Return to Productivity Projections for Individuals With Moderate to Severe TBI Following Inpatient Rehabilitation: A NIDILRR TBIMS and CDC Interagency Collaboration.

OBJECTIVE: Return to work and school following traumatic brain injury (TBI) is an outcome of central importance both to TBI survivors and to society. The current study estimates the probability of returning to productivity over 5 years following moderate to severe brain injury. DESIGN: A secondary longitudinal analysis using random effects modeling, that is, individual growth curve analysis based on a sample of 2542 population-weighted individuals from a multicenter cohort study. SETTING: Acute inpatient rehabilitation facilities. PARTICIPANTS: Individuals 16 years and older with a primary diagnosis of TBI who were engaged in school or work at the time of injury. MAIN OUTCOME MEASURES: Participation in productive activity, defined as employment or school, as reported during follow-up telephone interviews at 1, 2, and 5 years postinjury. RESULTS: Baseline variables, age of injury, race, level of education and occupational category at the time of injury, disability rating at hospital discharge, substance abuse status, and rehabilitation length of stay, are significantly associated with probability of return to productivity. Individual-level productivity trajectories generally indicate that the probability of returning to productivity increases over time. CONCLUSIONS: Results of this study highlight the importance of preinjury occupational status and level of education in returning to productive activity following moderate to severe TBI.

Functional Outcome Trajectories Following Inpatient Rehabilitation for TBI in the United States: A NIDILRR TBIMS and CDC Interagency Collaboration.

OBJECTIVE: To describe trajectories of functioning up to 5 years after traumatic brain injury (TBI) that required inpatient rehabilitation in the United States using individual growth curve models conditioned on factors associated with variability in functioning and independence over time. DESIGN: Secondary analysis of population-weighted data from a multicenter longitudinal cohort study. SETTING: Acute inpatient rehabilitation facilities. PARTICIPANTS: A total of 4624 individuals 16 years and older with a primary diagnosis of TBI. MAIN OUTCOME MEASURES: Ratings of global disability and supervision needs as reported by participants or proxy during follow-up telephone interviews at 1, 2, and 5 years postinjury. RESULTS: Many TBI survivors experience functional improvement through 1 and 2 years postinjury, followed by a decline in functioning and decreased independence by 5 years. However, there was considerable heterogeneity in outcomes across individuals. Factors such as older age, non-White race, lower preinjury productivity, public payer source, longer length of inpatient rehabilitation stay, and lower discharge functional status were found to negatively impact trajectories of change over time. CONCLUSIONS: These findings can inform the content, timing, and target recipients of interventions designed to maximize functional independence after TBI.

Re-inventing yourself after spinal cord injury: a site-specific randomized clinical trial.

STUDY DESIGN: Parallel-arm randomized controlled trial comparing an interactive group format versus a no-intervention control. OBJECTIVE: To evaluate the efficacy of a replicable group treatment program for improving self-efficacy after spinal cord injury (SCI) in a single center cohort of adults. SETTING: Regional SCI center. METHODS: Participants included 81 individuals with SCI who were at least 4 weeks post-discharge from initial rehabilitation. Those randomized to treatment participated in six interactive learning sessions (2 hours each, one session per week) with structured and facilitated group interactions to improve self-efficacy. A wait-list control group was followed at matching time points for all outcome measures. The primary outcome measure was the Moorong Self-Efficacy Scale (MSES); secondary outcomes were the Generalized Self-Efficacy Scale (GSES); Diener Satisfaction with Life Scale (SWLS); Participation Assessment with Recombined Tools - Objective (PART-O); Patient Health Questionnaire - 9 (PHQ-9); and General Anxiety Disorder 7-item (GAD-7). RESULTS: Individuals in the Treatment group had greater increases in MSES scores from baseline to immediately post-intervention (6 weeks) than the Control group, but that difference did not remain significant after controlling for multiple comparisons. However, the improvement in the treatment group relative to the control group was not maintained through follow-up at 30 weeks. There was no evidence of an immediate or sustained treatment effect on any of the secondary outcomes. CONCLUSIONS: Self-efficacy improved for participants with SCI in the Treatment group, however, this improvement was not significant or maintained on follow-up.

Representativeness of the Spinal Cord Injury Model Systems National Database.

STUDY DESIGN: Secondary analysis of prospectively collected observational data. OBJECTIVES: To assess the representativeness of the Spinal Cord Injury Model Systems National Database (SCIMS-NDB) of all adults aged 18 years or older receiving inpatient rehabilitation in the United States (US) for new onset traumatic spinal cord injury (TSCI). SETTING: Inpatient rehabilitation centers in the US. METHODS: We compared demographic, functional status, and injury characteristics (nine categorical variables comprising of 46 categories and two continuous variables) between the SCIMS-NDB (N = 5969) and UDS-PRO/eRehabData (N = 99,142) cases discharged from inpatient rehabilitation in 2000-2010. RESULTS: There are negligible differences (<5%) between SCIMS-NDB patients and the population for 31 of the 48 comparisons. Minor differences (5-10%) exist for age categories, sex, race/ethnicity, marital status, FIM Motor score, and time from injury to rehabilitation admission. Important differences (>10%) exist in mean age and preinjury occupational status; the SCIMS-NDB sample was younger and included a higher percentage of individuals who were employed (62.7 vs. 41.7%) and fewer who were retired (10.2 vs. 36.1%). CONCLUSIONS: Adults in the SCIMS-NDB are largely representative of the population of adults receiving inpatient rehabilitation for new onset TSCI in the US. However, users of the SCIMS-NDB may need to adjust statistically for differences in age and preinjury occupational status to improve generalizability of findings.

The Reliability of a Computer-Assisted Telephone Interview Version of the Ohio State University Traumatic Brain Injury Identification Method.

OBJECTIVES: Provide test-retest reliability (>5 months) of the Ohio State University Traumatic Brain Injury Identification Method modified for use as a computer-assisted telephone interview (CATI) to capture traumatic brain injury (TBI) and other substantial bodily injuries among a representative sample of noninstitutionalized adults living in Colorado. DESIGN: Four subsamples of 50 individuals, including people with no major lifetime injury, a major lifetime injury but no TBI, TBI with no loss of consciousness, and TBI with loss of consciousness, were interviewed using the CATI Ohio State University Traumatic Brain Injury Identification Method between 6 and 18 months after an initial interview. PARTICIPANTS: Stratified random sample of Coloradans (n = 200) selected from a larger study of TBI. PRIMARY MEASURES: Cumulative, Severity and Age-related indices were assessed for long-term reliability. Cumulative indices were those that summed the total number of specific TBI severities across the lifetime; Severity indices included measures of the most severe type of injury incurred throughout the lifetime; and Age-related indices assessed the timing of specific injury types across the lifespan. RESULTS: Test-retest reliabilities ranged from poor to excellent. The indices demonstrating the greatest reliability were Severity measures, with intraclass correlations for ordinal indices ranging from 0.62 to 0.78 and Cohen κ ranging from 0.50 to 0.62. One Cumulative outcome demonstrated high reliability (0.70 for number of TBIs with loss of consciousness ≥30 minutes), while the remaining Cumulative outcomes demonstrated low reliability, ranging from 0.06 to 0.21. Age-related test-retest reliabilities were fair to poor, with intraclass correlations of 0.38 to 0.49 and Cohen κ of 0.32 and 0.34. CONCLUSION: The CATI-modified Ohio State University Traumatic Brain Injury Identification Method used in this study is an effective measure for evaluating the maximum TBI severity incurred throughout the lifetime within a general population survey. The CATI measure is not recommended for use in determining cumulative counts of lifetime incidence of TBI.

Prevalence of Self-Reported Lifetime History of Traumatic Brain Injury and Associated Disability: A Statewide Population-Based Survey.

OBJECTIVE: To investigate the prevalence of all severities of traumatic brain injury (TBI), regardless of treatment setting, and their associated negative outcomes. PARTICIPANTS: A total of 2701 adult Coloradoans. DESIGN: A statewide, population-based, random digit-dialed telephone survey. MAIN MEASURES: The lifetime history of TBI was assessed by a modification of the Ohio State University TBI Identification Method; activity limitation and life satisfaction were also assessed. RESULTS: The distribution of self-reported lifetime injury was as follows: 19.8%, no injury; 37.7%, injury but no TBI; 36.4%, mild TBI; and 6.0%, moderate-severe TBI. Of those reporting a TBI, 23.1% were hospitalized, 38.5% were treated in an emergency department, 9.8% were treated in a physician's office, and 27.5% did not seek medical care. A clear gradient of activity limitations and low life satisfaction was seen, with the highest proportions of these negative outcomes occurring in people reporting more severe TBI and the lowest proportions in those not reporting a TBI. Approximately twice as many people reported activity limitations and low life satisfaction after nonhospitalized TBI compared with hospitalized TBI. CONCLUSIONS: This investigation highlights the seriousness of TBI as a public health problem and the importance of including all severities of TBI, no matter where, or if treated, in estimating the prevalence of disability co-occurring with TBI.

A validation study for using iterative proportional fitting to weight the Traumatic Brain Injury Model Systems National Database: an NIDRR-sponsored study.

OBJECTIVE: To verify that iterative proportional fitting (IPF), or raking, has the desired effect of aligning estimates and parameters so that researches have confidence in population projections when weighting the Traumatic Brian Injury Model Systems National Database. DESIGN: Secondary data analysis using IPF. SETTING: Inpatient rehabilitation. PARTICIPANTS: People aged 16 years and older with a primary diagnosis of traumatic brain injury receiving initial inpatient rehabilitation. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Age at injury, race, sex, marital status, rehabilitation length of stay, payer source, and motor and cognitive FIM scores. RESULTS: This study demonstrates the utility of applying IPF to weight the TBI Model System National Database so that results of ensuing statistical analyses better reflect those in the United States who are 16 years and older with a primary diagnosis of TBI and are receiving inpatient rehabilitation. CONCLUSIONS: In general, IPF aligns population estimates on the basis of weighted Traumatic Brian Injury Model Systems data and known population parameters. It is reasonable to assume that IPF has the same effect on unknown variables. This provides confidence to researchers wishing to use IPF for making population projections in analyses.

Ten-Year Employment Patterns of Working Age Individuals After Moderate to Severe Traumatic Brain Injury: A National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems Study.

OBJECTIVE: To describe the 10-year patterns of employment for individuals of working age discharged from a Traumatic Brain Injury Model Systems (TBIMS) center between 1989 and 2009. DESIGN: Secondary data analysis. SETTING: Inpatient rehabilitation centers. PARTICIPANTS: Patients aged 16 to 55 years (N=3618) who were not retired at injury, received inpatient rehabilitation at a TBIMS center, were discharged alive between 1989 and 2009, and had at least 3 completed follow-up interviews at postinjury years 1, 2, 5, and 10. INTERVENTIONS: Not applicable. MAIN OUTCOMES MEASURE: Employment. RESULTS: Patterns of employment were generated using a generalized linear mixed model, where these patterns were transformed into temporal trajectories of probability of employment via random effects modeling. Covariates demonstrating significant relations to growth parameters that govern the trajectory patterns were similar to those noted in previous cross-sectional research and included age, sex, race/ethnicity, education, preinjury substance misuse, preinjury vocational status, and days of posttraumatic amnesia. The calendar year in which the injury occurred also greatly influenced trajectories. An interactive tool was developed to provide visualization of all postemployment trajectories, with many showing decreasing probabilities of employment between 5 and 10 years postinjury. CONCLUSIONS: These results highlight that postinjury employment after moderate to severe traumatic brain injury (TBI) is a dynamic process, with varied patterns of employment for individuals with specific characteristics. The overall decline in trajectories of probability of employment between 5 and 10 years postinjury suggests that moderate to severe TBI may have unfavorable chronic effects and that employment outcome is highly influenced by national labor market forces. Additional research targeting the underlying drivers of the decline between 5 and 10 years postinjury is recommended, as are interventions that target influencing factors.

Unemployment in the United States after traumatic brain injury for working-age individuals: prevalence and associated factors 2 years postinjury.

OBJECTIVE: To estimate the prevalence of unemployment and part-time employment in the United States for working-age individuals completing rehabilitation for a primary diagnosis of traumatic brain injury (TBI) between 2001 and 2010. DESIGN: Secondary data analysis. SETTING: Acute inpatient rehabilitation facilities. PARTICIPANTS: Patients aged 16 to 60 years at injury who completed inpatient rehabilitation for TBI between 2001 and 2010. MAIN OUTCOME MEASURES: Unemployment; Part-time employment. RESULTS: The prevalence of unemployment for persons in the selected cohort was 60.4% at 2-year postinjury. Prevalence of unemployment at 2-year postinjury was significantly associated with the majority of categories of age group, race, gender, marital status, primary inpatient rehabilitation payment source, education, preinjury vocational status, length of stay, and Disability Rating Scale. The direction of association for the majority of these variables complement previous research in this area, with only Hispanic ethnicity and the FIM Cognitive subscale demonstrating disparate findings. For those employed at 2-year postinjury, the prevalence of part-time employment was 35.0%. The model of prevalence for part-time employment at 2-year postinjury was less robust, with significant relationships with some categorical components of age group, gender, marital status, primary payment source, preinjury vocational status, and Disability Rating Scale. CONCLUSIONS: The prevalence of unemployment for patients completing inpatient rehabilitation for TBI was substantial (60.4%). The majority of factors found to associate with 2 years' unemployment were complementary of previously published research; however, these were often smaller in magnitude than previous reports. The prevalence of part-time employment was also an issue for this cohort and included 35.0% of all employed individuals. In regard to the determination of factors associated with part-time employment, additional analyses that include more fine-grained factors associated with employment, including physical and psychosocial functioning, are recommended.

Epidemiology of adults receiving acute inpatient rehabilitation for a primary diagnosis of traumatic brain injury in the United States.

OBJECTIVE: To estimate the overall and by age-group characteristics at admission and discharge from rehabilitation between 2001 and 2010 of all late-teens and adults undergoing inpatient rehabilitation for a primary diagnosis of traumatic brain injury (TBI) in the United States. DESIGN: Secondary data analysis. SETTING: Acute inpatient rehabilitation facilities. PARTICIPANTS: Patients aged 16 years and older receiving inpatient rehabilitation for a primary diagnosis of TBI between 2001 and 2010. MAIN OUTCOME MEASURES: Functional independence, level of disability, and living situation. RESULTS: The incidence of TBI by age group found the largest proportion of cases to be aged 80 years and older, with a gradual decline in incidence in the age group of 30 years, at which point there was a slight increase. Injuries resulted predominantly from falls (49.8%) and motor vehicle crashes (40.8%); however, injuries to the youngest individuals were largely from motor vehicle crashes with decreasing rates as age increased, while injuries due to falls rose as age increased, with the oldest age groups most likely to incur a TBI. Preinjury alcohol misuse and substance use were found to occur in 22.9% and 12.2% of the total population, respectively; however, age distributions demonstrated high preinjury use among individuals younger than 50 years (eg, 46.4% and 30.6% for those aged 20 and 29 years, respectively) with decreasing misuse as age increased. Of the total population, 49.2% were retired, 31.1% employed, 14.1% not working, and 5.6% students. Trends by age showed that younger individuals were more likely to be students or employed (eg, 14.5% and 62.0% for those aged 20 and 29 years, respectively), with employment status peaking for those aged 30 to 39 years, and declining to 3.2% for the oldest age group (80 years and older). The trend of person(s) living alone between pre- and postrehabilitation showed the least amount of change for those aged 16 to 19 years with steadily increasing changes as age increased. Similar trends were seen for residence changes pre- and postrehabilitation, with the youngest most likely to return to living at a private residence, and a gradual decrease in return to living at a private residence as age increased. FIM instrument ("FIM") Motor and Cognitive subscale scores demonstrated that younger individuals had lower scores at admission to rehabilitation and higher scores at rehabilitation discharge. CONCLUSION: This study provides population estimates for all patients 16 years of age and older receiving inpatient rehabilitation for a primary diagnosis of TBI in the United States between 2001 and 2010. A recent trend shows the aging of the inpatient TBI rehabilitation population. Many characteristics important to rehabilitation outcomes are influenced by age, with older individuals trending toward being female, having less severe TBIs, incurring TBIs as a result of falls, but showing less improvement during rehabilitation, greater resulting disability, and more changes in their living situation postrehabilitation. These findings are of particular interest, as the oldest age groups considered in these analyses did not include the baby boom population.

US population estimates of health and social outcomes 5 years after rehabilitation for traumatic brain injury.

OBJECTIVE: To estimate the number of adults in the United States from 2006 to 2012 who manifest selected health and social outcomes 5 years following a traumatic brain injury (TBI) that required acute inpatient rehabilitation. DESIGN: Secondary data analysis. SETTING: Acute inpatient rehabilitation facilities. PARTICIPANTS: Patients 16 years and older receiving acute inpatient rehabilitation for a primary diagnosis of TBI. MAIN OUTCOME MEASURES: Mortality, functional independence, societal participation, subjective well-being, and global outcome. RESULTS: Annually from 2001 to 2007, an average of 13 700 patients aged 16 years or older received acute inpatient rehabilitation in the United States with a primary diagnosis of TBI. Approximately 1 in 5 patients had died by the 5-year postinjury assessment. Among survivors, 12% were institutionalized and 50% had been rehospitalized at least once. Approximately one-third of patients were not independent in everyday activities. Twenty-nine percent were dissatisfied with life, with 8% reporting markedly depressed mood. Fifty-seven percent were moderately or severely disabled overall, with 39% having deteriorated from a global outcome attained 1 or 2 years postinjury. Of those employed preinjury, 55% were unemployed. Poorer medical, functional, and participation outcomes were associated with, but not limited to, older age. Younger age groups had poorer mental and emotional outcomes. Deterioration in global outcome was common and not age-related. CONCLUSIONS: Significant mortality and morbidity were evident at 5 years postinjury. The deterioration in global outcomes observed regardless of age suggests that multiple influences contribute to poorer outcomes. Public health interventions intended to reduce post-acute inpatient rehabilitation mortality and morbidity rates will need to be multifaceted and age-specific.

Virtual reality-based therapy for the treatment of balance deficits in patients receiving inpatient rehabilitation for traumatic brain injury.

OBJECTIVE: To evaluate the feasibility and safety of utilizing a commercially available virtual reality gaming system as a treatment intervention for balance training. DESIGN: A randomized controlled trial in which assessment and analysis were blinded. SETTING: An inpatient rehabilitation facility. INTERVENTION: Interventions included balance-based physical therapy using a Nintendo Wii, as monitored by a physical therapist, and receipt of one-on-one balance-based physical therapy using standard physical therapy modalities available for use in the therapy gym. RESULTS: Participants in the standard physical therapy group were found to have slightly higher enjoyment at mid-intervention, while those receiving the virtual reality-based balance intervention were found to have higher enjoyment at study completion. Both groups demonstrated improved static and dynamic balance over the course of the study, with no significant differences between groups. Correlational analyses suggest a relationship exists between Wii balance board game scores and BBS scores for measures taken beyond the baseline assessment. CONCLUSIONS: This study provides a modest level of evidence to support using commercially available VR gaming systems for the treatment of balance deficits in patients with a primary diagnosis of TBI receiving inpatient rehabilitation. Additional research of these types of interventions for the treatment of balance deficits is warranted.

Extension of the representativeness of the Traumatic Brain Injury Model Systems National Database: 2001 to 2010.

OBJECTIVE: To extend the representativeness of the Traumatic Brain Injury Model Systems National Database (TBIMS-NDB) for individuals 16 years and older, admitted for acute, inpatient rehabilitation in the United States with a primary diagnosis of traumatic brain injury (TBI) analyses completed by Corrigan and colleagues by comparing this data set to national data for patients admitted to inpatient rehabilitation with identical inclusion criteria that included 3 additional years of data and 2 new demographic variables. DESIGN: Secondary analysis of existing data sets and extension of previously published analyses. SETTING: Acute inpatient rehabilitation facilities. PARTICIPANTS: Patients 16 years and older with a primary rehabilitation diagnosis of TBI; the US TBI Rehabilitation population, n = 156 447; and the TBIMS-NDB population, n = 7373. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Demographics, functional status, and length of stay in hospital. RESULTS: The TBIMS-NDB was largely representative of patients 16 years and older, admitted for rehabilitation in the United States with a primary diagnosis of TBI on or after October 1, 2001, and discharged as of December 31, 2010. The results of the extended analyses were similar to those reported by Corrigan and colleagues. Age accounted for the largest difference between the samples, with the TBIMS-NDB including a smaller proportion of patients 65 years and older than all those admitted for rehabilitation with a primary diagnosis of TBI in the United States. After partitioning each data set at age 65, most distributional differences found between samples were markedly reduced; however, differences in the preinjury vocational status of the employed and rehabilitation lengths of stay between 1 and 9 days remained robust. The subsamples of patients 64 years and younger were found to differ only slightly on all remaining variables, whereas those 65 years and older were found to have meaningful differences in insurance type and age distribution. CONCLUSIONS: These results reconfirm that the TBIMS-NDB is largely representative of patients with TBI receiving inpatient rehabilitation in the United States. Differences between the 2 data sets were found to be stable across the 3 additional years of data, and new differences were limited to those involving newly introduced variables. To use these data for population-based research, it is strongly recommended that statistical adjustment be conducted to account for the lower percentage of patients older than 65 years, inpatient rehabilitation stays less than 10 days, and preinjury vocational status in the TBIMS-NDB.

Representativeness of the Traumatic Brain Injury Model Systems National Database.

OBJECTIVE: To determine whether the Traumatic Brain Injury Model Systems National Database (TBIMS-NDB) is representative of individuals aged 16 years and older admitted for acute, inpatient rehabilitation in the United States with a primary diagnosis of traumatic brain injury (TBI). DESIGN: Secondary analysis of existing data sets. SETTING: Acute inpatient rehabilitation facilities. PARTICIPANTS: Patients aged 16 years and older with a primary rehabilitation diagnosis of TBI. MAIN OUTCOME MEASURES: Demographic characteristics, functional status, and hospital length of stay. RESULTS: Patients included in the TBIMS-NDB from October 2001 through December 2007 were largely representative of all individuals 16 years and older admitted for rehabilitation in the United States with a primary diagnosis of TBI. The major difference in distribution was age-the TBIMS-NDB cohort did not include as large a proportion of patients older than 65 years as were admitted for rehabilitation with a primary diagnosis of TBI in the United States. Distributional differences for age-related characteristics were observed; however, groups of patients partitioned at aged 65 years differed minimally, especially within the younger than 65 years subset. Regardless of age, the proportion of patients with a rehabilitation stay of 1 to 9 days was larger nationwide. Nationwide admissions showed an age distribution similar to patients discharged alive from acute care with moderate, severe or penetrating TBI. The proportion of patients aged 70 years and older admitted for TBI rehabilitation in the United States increased every year, a trend that was not evident in the general population, TBIMS-NDB or among TBI patients in acute care. CONCLUSIONS: These results provide substantial empirical evidence that the TBIMS-NDB is representative of patients receiving inpatient rehabilitation for TBI in the United States. Researchers utilizing the TBIMS-NDB may want to adjust statistically for the lower percentage of patients older than 65 years or those with stays less than 10 days.

Health and wellness characteristics of persons with traumatic brain injury.

OBJECTIVE: To describe health and wellness characteristics of persons with TBI living in the community, compare to other disability populations and evaluate the associations between health-related constructs. DESIGN: Observational. SETTING: Outpatient rehabilitation hospital and a Veterans Affairs Medical Centre. PARTICIPANTS: Seventy-four community-dwelling adults with moderate-to-severe TBI. INTERVENTIONS: None. MAIN MEASURES: Health Promoting Lifestyle Profile II (HPLP-II), Self Rated Abilities Health Practices Scale (SRAHP), Barriers to Health Promoting Activities for Disabled Scale (BHPAD), Medical Outcomes Study 12-Item Health Status Survey Short Form (SF-12), Personal Resource Questionnaire-adapted (PRQ-a), Perceived Wellness Survey (PWS), Diener Satisfaction with Life Scale (SWLS) and Participation Assessment with Recombined Tools-Objective (PART-O). RESULTS: Health-promoting behaviours, self-efficacy and barriers to health were comparable to other disability populations. Perceived health status, participation and life satisfaction were decreased. Measures of health promotion and self-efficacy were positively associated with perceived mental health status, life satisfaction and participation. Barriers to healthy activities were negatively associated with health promotion, self-efficacy and perceived mental health status. CONCLUSIONS: Health and wellness status was below desired levels for the study cohort, and comparable to other disability populations. Better understanding of associations among health-related constructs is needed. Continued research on conceptually-based health and wellness interventions for persons with TBI is recommended.

Factors that predict acute hospitalization discharge disposition for adults with moderate to severe traumatic brain injury.

OBJECTIVE: To identify factors predicting acute hospital discharge disposition after moderate to severe traumatic brain injury (TBI). DESIGN: Secondary analysis of existing datasets. SETTING: Acute care hospitals. PARTICIPANTS: Adults hospitalized with moderate to severe TBI included in 3 large sets of archival data: (1) Centers for Disease Control and Prevention Central Nervous System Injury Surveillance database (n=15,646); (2) the National Trauma Data Bank (n=52,012); and (3) the National Study on the Costs and Outcomes of Trauma (n=1286). INTERVENTIONS: None. MAIN OUTCOME MEASURE: Discharge disposition from acute hospitalization to 1 of 3 postacute settings: (1) home, (2) inpatient rehabilitation, or (3) subacute settings, including nursing homes and similar facilities. RESULTS: The Glasgow Coma Scale (GCS) score and length of acute hospital length of stay (LOS) accounted for 35% to 44% of the variance in discharges to home versus not home, while age and sex added from 5% to 8%, and race/ethnicity and hospitalization payment source added another 2% to 5%. When predicting discharge to rehabilitation versus subacute care for those not going home, GCS and LOS accounted for 2% to 4% of the variance, while age and sex added 7% to 31%, and race/ethnicity and payment source added 4% to 5%. Across the datasets, longer LOS, older age, and white race increased the likelihood of not being discharged home; the most consistent predictor of discharge to rehabilitation was younger age. CONCLUSIONS: The decision to discharge to home a person with moderate to severe TBI appears to be based primarily on severity-related factors. In contrast, the decision to discharge to rehabilitation rather than to subacute care appears to reflect sociobiologic and socioeconomic factors; however, generalizability of these results is limited by the restricted range of potentially important variables available for analysis.

Mechanical ventilation, health, and quality of life following spinal cord injury.

OBJECTIVE: To examine differences in perceived quality of life (QOL) at 1 year postinjury between people with tetraplegia who required mechanical ventilation assistance at discharge from rehabilitation and those who did not. DESIGN: Prospective cross-sectional examination of people with spinal cord injury (SCI) drawn from the SCI Model Systems National Database. SETTING: Community. PARTICIPANTS: People with tetraplegia (N=1635) who sustained traumatic SCI between January 1, 1994, and September 30, 2008, who completed a 1-year follow-up interview, including 79 people who required at least some use of a ventilator at discharge from rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Satisfaction With Life Scale (SWLS); Craig Handicap Assessment and Reporting Technique (CHART)-Short Form Physical Independence, Mobility, Social Integration, and Occupation subscales; Patient Health Questionnaire-9 (PHQ-9), Medical Outcomes Study 36-Item Short-Form Health Survey self-perceived health status. RESULTS: Significant differences were found between the ventilator-user (VU) group and non-ventilator-user (NVU) group for cause of trauma, proportion with complete injury, neurologic impairment level, and number of rehospitalizations. The NVU group had significantly higher SWLS and CHART Social Integration scores than the VU group after controlling for selected covariates. The NVU group also had more positive perceived health status compared with a year previously and a lower incidence of depression assessed by using the PHQ-9 than the VU group. There were no significant differences between groups for perceived current health status. CONCLUSIONS: People in this study who did not require mechanical ventilation at discharge from rehabilitation post-SCI reported generally better health and improved QOL compared with those who required ventilator assistance at 1 year postinjury. Nonetheless, the literature suggests that perceptions of QOL improve as people live in the community for longer periods.

Life Expectancy after Inpatient Rehabilitation for Traumatic Brain Injury in the United States.

This study characterized life expectancy after traumatic brain injury (TBI). The TBI Model Systems (TBIMS) National Database (NDB) was weighted to represent those ≥16 years of age completing inpatient rehabilitation for TBI in the United States (US) between 2001 and 2010. Analyses included Standardized Mortality Ratios (SMRs), Cox regression, and life expectancy. The US mortality rates by age, sex, race, and cause of death for 2005 and 2010 were used for comparison purposes. Results indicated that a total of 1325 deaths occurred in the weighted cohort of 6913 individuals. Individuals with TBI were 2.23 times more likely to die than individuals of comparable age, sex, and race in the general population, with a reduced average life expectancy of 9 years. Independent risk factors for death were: older age, male gender, less-than-high school education, previously married at injury, not employed at injury, more recent year of injury, fall-related TBI, not discharged home after rehabilitation, less functional independence, and greater disability. Individuals with TBI were at greatest risk of death from seizures; accidental poisonings; sepsis; aspiration pneumonia; respiratory, mental/behavioral, or nervous system conditions; and other external causes of injury and poisoning, compared with individuals in the general population of similar age, gender, and race. This study confirms prior life expectancy study findings, and provides evidence that the TBIMS NDB is representative of the larger population of adults receiving inpatient rehabilitation for TBI in the US. There is an increased risk of death for individuals with TBI requiring inpatient rehabilitation.

Components of traumatic brain injury severity indices.

The purpose of this study was to determine whether there are underlying dimensions common among traditional traumatic brain injury (TBI) severity indices and, if so, the extent to which they are interchangeable when predicting short-term outcomes. This study had an observational design, and took place in United States trauma centers reporting to the National Trauma Data Bank (NTDB). The sample consisted of 77,470 unweighted adult cases reported to the NTDB from 2007 to 2010, with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) TBI codes. There were no interventions. Severity indices used were the Emergency Department Glasgow Coma Scale (GCS) Total score and each of the subscales for eye opening (four levels), verbal response (five levels), and motor response (six levels); the worst Abbreviated Injury Scale (AIS) severity score for the head (six levels); and the worst Barell index type (three categories). Prediction models were computed for acute care length of stay (days), intensive care unit length of stay (days), hospital discharge status (alive or dead), and, if alive, discharge disposition (home versus institutional). Multiple correspondence analysis (MCA) indicated a two dimensional relationship among items of severity indexes. The primary dimension reflected overall injury severity. The second dimension seemed to capture volitional behavior without the capability for cogent responding. Together, they defined two vectors around which most of the items clustered. A scale that took advantage of the order of items along these vectors proved to be the most consistent index for predicting short-term health outcomes. MCA provided useful insight into the relationships among components of traditional TBI severity indices. The two vector pattern may reflect the impact of injury on different cortical and subcortical networks. Results are discussed in terms of score substitution and the ability to impute missing values.

Traumatic brain injury among older adults at level I and II trauma centers.

Individuals 65 years of age and over have the highest rates of traumatic brain injury (TBI)-related hospitalizations and deaths, and older adults (defined variably across studies) have particularly poor outcomes after TBI. The factors predicting these outcomes remain poorly understood, and age-specific care guidelines for TBI do not exist. This study provides an overview of TBI in older adults using data from the National Trauma Data Bank (NTDB) gathered between 2007 and 2010, evaluates age group-specific trends in rates of TBI over time using U.S. Census data, and examines whether routinely collected information is able to predict hospital discharge status among older adults with TBI in the NTDB. Results showed a 20-25% increase in trauma center admissions for TBI among the oldest age groups (those >=75 years), relative to the general population, between 2007 and 2010. Older adults (>=65 years) with TBI tended to be white females who have incurred an injury from a fall resulting in a "severe" Abbreviated Injury Scale (AIS) score of the head. Older adults had more in-hospital procedures, such as neuroimaging and neurosurgery, tended to experience longer hospital stays, and were more likely to require continued medical care than younger adults. Older age, injury severity, and hypotension increased the odds of in-hospital death. The public health burden of TBI among older adults will likely increase as the Baby Boom generation ages. Improved primary and secondary prevention of TBI in this cohort is needed.