Cause of Death after Traumatic Brain Injury: A Population-Based Health Record Review Analysis Referenced for Nonhead Trauma.

INTRODUCTION: Traumatic brain injury (TBI) is a leading cause of disability and is associated with decreased survival. Although it is generally accepted that TBI increases risk of death in acute and postacute periods after injury, causes of premature death after TBI in the long term are less clear. METHODS: A cohort sample of Olmsted County, Minnesota, residents with confirmed TBI from January 1987 through December 1999 was identified. Each case was assigned an age- and sex-matched non-TBI referent case, called regular referent. Confirmed TBI cases with simultaneous nonhead injuries were identified, labeled special cases. These were assigned 2 age- and sex-matched special referents with nonhead injuries of similar severity. Underlying causes of death in each case were categorized using death certificates, International Classification of Diseases, Ninth Revision, International Statistical Classification of Diseases, Tenth Revision, and manual health record review. Comparisons were made over the study period and among 6-month survivors. RESULTS: Case-regular referent pairs (n = 1,257) were identified over the study period, and 221 were special cases. In total, 237 deaths occurred among these pairs. A statistically significant difference was observed between total number of deaths among all cases (n = 139, 11%) and regular referents (n = 98, 8%) (p = 0.006) over the entire period. This outcome was not true for special cases (32/221, 14%) and special referents (61/441, 14%) (p = 0.81). A greater proportion of deaths by external cause than all other causes was observed in all cases (52/139, 37%) versus regular referents (3/98, 3%) and in special cases (13/32, 41%) versus special referents (5/61, 8%) (p < 0.001 for both). Among all case-referent pairs surviving 6 months, no difference was found between total number of deaths (p = 0.82). The underlying cause of death between these 2 groups was significantly different for external causes only (p < 0.01). For special cases surviving 6 months versus special referents, no difference was observed in total number of deaths (p = 0.24) or underlying causes of death (p = 1.00) between groups. DISCUSSION/CONCLUSION: This population-based case-matched referent study showed that increased risk of death after TBI existed only during the first 6 months after injury, and the difference was due to external causes.

Pilot Study of Kano "Attractive Quality" Techniques to Identify Change in Emergency Department Patient Experience.

STUDY OBJECTIVE: We describe the use of the Kano Attractive Quality analytic tool to improve an identified patient experience gap in perceived compassion by emergency department (ED) providers. METHODS: In phase 1, point-of-service surveying assessed baseline patient perception of ED provider compassion. Phase 2 deployed Kano surveys to predict the effect of 4 proposed interventions on patient perception. Finally, phase 3 compared patients receiving standard care versus the Kano-identified intervention to assess the actual effect on patient experience. RESULTS: In phase 1, 193 of 200 surveys (97%) were completed, showing a baseline median score of 4 out of 5 (interquartile range [IQR] 3 to 5), with top box percentage of 33% for patients' perception of receiving compassionate care. In phase 2, 158 of 180 surveys (88%) using Kano-formatted questions were completed, and the data predicted that increasing shared decisionmaking would cause the greatest improvement in the patient experience. Finally, in phase 3, 45 of 49 surveys (92%) were returned and demonstrated a significant improvement in perceived concern and sensitivity, 5 (IQR 5 to 5) versus 4 (IQR 3 to 5) with a difference of 1 (95% CI 0.1-1.9) and a top box rating of 79% versus 35% with a difference of 44% (95% CI 12-66) by patients who received dedicated shared decisionmaking interventions versus those receiving standard of care. CONCLUSION: Kano analysis is likely predictive of change in patient experience. Kano methods may prove as useful in changing management of the health care industry as it has been in other industries.

Relationship between employment status and sexual functioning after traumatic brain injury.

OBJECTIVE: To determine if correlations exist between employment status and sexual functioning in persons with traumatic brain injury (TBI). DESIGN: Descriptive cross-sectional. SETTING: Community. PARTICIPANTS: One hundred and forty-six English-speaking, community dwelling adults, without other neurological or psychiatric disorder that could impact outcome and (1) enrolled in TBI Model Systems sexuality study database or (2) admitted to Rehabilitation Institute of Chicago with primary diagnosis of TBI between 2004-2006. MAIN OUTCOME MEASURES: Employment status, annual income, Derogatis Interview for Sexual Functioning Self Report (DISF-SR) sum and sub-scale scores, Global Sexual Satisfaction Index (GSSI). RESULTS: No significant difference was found in GSSI scores between employed, unemployed or students/volunteers (p = 0.20); however, lower income marginally correlated with lower GSSI scores (p = 0.09). Marginally significant lower DISF-SR Sexual Cognition sub-group (p = 0.09) scores were found in unemployed vs. employed. Lower annual income also correlated with lower DISF-SR sum scores (p = 0.06), Sexual cognition/fantasy (p = 0.07), Orgasm/ejaculation (p = 0.003) and Sexual drive and relationship (p = 0.01) scores. CONCLUSIONS: Lower quality sexual functioning and satisfaction was present in persons with TBI and concomitant unemployment or lower annual income. Efforts are needed to increase awareness amongst the TBI population and rehabilitation professionals of the potential impact unemployment or financial stress has on sexual functioning and satisfaction.

Management of Medical Complications During the Rehabilitation of Moderate-Severe Traumatic Brain Injury.

Brain injury specialists are experienced providers able to identify and treat the unique medical complications after moderate-severe traumatic brain injury, including posttraumatic seizures, paroxysmal sympathetic hyperactivity, spasticity, hydrocephalus, agitation, neuroendocrine dysfunction, heterotopic ossification, venous thromboembolism, and cranial nerve dysfunction. Owing to the potential negative impact on outcome if left untreated, identification and appropriate treatment is essential. An additional role of the brain injury specialist is to educate family about potential medical complications and anticipated outcomes after brain injury. The provider, patient, and family work together to identify and treat any potential sequelae of the moderate-severe brain injury.