast i fallrelaterade skador (där ålder och komorbiditet är högre). Metoden med ICISS är en värdefull metod för att undersöka stora datamaterial och dödlighet i stora grupper i Sverige. Detta kan göras med redan insamlade data i sjukvårdsregistren.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2019. p. 77
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1660
National Category
Public Health, Global Health, Social Medicine and Epidemiology Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:liu:diva-154415 (URN)10.3384/diss.diva-154415 (DOI)9789176851401 (ISBN)
Public defence
2019-02-15, Granitsalen, Campus US, Linköping, 09:00 (English)
Opponent
Supervisors
Note

Minor corrections are made in the electronic version of the thesis. / Mindre korreigeringar är gjorda i den elektroniska versionen av avhandlingen.

Available from: 2019-02-11 Created: 2019-02-11 Last updated: 2019-04-18Bibliographically approved

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Division of Surgery, Orthopedics and OncologyFaculty of Medicine and Health SciencesDepartment of Anaesthesiology and Intensive Care in LinköpingDepartment of Hand and Plastic SurgeryDivision of Drug ResearchDepartment of Anaesthesiology and Intensive Care in NorrköpingDivision of Neuro and Inflammation Science
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