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Does the Glasgow Outcome Score Predict the
Functional Independence Measure in Major Trauma Patients?
OPALS Site Investigators November 2006OPALS Site Investigators November 2006
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Lisa NesbittLisa Nesbitt Ian Stiell Ian Stiell Justin MaloneyJustin Maloney Jon Dreyer Jon Dreyer Doug Doug MunkleyMunkley Jane Banek Jane Banek David Brisson George WellsDavid Brisson George Wells
Department of Emergency MedicineDepartment of Emergency MedicineOttawa Health Research InstituteOttawa Health Research Institute
University of Ottawa, CanadaUniversity of Ottawa, Canada
Funded by MOHLTC and CIHRFunded by MOHLTC and CIHR
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Measuring Patient Outcomes After Major Trauma
• There is a need to measure more than just mortality in trauma patients
• Many tools are available – some complex and costly, other simple and inexpensive
• The Functional Independence Measure (FIM) is one tool
• Glasgow Outcome Scale (GOS) is another• What could one tell us about the other?
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What is the Glasgow Outcome Score?
• The Glasgow Outcome Score (GOS) is a simple measure of functional outcome following major trauma
• Categories range from 5 (good recovery)to 1 (death)
• GOS is useful to Trauma Registries as it is readily obtained from the patient chart
• Few data regarding its validity
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What is the FIM Score?
• The Functional Independence Measure (FIM)score is the gold standard for measuring functional outcome following injury
• Well validated - used in many clinical studies
• Evaluates independence from 18 [dependent] to 126 [independent]
• Requires a trained nurse to administer the 18 item interview directly to the patient or proxy
• A lot of work !
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Objective
To determine how well the Glasgow Outcome Score compares with scores
obtained using the Functional Independence Measurement system
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Methods
• Prospective cohort substudy of the Ontario Prehospital Advanced Life Support (OPALS) Major Trauma Study
• A convenience sample of adult out-of-hospital major trauma survivors treated in one city with mixed BLS-D/ALS EMS systems
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Methods: Intervention
• Major trauma survivors were interviewed at discharge
• GOS and FIMscores were measured
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Methods: Data Analyses
Data analyses included:• Classification performance (sensitivity
and specificity)• Spearman correlation• kappa statistics
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Major Trauma Cases
Mean age, yrs 44Range 16-94
Male 75%Mean Trauma Scores
Initial GCS 11Initial GCS<9 29% Initial Revised Trauma Score 6.9Injury Severity Score 24
Patient Characteristics (N=733)
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Major Trauma Cases
Injury MechanismBlunt 98%Penetrating 2%
EMS Endotracheal Intubation 3%EMS Intravenous line 3%
Patient Characteristics (N=733)
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24
201
111
397
0
250
500
Distribution of GOS Scores
GOS SCORE
No. of Cases
1/2=Death/Vegetative
5=Good4=Moderate3=Severe
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59 55 61102
189
267
0
200
400
Distribution of FIM Scores
No. of Cases
FIM Score
<30 51-70 71-90 >12031-50 91-110
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Distribution of FIM by GOS Category
GOS 5 ‘Good Recovery’
GOS 4 ‘Moderate Disability’
GOS 3 ‘Severe Disability’
GOS 1/2 ‘Dead or Vegetative State’
2 2
0 1 0 0 0 0 0 0 1 00
7 0
1 4 0
< 3 0 4 0 5 0 6 0 7 0 8 0 9 0 1 0 0 1 1 0 1 2 0 > 1 2 0
3 7
2 2 2 6 2 3 2 1 1 62 3
1 1 1 48
00
7 0
1 4 0
`
0 1 2 06 1 1 1 6
2 4 2 2 2 2
7
0
7 0
1 4 0 0 1 2 29 1 2
2 4
4 2
7 6
1 2 6
1 0 3
0
7 0
1 4 0
0
0
0
0
<30 55 80 110 >120
FIM Score
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Univariate Agreement of GOS and FIM Scores
FIM Median 102
GOS Median 5
Agreement Between GOS and FIM Scores
kappa 0.14
Spearman 0.66
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Accuracy of GOS for Predicting ‘Good’ FIM Scores
FIM
GOS314212At Least Moderate
Disability (GOS < 5)
22185Good Recovery(GOS = 5)
<115>115
Sensitivity 47% (42-52%)Specificity 94% (91-96%)PPV 89% NPV 60%
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Accuracy of GOS for Predicting ‘Poor’ FIM Scores
FIM
GOS47566
Moderate disability to Good Recovery
(GOS >3)
33159At least severe disability (GOS < 3)
>75<75
Sensitivity 71% (65-77%)Specificity 94% (91-96%)PPV 83%NPV 88%
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ROC Curve: Discrimination of GOS Levels in Identifying FIM Score
FIM < 75
0
0.2
0.4
0.6
0.8
1
0 0.2 0.4 0.6 0.8 1False Positive Rate
True
Pos
itive
Rat
eArea = 0.85
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ROC Curve: Discrimination of GOS Levels in Identifying FIM Score
0
0.2
0.4
0.6
0.8
1
0 0.2 0.4 0.6 0.8 1False Positive Rate
True
Pos
itive
Rat
e
FIM > 115
Area = 0.76
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Discussion
• 54% of patients have good recovery according to the GOS, which is consistent with a median FIM of 102
• Distributions showed raters have some difficulty to differentiate moderate vs. severe disability using GOS
• Spearman showed fair correlation and kappa association was poor
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Discussion
• GOS is highly specific to rule in both good and poor FIM scores
• Choice of cut points for ‘good’ and ‘poor’ FIM scores was arbitrary
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Conclusions• This is the first study to compare the use
of GOS and FIM instruments in major trauma survivors
• Refining definitions of GOS 3 vs. GOS 4 may improve differentiation of moderate vs. severe disability
• The GOS appears to be a simple and accurate predictor of functional outcome at discharge and may be used as both a clinical and a research tool for major trauma patients
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Glasgow Outcome Score Definitions
5 – Good Recovery: resumption of normal life despite minor deficits
4- Moderate Disability: Disabled but independent; can work in sheltered setting
3- Severe Disability: Conscious but disabled; dependant for daily support
2- Vegetative: minimal responsiveness1- Death
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FIM Domains and ScoringPoints from each of 6 items are totaled to
arrive at a score between 18 (lowest) and 126 (highest) independence:
1. Self Care2. Sphincter Control3. Transfers4. Locomotion5. Communication6. Social Cognition
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Is the Cerebral Performance Is the Cerebral Performance Category Score a Valid Measure of Category Score a Valid Measure of
Functional Outcome After Functional Outcome After OutOut--ofof--Hospital Cardiac Arrest?Hospital Cardiac Arrest?
OPALS PRG Annual Meeting 2005
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CPC vs HUIObjective was to determine how well Cerebral Performance Category (CPC) Score compared with scores obtained using the Health Utilities Index Mark 3 (HUI3)
OPALS Cardiac Arrest DatasetFirst study to compare CPC and HUI3 instruments in 1-year survivors of cardiac arrestCPC Score is a fair predictor of functional outcome relative to HUI3 ScoreCPC Score should not be considered a substitute for HUI3 Score for cardiac arrest survivors
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What Are We Doing This Year??
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BIPHASIC Trial Cases 2002-2005 (N=256)
Received at least 1 Biphasic AED shock (N=221)
Survived to Hospital Discharge (N=36)
Died (N=185)
Non-Cardiac (N=2)No Data Download (N=7)Shocked on Asystole (N=26)