JBUR-4527; No. of Pages 7 burns xxx (2015) xxx–xxx
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Health-related quality of life 6 months after burns among hospitalized patients: Predictive importance of mental disorders and burn severity Raimo Palmu a,b,*, Timo Partonen b, Kirsi Suominen b,d, Samuli I. Saarni a,b,c, Jyrki Vuola e, Erkki Isometsa¨ a,b a
Department of Psychiatry, Helsinki University Central Hospital, Helsinki, Finland Department of Mental Health and Substance Abuse Services, National Institute for Health and Welfare, Helsinki, Finland c Turku University Hospital, Turku, Finland d Department of Psychiatry, City of Helsinki, Social Services and Health Care, Helsinki, Finland e Helsinki Burn Centre, Department of Plastic Surgery, Helsinki University Central Hospital, Helsinki, Finland b
article info
abstract
Article history:
Rationale: Major burns are likely to have a strong impact on health-related quality of life
Accepted 5 November 2014
(HRQoL). We investigated the level of and predictors for quality of life at 6 months after acute burn.
Keywords:
Methods: Consecutive acute adult burn patients (n = 107) admitted to the Helsinki Burn
Health-related quality of life
Centre were examined with a structured diagnostic interview (SCID) at baseline, and 92
Burn
patients (86%) were re-examined at 6 months after injury. During follow-up 55% (51/92)
Mental disorders
suffered from at least one mental disorder. The mean %TBSA was 9. TBSA of men did not differ from that of women. Three validated instruments (RAND-36, EQ-5, 15D) were used to evaluate the quality of life at 6 months. Results: All the measures (RAND-36, EQ-5, 15D) consistently indicated mostly normal HRQoL at 6 months after burn. In the multivariate linear regression model, %TBSA predicted HRQoL in one dimension (role limitations caused by physical health problems, p = 0.039) of RAND36. In contrast, mental disorders overall and particularly major depressive disorder (MDD) during follow-up ( p-values of 0.001–0.002) predicted poor HRQoL in all dimensions of RAND36. HRQoL of women was worse than that of men. Conclusion: Self-perceived HRQoL among acute burn patients at 6 months after injury seems to be mostly as good as in general population studies in Finland. The high standard of acute treatment and the inclusion of small burns (%TBSA < 5) in the cohort may partly explain the weak effect of burn itself on HRQoL. Mental disorders strongly predicted HRQoL at 6 months. # 2014 Elsevier Ltd and ISBI. All rights reserved.
* Corresponding author at: Department of Psychiatry, Helsinki University Central Hospital, P.O. Box 590, FI-00029 HUS, Finland. Tel.: +358 400 709301; fax: +358 9 47163735. E-mail addresses: [email protected], [email protected] (R. Palmu). http://dx.doi.org/10.1016/j.burns.2014.11.006 0305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved.
Please cite this article in press as: Palmu R, et al. Health-related quality of life 6 months after burns among hospitalized patients: Predictive importance of mental disorders and burn severity. Burns (2015), http://dx.doi.org/10.1016/j.burns.2014.11.006
JBUR-4527; No. of Pages 7
2
burns xxx (2015) xxx–xxx
1.
Introduction
Health-related quality of life (HRQoL) is an increasingly important outcome measure in healthcare, as it represents patient-relevant aspects of health problems and allows comparison between different illnesses and treatments. In earlier studies, generic HRQoL has been lower in patients with severe burns than in the normal population over a 12-month period [1]. However, even survivors of massive burn can reach a satisfying quality of life in most domains [2]. In a previous prospective cohort study of acute hospitalized burn patients, we found 55% to suffer from at least one mental disorder during a 6-month follow-up [3]. This 6-month prevalence of mental disorders increased as burn severity (%TBSA) increased. The relationship was statistically significant with regard to Axis I disorders overall, and anxiety disorders and disorders due to general medical condition (GMC) specifically. Studies excluding minor burns did not show this kind of relationship, probably because the variation in severity of burns was limited [4,5]. Burn severity and mental disorders are related in a complex way; suicidal or psychotic patients can be predisposed to burns, and severe burns can predispose to mental disorders. However, both burn severity and mental disorders can influence on prognosis of recovery and rehabilitation after burn, influencing the final HRQoL achieved. The question of how mental disorders and burn severity influence HRQoL is of great significance for burn rehabilitation services; however, few studies with proper methods, specifically in assessment of mental disorders, exist on this subject. Burn Specific Health Scale (BSHS) has a long history and has in recent years been the most frequently used specific measure for overall outcome and recovery after burns [6–8]. The abbreviated version of BSHS has been used also in Finland in evaluation of the recovery of burn survivors [9]. However, although illness-specific quality of life scales may capture specific problems related to each illness, their use renders a comparison between illnesses difficult. In earlier studies [10–12], Medical Outcome Study 36-item Short Form (SF-36), equivalent to RAND-36 and used especially in the United States, and, EQ-5D (Euro-QoL), used mostly in Europe, have served as generic scales and have appeared to be sensitive in measuring HRQoL among burn populations. The former provides a psychometric approach leading to several domains, and the latter a one-dimensional scale from 0 to 1 for quantification of health loss. The aim of this study was to estimate the HRQoL at 6 months after burn and to investigate which factors predicted HRQoL at this point. In particular, we examined whether the severity of burn or the presence of a psychiatric disorder (preburn or post-burn) determines HRQoL after the burn.
Central Hospital which has catchment area of approximately 1.4 million inhabitants. In addition to this responsibility, all of the most severe burns in Finland (population of 5.4 million) are treated in Helsinki Burn Centre. After all consecutive acute adult burn patients (at least 18 years old and Finnish-speaking) were admitted and exclusion criteria considered, the final sample comprised of 107 patients. The methodology was described in more detail repeatedly elsewhere [3,13,14]. Ethics Committee of Helsinki Central University Hospital approved by the study protocol.
2.2.
Procedure
All of the eligible, consecutive acute burn patients were interviewed by an experienced psychiatrist (R.P.). Clinical Version of the Structured Clinical Interview for DSM-IV-TR (SCID-CV) [15] was used to diagnose mental disorders in three different timeframes. SCID-II [16] was used to diagnose personality disorders. The subjects filled also in structured questionnaires covering psychological symptoms. Total body surface area (%TBSA), was used as the measure of severity of burns [3,13,14]. During their lifetime preceding the burn, almost two-thirds (60%), and during the final month prior to burn, 40% of subjects had at least one mental disorder [13]. The lifetime prevalence rates of some diagnostic subgroups substance-related (47%), psychotic (10%) and personality disorders (23%) were markedly higher than in general population studies. More specific, every fourth had some depressive and 15% MDD, 8% PTSD in their lifetime pre-burn [13]. The majority of subjects (86% of the whole study cohort) participated in the follow-up examination. They were interviewed for a second time (SCID-CV) by the same psychiatrist 6 months after injury [3,14]. The subjects (n = 15) who dropped out of the cohort are described in detail in our previous papers [3,14]. Most of the participants of the follow-up were middleaged men with low level of education and many had a history of psychiatric illness, psychiatric hospitalization, or suicide attempt before the injury (Table 1). The mean %TBSA was 9.7 (Table 1). Two-thirds of them had hand burns. At the follow-up interview, SCID-CV was repeated to diagnose mental disorders (a) during the 6 months after the burn and (b) during the last month of follow-up. During the 6 months after burn more than half (55%) of the subjects had some Axis I disorder (Table 2). Substance-related disorders were most common (27%) subgroup. Of those with no preburn mental disorder, 37% (n = 14) had at least one Axis I disorder during follow-up. Comorbidity was quite common while more than one-third (37%) of the patients had also another Axis I disorder during the follow-up. These descriptive findings have been previously published [3], but are presented here because of their important role as predictors for quality of life.
2.
Method
2.3.
2.1.
Participants
At baseline and at 6 months, the subjects answered the same single question concerning global quality of life during the preceding month on a four-point Likert scale (poor, moderate, good, or excellent). At 6 months, the patients filled in three
The study was conducted between May 5, 2006 and October 31, 2007 in Helsinki Burn Centre. It is part of Helsinki University
Health-related quality of life
Please cite this article in press as: Palmu R, et al. Health-related quality of life 6 months after burns among hospitalized patients: Predictive importance of mental disorders and burn severity. Burns (2015), http://dx.doi.org/10.1016/j.burns.2014.11.006
JBUR-4527; No. of Pages 7
3
burns xxx (2015) xxx–xxx
Table 1 – Sociodemographic and clinical characteristics of 92 acute burn patients in a 6-month follow-up. Men
Women
Total
n 64
% 69.6
n 28
% 30.4
n 92
% 100
45.1
(16.0)
49.0
(17.6)
46.3
(16.5)
14 40 8 2
21.9 62.5 12.5 3.1
5 10 6 7
17.9 35.7 21.4 25.0
19 50 14 9
20.7 54.3 15.2 9.8
Level of education Elementary Gymnasium
45 19
70.3 29.7
19 9
67.9 32.1
64 28
69.6 30.4
Working statusb Employed Unemployed Student Disability pension Retired
36 11 1 9 7
56.3 17.2 1.6 14.1 10.9
8 7 1 8 4
28.6 25.0 3.6 28.6 14.3
44 18 2 17 11
47.8 19.6 2.2 18.5 12.0
Social assistance recipientc None Occasionally As principal income
55 5 4
85.9 7.8 6.3
19 8 1
67.9 28.6 3.6
74 13 5
80.4 14.1 5.4
Type of burn Flame Liquid Electrical Other
29 10 5 20
45.3 15.6 7.8 31.3
11 12 0 5
39.3 42.9 0 17.9
40 22 5 25
43.5 23.9 5.4 27.2d
%TBSA 0–5 >5–10 >10–20 >20
29 11 13 11
45.3 17.2 20.3 17.2
15 5 4 4
53.6 17.9 14.3 14.3
44 16 17 15
47.8 17.4 18.5 16.3
Part of body burned Head Hand Genital area Other
22 30 6 55
34.4 46.9 9.4 85.9
12 9 1 19
42.9 32.1 3.6 67.9
34 39 7 74
37.0 42.4 7.6 80.4
Length of staye 1 day or less 2–7 days 8–30 days Over 30 days
5 22 29 8
7.8 34.4 45.3 12.5
2 8 15 3
7.1 28.6 53.6 10.7
7 30 44 11
7.6 32.6 47.8 12.0
Treatment at burn unit ICUf Floor
19 45
29.7 70.3
7 21
25.0 75.0
26 66
28.3 71.7
Outpatient visitse 0 1 2–5 6
3 9 38 14
4.7 14.1 59.4 21.9
1 3 14 10
3.6 10.7 50.0 35.7
4 12 52 24
4.3 13.0 56.5 26.1
Sick leaveg 1–7 days 8–30 days 1–6 months >6 months
0 8 24 5
0 21.6 64.9 13.5
0 1 5 3
0 11.1 55.6 33.3
0 9 29 8
0 19.6 63.0 17.4
Mean age (SD)a Marital status Single Married or cohabiting Divorced Widowed
a b c d e f g
t-test. Before burn. Need for social assistance recipient (during last 12 months). Including several types of burns, each with only a small number. In the Helsinki Burn Centre. Intensive Care Unit. Patients who did not have sick leave are not included.
Please cite this article in press as: Palmu R, et al. Health-related quality of life 6 months after burns among hospitalized patients: Predictive importance of mental disorders and burn severity. Burns (2015), http://dx.doi.org/10.1016/j.burns.2014.11.006
JBUR-4527; No. of Pages 7
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burns xxx (2015) xxx–xxx
Table 2 – Psychiatric diagnoses among 92 patients during the 6-month follow-up. n 92
% 100.0
At least one Axis I or II disorder Axis I disorders
54 51
58.7 55.4
Any mood disorder Major depressive disorder
14 12
15.2 13.0
Any anxiety disorder PTSD
20 10
21.7 10.9
7 3
7.6 3.3
Any substance-related disorder Alcohol dependence
25 21
27.2 22.8
Disorders due to GMC Delirium NOS
15 15
16.3 16.3
Eating disorder Bulimia NOS Personality disorder (=Axis II)
1 1 19
1.1 1.1 20.7
Any psychotic disorder Schizophrenia
PTSD, post-traumatic stress disorder; GMC, general medical condition; NOS, not otherwise defined.
The EQ-5D includes five dimensions: mobility, self-care, usual activities, pain or discomfort, and anxiety or depression. These are each divided into three categories of severity (none, moderate, or extreme problems). The EQ-5D thereby defines 243 different health states that can be converted into a single index score representing health utilities, anchored from 0 (dead) to 1 (full health) [20]. In addition, the EQ-5D includes a VAS (Visual Analog Scale) scale on HRQoL scaled vertically between 0 and 100. EQ-5D has recently been shown to have good psychometric properties in burn populations [10]. The 15D includes 15 dimensions: mobility, vision, hearing, breathing, sleeping, eating, speech, elimination, usual activities, mental function, discomfort and symptoms, depression, distress, vitality, and sexual activity. Each dimension has five grades of severity. The 15D can be used as a singleindex (from 0 to 1) health utility measure, like the EQ-5D, or as a profile. It has recently been successfully used also in HRQoL evaluation of hospitalized burn patients in a prospective study in the Helsinki Burn Centre, Finland [21–23]. EQ-5D and 15D have been compared as HRQoL measures in the Finnish nationwide Health 2000 study among the general adult population [24,25].
2.4. widely used and well-validated HRQoL self-report questionnaires: the RAND-36, the EQ-5D, and the 15D. The RAND-36 is perhaps the most widely used HRQoL survey instrument in the world today [17]. It comprises 36 items that assess eight health concepts: physical functioning, role limitations caused by general health perceptions, physical health problems, role limitations caused by emotional problems, social functioning, emotional well-being, energy/ fatigue, and pain. Here, the nationwide scores were used as the reference for comparison. The few minor differences between SF-36 and RAND-36 were described by Hays et al. [18]. Reliability, construct validity and reference values of RAND-36 in the Finnish general population have been tested [19].
Statistical analysis
Chi-square test and Student’s t-test were used as appropriate. To examine the independent effects of sociodemographic, burn-related, and psychiatric (pre-burn and post-burn mental disorders) factors, linear regression models were calculated. First, all variables in Table 1 (sociodemographic, and clinical, burn-related) were calculated in univariate linear regression. The statistically significant variables of Table 1 were then tested together in a multivariate model. Mental disorders were tested in a univariate model at three levels: Axis I disorders, categories of disorders (e.g. any anxiety disorders), and specific disorders (e.g. MDD). These were tested both during the lifetime and at the 6-month follow-up.
Table 3 – Quality of life measures (RAND-36, EQ-5, and 15D) among burn patients in the follow-up (n = 92). Men n = 64
Women n = 28
Total n = 92
p
Mean
S.D.
Mean
S.D.
Mean
S.D.
82.98 72.98 73.95 83.03 86.56 89.92 85.06
22.692 18.185 17.768 15.613 28.604 19.580 17.679
65.10 58.80 59.40 68.36 61.11 71.00 62.80
28.150 22.559 30.391 28.347 47.819 30.559 33.294
77.84 68.91 69.77 78.82 79.46 84.48 78.67
25.547 20.452 22.924 21.018 36.575 24.631 25.174
0.003 0.003 0.007 0.003 0.003 0.001
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Health-related quality of life 6 months after burns among hospitalized patients: Predictive importance of mental disorders and burn severity Raimo Palmu a,b,*, Timo Partonen b, Kirsi Suominen b,d, Samuli I. Saarni a,b,c, Jyrki Vuola e, Erkki Isometsa¨ a,b a
Department of Psychiatry, Helsinki University Central Hospital, Helsinki, Finland Department of Mental Health and Substance Abuse Services, National Institute for Health and Welfare, Helsinki, Finland c Turku University Hospital, Turku, Finland d Department of Psychiatry, City of Helsinki, Social Services and Health Care, Helsinki, Finland e Helsinki Burn Centre, Department of Plastic Surgery, Helsinki University Central Hospital, Helsinki, Finland b
article info
abstract
Article history:
Rationale: Major burns are likely to have a strong impact on health-related quality of life
Accepted 5 November 2014
(HRQoL). We investigated the level of and predictors for quality of life at 6 months after acute burn.
Keywords:
Methods: Consecutive acute adult burn patients (n = 107) admitted to the Helsinki Burn
Health-related quality of life
Centre were examined with a structured diagnostic interview (SCID) at baseline, and 92
Burn
patients (86%) were re-examined at 6 months after injury. During follow-up 55% (51/92)
Mental disorders
suffered from at least one mental disorder. The mean %TBSA was 9. TBSA of men did not differ from that of women. Three validated instruments (RAND-36, EQ-5, 15D) were used to evaluate the quality of life at 6 months. Results: All the measures (RAND-36, EQ-5, 15D) consistently indicated mostly normal HRQoL at 6 months after burn. In the multivariate linear regression model, %TBSA predicted HRQoL in one dimension (role limitations caused by physical health problems, p = 0.039) of RAND36. In contrast, mental disorders overall and particularly major depressive disorder (MDD) during follow-up ( p-values of 0.001–0.002) predicted poor HRQoL in all dimensions of RAND36. HRQoL of women was worse than that of men. Conclusion: Self-perceived HRQoL among acute burn patients at 6 months after injury seems to be mostly as good as in general population studies in Finland. The high standard of acute treatment and the inclusion of small burns (%TBSA < 5) in the cohort may partly explain the weak effect of burn itself on HRQoL. Mental disorders strongly predicted HRQoL at 6 months. # 2014 Elsevier Ltd and ISBI. All rights reserved.
* Corresponding author at: Department of Psychiatry, Helsinki University Central Hospital, P.O. Box 590, FI-00029 HUS, Finland. Tel.: +358 400 709301; fax: +358 9 47163735. E-mail addresses: [email protected], [email protected] (R. Palmu). http://dx.doi.org/10.1016/j.burns.2014.11.006 0305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved.
Please cite this article in press as: Palmu R, et al. Health-related quality of life 6 months after burns among hospitalized patients: Predictive importance of mental disorders and burn severity. Burns (2015), http://dx.doi.org/10.1016/j.burns.2014.11.006
JBUR-4527; No. of Pages 7
2
burns xxx (2015) xxx–xxx
1.
Introduction
Health-related quality of life (HRQoL) is an increasingly important outcome measure in healthcare, as it represents patient-relevant aspects of health problems and allows comparison between different illnesses and treatments. In earlier studies, generic HRQoL has been lower in patients with severe burns than in the normal population over a 12-month period [1]. However, even survivors of massive burn can reach a satisfying quality of life in most domains [2]. In a previous prospective cohort study of acute hospitalized burn patients, we found 55% to suffer from at least one mental disorder during a 6-month follow-up [3]. This 6-month prevalence of mental disorders increased as burn severity (%TBSA) increased. The relationship was statistically significant with regard to Axis I disorders overall, and anxiety disorders and disorders due to general medical condition (GMC) specifically. Studies excluding minor burns did not show this kind of relationship, probably because the variation in severity of burns was limited [4,5]. Burn severity and mental disorders are related in a complex way; suicidal or psychotic patients can be predisposed to burns, and severe burns can predispose to mental disorders. However, both burn severity and mental disorders can influence on prognosis of recovery and rehabilitation after burn, influencing the final HRQoL achieved. The question of how mental disorders and burn severity influence HRQoL is of great significance for burn rehabilitation services; however, few studies with proper methods, specifically in assessment of mental disorders, exist on this subject. Burn Specific Health Scale (BSHS) has a long history and has in recent years been the most frequently used specific measure for overall outcome and recovery after burns [6–8]. The abbreviated version of BSHS has been used also in Finland in evaluation of the recovery of burn survivors [9]. However, although illness-specific quality of life scales may capture specific problems related to each illness, their use renders a comparison between illnesses difficult. In earlier studies [10–12], Medical Outcome Study 36-item Short Form (SF-36), equivalent to RAND-36 and used especially in the United States, and, EQ-5D (Euro-QoL), used mostly in Europe, have served as generic scales and have appeared to be sensitive in measuring HRQoL among burn populations. The former provides a psychometric approach leading to several domains, and the latter a one-dimensional scale from 0 to 1 for quantification of health loss. The aim of this study was to estimate the HRQoL at 6 months after burn and to investigate which factors predicted HRQoL at this point. In particular, we examined whether the severity of burn or the presence of a psychiatric disorder (preburn or post-burn) determines HRQoL after the burn.
Central Hospital which has catchment area of approximately 1.4 million inhabitants. In addition to this responsibility, all of the most severe burns in Finland (population of 5.4 million) are treated in Helsinki Burn Centre. After all consecutive acute adult burn patients (at least 18 years old and Finnish-speaking) were admitted and exclusion criteria considered, the final sample comprised of 107 patients. The methodology was described in more detail repeatedly elsewhere [3,13,14]. Ethics Committee of Helsinki Central University Hospital approved by the study protocol.
2.2.
Procedure
All of the eligible, consecutive acute burn patients were interviewed by an experienced psychiatrist (R.P.). Clinical Version of the Structured Clinical Interview for DSM-IV-TR (SCID-CV) [15] was used to diagnose mental disorders in three different timeframes. SCID-II [16] was used to diagnose personality disorders. The subjects filled also in structured questionnaires covering psychological symptoms. Total body surface area (%TBSA), was used as the measure of severity of burns [3,13,14]. During their lifetime preceding the burn, almost two-thirds (60%), and during the final month prior to burn, 40% of subjects had at least one mental disorder [13]. The lifetime prevalence rates of some diagnostic subgroups substance-related (47%), psychotic (10%) and personality disorders (23%) were markedly higher than in general population studies. More specific, every fourth had some depressive and 15% MDD, 8% PTSD in their lifetime pre-burn [13]. The majority of subjects (86% of the whole study cohort) participated in the follow-up examination. They were interviewed for a second time (SCID-CV) by the same psychiatrist 6 months after injury [3,14]. The subjects (n = 15) who dropped out of the cohort are described in detail in our previous papers [3,14]. Most of the participants of the follow-up were middleaged men with low level of education and many had a history of psychiatric illness, psychiatric hospitalization, or suicide attempt before the injury (Table 1). The mean %TBSA was 9.7 (Table 1). Two-thirds of them had hand burns. At the follow-up interview, SCID-CV was repeated to diagnose mental disorders (a) during the 6 months after the burn and (b) during the last month of follow-up. During the 6 months after burn more than half (55%) of the subjects had some Axis I disorder (Table 2). Substance-related disorders were most common (27%) subgroup. Of those with no preburn mental disorder, 37% (n = 14) had at least one Axis I disorder during follow-up. Comorbidity was quite common while more than one-third (37%) of the patients had also another Axis I disorder during the follow-up. These descriptive findings have been previously published [3], but are presented here because of their important role as predictors for quality of life.
2.
Method
2.3.
2.1.
Participants
At baseline and at 6 months, the subjects answered the same single question concerning global quality of life during the preceding month on a four-point Likert scale (poor, moderate, good, or excellent). At 6 months, the patients filled in three
The study was conducted between May 5, 2006 and October 31, 2007 in Helsinki Burn Centre. It is part of Helsinki University
Health-related quality of life
Please cite this article in press as: Palmu R, et al. Health-related quality of life 6 months after burns among hospitalized patients: Predictive importance of mental disorders and burn severity. Burns (2015), http://dx.doi.org/10.1016/j.burns.2014.11.006
JBUR-4527; No. of Pages 7
3
burns xxx (2015) xxx–xxx
Table 1 – Sociodemographic and clinical characteristics of 92 acute burn patients in a 6-month follow-up. Men
Women
Total
n 64
% 69.6
n 28
% 30.4
n 92
% 100
45.1
(16.0)
49.0
(17.6)
46.3
(16.5)
14 40 8 2
21.9 62.5 12.5 3.1
5 10 6 7
17.9 35.7 21.4 25.0
19 50 14 9
20.7 54.3 15.2 9.8
Level of education Elementary Gymnasium
45 19
70.3 29.7
19 9
67.9 32.1
64 28
69.6 30.4
Working statusb Employed Unemployed Student Disability pension Retired
36 11 1 9 7
56.3 17.2 1.6 14.1 10.9
8 7 1 8 4
28.6 25.0 3.6 28.6 14.3
44 18 2 17 11
47.8 19.6 2.2 18.5 12.0
Social assistance recipientc None Occasionally As principal income
55 5 4
85.9 7.8 6.3
19 8 1
67.9 28.6 3.6
74 13 5
80.4 14.1 5.4
Type of burn Flame Liquid Electrical Other
29 10 5 20
45.3 15.6 7.8 31.3
11 12 0 5
39.3 42.9 0 17.9
40 22 5 25
43.5 23.9 5.4 27.2d
%TBSA 0–5 >5–10 >10–20 >20
29 11 13 11
45.3 17.2 20.3 17.2
15 5 4 4
53.6 17.9 14.3 14.3
44 16 17 15
47.8 17.4 18.5 16.3
Part of body burned Head Hand Genital area Other
22 30 6 55
34.4 46.9 9.4 85.9
12 9 1 19
42.9 32.1 3.6 67.9
34 39 7 74
37.0 42.4 7.6 80.4
Length of staye 1 day or less 2–7 days 8–30 days Over 30 days
5 22 29 8
7.8 34.4 45.3 12.5
2 8 15 3
7.1 28.6 53.6 10.7
7 30 44 11
7.6 32.6 47.8 12.0
Treatment at burn unit ICUf Floor
19 45
29.7 70.3
7 21
25.0 75.0
26 66
28.3 71.7
Outpatient visitse 0 1 2–5 6
3 9 38 14
4.7 14.1 59.4 21.9
1 3 14 10
3.6 10.7 50.0 35.7
4 12 52 24
4.3 13.0 56.5 26.1
Sick leaveg 1–7 days 8–30 days 1–6 months >6 months
0 8 24 5
0 21.6 64.9 13.5
0 1 5 3
0 11.1 55.6 33.3
0 9 29 8
0 19.6 63.0 17.4
Mean age (SD)a Marital status Single Married or cohabiting Divorced Widowed
a b c d e f g
t-test. Before burn. Need for social assistance recipient (during last 12 months). Including several types of burns, each with only a small number. In the Helsinki Burn Centre. Intensive Care Unit. Patients who did not have sick leave are not included.
Please cite this article in press as: Palmu R, et al. Health-related quality of life 6 months after burns among hospitalized patients: Predictive importance of mental disorders and burn severity. Burns (2015), http://dx.doi.org/10.1016/j.burns.2014.11.006
JBUR-4527; No. of Pages 7
4
burns xxx (2015) xxx–xxx
Table 2 – Psychiatric diagnoses among 92 patients during the 6-month follow-up. n 92
% 100.0
At least one Axis I or II disorder Axis I disorders
54 51
58.7 55.4
Any mood disorder Major depressive disorder
14 12
15.2 13.0
Any anxiety disorder PTSD
20 10
21.7 10.9
7 3
7.6 3.3
Any substance-related disorder Alcohol dependence
25 21
27.2 22.8
Disorders due to GMC Delirium NOS
15 15
16.3 16.3
Eating disorder Bulimia NOS Personality disorder (=Axis II)
1 1 19
1.1 1.1 20.7
Any psychotic disorder Schizophrenia
PTSD, post-traumatic stress disorder; GMC, general medical condition; NOS, not otherwise defined.
The EQ-5D includes five dimensions: mobility, self-care, usual activities, pain or discomfort, and anxiety or depression. These are each divided into three categories of severity (none, moderate, or extreme problems). The EQ-5D thereby defines 243 different health states that can be converted into a single index score representing health utilities, anchored from 0 (dead) to 1 (full health) [20]. In addition, the EQ-5D includes a VAS (Visual Analog Scale) scale on HRQoL scaled vertically between 0 and 100. EQ-5D has recently been shown to have good psychometric properties in burn populations [10]. The 15D includes 15 dimensions: mobility, vision, hearing, breathing, sleeping, eating, speech, elimination, usual activities, mental function, discomfort and symptoms, depression, distress, vitality, and sexual activity. Each dimension has five grades of severity. The 15D can be used as a singleindex (from 0 to 1) health utility measure, like the EQ-5D, or as a profile. It has recently been successfully used also in HRQoL evaluation of hospitalized burn patients in a prospective study in the Helsinki Burn Centre, Finland [21–23]. EQ-5D and 15D have been compared as HRQoL measures in the Finnish nationwide Health 2000 study among the general adult population [24,25].
2.4. widely used and well-validated HRQoL self-report questionnaires: the RAND-36, the EQ-5D, and the 15D. The RAND-36 is perhaps the most widely used HRQoL survey instrument in the world today [17]. It comprises 36 items that assess eight health concepts: physical functioning, role limitations caused by general health perceptions, physical health problems, role limitations caused by emotional problems, social functioning, emotional well-being, energy/ fatigue, and pain. Here, the nationwide scores were used as the reference for comparison. The few minor differences between SF-36 and RAND-36 were described by Hays et al. [18]. Reliability, construct validity and reference values of RAND-36 in the Finnish general population have been tested [19].
Statistical analysis
Chi-square test and Student’s t-test were used as appropriate. To examine the independent effects of sociodemographic, burn-related, and psychiatric (pre-burn and post-burn mental disorders) factors, linear regression models were calculated. First, all variables in Table 1 (sociodemographic, and clinical, burn-related) were calculated in univariate linear regression. The statistically significant variables of Table 1 were then tested together in a multivariate model. Mental disorders were tested in a univariate model at three levels: Axis I disorders, categories of disorders (e.g. any anxiety disorders), and specific disorders (e.g. MDD). These were tested both during the lifetime and at the 6-month follow-up.
Table 3 – Quality of life measures (RAND-36, EQ-5, and 15D) among burn patients in the follow-up (n = 92). Men n = 64
Women n = 28
Total n = 92
p
Mean
S.D.
Mean
S.D.
Mean
S.D.
82.98 72.98 73.95 83.03 86.56 89.92 85.06
22.692 18.185 17.768 15.613 28.604 19.580 17.679
65.10 58.80 59.40 68.36 61.11 71.00 62.80
28.150 22.559 30.391 28.347 47.819 30.559 33.294
77.84 68.91 69.77 78.82 79.46 84.48 78.67
25.547 20.452 22.924 21.018 36.575 24.631 25.174
0.003 0.003 0.007 0.003 0.003 0.001
