title: Discovering the truth about life after discharge: Long-term trauma-related mortality.
abstract: BACKGROUND
  Outcome after traumatic injury has typically been limited to the determination at time of discharge or brief follow-up. This study investigates the natural history of long-term survival after trauma.
  
  
  METHODS
  All highest-level activation patients prospectively enrolled in an ongoing cohort study from 2005 to 2012 were selected. To allow for long-term follow-up, patients had to be enrolled at least 1 year before the latest available data from the National Death Index (NDI, 2013). Time and cause of mortality was determined based on death certificates. Survival status was determined by the latest date of either care in our institution or NDI query. Kaplan-Meier curves were created stratified for Injury Severity Score (ISS). Survival was compared with estimated actuarial survival based on age, sex, and race.
  
  
  RESULTS
  A total of 908 highest-level activation patients (median ISS, 18) were followed up for a median 1.7 years (interquartile range 1.0-2.9; maximum, 9.8 years). Survival data were available on 99.8%. Overall survival was 73% (663 of 908). For those with at least 2-year follow-up, survival was only 62% (317 of 509). Severity of injury predicted long-term survival (p < 0.0001) with those having ISS of 25 or greater with the poorest outcome (57% survival at 5 years). For all ISS groups, survival was worse than predicted actuarial survival (p < 0.001). When excluding early deaths (≤30 days), observed survival was still significantly lower than estimated actuarial survival (p < 0.002). Eighteen percent (44 of 245 deaths) of all deaths occurred after 30 days. Among late deaths, 53% occurred between 31 days and 1 year after trauma. Trauma-related mortality was the leading cause of postdischarge death, accounting for 43% of the late deaths.
  
  
  CONCLUSIONS
  Postdischarge deaths represent a significant percentage of total trauma-related mortality. Despite having "survived" to leave the hospital, long-term survival was worse than predicted actuarial survival, suggesting that the mortality from injury does not end at "successful" hospital discharge.
  
  
  METHODS
  Prognostic study, level III.
authors.affiliation: From the Department of Surgery (R.A.C., G.W., A.S.C., L.Z.K., B.M.H., M.F.N., M.J.C.), San Francisco General Hospital, University of California, San Francisco; and Department of Surgery (M.W.M.), Stanford University, Stanford, California; and Department of Surgery (E.M.C.), Denver Health Medical Center, University of Colorado School of Medicine, Denver, Colorado.
authors.forename: Rachael A
authors.initials: RA
authors.lastname: Callcut
authors.forename: Glenn
authors.initials: G
authors.lastname: Wakam
authors.forename: Amanda S
authors.initials: AS
authors.lastname: Conroy
authors.forename: Lucy Z
authors.initials: LZ
authors.lastname: Kornblith
authors.forename: Benjamin M
authors.initials: BM
authors.lastname: Howard
authors.forename: Eric M
authors.initials: EM
authors.lastname: Campion
authors.forename: Mary F
authors.initials: MF
authors.lastname: Nelson
authors.forename: Matthew W
authors.initials: MW
authors.lastname: Mell
authors.forename: Mitchell J
authors.initials: MJ
authors.lastname: Cohen
mesh_terms: D015998:Abbreviated Injury Scale; D000206:Actuarial Analysis; D000328:Adult; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality; D006760:Hospitalization; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D015996:Survival Rate; D014193:Trauma Centers; D014947:Wounds and Injuries / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy