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The importance of outcome after major injury has continued to gain attention in light of the ongoing development of sophisticated trauma care systems in the United States. The Trauma Recovery Project (TRP) is a large prospective epidemiologic study designed to examine multiple outcomes after major trauma in adults aged 18 years and older, including quality of life, functional outcome, and psychologic sequelae such as depression and posttraumatic stress disorder (PTSD). Patient outcomes were assessed at discharge and at 6, 12, and 18 months after discharge. The specific objectives of the present report are to describe functional outcomes at the 12-month and 18-month follow-ups in the TRP population and to examine the association of putative risk factors with functional outcome.Between December 1, 1993, and September 1, 1996, 1,048 eligible trauma patients triaged to four participating trauma center hospitals in the San Diego Regionalized Trauma System were enrolled in the TRP study. The admission criteria for patients were as follows: (1) age 18 years or older; (2) Glasgow Coma Scale score on admission of 12 or greater; and (3) length of stay greater than 24 hours. Functional outcome after trauma was measured before and after injury using the Quality of Well-Being (QWB) Scale, an index sensitive to the well end of the functioning continuum (0 = death, 1.000 = optimum functioning). Follow-up at 12 months after discharge was completed for 806 patients (79%), and follow-up at 18 months was completed for 780 patients (74%). Follow-up contact at any of the study time points (6, 12, or 18 months) was achieved for 926 (88%) patients.The mean age was 36 +/- 14.8 years, and 70% of the patients were male; 52% were white, 30% were Hispanic, and 18% were black or other. Less than 40% of study participants were married or living together. The mean Injury Severity Score was 13 +/- 8.5, with 85% blunt injuries and a mean length of stay of 7 +/- 9.2 days. QWB scores before injury reflected the norm for a healthy adult population (mean, 0.810 +/- 0.171). At the 12-month follow-up, there were very high levels of functional limitation (QWB mean score, 0.670 +/- 0.137). Only 18% of patients followed at 12 months had scores above 0.800, the norm for a healthy population. There was no improvement in functional limitation at the 18-month follow-up (QWB mean score, 0.678 +/- 0.130). The majority of patients (80%) at the 18-month follow-up continued to have QWB scores below the healthy norm of 0.800. Postinjury depression, PTSD, serious extremity injury, and intensive care unit days were significant independent predictors of 12-month and 18-month QWB outcome.This study demonstrates a prolonged and profound level of functional limitation after major trauma at 12-month and 18-month follow-up. This is the first report of long-term outcome based on the QWB Scale, a standardized quality-of-life measure, and provides new and provocative evidence that the magnitude of dysfunction after major injury has been underestimated. Postinjury depression, PTSD, serious extremity injury, and intensive care unit days are significantly associated with 12-month and 18-month QWB outcome.