Individual and Population Burdens of Major Trauma in the Netherlands/Poids Pour Les Individus et la Population Des Traumatismes Majeurs Aux Pays-Bas/Carga Individual Y Poblacional De Traumatismos Graves En Los Paises Bajos

Introduction Injury is not only the leading cause of death in adults below the age of 45 years (1) but also an important cause of functional limitations. (2-4) As survival is a limited indicator of outcome, the focus in evaluations of medical interventions has shifted to health-related quality of life. The combined impact of mortality and morbidity resulting from injury is, however, largely unknown, but it can be quantified with the help of the disability-adjusted life year (DALY) methodology, developed by WHO and the World Bank) This methodology assesses the impact of diseases and injury in terms of years of life lost (YLL) in fatal diseases and years lived with disability (YLD) in non-fatal diseases. The DALY methodology has been used as an assessment approach in the global burden of disease and injury study to set global priorities for health research and to assess global health trends. (5-10) This tool can help decision-makers set priorities for prevention and evaluates the effectiveness and cost-effectiveness of health-care policies. Its application depends primarily on the availability of representative and valid epidemiological data on diseases and injuries. Previous estimates of injury-related DALYs (1,11) were based on statistical information in various databases of injury mortality and morbidity, which imposes several limitations. (12) The DALY method has not previously been applied to major trauma, probably because combined data systems on fatalities and permanent consequences among survivors are scarce. The aim of this study was to quantify the burden of major trauma at the individual and population levels in the catchment area of our trauma-care centre in the Netherlands in the years 1999-2000. We investigated the impact on health in terms of burden of injury, YLD, YLL and DALYs. Patients and methods Patients The study was done at the University Medical Centre Utrecht (UMCU), in cooperation with the Utrecht Regional Ambulance Services. The UMCU is one of 10 level-1 trauma hospitals in the Netherlands, with a catchment population of 1.1 million with a population density of 813 inhabitants per square kilometre. Level-1 is a certification of the hospital about the circumstances and skills for treating all kinds of trauma patients. All severely injured survivors in the province of Utrecht (i.e. an administrative part of the Netherlands with its own regional board of governors) are transported to this trauma centre. Utrecht is in the middle of the country in an urban-rural region. The comprehensive registration required for the study, would not have been possible in many other trauma centres. Over two years (January 1999 to January 2001) data on all non-natural deaths (prehospital, in-hospital and post-hospital) in the region were collected, in cooperation with forensic medicine specialists and representatives of the justice department. This database provides validated personal and medical data (e.g. after autopsy) about the circumstances of the injury, injury localization and cause of death. In addition, all survivors over the age of 15 years with an injury severity score (13) higher than 15 were approached one year after the injury. The cut-off point of 15 is an international accepted standard by trauma surgeons. (13) Patients with an injury severity score greater than 15 are defined as survivors of major trauma, an injury severity score of 75 is counted as unnatural deaths. The study protocol was approved by the medical ethics committee of the UMCU. Outcome assessment We used the EuroQol-5D (EQ-5D) as a generic instrument to measure health status. This instrument has been developed and validated in samples of patients from several European countries, including the Netherlands. (14,15) It defines health along five dimensions: mobility, self-care, daily activities (such as work, study, housework and leisure activities), pain or discomfort and anxiety or depression. …