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What was the research about?

Each year, millions of Americans have injuries serious enough that they need to stay in the hospital. These injuries may be from car and motorcycle crashes, falls or other accidents, or gunshot or stab wounds.

In this study, the research team wanted to learn about ways to help patients after a serious injury. A member of the research team talked with patients in the study while they were still at the hospital after their injuries to learn about their concerns.

The team compared two approaches to supporting patients with the concerns they raised:

• Care management. Care managers worked closely with the patients in this group. They created a plan for patients’ health care and helped patients get the type and amount of care that they wanted. Care managers gave extra support to patients with symptoms that were more serious, such as helping them get mental health care when needed. The research team also gave patients a phone number to call if they had questions or wanted to talk at any time.
• Nurse alert. The team told the hospital nurses about the concerns that the patients in this group raised.

What were the results?

Patients in the care management group had fewer serious concerns over the course of the study than patients in the nurse-alert group did. In the three to six months after their injuries, patients in the care management group had fewer visits to the emergency room, or ER, than patients in the nurse-alert group did. But the team found no difference when comparing ER visits between groups over the full year.

There was no difference between the two groups in how many patients had symptoms of depression or posttraumatic stress disorder. Patients in each group reported similar physical health, quality of life, and satisfaction with their care. They also reported engaging in a similar amount of risky behaviors such as alcohol and drug use.

Who was in the study?

The study included 171 patients who stayed in the hospital for at least one day after a serious injury. Patients reported having at least three serious concerns after their injuries. Patients in the study were 14 years old or older, and the average age was 42. Of the 171 patients, 57 percent were female, 56 percent were white, 16 percent were African American, and 13 percent were American Indian.

What did the research team do?

The research team assigned patients by chance to either the care management group or nurse-alert group. In both groups, the team interviewed patients at one, three, and six months after their injuries. The team also looked at how often patients went to the ER during the first year after their injuries.

What were the limits of the study?

The study was at one hospital that treats people with serious injuries in Washington State. Results may be different in other places or other types of hospitals. Patients in the study had trouble remembering all the concerns they had between interviews, making it hard for the team to assess the full number of patient concerns. The care management program did a number of things for patients. As a result, it was hard for the team to know which parts of care management helped patients the most.

Future research could include patients from other places and look more closely at ER use.

How can people use the results?

Trauma centers can consider offering care management programs like the one in this study to help reduce patients’ concerns after a serious injury.

Objective

To compare the effectiveness of care management versus enhanced usual care to prevent postinjury concerns and symptoms for hospitalized patients with serious injuries

Study Design

This randomized controlled trial compared care management with enhanced usual care for hospitalized patients with serious injuries.

The study included 171 hospitalized patients in a level 1 trauma center in the Pacific Northwest who reported substantial postinjury distress. Serious injuries included motor vehicle, pedestrian, and bicycle accidents (50%); falls (31%); and intentional injuries from physical assaults, including gunshots and stabbings (14%). The average age of the 171 patients was 42, and 57% were female. The study included patients who were white (56%), African American (16%), and American Indian (13%).

Researchers randomly assigned participants to either the care management group or the enhanced usual care group. In both groups, researchers interviewed participants at baseline to understand their primary postinjury concerns. In the care management group, a care manager worked with patients to develop individualized treatment plans based on the patients’ care preferences. The care managers provided ongoing support to patients, including providing a contact number and encouraging them to call at any time. In addition, the care managers provided support and referrals to patients who presented with symptoms of depression, posttraumatic stress disorder (PTSD), alcohol use problems, or other risk behaviors. In the enhanced usual care group, researchers notified the patients’ nurses about the concerns the patients shared at baseline for further follow-up as deemed necessary by the nurses.

Researchers interviewed patients in both groups again at one, three, and six months after their injuries. In addition, researchers monitored patients’ emergency department visits for one year.

Patients, clinicians, patient advocates, and policy makers worked with researchers and provided input on the study design and implementation.

Results

Patients in the enhanced usual care group were more likely than patients in the care management group to report one or more serious concerns over the course of the study (p=0.01) and at six months postinjury (p=0.02). Researchers found no clinically or statistically significant differences between the two groups for PTSD or depressive symptoms.

Patients in the care management group had fewer emergency department visits three to six months postinjury compared with those in the enhanced usual care group (p=0.03), but there was no statistically significant difference over a full year. Researchers also found no statistically significant differences between groups for physical health, quality of life, satisfaction with care, or risk behaviors.

Limitations

Patients found it difficult to remember all their postinjury concerns between the data collection time points and, as a result, may not have reported all concerns.

Because there were many components to the intervention, it is difficult to know which parts of the care management approach led to reductions in postinjury concerns and emergency department use three to six months after the injury. In addition, because the study occurred at a single trauma center, the findings may not be generalizable to other areas or settings.

Conclusions and Relevance

Patients with a serious injury who received care management had fewer postinjury concerns and fewer visits to the emergency department three to six months after their injuries than patients who received enhanced usual care. Trauma centers may consider offering care management services to help reduce patients’ concerns after a serious injury.

Future Research Needs

Future studies could examine which features of the care management intervention led to reductions in postinjury concerns and further investigate differences in emergency department use.