Postinjury Employment As a Surrogate for Functional Outcomes: A Quality Indicator for Trauma Systems (Report‪)‬

Traumatic brain injury (TBI) is a leading cause of death and disability in trauma patients, with approximately 2% of the US population (5.3 million) living with TBI-related functional deficits (1). So far, trauma centers have focused on risk-adjusted survival rates as a measure of their performance (2). Recently, there has been an increasing interest in the trauma community to develop a set of quality indicators to determine outcomes of trauma patients other than survival alone (3). This coincides with a 1998 consensus statement of the Institute of Medicine identifying the need to broaden the domain of performance measures by developing outcome measures that go beyond immediate morbidity and mortality to include various measures of functional status (4). Functional status is an important determinant of quality of life of patients, but it is inadequately measured by existing trauma registries. Some centers capture functional status using measures such as Functional Independence Measure scores at discharge from acute hospitalization (5, 6). However, little is known about the functional status of trauma patients in the weeks, months, and years following discharge from acute hospitalization. There are several measures of functional status, such as the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36), Sickness Impact Profile, Quality of Well-Being scale, Health Utilities Index, and EuroQol (7, 8). However, most of these measures require instruments that are long and cumbersome, require several minutes to more than an hour to complete, and require additional training before they can be used (9). Hence, there is a need to identify a simple, easy-to-use measure that can be used repeatedly to monitor patients' functional status. From patients' perspective, return to employment after injuries has been shown to be a valued long-term indicator of quality of life (10). Employment is important not only for earning a livelihood, but in our society, for determining access to health care, social support systems, and self-esteem. Lack of employment also has ripple effects on patients' family members through loss of income, interpersonal relationships, and interactions with society at large. From society's perspective, return to employment after injury has significant economic benefit. The lifetime cost of injuries to society is estimated at $406 billion per year, almost 80% of which is related to lost productivity (11).