European Journal of Epidemiology

, Volume 27, Issue 3, pp 233–241 | Cite as

Time dependent influence of host factors on outcome after trauma

  • Olof Brattström
  • Emma Larsson
  • Fredrik Granath
  • Louis Riddez
  • Max Bell
  • Anders Oldner


The impact of host factors, such as gender and co-morbidity, on mortality after trauma has been debated. Quantification of risk factors is dependent on methodological considerations including follow-up time, definitions and adjustment of potential confounders. Optimal follow-up time of trauma patients remains to be elucidated. We investigated the impact of gender and co-morbidity on short and long term mortality in a cohort including 4,051 patients from a level 1 trauma centre. Data from the trauma cohort were linked to validated national registries. 30 and 360-day survival were analysed with logistic and Cox regression, respectively. Long term survival was also estimated as standardardized mortality ratio, which implies a comparison with a matched general population. The influence of host factors on outcome after trauma differed over time. Male gender was an independent risk factor for mortality at 1 year but not at 30-days post-injury, even after adjustment for clinically relevant confounders. This gender difference was also apparent when comparing mortality rates with the general population. Moreover, the effect of gender seems to be restricted to elderly patients. The presence of co-morbidity became a significant risk factor beyond 30 days after trauma, suggesting that this patient group may benefit from a more thorough follow up after hospital discharge. A persistent excess mortality compared to the general population was still seen 1 year after the trauma. Our findings indicate that the effect of trauma is not limited to the early post-injury period but adversely affects the long term outcome.


Trauma Outcome Mortality Standardized mortality ratio Co-morbidity Gender 



Abbreviated Injury Scale


Confidence intervals


Glasgow Coma Scale


Hazards ratio


International classification of diseases


Interquartile ranges


Injury severity score


Swedish National Board of Health and Welfare


Odds ratio


Systolic arterial blood pressure


Standardized mortality ratio


Trauma audit and research network



We are sincerely grateful to our trauma registry nurses Lisbeth Bergendal, Lena Jansson and Katarina Ramsberg-Enegren for their invaluable work with the trauma registry. We also thank Dr Timothy Baker for providing linguistic expertise. This study was supported by the Laerdal Foundation, the Magn Bergvall Foundation, the LPS Medical Foundation, the Cancer and Traffic Injury Fund, Funds from Karolinska Institutet and the Swedish Society of Medicine. Financial support was also provided through the regional agreement on medical and clinical research (ALF) between Stockholm County Council and Karolinska Institutet.


  1. 1.
    Hoyt DB, Bulger EM, Knudson MM, Morris J, Ierardi R, Sugerman HJ, et al. Death in the operating room: an analysis of a multi-center experience. J Trauma [Multicenter Study]. 1994;37(3):426–32.CrossRefGoogle Scholar
  2. 2.
    Smith W, Williams A, Agudelo J, Shannon M, Morgan S, Stahel P, et al. Early predictors of mortality in hemodynamically unstable pelvis fractures. J Orthop Trauma [Research Support, Non-U.S. Gov’t]. 2007;21(1):31–7.Google Scholar
  3. 3.
    Morris JA Jr, MacKenzie EJ, Damiano AM, Bass SM. Mortality in trauma patients: the interaction between host factors and severity. J Trauma. 1990;30(12):1476–82.PubMedCrossRefGoogle Scholar
  4. 4.
    Hollis S, Lecky F, Yates DW, Woodford M. The effect of pre-existing medical conditions and age on mortality after injury. J Trauma. 2006;61(5):1255–60.PubMedCrossRefGoogle Scholar
  5. 5.
    Bamvita JM, Bergeron E, Lavoie A, Ratte S, Clas D. The impact of premorbid conditions on temporal pattern and location of adult blunt trauma hospital deaths. J Trauma. 2007;63(1):135–41.PubMedCrossRefGoogle Scholar
  6. 6.
    Kozlov AV, Duvigneau JC, Hyatt TC, Raju R, Behling T, Hartl RT, et al. Effect of estrogen on mitochondrial function and intracellular stress markers in rat liver and kidney following trauma-hemorrhagic shock and prolonged hypotension. Mol Med [Research Support, N.I.H., Extramural Research Support, U.S. Gov’t, Non-P.H.S.]. 2010;16(7-8):254–61.Google Scholar
  7. 7.
    Kuebler JF, Jarrar D, Toth B, Bland KI, Rue L III, Wang P, et al. Estradiol administration improves splanchnic perfusion following trauma-hemorrhage and sepsis. Arch Surg [Research Support, U.S. Gov’t, P.H.S.]. 2002;137(1):74–9.Google Scholar
  8. 8.
    Kan WH, Hsieh CH, Schwacha MG, Choudhry MA, Raju R, Bland KI, et al. Flutamide protects against trauma-hemorrhage-induced liver injury via attenuation of the inflammatory response, oxidative stress, and apopotosis. J App Physiol [Research Support, N.I.H., Extramural]. 2008;105(2):595–602.Google Scholar
  9. 9.
    Harbrecht BG, Peitzman AB, Rivera L, Heil B, Croce M, Morris JA Jr, et al. Contribution of age and gender to outcome of blunt splenic injury in adults: multicenter study of the eastern association for the surgery of trauma. J Trauma. 2001;51(5):887–95.PubMedCrossRefGoogle Scholar
  10. 10.
    Wohltmann CD, Franklin GA, Boaz PW, Luchette FA, Kearney PA, Richardson JD, et al. A multicenter evaluation of whether gender dimorphism affects survival after trauma. Am J Surg. 2001;181(4):297–300.PubMedCrossRefGoogle Scholar
  11. 11.
    Bowles BJ, Roth B, Demetriades D. Sexual dimorphism in trauma? A retrospective evaluation of outcome. Injury. 2003;34(1):27–31.PubMedCrossRefGoogle Scholar
  12. 12.
    Frink M, Pape HC, van Griensven M, Krettek C, Chaudry IH, Hildebrand F. Influence of sex and age on mods and cytokines after multiple injuries. Shock (Augusta, Ga.). 2007;27(2):151–6.Google Scholar
  13. 13.
    Haider AH, Crompton JG, Chang DC, Efron DT, Haut ER, Handly N, et al. Evidence of hormonal basis for improved survival among females with trauma-associated shock: an analysis of the national trauma data bank. J Trauma. 2010;69(3):537–40.PubMedCrossRefGoogle Scholar
  14. 14.
    Gubler KD, Davis R, Koepsell T, Soderberg R, Maier RV, Rivara FP. Long-term survival of elderly trauma patients. Arch Surg. 1997;132(9):1010–4.PubMedCrossRefGoogle Scholar
  15. 15.
    Mullins RJ, Mann NC, Hedges JR, Worrall W, Helfand M, Zechnich AD, et al. Adequacy of hospital discharge status as a measure of outcome among injured patients. JAMA. 1998;279(21):1727–31.PubMedCrossRefGoogle Scholar
  16. 16.
    MacKenzie EJ, Rivara FP, Jurkovich GJ, Nathens AB, Frey KP, Egleston BL, et al. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med. 2006;354(4):366–78.PubMedCrossRefGoogle Scholar
  17. 17.
    Ludvigsson JF, Otterblad-Olausson P, Pettersson BU, Ekbom A. The Swedish personal identity number: possibilities and pitfalls in healthcare and medical research. Eur J Epidemiol. 2009;24(11):659–67.PubMedCrossRefGoogle Scholar
  18. 18.
    Baker SP, O’Neill B, Haddon W Jr, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974;14(3):187–96.PubMedCrossRefGoogle Scholar
  19. 19.
    Gabbe BJ, Magtengaard K, Hannaford AP, Cameron PA. Is the Charlson Comorbidity Index useful for predicting trauma outcomes? Acad Emerg Med. 2005;12(4):318–21.Google Scholar
  20. 20.
    Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–83.PubMedCrossRefGoogle Scholar
  21. 21.
    Wutzler S, Maegele M, Marzi I, Spanholtz T, Wafaisade A, Lefering R. Association of preexisting medical conditions with in-hospital mortality in multiple-trauma patients. J Am Coll Surg. 2009;209(1):75–81.PubMedCrossRefGoogle Scholar
  22. 22.
    Skaga NO, Eken T, Jones JM, Steen PA. Different definitions of patient outcome: consequences for performance analysis in trauma. Injury. 2008;39(5):612–22.PubMedCrossRefGoogle Scholar
  23. 23.
    Jencks SF, Williams DK, Kay TL. Assessing hospital-associated deaths from discharge data. The role of length of stay and comorbidities. JAMA. 1988;260(15):2240–6.PubMedCrossRefGoogle Scholar
  24. 24.
    Bouamra O, Wrotchford A, Hollis S, Vail A, Woodford M, Lecky F. A new approach to outcome prediction in trauma: a comparison with the TRISS model. J Trauma (Comparative Study). 2006;61(3):701–10.Google Scholar
  25. 25.
    Niskanen M, Kari A, Halonen P. Five-year survival after intensive care–comparison of 12,180 patients with the general population. Finnish ICU Study Group. Crit Care Med. 1996;24(12):1962–7.PubMedCrossRefGoogle Scholar
  26. 26.
    Ulvik A, Wentzel-Larsen T, Flaatten H. Trauma patients in the intensive care unit: short- and long-term survival and predictors of 30-day mortality. Acta Anaesthesiol Scand. 2007;51(2):171–7.PubMedCrossRefGoogle Scholar
  27. 27.
    Magnotti LJ, Fischer PE, Zarzaur BL, Fabian TC, Croce MA. Impact of gender on outcomes after blunt injury: a definitive analysis of more than 36,000 trauma patients. J Am Coll Surg. 2008;206(5):984–91 (discussion 91–2).Google Scholar
  28. 28.
    Mushkudiani NA, Engel DC, Steyerberg EW, Butcher I, Lu J, Marmarou A, et al. Prognostic value of demographic characteristics in traumatic brain injury: results from the IMPACT study. J Neurotrauma (Research Support, N.I.H., Extramural). 2007;24(2):259–69.Google Scholar
  29. 29.
    Sperry JL, Minei JP. Gender dimorphism following injury: making the connection from bench to bedside. J Leukoc Biol. 2008;83(3):499–506.PubMedCrossRefGoogle Scholar
  30. 30.
    Mostafa G, Huynh T, Sing RF, Miles WS, Norton HJ, Thomason MH. Gender-related outcomes in trauma. J Trauma. 2002;53(3):430–4 (discussion 4–5).Google Scholar
  31. 31.
    Haider AH, Crompton JG, Oyetunji T, Stevens KA, Efron DT, Kieninger AN, et al. Females have fewer complications and lower mortality following trauma than similarly injured males: a risk adjusted analysis of adults in the National Trauma Data Bank. Surgery. 2009;146(2):308–15.PubMedCrossRefGoogle Scholar
  32. 32.
    Sperry JL, Nathens AB, Frankel HL, Vanek SL, Moore EE, Maier RV, et al. Characterization of the gender dimorphism after injury and hemorrhagic shock: are hormonal differences responsible? Criti Care Med. 2008;36(6):1838–45.Google Scholar
  33. 33.
    Ottochian M, Salim A, Berry C, Chan LS, Wilson MT, Margulies DR. Severe traumatic brain injury: is there a gender difference in mortality? Am J Surg. 2009;197(2):155–8.Google Scholar
  34. 34.
    Wigginton JG, Pepe PE, Idris AH. Rationale for routine and immediate administration of intravenous estrogen for all critically ill and injured patients. Crit Care Med. 2010;38(10 Suppl):S620–9.PubMedCrossRefGoogle Scholar
  35. 35.
    Bullard MK, Bir N, Kwan R, Cureton E, Knudson P, Harken A. Women rule. Surgery. 2010;147(1):134–7.PubMedCrossRefGoogle Scholar
  36. 36.
    George RL, McGwin G Jr, Metzger J, Chaudry IH, Rue LW III. The association between gender and mortality among trauma patients as modified by age. J Trauma. 2003;54(3):464–71.PubMedCrossRefGoogle Scholar
  37. 37.
    Morris JA Jr, MacKenzie EJ, Edelstein SL. The effect of preexisting conditions on mortality in trauma patients. JAMA. 1990;263(14):1942–6.PubMedCrossRefGoogle Scholar
  38. 38.
    Patel MS, Malinoski DJ, Nguyen XM, Hoyt DB. The impact of select chronic diseases on outcomes after trauma: a study from the National Trauma Data Bank. J Am Coll Surg. 2011;212(1):96–104.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media B.V. 2012

Authors and Affiliations

  • Olof Brattström
    • 1
    • 2
  • Emma Larsson
    • 2
    • 3
  • Fredrik Granath
    • 4
  • Louis Riddez
    • 3
  • Max Bell
    • 1
    • 2
  • Anders Oldner
    • 1
    • 2
  1. 1.Section of Anesthesiology and Intensive Care Medicine, Department of Physiology and PharmacologyKarolinska InstitutetStockholmSweden
  2. 2.Department of Anesthesiology, Surgical Services and Intensive Care MedicineKarolinska University Hospital, SolnaStockholmSweden
  3. 3.Department of Molecular Medicine and SurgeryKarolinska InstitutetStockholmSweden
  4. 4.Department of Medicine, Clinical Epidemiology UnitKarolinska InstitutetStockholmSweden

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