Menopause, anti-Müllerian hormone and cognition in a cohort of women with persistent symptoms following TBI: a case for future research.

Objectives: Primary: To explore anti-Müllerian Hormone (AMH) levels in community dwelling women following TBI. Secondary: To explore the relation of AMH to menstrual cycle, cognition, distress and symptoms of menopause.Setting: Large adult TBI outpatient clinic in Toronto Canada.Research design: Prospective study of 10 women with persistent symptoms who were one or more years post TBI.Methods: Consenting participants provided a serum sample for AMH levels, and completed the Menopause Rating Scale (MRS), Symptom Checklist-90 r (SCL-90 r), Repeatable Battery for the Assessment of Neurological Status (RBANS) and a health questionnaire.Main outcomes and results: This study found lower than expected levels of AMH in 50% of participants relative to age matched norms and 50% of participants experienced new onset of menstrual changes. Also notable were findings of lower-than-expected cognitive scores in women over 35 and reports of menopause-related symptoms across all ages groups.Conclusions: As our understanding of the role of AMH grows, examining changes in this novel biomarker in the long-term post-TBI is warranted. Future research should be sufficiently powered to expand on and validate the study's findings.

Determinants of Discharge Disposition From Acute Care for Survivors of Hypoxic-Ischemic Brain Injury: Results From a Large Population-Based Cohort Data Set.

OBJECTIVE: To identify determinants of discharge disposition from acute care among survivors of hypoxic-ischemic brain injury (HIBI), stratified by sex. DESIGN: Population-based retrospective cohort study using provincial data in Ontario, Canada. The determinants were grouped into predisposing, need, and enabling factors using the Anderson Behavioral Model. SETTING: Acute care. PARTICIPANTS: Survivors of HIBI aged ≥20 years at the time of hospitalization and discharged alive from acute care between April 1, 2002, and March 31, 2017. There were 7492 patients with HIBI, of whom 28% (N=2077) survived their acute care episode. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Discharge disposition from acute care, categorized as complex continuing care (CCC), long-term care (LTC), inpatient rehabilitation (IR), home with support, home without support, and transferred to another acute care. RESULTS: The discharge dispositions for the 2077 survivors were IR 23.4% (n=487), CCC 19.5% (n=404), LTC 6.2% (n=128), home without support 31.2% (n=647), home with support 15.1% (n=314), and other 4.6%. Multinomial multivariable logistic regression analysis using home without support as the reference category revealed that female patients were significantly more likely than male patients to be discharged to LTC/CCC. Those who were older, were frail, and had longer stay in acute care or special care unit (SCU) were more likely to be discharged to LTC/CCC. The only significant determinant for IR was longer stay in acute care. Survivors with cardiac-related injury were less likely to be discharged to LTC/CCC. Income was a significant factor for male patients but not for female patients in the sex-stratified analysis. The following variables were investigated but were not significant determinants in this study: need factors (comorbidity score, prior psychiatric disorders, health care utilization) and enabling factors (income quintile, rural area of residence). CONCLUSIONS: Predisposing (age, sex) and need factors (frailty, acute care days, SCU days, type of injury) were significant determinants of discharge disposition from acute care after HIBI. In spite of a system with universal coverage, sex differences were found, with more female patients being discharged to CCC/LTC rather than IR, controlling for age and other confounders. These findings should be considered in appropriate discharge planning from acute care for survivors of HIBI.

Assault by strangulation: sex differences in patient profile and subsequent readmissions.

OBJECTIVES: Assault by strangulation has the potential for severe brain injury or death. The objectives of this study were to describe the profile of individuals who had strangulation-related emergency department (ED) or acute care visits, and to explore 1-year readmission outcomes among survivors. METHODS: A population-based retrospective cohort study was conducted using health administrative data in Ontario, Canada. Adults aged 15 years and older who were seen in the ED or acute care with assault by strangulation between fiscal years 2002/2003 and 2016/2017 were included in the study. Bivariate analyses were conducted to compare the patient profile and subsequent readmissions within 1 year of discharge, stratified by sex. RESULTS: A total of 586 patients were included in the study. The majority of these patients were seen in the ED (93%), predominantly female (70%), aged ≤ 39 years (68%), and of lower income quintiles of ≤ 3 (73%). Of the 579 patients who survived the initial admission, 52% had subsequent ED readmission and 21% had acute care readmission within 1 year. In sex-stratified analyses, a higher proportion of females were between 20 to 39 years (58.7% vs. 44.1%, p = 0.001), discharged home (88% vs. 81%, p < 0.001), and had ED readmission within 1 year of discharge (56% vs. 17%, p = 0.002). Males had comparatively higher 1-year acute care readmissions. CONCLUSION: The study shows high readmissions with sex differences among individuals with an assault by strangulation, suggesting sex-specific approach to health care practices to support the needs of this vulnerable population, thus reducing health system inefficiencies.

Predictors of in-hospital mortality following hypoxic-ischemic brain injury: a population-based study.

Objective: To identify predictors of in-hospital mortality following Hypoxic-Ischemic Brain Injury (HIBI) using the Anderson Behavioral Model.Design and Setting: Population based retrospective cohort study in Ontario, Canada with data collected between 1 April 2002 and 31 March 2017.Patients: Adult patients aged 20 years and older with HIBI-related acute care admission were identified in the health administrative data. Multivariable cox proportional hazard regression models were used to identify predisposing, need and enabling factors that predict in-hospital mortality.Results: Of the 7492 patients admitted to acute care with HIBI, the in-hospital mortality rate was 71%. The predisposing factors associated with mortality were female sex (HR, 1.16; 95% CI, 1.10-1.23) and older age (65-79 vs. 20-34: HR, 1.17; 95% CI, 1.02-1.35). The need factors associated with mortality were the presence of COPD (HR, 1.10; 95% CI, 1.02-1.17), psychiatric illness (HR, 1.13; 95% CI, 1.05-1.20) injury due to cardiac illness (HR, 1.19; 95% CI, 1.12-1.26) and longer emergency department length of stay. Having spending any time in an alternate level of care and the application of tracheotomy procedures were found to reduce mortality.Conclusions: The acute/critical care centers need to consider these findings to adopt prevention strategies targeting reduced in-hospital mortality.

Occupational and Physical Therapy Activities and Level of Effort in Patients With Traumatic Brain Injury: Association With Functional Outcomes.

BACKGROUND: Although some attention has been given to the association of functional outcomes with rehabilitation intensity, the evidence is still sparse in this field. OBJECTIVE: To investigate the effect of inpatient rehabilitation (IR) on discharge cognitive and motor function and the association of time spent in occupational and physical therapy and level of effort with cognitive and motor function in patients with traumatic brain injury (TBI). DESIGN: Secondary analysis of TBI-Practice Based Evidence dataset. SETTINGS: Inpatient rehabilitation. PARTICIPANTS: One hundred forty-nine patients with TBI who were consecutively admitted for IR between 2008 and 2011 in Ontario, Canada. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASUREMENTS: Admission and discharge Functional Independence Measure-Rasch Cognitive and Motor Scores. RESULTS: Patients showed significant improvement in cognitive and motor function from admission to discharge (P < .0001). After controlling for confounding factors, discharge FIM-Rasch cognitive and motor scores were not associated with either level of effort or time spent in physical therapy activities. Discharge motor, but not cognitive function, was associated with more time spent in the complex (ß = 0.20, confidence interval [CI] 0.005, 0.05) and less time spent in simple OT activities (ß = -0.13, CI -0.13, -0.01). CONCLUSION: This study provides valuable information for clinicians about the effectiveness of IR on the improvement of motor and cognitive outcomes and the importance of considering the amount of time spent in activities based on their level of complexity rather than the total time of therapy to improve motor outcomes in this population. LEVEL OF EVIDENCE: III.

Content of inpatient rehabilitation for patients with traumatic brain injury: A comparison of Canadian and American facilities.

Objective: To compare components of inpatient rehabilitation (IR) for patients with traumatic brain injury (TBI) between Canada and the US facilities. Design: Secondary analysis of the TBI-practice-based evidence dataset. Participants: Patients with TBI who had a higher Functional Independence Measure (FIMTM) cognitive function score (≥21) that were admitted to 1 IR facility in Canada (n = 103) and 9 IR facilities in the US (n = 401). Main measures: demographic and clinical characteristics, type and intensity of activities by discipline, discharge location, FIM-Rasch score, social participation and quality of life. Results: Time from injury to rehabilitation admission was significantly longer in the Canadian cohort and they experienced a longer rehabilitation length of stay (p < .001, Cohen's d > .8). Patients in Canada received a greater total time of individual therapy and lower intensity of interventions per week from all disciplines. They also showed a higher score at discharge in FIM components, while US patients had better cognitive recovery and community participation long-term post-discharge. Conclusions: This study informs stakeholders of the large variation in service provision for patients who were treated in these two countries. These findings suggest the need for robust analyzes to investigate predictors of short and long-term outcomes considering the variation in health-care delivery. List of abbreviations: TBI: traumatic brain injury, CSI: comprehensive severity index, LoS: length of stay, OT: occupational therapy, PT: physical therapy, SLP: speech language pathology, IR: inpatient rehabilitation.

Battered and Brain Injured: Assessing Knowledge of Traumatic Brain Injury Among Intimate Partner Violence Service Providers.

Background: Traumatic brain injury (TBI) as a result of intimate partner violence (IPV) is a significant health concern; yet, little is known about the intersection between the two. Existing research is scarce, limiting the ability of health care providers to develop effective supports. This pilot project surveyed the IPV support community in Toronto, Canada to understand the degree of existing TBI-specific knowledge and relevant services available among these service providers and to seek to bridge the divide between research and practice by developing a national knowledge-to-practice network to support brain-injured women survivors of IPV. Materials and Methods: In phase 1, 68 agencies providing IPV support services were invited to complete an anonymous online survey. In phase 2, 22 stakeholders attended a workshop held to disseminate existing knowledge, develop a national knowledge-to-practice network, and determine next steps in research and practice. Results: The results highlighted a general lack of TBI awareness and understanding among IPV service providers. In addition, participants stated that frontline workers and women survivors of IPV alike do not recognize signs or symptoms of TBI. Recommendations addressing research gaps, professional and public education, and service development were identified and are discussed herein. Conclusions: The identified lack of TBI knowledge among IPV service providers highlights the immediate need to increase education among management and frontline workers. Further investigation identifying best practices for knowledge transfer are suggested. The development of a national strategy addressing education, research, and funding is critical for successful uptake and integration of TBI-sensitive services within the IPV sector.

Change in Function Over Inpatient Rehabilitation After Hypoxic Ischemic Brain Injury: A Population-Wide Cohort Study.

OBJECTIVE: To estimate change in motor, cognitive, and overall functional performance during inpatient rehabilitation (IR) and to identify potential determinants of these outcomes among patients with hypoxic-ischemic brain injury (HIBI). DESIGN: Population-based retrospective cohort study using Ontario's health administrative data. SETTING: Inpatient rehabilitation. PARTICIPANTS: Survivors of HIBI 20 years and older discharged from acute care between fiscal years 2002-2003 and 2010-2011 and admitted to IR within 1 year of acute care discharge (N=159). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Functional status as measured by FIM, total, and scores on motor and cognitive subscales. RESULTS: A higher proportion (77%) of HIBI patients in the study were male and 28% were older than 65 years. We observed material improvements in FIM total, motor, and cognitive scores from across the IR episode. Potential determinants of total FIM gain were living in rural location (ß, 10.4; 95% CI, 0.21-21), having shorter preceding acute care length of stay (15-30 vs >60 days ß, 10.4; 95% CI, 1.4-19.5), and failing to proceed directly to IR following acute care discharge (ß, 8.7; 95% CI, 1.8-15.5). Motor FIM gain had similar identified potential determinants. Identified potential determinants of cognitive FIM gain were shorter (ie, 31-60 vs >60 days) preceding acute care, longer IR and length of stay, and proceeding directly to IR. There were no sex differences in functional gain. CONCLUSIONS: Inpatient rehabilitation is beneficial to HIBI survivors. Timely access to these services may be crucial in achieving optimal outcomes for these patients.

Cognitive and Motor Recovery and Predictors of Long-Term Outcome in Patients With Traumatic Brain Injury.

OBJECTIVES: To explore the patterns of cognitive and motor recovery at 4 time points from admission to 9 months after discharge from inpatient rehabilitation (IR) and to investigate the association of therapeutic factors and conditions before and after discharge with long-term outcomes. DESIGN: Secondary analysis of traumatic brain injury (TBI) and practice-based evidence dataset. SETTING: IR in Ontario, Canada. PARTICIPANTS: Patients with TBI consecutively admitted for IR between 2008 and 2011 who had data available from admission to 9 months after discharge (N=85). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: FIM-Rasch cognitive and motor scores at admission, discharge, 3 months after discharge, and 9 months after discharge. RESULTS: Cognitive and motor recovery showed similar patterns of improvement with recovery up to 3 months but no significant change from 3 to 9 months. Having fewer postdischarge health conditions was associated with better long-term cognitive scores (95% confidence interval, -13.06 to -1.2) and added 9.9% to the explanatory power of the model. More therapy time in complex occupational therapy activities (95% confidence interval, .02 to .09) and fewer postdischarge health conditions (95% confidence interval, -19.5 to -3.8) were significant predictors of better long-term motor function and added 14.3% and 7.2% to the explanatory power of the model, respectively. CONCLUSION: Results of this study inform health care providers about the influence of the timing of IR on cognitive and motor recovery. In addition, it underlines the importance of making patients and families aware of residual health conditions following discharge from IR.

Predictors of Discharge Destination From Acute Care in Patients With Traumatic Brain Injury: A Systematic Review.

OBJECTIVE: To systematically review studies on clinical and nonclinical predictors of discharge destination from acute care in patients with traumatic brain injury. METHODS: The search was conducted using 7 databases up to December 2016. A systematic review and in-depth quality synthesis were conducted on eligible articles that met the inclusion criteria. RESULTS: The search yielded 8503 articles of which 18 studies met the inclusion criteria. This study demonstrated that a larger proportion of patients with traumatic brain injury were discharged home. The main predictors of discharge to a setting with rehabilitation services versus home included increasing age, white and non-Hispanic race/ethnicity, having insurance coverage, greater severity of the injury, and longer acute care length of stay. Age was the only consistent factor that was negatively associated with discharge to inpatient rehabilitation facilities versus other institutions. CONCLUSION: Results of this study support healthcare providers in providing consultation to patients about the expected next level of cares while considering barriers that may helpful in effective discharge planning, decreasing length of stay and saving resources. These findings also suggest the need for further studies with a stronger methodology on the contribution of patients and families/caregivers to distinguish the predictors of discharge to dedicated rehabilitation facilities.

Readmission following hypoxic ischemic brain injury: a population-based cohort study.

BACKGROUND: Readmission to acute care is common and is associated with indicators of suboptimal care and health system inefficiencies. The objective of this study was to identify independent determinants of readmission following survival of hypoxic ischemic brain injury. METHODS: We conducted a population-based retrospective cohort study using Ontario's administrative health data. Survivors of hypoxic ischemic brain injury aged 20 years or more discharged from acute care between fiscal years 2002/03 and 2010/11 were included. Multivariable negative binomial regression was used to identify independent determinants of both number of readmissions and cumulative duration of hospital stay(s) within 1 year after the index discharge. RESULTS: Of the 593 patients with hypoxic ischemic brain injury, 233 (39.3%) were readmitted within 1 year of the index acute care discharge. The number of readmissions was associated with age (35-49 yr v. 65-79 yr: rate ratio [RR] 0.57, 95% confidence interval [CI] 0.38-0.85; ≥ 80 yr v. 65-79 yr: RR 0.58, 95% CI 0.34-0.97) and higher comorbidity score (Johns Hopkins Aggregated Diagnosis Groups score > 30 v. < 10: RR 1.60, 95% CI 1.11-2.31). Cumulative readmission stay was associated with increased index acute care length of stay (31-90 d v. ≥ 90 d: RR 4.17, 95% CI 1.38-12.64), prior use of health care services (minimal v. very high: RR 0.15, 95% CI 0.05-0.49) and discharge disposition (home v. continuing/long-term care: RR 0.44, 95% CI 0.21-0.91). INTERPRETATION: The findings indicate a high readmission rate in the first year after the index acute care admission for survivors of hypoxic ischemic brain injury, reflecting care gaps and system inefficiencies. This suggests that bolstered discharge and home care planning and support are needed to address the specific needs of those with hypoxic ischemic brain injury.

Research Priorities for Optimizing Long-term Community Integration after Brain Injury.

OBJECTIVE: This paper reports on a funded summit, which convened a multidisciplinary group of experts to provide consensus on the research priorities necessary for improving long-term community integration of individuals with traumatic brain injury (TBI) and their caregivers. METHODS: The 2-day summit was directed using the World Café Methodology, to engage stakeholders and collaboratively arrive at a consensus on the problems to be targeted in research. Participants (n=54), drawn from two Canadian provinces, included an interdisciplinary group of researchers, clinicians, representatives from brain injury associations, individuals with TBI, and caregivers. In small groups, participants discussed challenges to long-term community integration and potential initiatives that would address these barriers. Field notes from the discussions were analyzed using qualitative content analysis. RESULTS: The consensus on prioritized research directions included developing interventions to optimize the functioning and participation of individuals with TBI, reducing caregiver burden, and evaluating how emerging technology can facilitate delivery of care. CONCLUSIONS: The World Café Methodology was an effective method for developing research priorities. The breadth of expertise of participants and the collegial environment allowed for the identification of a broad perspective on important future research directions with potential to enhance the long-term community integration of individuals with brain injury.

Association between cognitive ability and functional outcomes following traumatic brain injury- using a computer-based neurocognitive battery.

OBJECTIVE: To investigate the contribution of the Cogstate Brief Battery (CBB TM) in the explanation of variation of functional outcomes. DESIGN: Secondary analysis of the practice-based evidence data set. SETTING: Inpatient rehabilitation setting. PARTICIPANTS: Patients (≥ 18 years of age) with traumatic brain injury who were consecutively admitted to the Toronto Rehabilitation Institute between 2008 and 2011 (n = 65). INTERVENTIONS: Not applicable Main outcome measure: Cognitive and motor components of the Functional Independence Measure. RESULTS: The addition of the CBB TM components resulted in a significantly better model for predicting outcomes than a basic model using demographics and clinical factors. Among all CBB TM components, speed and variation in the identification task and accuracy in the one card learning task were significantly associated with cognitive functional outcomes after controlling for demographic and clinical factors. Rehabilitation length of stay was the only significant clinical factor that was correlated with both cognitive and motor outcomes. CONCLUSIONS: Findings of this study suggest the importance of considering visual attention and visual memory in predication of cognitive outcome and provide valuable information for researchers to consider the specific cognitive abilities in functional outcome model in future studies in addition to more traditional factors.

Post-acute care referral and inpatient rehabilitation admission criteria for persons with brain injury across two Canadian provinces.

PURPOSE: Investigate health care providers' perceptions of referral and admission criteria to brain injury inpatient rehabilitation in two Canadian provinces. METHODS: Health care providers (n = 345) from brain injury programs (13 acute care and 16 rehabilitation facilities) participated in a cross-sectional web-based survey. The participants rated the likelihood of patients (traumatic brain injury and cerebral hypoxia) to be referred/admitted to rehabilitation and the influence of 19 additional factors (e.g., tracheostomy). The participants reported the perceived usefulness of referral/admission policies and assessment tools used. RESULTS: Ninety-one percent acute care and 98% rehabilitation participants reported the person with traumatic brain injury would likely or very likely be referred/admitted to rehabilitation compared to respectively 43% and 53% for the patient with hypoxia. Two additional factors significantly decreased the likelihood of referral/admission: older age and the combined presence of minimal learning ability, memory impairment and physical aggression. Some significant inter-provincial variations in the perceived referral/admission procedure were observed. Most participants reported policies were helpful. Similar assessment tools were used in acute care and rehabilitation. CONCLUSIONS: Health care providers appear to consider various factors when making decisions regarding referral and admission to rehabilitation. Variations in the perceived likelihood of referral/admission suggest a need for standardized referral/admission practices. Implications for Rehabilitation Various patient characteristics influence clinicians' decisions when selecting appropriate candidates for inpatient rehabilitation. In this study, acute care clinicians were less likely to refer patients that their rehabilitation counter parts would likely have admitted and a patient with hypoxic brain injury was less likely to be referred or admitted in rehabilitation than a patient with a traumatic brain injury. Such discrepancies suggest that policy-makers, managers and clinicians should work together to develop and implement more standardized referral practices and more specific admission criteria in order to ensure equitable access to brain injury rehabilitation services.

Predictors of discharge destination from acute care in patients with traumatic brain injury.

INTRODUCTION: Many studies have assessed the predictors of morbidity/mortality of patients with traumatic brain injury (TBI) in acute care. However, with the increasing rate of survival after TBI, more attention has been given to discharge destinations from acute care as an important measure of clinical priorities. This study describes the design of a systematic review compiling and synthesising studies on the prognostic factors of discharge settings from acute care in patients with TBI. METHODS AND ANALYSIS: This systematic review will be conducted on peer-reviewed studies using seven databases including Medline/Medline in-Process, Embase, Cochrane Database of Systematic Reviews, Cochrane CENTRAL, PsycINFO, CINAHL and Supplemental PubMed. The reference list of selected articles and Google Scholar will also be reviewed to determine other relevant articles. This study will include all English language observational studies that focus on adult patients with TBI in acute care settings. The quality of articles will be assessed by the Quality in Prognostic Studies tool. ETHICS AND DISSEMINATION: The results of this review will provide evidence that may guide healthcare providers in making more informed and timely discharge decisions to the next level of care for patient with TBI. Also, this study will provide valuable information to address the gaps in knowledge for future research. TRIAL REGISTRATION NUMBER: Trial registration number (PROSPERO) is CRD42016033046.

Long-Term Functional and Psychosocial Outcomes After Hypoxic-Ischemic Brain Injury: A Case-Controlled Comparison to Traumatic Brain Injury.

BACKGROUND: Despite the increasing rate of survival from hypoxic-ischemic brain injury (HIBI), there is a paucity of evidence on the long-term functional outcomes after inpatient rehabilitation among these nontrauma patients compared to patients with traumatic brain injury (TBI). OBJECTIVES: To compare functional and psychosocial outcomes of patients with HIBI to those of case-matched patients with TBI 4-11 years after brain insult. DESIGN: Retrospective, matched case-controlled study. METHODS: Data at the time of rehabilitation admission and discharge were collected as part of a larger acquired brain injury (ABI) database at Toronto Rehabilitation Institute (TRI) between 1999 and 2009. This study consisted of 11 patients with HIBI and 11 patients with TBI that attended the neuro-rehabilitation day program at TRI during a similar time frame and were matched on age, admission Functional Independence Measure (FIM) scores, and acute care length of stay (ALOS). At 4-11 years following brain insult, patients were reassessed using the FIM, Disability Rating Scale (DRS), Personal Health Questionnaire Depression Scale (PHQ-9), and the Mayo-Portland Adaptability Inventory 4 (MPAI-4). RESULTS: At follow-up, patients with HIBI had significantly lower FIM motor and cognitive scores than patients with TBI (75.3 ± 20.6 versus 88.1 ± 4.78, P < .05, and 25.5 ± 5.80 versus 32.7 ± 2.54, P <.05, respectively) despite having a similar time frame postinsult (ie, 4-11 years). In addition, there were significant differences in motor and total FIM change from admission to follow-up between HIBI and TBI patients (P < .05). Patients with HIBI also had significantly lower scores on the DRS, PHQ-9, and total MPAI-4 at follow-up (P < .05). CONCLUSIONS: The study results suggest that patients with HIBI achieve less long-term functional improvements compared to patients with TBI. Further research is warranted to compare the components of inpatient rehabilitation while adjusting for demographics and clinical characteristics between these 2 groups of patients. LEVEL OF EVIDENCE: III.

Determinants of alternate-level-of-care delayed discharge among acute care survivors of hypoxic-ischemic brain injury: a population-based cohort study.

BACKGROUND: Delayed discharge, captured as alternate-level-of-care days, represents inefficient use of high-demand acute care resources and results in potentially poorer patient outcomes. We performed a study to determine the extent of alternate-level-of-care days among patients who survived hypoxic-ischemic brain injury in inpatient hospital care in Ontario and to identify predictors of alternate-level-of-care use in this population. METHODS: A population-based cohort of acute care survivors of hypoxic-ischemic brain injury aged 20 years or more from 2002/03 through 2011/12 was identified. We used 2 case definitions, the more specific identifying patients with a most responsible diagnosis of "anoxic brain damage," and the more sensitive capturing additional likely causative conditions as the most responsible diagnosis. Multivariable zero-inflated negative binomial regression was used to estimate independent effects on the relative incidence of alternate-level-of-care days. RESULTS: We identified 491 patients using the specific case definition and 669 patients using the extended case definition. After deaths were excluded, 232 patients (47.2%) and 278 patients (41.6%), respectively, had at least 1 alternate-level-of-care day (median 20 and 19 d, respectively). In both cohorts, decreasing age, no special care unit hours and acute care episode earlier in the study period were predictive of increased alternate-level-of-care days relative to length of stay. Discharge disposition and psychiatric/behavioural comorbidity were most predictive of having any alternate-level-of-care days. INTERPRETATION: Patients with hypoxic-ischemic brain injury had a greater proportion of alternate-level-of-care days than has been reported for patients with other types of acquired brain injury. This finding suggests that substantial barriers to appropriate discharge exist for this population. Predictors of increased alternate-level-of-care days were also shown to be unique. Further study of care deficits among patients with hypoxic-ischemic brain injury is warranted.

Determinants of Admission to Inpatient Rehabilitation Among Acute Care Survivors of Hypoxic-Ischemic Brain Injury: A Prospective Population-Wide Cohort Study.

OBJECTIVE: To investigate demographic and acute care clinical determinants of admission to inpatient rehabilitation (IR) among patients with hypoxic-ischemic brain injury (HIBI) who survive the initial acute care episode. DESIGN: Population-wide prospective cohort study using Canadian Institutes for Health Information administrative health data from Ontario, Canada. All patients who survived their HIBI acute care episode during the study period remained eligible for the outcome, admission to IR, for 1 year postacute care discharge. SETTING: Inpatient rehabilitation. PARTICIPANTS: We included all patients with HIBI using International Classification of Diseases, Tenth Revision, Canadian Enhancement codes recorded at acute care admission who were ≥20 years old (N=599) and discharged from acute care between the 2002 and 2010 fiscal years, inclusive. Six patients were excluded from analyses because of missing data. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Admission to IR. RESULTS: Of HIBI survivors admitted to IR within 1 year of acute care discharge (n=169), most (56.2%) had an IR admitting diagnosis indicating anoxic brain damage. Younger age, being a man, lower comorbidity burden, longer length of stay of preceding acute care episode, and shorter duration in special care were most predictive of admission to IR in multivariable regression models. Women had an almost 2-fold lower incidence of admission to IR (risk ratio, .62; 95% confidence interval, .46-.84). CONCLUSIONS: Older age, higher comorbidity burden, and shorter lengths of stay and delayed discharge from acute care are associated with lower incidence of IR admission for patients with HIBI. That women are almost 2-fold less likely to receive rehabilitation requires further investigation.

Long-Term Health Service Outcomes Among Women With Traumatic Brain Injury.

OBJECTIVES: To (1) assess long-term health care service utilization and satisfaction with health care services among women with traumatic brain injury (W-TBI); (2) examine barriers that prevent W-TBI from receiving care when needed; and (3) understand the perceived supports available for W-TBI. DESIGN: Retrospective cohort study. SETTING: Community. PARTICIPANTS: W-TBI (n=105) 5 to 12 years postinjury and women without TBI (n=105) matched on age, education, and geographic location. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Pre- and postinjury data were collected using a questionnaire administered via a semistructured interview. Questions on health services utilization, satisfaction with and quality of services, barriers to receiving care, and perceived social support were from the Canadian Community Health Survey; additional questions on perceived social support were from another large-scale study of people with moderate to severe brain injury. RESULTS: Compared with women without TBI, W-TBI reported using more family physician and community health services. W-TBI reported that they did not receive care when needed (40%), particularly for emotional/mental health problems. Significantly more W-TBI reported financial and structural barriers. There were no significant differences in reported satisfaction with services between women with and without TBI. CONCLUSIONS: Health service providers and policymakers should recognize the long-term health and social needs of W-TBI and address societal factors that result in financial and structural barriers, to ensure access to needed services.

Institutional Variation in Traumatic Brain Injury Acute Rehabilitation Practice.

OBJECTIVE: To describe institutional variation in traumatic brain injury (TBI) inpatient rehabilitation program characteristics and evaluate to what extent patient factors and center effects explain how TBI inpatient rehabilitation services are delivered. DESIGN: Secondary analysis of a prospective, multicenter, cohort database. SETTING: TBI inpatient rehabilitation programs. PARTICIPANTS: Patients with complicated mild, moderate, or severe TBI (N=2130). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Mean minutes; number of treatment activities; use of groups in occupational therapy, physical therapy, speech therapy, therapeutic recreation, and psychology inpatient rehabilitation sessions; and weekly hours of treatment. RESULTS: A wide variation was observed between the 10 TBI programs, including census size, referral flow, payer mix, number of dedicated beds, clinician experience, and patient characteristics. At the centers with the longest weekday therapy sessions, the average session durations were 41.5 to 52.2 minutes. At centers with the shortest weekday sessions, the average session durations were approximately 30 minutes. The centers with the highest mean total weekday hours of occupational, physical, and speech therapies delivered twice as much therapy as the lowest center. Ordinary least-squares regression modeling found that center effects explained substantially more variance than patient factors for duration of therapy sessions, number of activities administered per session, use of group therapy, and amount of psychological services provided. CONCLUSIONS: This study provides preliminary evidence that there is significant institutional variation in rehabilitation practice and that center effects play a stronger role than patient factors in determining how TBI inpatient rehabilitation is delivered.