Impact of posttraumatic stress disorder and depressive symptoms on quality of life in adolescents after general traumatic injury.

Posttraumatic stress disorder (PTSD) and depressive symptoms have been associated with poorer health-related quality of life in adolescents after general traumatic injuries; few studies have examined the broader construct of postinjury quality of life (QOL). We evaluated the impact of traumatic injury on adolescent QOL and examined factors that potentially contribute to poorer outcomes, using the Youth Quality of Life Instrument-Research Version as the outcome measure. Data were collected within 30 days postinjury and 2, 5, and 12 months postinjury. Mixed-model regression (MMR) was used for the main analyses. Participants (N = 204) were drawn from a prospective cohort study of 12-18-year-olds admitted to a Level 1 trauma center (n = 108) and healthy participants from a local cross-sectional study (n = 116); study group participants were significantly older. The initial MMR indicated that female adolescents had significantly lower QOL, B = -2.69, 95% CI [-4.68, -0.70], and were more likely to score above the cutoffs for PTSD (19.1% vs. 2.0%), χ2 (1, N = 381) = 34.6, p < .001, or depression (32.8% vs. 14.0%), χ2 (1, N = 381) = 18.7, p < .001, on post hoc analyses. Adolescents with mental health conditions in the year postinjury had significant QOL deficits without predicted improvements toward baseline, PTSD: B = -10.05, 95% CI [-15.29, -4.81]; depression: B = -18.00, 95% CI [-21.69, -14.31]. These findings highlight the importance of ongoing mental health monitoring and care for adolescents, particularly female adolescents, following traumatic injury even when physical recovery appears complete.

A Prospective US National Trauma Center Study of Firearm Injury Survivors Weapon Carriage and Posttraumatic Stress Disorder Symptoms.

OBJECTIVE: To describe the demographic, injury-related, and mental health characteristics of firearm injury patients and trace firearm weapon carriage and PTSD symptoms over the year after injury. SUMMARY AND BACKGROUND DATA: Based on the increasing incidence of firearm injury and need for novel injury prevention strategies, hospital-based violence intervention programs are being implemented in US trauma centers. There is limited data on the long-term outcomes and risk behaviors of firearm injury survivors to guide this work. METHODS: We conducted a secondary analysis of a pragmatic 25-trauma center randomized trial (N = 635). Baseline characteristics of firearm-injured patients (N = 128) were compared with other trauma patients. Mixed model regression was used to identify risk factors for postinjury firearm weapon carriage and PTSD symptoms. RESULTS: Firearm injury patients were younger and more likely to be black, male and of lower socioeconomic status, and more likely to carry a firearm in the year before injury. Relative to preinjury, there was a significant drop in firearm weapon carriage at 3- and 6-months postinjury, followed by a return to preinjury levels at 12-months. Firearm injury was significantly and independently associated with an increased risk of postinjury firearm weapon carriage [relative risk = 2.08, 95% confidence interval (1.34, 3.22), P < 0.01] and higher PTSD symptom levels [Beta = 3.82, 95% confidence interval (1.29, 6.35), P < 0.01]. CONCLUSIONS: Firearm injury survivors are at risk for firearm carriage and high PTSD symptom levels postinjury. The significant decrease in the high-risk behavior of firearm weapon carriage at 3-6 months postinjury suggests that there is an important postinjury "teachable moment" that should be targeted with preventive interventions. TRIAL REGISTRATION: ClinicalTrials.gov NCT02655354.

Parent Traumatic Events and Adolescent Internalizing Symptoms: The Mediating Role of Parental Depression Among Youth with Persistent Post-concussive Symptoms.

OBJECTIVE: Research has demonstrated associations between parental depression (PD) and negative psychological outcomes among their children. However, little is known about the pathways through which lifetime parent traumatic events (PTEs) influence their adolescents' internalizing symptoms. Our study examined whether PD mediates the association between PTE and adolescent depressive and anxious symptoms among youth with persistent postconcussive symptoms (PPCS). METHODS: We used baseline data from a randomized effectiveness trial of collaborative care for treatment of persistent postconcussive symptoms among sports-injured adolescents aged 11-18 years. Parent-adolescent dyads were recruited from pediatric clinics throughout western Washington. Eligible adolescents had three or more PPCS that lasted for at least 1 month but <9 months and spoke English. Of 1,870 potentially eligible adolescents, 1,480 (79%) were excluded for not meeting the inclusion criteria. Of the eligible 390 adolescents, 189 (49%) declined to participate/consent. Participants included 200 parent-adolescent dyads (adolescent Mage = 14.7 years, SD = 1.7). Parent respondents were mostly female (83%) and mothers (81%). Adolescents reported on their depressive (Patient Health Questionnaire-9; PHQ-9) and anxious symptoms (Revised Child Anxiety and Depression Scale-Short Version [anxiety subscale]) and parents reported on their depressive symptoms (M = 3.7, SD = 3.7; PHQ-9). RESULTS: Mediation analyses revealed two (out of four) significant indirect effects of PTE on both adolescent and parent report of depressive symptoms, but not anxiety. CONCLUSIONS: This study elucidates one pathway (PD) through which PTE history influences adolescent depressive symptoms, supporting a two-generation approach to pediatric patient care for youth experiencing PPCS.

Child- compared with parent-report ratings on psychosocial measures following a mild traumatic brain injury among youth with persistent post-concussion symptoms.

Primary Objective: To compare child- and parent-report ratings on the Health Behavior Inventory, Revised Child Anxiety and Depression Scale-Short Version (anxiety subscale), Patient Health Questionnaire-9, and Pediatric Quality of Life InventoryTM among children with persistent post-concussive symptoms following a sports- or recreation-related concussion, overall and by child age and gender.Research Design: Cross-sectional study examining baseline data from a randomized, comparative effectiveness trial.Methods and Procedures: Inter-rater reliability was assessed using two-way random effects model (absolute agreement) intraclass correlations, correlations were examined using Spearman's rho, mean differences were determined using paired t-tests, and agreement was examined using Bland-Altman plots.Main Outcomes and Results: The final analytic sample was 200 parent-child dyads [child Mage = 14.7 (95% CI: 14.5, 15.0)]. Reliability and correlations were modest overall. When considering child age and gender, reliability ranged from poor to excellent (-1.01-0.95) and correlations ranged from weak to strong (-0.64-0.94). Overall, children reported more symptoms but better functioning than parents, and mean differences in scores were greater among females (versus males) and ages 16-18 (versus younger groups).Conclusions: Findings should inform the use and interpretation of psychosocial measures when developing appropriate youth concussion treatment plans.

Prevalence and risk factors for depression, anxiety and suicidal ideation in youth with persistent post-concussive symptoms (PPCS).

Objectives: To assess the prevalence and risk factors for emotional distress in youth with persistent post-concussive symptoms (PPCS) greater than one month.Methods: We used baseline data from an intervention study for youth with PPCS, utilizing Poisson regression to examine factors associated with exceeding clinical cut-points on measures of depression, anxiety, self-harm and suicidal ideation. Predictors included: age, sex, socioeconomic status, mental health history, duration of concussion symptoms, history of prior concussion, trauma history and sleep quality.Results: The sample included 200 youth with PPCS, (mean 14.7 SD 1.7 years, 82% white, 62% female). Forty percent reported clinically significant depressive symptoms, 25% anxiety, 14% thoughts of self-harm and 8% thoughts of suicide. History of depression was associated with 3-fold higher risk for thoughts of self-harm (95% CI:1.82-6.99) and 6-fold higher risk for suicidal ideation (95% CI:1.74-24.46). Better sleep quality was associated with lower risk for all outcomes. History of prior concussion and duration of PPCS were not significantly associated with any outcomes.Conclusions: Suicidal thoughts are common post-concussion, and history of depression is a strong risk factor. Tailored interventions may be needed to address mental health in this population.

Traumatic Brain Injury and the Risk for Subsequent Crime Perpetration.

OBJECTIVE: To examine whether patients with traumatic brain injury (TBI) are at higher risk for subsequent crime perpetration compared with injured patients without TBI and those hospitalized for reasons other than injury. SETTING AND PARTICIPANTS: Patients hospitalized in Washington State from 2006-2007. DESIGN: A retrospective cohort study using linked statewide datasets. MAIN MEASURES: Primary outcomes were arrest for any violent or nonviolent crime within 5 years of discharge. Adjusted subhazard ratios were calculated using regression models incorporating death as a competing risk. RESULTS: Compared with uninjured patients (n = 158 247), the adjusted rate of arrest for any crime was greater among injured patients with TBI (n = 6894; subdistribution hazard ratios [sHR], 1.57; 95% confidence interval [CI], 1.49-1.62) and without TBI (n = 40 035; sHR, 1.55; 95% CI, 1.49-1.62). When patients with TBI were directly compared with injured patients without TBI, no effect of TBI on subsequent arrests was found (sHR, 1.02; 95% CI, 0.94-1.11). TBI did not increase the likelihood of either violent or nonviolent crime when these outcomes were examined separately. CONCLUSIONS: TBI survivors do not appear to be at increased risk for criminality compared with injured individuals without TBI. However, injured persons with or without TBI may be at elevated risk of crime perpetration compared with those who are uninjured.

Task-shifting to improve the reach of mental health interventions for trauma patients: findings from a pilot study of trauma nurse training in patient-centered activity scheduling for PTSD and depression.

Despite high rates of posttraumatic stress disorder (PTSD) and depression among traumatically injured patients, engagement in session-based psychotherapy early after trauma is limited due to various service utilization and readiness barriers. Task-shifting brief mental health interventions to routine trauma center providers is an understudied but potentially critical part of the continuum of care. This pilot study assessed the feasibility of training trauma nurses to engage patients in patient-centered activity scheduling based on a Behavioral Activation paradigm, which is designed to counteract dysfunctional avoidance/withdrawal behavior common among patients after injury. Nurses (N = 4) and patients (N = 40) were recruited from two level II trauma centers. A portion of a one day in-person workshop included didactics, demonstrations, and experiential activities to teach brief intervention delivery. Nurses completed pre- and posttraining standardized patient role-plays prior to and two months after training, which were coded for adherence to the intervention. Nurses also completed exit interviews to assess their perspectives on the training and addressing patient mental health concerns. Findings support the feasibility of training trauma nurses in a brief mental health intervention. Task-shifting brief interventions holds promise for reaching more of the population in need of posttrauma mental health care.

Timely Hemodynamic Resuscitation and Outcomes in Severe Pediatric Traumatic Brain Injury: Preliminary Findings.

OBJECTIVES: Early resuscitation may improve outcomes in pediatric traumatic brain injury (TBI). We examined the association between timely treatment of hypotension and hypoxia during early care (prehospital or emergency department locations) and discharge outcomes in children with severe TBI. METHODS: Hypotension was defined as systolic blood pressure less than 70 + 2 (age in years), and hypoxia was defined as PaO2 less than 60 mm Hg or oxygen saturation less than 90% in accordance with the 2003 Brain Trauma Foundation guidelines. Timely treatment of hypotension and hypoxia during early care was defined as the treatment within 30 minutes of a documented respective episode. Two hundred thirty-six medical records of children younger than 18 years with severe TBI from 5 regional pediatric trauma centers were examined. Main outcomes were in-hospital mortality and discharge Glasgow Outcome Scale (GOS) score. RESULTS: Hypotension occurred in 26% (60/234) during early care and was associated with in-hospital mortality (23.3% vs 8.6%; P = 0.01). Timely treatment of hypotension during early care occurred in 92% (55/60) by use of intravenous fluids, blood products, or vasopressors and was associated with reduced in-hospital mortality [adjusted relative risk (aRR), 0.46; 95% confidence interval, 0.24-0.90] and less likelihood of poor discharge GOS (aRR, 0.54; 95% confidence interval, 0.39-0.76) when compared to children with hypotension who were not treated in a timely manner. Early hypoxia occurred in 17% (41/236) and all patients received timely oxygen treatment. CONCLUSIONS: Timely resuscitation during early care was common and associated with lower in-hospital mortality and favorable discharge GOS in severe pediatric TBI.

Frequency of and factors associated with emergency department intracranial pressure monitor placement in severe paediatric traumatic brain injury.

OBJECTIVE: To examine the frequency of and factors associated with emergency department (ED) intracranial pressure (ICP) monitor placement in severe paediatric traumatic brain injury (TBI). METHODS: Retrospective, multicentre cohort study of children <18 years admitted to the ED with severe TBI and intubated for >48 hours from 2007 to 2011. RESULTS: Two hundred and twenty-four children had severe TBI and 75% underwent either ED, operating room (OR) or paediatric intensive care unit (PICU) ICP monitor placement. Four out of five centres placed ICP monitors in the ED, mostly (83%) fibreoptic. Nearly 40% of the patients who received ICP monitors get it placed in the ED (29% overall). Factors associated with ED ICP monitor placement were as follows: age 13 to <18 year olds compared to infants (aRR 2.02; 95% CI 1.37, 2.98), longer ED length of stay (LOS) (aRR 1.15; 95% CI 1.08, 1.21), trauma centre designation paediatric only I/II compared to adult/paediatric I/II (aRR 1.71; 95% CI 1.48, 1.98) and higher mean paediatric TBI patient volume (aRR 1.88;95% CI 1.68, 2.11). Adjusted for centre, higher bedside ED staff was associated with longer ED LOS (aRR 2.10; 95% CI 1.06, 4.14). CONCLUSION: ICP monitors are frequently placed in the ED at paediatric trauma centres caring for children with severe TBI. Both patient and organizational level factors are associated with ED ICP monitor placement.

Guideline Adherence and Hospital Costs in Pediatric Severe Traumatic Brain Injury.

OBJECTIVES: Adherence to pediatric traumatic brain injury guidelines has been associated with improved survival and better functional outcome. However, the relationship between guideline adherence and hospitalization costs has not been examined. To evaluate the relationship between adherence to pediatric severe traumatic brain injury guidelines, measured by acute care clinical indicators, and the total costs of hospitalization associated with severe traumatic brain injury. DESIGN: Retrospective cohort study. SETTING: Five regional pediatric trauma centers affiliated with academic medical centers. PATIENTS: Demographic, injury, treatment, and charge data were included for pediatric patients (17 yr) with severe traumatic brain injury. INTERVENTIONS: Percent adherence to clinical indicators was determined for each patient. Cost-to-charge ratios were used to estimate ICU and total hospital costs for each patient. Generalized linear models evaluated the association between healthcare costs and adherence rate. MEASUREMENTS AND MAIN RESULTS: Cost data for 235 patients were examined. Estimated mean adjusted hospital costs were $103,485 (95% CI, 98,553-108,416); adjusted ICU costs were $82,071 (95% CI, 78,559-85,582). No association was found between adherence to guidelines and total hospital or ICU costs, after adjusting for patient and injury characteristics. Adjusted regression model results provided cost ratio equal to 1.01 for hospital and ICU costs (95% CI, 0.99-1.03 and 0.99-1.02, respectively). CONCLUSIONS: Adherence to severe pediatric traumatic brain injury guidelines at these five leading pediatric trauma centers was not associated with increased hospitalization and ICU costs. Therefore, cost should not be a factor as institutions and providers strive to provide evidence-based guideline driven care of children with severe traumatic brain injury.

Acute care clinical indicators associated with discharge outcomes in children with severe traumatic brain injury.

OBJECTIVE: The effect of the 2003 severe pediatric traumatic brain injury (TBI) guidelines on outcomes has not been examined. We aimed to develop a set of acute care guideline-influenced clinical indicators of adherence and tested the relationship between these indicators during the first 72 hours after hospital admission and discharge outcomes. DESIGN: Retrospective multicenter cohort study. SETTING: Five regional pediatric trauma centers affiliated with academic medical centers. PATIENTS: Children under 18 years with severe traumatic brain injury (admission Glasgow Coma Scale score ≤ 8, International Classification of Diseases, 9th Edition, diagnosis codes of 800.0-801.9, 803.0-804.9, 850.0-854.1, 959.01, 950.1-950.3, 995.55, maximum head abbreviated Injury Severity Score ≥ 3) who received tracheal intubation for at least 48 hours in the ICU between 2007 and 2011 were examined. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Total percent adherence to the clinical indicators across all treatment locations (prehospital, emergency department, operating room, and ICU) during the first 72 hours after admission to study center were determined. Main outcomes were discharge survival and Glasgow Outcome Scale score. Total adherence rate across all locations and all centers ranged from 68% to 78%. Clinical indicators of adherence were associated with survival (adjusted hazard ratios, 0.94; 95% CI, 0.91-0.96). Three indicators were associated with survival: absence of prehospital hypoxia (adjusted hazard ratios, 0.20; 95% CI, 0.08-0.46), early ICU start of nutrition (adjusted hazard ratios, 0.06; 95% CI, 0.01-0.26), and ICU PaCO2 more than 30 mm Hg in the absence of radiographic or clinical signs of cerebral herniation (adjusted hazard ratios, 0.22; 95% CI, 0.06-0.8). Clinical indicators of adherence were associated with favorable Glasgow Outcome Scale among survivors (adjusted hazard ratios, 0.99; 95% CI, 0.98-0.99). Three indicators were associated with favorable discharge Glasgow Outcome Scale: all operating room cerebral perfusion pressure more than 40 mm Hg (adjusted relative risk, 0.61; 95% CI, 0.58-0.64), all ICU cerebral perfusion pressure more than 40 mm Hg (adjusted relative risk, 0.73; 95% CI, 0.63-0.84), and no surgery (any type; adjusted relative risk, 0.68; 95% CI, 0.53- 0.86). CONCLUSIONS: Acute care clinical indicators of adherence to the Pediatric Guidelines were associated with significantly higher discharge survival and improved discharge Glasgow Outcome Scale. Some indicators were protective, regardless of treatment location, suggesting the need for an interdisciplinary approach to the care of children with severe traumatic brain injury.

Engaging and following physical injury survivors at risk for developing posttraumatic stress disorder symptoms: A 25 site US national study.

INTRODUCTION: Early intervention for patients at risk for Posttraumatic Stress Disorder (PTSD) relies upon the ability to engage and follow trauma-exposed patients. Recent requirements by the American College of Surgeons Committee on Trauma (College) have mandated screening and referral for patients with high levels of risk for the development of PTSD or depression. Investigations that assess factors associated with engaging and following physically injured patients may be essential in assessing outcomes related to screening, intervention, and referral. METHODS: This investigation was a secondary analysis of data collected as part of a United States level I trauma center site randomized clinical trial. All 635 patients were ages ≥18 and had high PTSD symptom levels (i.e., DSM-IV PTSD Checklist score ≥35) at the time of the baseline trauma center admission. Baseline technology use, demographic, and injury characteristics were collected for patients who were followed up with over the course of the year after physical injury. Regression analyses were used to assess the associations between technology use, demographic and injury characteristics, and the attainment of follow-up outcome assessments. RESULTS: Thirty-one percent of participants were missing one or more 3-, 6- or 12-month follow-up outcome assessments. Increased risk of missing one or more outcome assessments was associated with younger age (18-30 versus ≥55 Relative Risks [RR] = 1.78, 95 % Confidence Interval [CI] = 1.09, 2.91), lack of cell phone (RR = 1.32, 95 % CI = 1.01, 1.72), no internet access (RR = 1.47, 95 % CI = 1.01, 2.16), public versus private insurance (RR = 1.47, 95 % CI = 1.12, 1.92), having no chronic medical comorbidities (≥4 versus none, RR = 0.28, 95 % CI = 0.20, 0.39), and worse pre-injury mental health function (RR = 0.99, 95 % CI = 0.98, 0.99). CONCLUSIONS: This multisite investigation suggests that younger and publicly insured and/or uninsured patients with barriers to cell phone and internet access may be particularly vulnerable to lapses in trauma center follow-up. Clinical research informing trauma center-based screening, intervention, and referral procedures could productively explore strategies for patients at risk for not engaging and adhering to follow-up care and outcome assessments.

Can stepped collaborative care interventions improve post-traumatic stress disorder symptoms for racial and ethnic minority injury survivors?

Objectives: No large-scale randomized clinical trial investigations have evaluated the potential differential effectiveness of early interventions for post-traumatic stress disorder (PTSD) among injured patients from racial and ethnic minority backgrounds. The current investigation assessed whether a stepped collaborative care intervention trial conducted at 25 level I trauma centers differentially improved PTSD symptoms for racial and ethnic minority injury survivors. Methods: The investigation was a secondary analysis of a stepped wedge cluster randomized clinical trial. Patients endorsing high levels of distress on the PTSD Checklist (PCL-C) were randomized to enhanced usual care control or intervention conditions. Three hundred and fifty patients of the 635 randomized (55%) were from non-white and/or Hispanic backgrounds. The intervention included care management, cognitive behavioral therapy elements and, psychopharmacology addressing PTSD symptoms. The primary study outcome was PTSD symptoms assessed with the PCL-C at 3, 6, and 12 months postinjury. Mixed model regression analyses compared treatment effects for intervention and control group patients from non-white/Hispanic versus white/non-Hispanic backgrounds. Results: The investigation attained between 75% and 80% 3-month to 12-month follow-up. The intervention, on average, required 122 min (SD=132 min). Mixed model regression analyses revealed significant changes in PCL-C scores for non-white/Hispanic intervention patients at 6 months (adjusted difference -3.72 (95% CI -7.33 to -0.10) Effect Size =0.25, p<0.05) after the injury event. No significant differences were observed for white/non-Hispanic patients at the 6-month time point (adjusted difference -1.29 (95% CI -4.89 to 2.31) ES=0.10, p=ns). Conclusion: In this secondary analysis, a brief stepped collaborative care intervention was associated with greater 6-month reductions in PTSD symptoms for non-white/Hispanic patients when compared with white/non-Hispanic patients. If replicated, these findings could serve to inform future American College of Surgeon Committee on Trauma requirements for screening, intervention, and referral for PTSD and comorbidities. Level of evidence: Level II, secondary analysis of randomized clinical trial data reporting a significant difference. Trial registration number: NCT02655354.

The effect of perceived person-job fit on employee attitudes toward change in trauma centers.

BACKGROUND: Employee attitudes toward change are critical for health care organizations implementing new procedures and practices. When employees are more positive about the change, they are likely to behave in ways that support the change, whereas when employees are negative about the change, they will resist the changes. PURPOSE: This study examined how perceived person-job (demands-abilities) fit influences attitudes toward change after an externally mandated change. Specifically, we propose that perceived person-job fit moderates the negative relationship between individual job impact and attitudes toward change. METHODOLOGY: We examined this issue in a sample of Level 1 trauma centers facing a regulatory mandate to develop an alcohol screening and brief intervention program. A survey of 200 providers within 20 trauma centers assessed perceived person-job fit, individual job impact, and attitudes toward change approximately 1 year after the mandate was enacted. RESULTS: Providers who perceived a better fit between their abilities and the new job demands were more positive about the change. Further, the impact of the alcohol screening and brief intervention program on attitudes toward change was mitigated by perceived fit, where the relationship between job impact and change attitudes was more negative for providers who perceived a worse fit as compared with those who perceived a better fit. PRACTICAL IMPLICATIONS: Successful implementation of changes to work processes and procedures requires provider support of the change. Management can enhance this support by improving perceived person-job fit through ongoing training sessions that enhance providers' abilities to implement the new procedures.

Exploring Collaborative Care Effects on the Mental and Physical Health of Patients With and Without Violent Victimization Histories.

Collaborative care is a multicomponent intervention delivered by frontline social work, nursing, and physician providers to address patients' physical, emotional, and social needs. We argued that collaborative care may particularly benefit patients with a violent victimization history because it practices three principles of trauma-informed care: patient-provider collaboration, preventing repeat trauma in clinical and community settings, and delivering comprehensive mental and physical healthcare. We conducted an exploratory secondary data analysis of a collaborative care randomized clinical trial involving patients who presented with traumatic physical injury at a Level I trauma center in Washington state between 2006 and 2009. We used random-effect linear regression models to estimate how histories of multiple violent traumas moderated the effects of the collaborative care intervention on Short Form-36 Mental Component Summary (MCS) and Physical Component Summary (PCS) T-scores over time. Collaborative care significantly improved follow-up MCS scores among patients who experienced three to four types of violent victimization in their lifetime. Additionally, intervention effects on MCS scores at the 3- and 6-month follow-up were clinically stronger for patients who reported three to four types of violent victimization (3-month = 7.5, 95% confidence level [CI] = 5.1 to 18.7; 6-month = 11.9, 95% CI = 5.1 to 18.7) than those without a history of violent victimization (3-month = 0.8, 95% CI = -5.1, 6.6; 6-month = 5.6, -2.4 to 13.5). We did not find that intervention effects on PCS scores differed between these groups at any wave. Collaborative care may be a promising approach to delivering trauma-informed mental healthcare to patients with histories of multiple types of violent victimization.

Evaluation of a Health Information Exchange for Linkage to Mental Health Care After an Emergency Department Visit.

Aligning with Washington State's goal of reducing unnecessary emergency department (ED) use and improving linkage to outpatient primary and behavioral health care, this study evaluated whether an Emergency Department Information Exchange (EDIE) improved linkage to care for Medicaid enrollees with mental health conditions. Follow-up with any physician at 30 days increased slightly, although mental health-specific follow-up declined over time. Difference-in-differences estimates revealed no effect of EDIE on linkage to care after an ED visit. Medicaid beneficiaries with mental health needs and high utilization of the ED likely require additional support to increase timely and appropriate follow-up care.

Psychometric Properties and Validation of the General Anxiety Disorder 7-Item Scale Among Adolescents With Persistent Post-Concussive Symptoms.

The General Anxiety Disorder 7-Item (GAD-7) scale is commonly used in primary care as a self-report measure of general anxiety symptoms with adult populations. There is little psychometric research on this measure with adolescent populations, particularly those with persistent post-concussive symptoms (PPCS). This study examined the psychometrics properties of the GAD-7 among youth with PPCS. We used baseline data from a randomized controlled trial of collaborative care for treatment of PPCS among 200 sports-injured adolescents 11-18 years of age (Mage = 14.7 years, standard deviation = 1.7). Eligible adolescents had three or more PPCS that lasted for ≥1 month and spoke English. Adolescents reported on their anxious (GAD-7 and Revised Child Anxiety and Depression Scale-Short Version [anxiety subscale]; RCADS) and depressive (Patient Health Questionnaire-9; PHQ-9) symptoms. Parents used the RCADS to report on their adolescents' anxious symptoms. The GAD-7 had good internal validity (Cronbach's alpha = 0.87), and significant (p < 0.001) correlations were detected between the GAD-7 and youth and parent report of anxiety on RCADS (r = 0.73 and r = 0.29) and PHQ-9 (r = 0.77) scores. Confirmatory factor analysis suggested a one-factor solution. These results suggest that the GAD-7 is a valid measure of anxiety with good psychometric properties for youth experiencing PPCS. ClinicalTrials.gov identifier: NCT03034720.

Association between posttraumatic stress, depression, and functional impairments in adolescents 24 months after traumatic brain injury.

The degree to which postinjury posttraumatic stress disorder (PTSD) and/or depressive symptoms in adolescents are associated with cognitive and functional impairments at 12 and 24 months after traumatic brain injury (TBI) is not yet known. The current study used a prospective cohort design, with baseline assessment and 3-, 12-, and 24-month followup, and recruited a cohort of 228 adolescents ages 14-17 years who sustained either a TBI (n = 189) or an isolated arm injury (n = 39). Linear mixed-effects regression was used to assess differences in depressive and PTSD symptoms between TBI and arm-injured patients and to assess the association between 3-month PTSD and depressive symptoms and cognitive and functional outcomes. Results indicated that patients who sustained a mild TBI without intracranial hemorrhage reported significantly worse PTSD (Hedges g = 0.49, p = .01; Model R(2) = .38) symptoms across time as compared to the arm injured control group. Greater levels of PTSD symptoms were associated with poorer school (η(2) = .07, p = .03; Model R(2) = .36) and physical (η(2) = .11, p = .01; Model R(2) = .23) functioning, whereas greater depressive symptoms were associated with poorer school (η(2) = .06, p = .05; Model R(2) = .39) functioning.

Impact of a statewide Emergency Department Information Exchange on health care use and expenditures.

OBJECTIVE: To assess the effects of a program mandating the statewide adoption of an Emergency Department Information Exchange (EDIE) on health care utilization and spending among Medicaid enrollees in Washington state. DATA SOURCE: Medicaid claims and managed care encounters from the Washington Health Care Authority. STUDY DESIGN: A difference-in-differences analysis with trends was used to compare changes in ED visits, inpatient admissions, primary care visits, and expenditures among frequent ED users (≥5 ED visits in past year) to those of infrequent users through the second year Washington's program. DATA EXTRACTION: The study population included adult Medicaid enrollees with ED visits between January 2010 and October 2014. PRINCIPAL FINDINGS: There were 505,667 ED visits among 153,543 unique enrollees included in the analysis. Washington's program was associated with a small, but statistically significant differential change of -0.70 ED visits per enrollee per year (95% CI: -1.24, -0.16) in the first year after EDIE was mandated, or 8.2% of the baseline ED visit rate among frequent users. However, by the second year of implementation, these effects on ED use were no longer significant, nor were there any measurable effects on inpatient admissions, primary care use, or expenditures in any period. CONCLUSIONS: Statewide implementation of EDIE was associated with a small reduction in ED use among frequent users in the first year of the program but did not change overall spending or other utilization outcomes.