An Eye On Outcomes

Published on April 18, 2016
Should we, as emergency physicians, think about long-term recovery?

After completing my most recent evening shift, I was glad to get home and feel that I probably hadn’t missed much in terms of difficult diagnoses, and hopefully I hadn’t inadvertently sent too many sick people home. Most of my patients had been very ill, and I had admitted those cases under an inpatient unit. I had seen some fascinating cases, including a stab wound with no blood pressure, a dissecting abdominal aortic aneurysm in a 20-year-old presenting with gastro, a meningococcal meningitis, plus the usual cases of heart failure and chest pain.

Upon further reflection, I realized that once I had resuscitated each patient, performed the necessary procedures, and handed the case on to the inpatient unit, I quickly lost interest! As emergency physicians, we don’t hear much about what happens in the ward, and we know even less about what happens when the patient is discharged. We have no concept about the impact that any admission might have on the individual or their family, and the wider community.

The next morning, I did my day job, which focuses mainly on research. One of the major areas of my research focuses on long-term outcomes following major trauma. This is where I get to see what happened to all the maimed people months and years down the track. Over a prolonged period, we have begun to understand a lot more about how people recover from injury and illness, and what influences recovery. When I started out in this area, I thought that the biggest determinant of outcome was the severity of the illness. As we looked into this, we found that the type of injury and severity of injury had less to do with the final outcome than other factors such as age, sex, socioeconomic circumstance, family support, and work status. In fact, for injured cases, severity of injury for major trauma cases was only a small component of the prediction model for the trajectory of recovery.(1) Importantly, we found that supposedly “moderate” degrees of injury could take years to recover from. For example, although a patient may only spend a few days in hospital after a long bone fracture of the lower limb, their recovery may be a long and drawn out process.

We then looked at other factors, such as the attitude of the patient toward the injury, and how they think they might have contributed to the injury event. When patients think they were a victim and someone else was at fault, they did badly. When they thought that it was mostly due to their own stupidity or carelessness, they actually recovered more quickly.

Importantly, the promise of compensation was found to delay recovery.(2,3,4) Outcomes were even worse in a scenario where there was protracted delay in settlement due to legal feuds. It could be argued that the mere act of giving compensation could result in preventing or delaying recovery. There are some obvious reasons for this, especially for low income or unemployed people who have little incentive to return to work when they are paid for not working.

However, the effect seems to go beyond malingering, and may possibly be correlated with real physical differences in degree of recovery. Although this work is most clearly related to injury, for which there is often an overt precipitating cause, the effects of attitude and social circumstance on speed of recovery probably relates to other serious illness as well; for example, someone suffering from cancer, where the cause might be work-related, or cases where chronic lung disease may be due to passive smoking.

It is all very well to say that non-illness related factors such as attitude and socioeconomic status make a difference, but is there anything we as clinicians can do about it?

First of all, statistically, we can identify patients at higher risk of poor or slow recovery. Secondly, if we believe the numbers that we are seeing (and the numbers are very strong), then early intervention may make a difference—but only if we can change the attitudes of patients during recovery.

Is there any evidence that we, as clinicians, can change the attitude of patients? There is a lot of work happening in this area, although large-scale randomized trials are lacking. A number of studies have shown that coaching and peer support may have some influence. One particular fad is “mindfulness” (coaching people to understand that they should not focus on negative or unproductive thoughts but more on positive outcomes instead). In the case of patients who may have been “wronged,” either through injury or illness, letting go of the victim mentality may be very important.(5) Patients can be helped to achieve this through counseling, meditation, group therapy, and other techniques. The idea that patients do worse when compensation or wrongdoing are involved, especially in cases involving a lawyer, is not new.(6) The evidence is now overwhelming, however, that focusing on this aspect of their injury harms people’s recovery.

So what has all this got to do with ED physicians? Should we be thinking more about recovery and how we might influence the final outcome? As ED physicians, we see our job as being focused on patching people up and sending them on to hospital or community care. Maybe we should be focused more on the recovery aspect. Clearly, we have a very short time with the patient, compared with many other clinicians, but, as with most aspects of medicine, if we put our patients on the right “conveyer belt” to recovery, then there is a chance they will do well. As a start, this may include the language we use with patients, encouraging them to not blame others, not to seek compensation, to maintain positive attitudes to recovery. Arranging post-discharge follow-up, telephone support, coaching and so on, through a hospital/community liaison might also help. In resource-limited countries, maybe we could use post-discharge messaging and other more innovative solutions to assist with positive thought in the recovery phase. For example, we are now undertaking trials in India for rehabilitation following leg injury using texting, in order to assist in recovery from injury.

Where does the ED physician’s responsibility end? Surely, we are just the patch up docs—“see and street,” right? I would argue, though, that part of the patching up involves putting the patient on a pathway to optimal recovery, and setting expectations around attitude, peer support and appropriate coaching—if it is evidence-based—is part of our job. We seem happy to arrange for blood pressure tablets post discharge in a well patient with moderately elevated blood pressure for an NNT of 1/700 treatment years. But when it comes to things that really matter, like speed of recovery from a serious illness, our attitude usually seems to be: not included in my pay grade!

REFERENCES

  1. Gabbe B, Simpson P , Harrison J, et al. Return to Work and Functional Outcomes After Major Trauma. Who Recovers, When, and How Well? Ann Surg. 2016;263:623–632.

  2. Gabbe B, Cameron P, Williamson O, et al. The relationship between compensable status and long-term patient outcomes following orthopaedic trauma. Med J Aust. 2007;187:14-17.

  3. Harris I, Mulford J, Solomon M, et al. Association between compensation status and outcome after surgery, a meta-analysis. JAMA. 2005;293:1644-1652.

  4. Harris I, Murgatroyd D, Cameron I, et al. The effect of compensation on health care utilisation in a trauma cohort. Med J Aust. 2009;190:619–22.

  5. Gabbe B, Simpson P, Cameron P, et al. Association between perception of fault for the crash and function, return to work and health status 1 year after road traffic injury: a registry based cohort study. BMJ Open. March 2016.

  6. Murgatroyd D, Casey P, Cameron I, Harris I. The Effect of Financial Compensation on Health Outcomes following Musculoskeletal Injury: Systematic Review. PLoS One. 2015;10(2): e0117597.

Dr. Peter Cameron is the immediate past president of the International Federation for Emergency Medicine (IFEM).

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