Journey to 1 Million Steps: A Retrospective Case Series Analyzing the Implementation of Robotic-Assisted Gait Training Into an Outpatient Pediatric Clinic.

PURPOSE: To describe the implementation of an exoskeleton program in a rehabilitation setting using a Design Thinking framework. METHODS: This is a retrospective case series of 3 randomly selected children who participated in skilled physical therapy using a pediatric exoskeleton that occurred on our journey to walking 1 000 000 steps in the exoskeleton devices. Participants ranged in age from 3 to 5 years, and all had neurologic disorders. RESULTS: All participants improved toward achieving their therapy goals, tolerated the exoskeleton well, and had an increased number of steps taken over time. CONCLUSION: The implementation of new technology into pediatric care and an established outpatient therapy clinic is described. The Design Thinking process applies to health care professionals and improves clinical care. Exoskeletons are effective tools for use in pediatric physical therapy.

The Association Between Payer Source and Traumatic Brain Injury Rehabilitation Outcomes: A TBI Model Systems Study.

OBJECTIVE: To examine the relationship between payer source for acute rehabilitation, residential median household income (MHI), and outcomes at rehabilitation discharge after traumatic brain injury (TBI). SETTING: Acute inpatient rehabilitation facilities. PARTICIPANTS: In total, 8558 individuals enrolled in the Traumatic Brain Injury Model Systems (TBIMS) National Database who were admitted to inpatient rehabilitation between 2006 and 2019 and were younger than 64 years. DESIGN: Secondary data analysis from a multicenter longitudinal cohort study. MAIN MEASURES: Payer source was divided into 4 categories: uninsured, public insurance, private insurance, and workers' compensation/auto. Relationships between payer source with residential MHI, rehabilitation length of stay (RLOS), and the FIM Instrument at discharge were examined. Covariates included age, injury severity, FIM at admission, and a number of sociodemographic characteristics including minority status, preinjury limitations, education level, and employment status. RESULTS: Individuals with workers' compensation/auto or private insurance had longer RLOS than uninsured individuals or those with public insurance after controlling for demographics and injury characteristics. An adjusted model controlling for demographics and injury characteristics showed a significant main effect of payer source on FIM scores at discharge, with the highest scores noted among those with workers' compensation/auto insurance. The main effect of payer source on FIM at discharge became nonsignificant after RLOS was added to the model as a covariate, suggesting a mediating effect of RLOS. CONCLUSION: Payer source was associated with preinjury residential MHI and predicted RLOS. While prior studies have demonstrated the effect of payer source on long-term outcomes due to lack of inpatient rehabilitation or quality follow-up care, this study demonstrated that individuals with TBI who are uninsured or have public insurance may be at risk for poorer functional status at the point of rehabilitation discharge than those with private insurance, particularly compared with those with workers' compensation/auto insurance. This effect may be largely driven by having a shorter length of stay in acute rehabilitation.

Race/Ethnicity and Community Participation Among Veterans and Service Members With Traumatic Brain Injury: A VA Traumatic Brain Injury Model Systems Study.

OBJECTIVE: To examine racial/ethnic disparities in community participation among veterans and active duty service members with traumatic brain injury (TBI). SETTING: Five Department of Veterans Affairs (VA) TBI Model Systems (TBIMS) Polytrauma Rehabilitation Centers (PRCs). Participants: Three hundred forty-two community-dwelling adults (251 White, 34 Black, and 57 Hispanic) with TBI enrolled in the VA TBIMS National Database who completed a 1-year follow-up interview. Mean age was 38.6 years (range, 19-84 years). DESIGN: Cross-sectional analysis of a prospective observational cohort study. Main Measures: Community participation at 1 year postinjury assessed by 3 domains of the Participation Assessment with Recombined Tools-Objective (PART-O): Out & About, Productivity, and Social Relations. RESULTS: Significant differences were observed among race/ethnicity groups in PART-O Productivity and Out & About domains without controlling for relevant participant characteristics; Productivity scores were significantly higher for non-Hispanic Black than for non-Hispanic White participants (t = 2.40, P = .0169). Out & About scores were significantly higher for Hispanic than for non-Hispanic White participants (t = 2.79, P = .0056). However, after controlling for demographic, injury severity, and 1-year follow-up characteristics, only differences in the Out & About domain remained statistically significant (t = 2.62, P = .0094), with scores being significantly higher for Hispanics than for non-Hispanic Whites. CONCLUSIONS: The results, which differ from findings from studies conducted in non-VA healthcare settings where there are greater racial/ethnic disparities in participation outcomes, could reflect differences between military and civilian samples that may reduce disparities.

Psychosocial Impacts of the COVID-19 Quarantine: A Study of Gender Differences in 59 Countries.

Background and Objectives: There is strong evidence in the literature that women experience psychological disorders at significantly higher rates than men. The higher rates of psychological disorders in women may partly be attributable to gender differences in response to stressors and coping styles. The objective of this study was to contribute to the growing body of literature investigating gender differences in mental health outcomes and coping styles during the coronavirus disease 2019 pandemic in a large sample of individuals from 59 countries with variable demographic and socio-cultural characteristics. Materials and Methods: Survey data were collected from the general population following a snowball sampling method, and the survey was promoted through social media platforms and mailing lists. Participants included 6882 individuals from the general population from 59 countries around the world. A combination of both standardized and adapted measures was used to create a survey, originally in English and then translated to Spanish, Italian, French, German, and Turkish. Results: Compared with men, women presented with higher levels of trauma-related distress; had a harder time decompressing; were more depressed, anxious and stressed; showed decreased frustration tolerance and reported lower quality of sleep and an increased likelihood of taking sleep medication or other natural sleep remedies. Overall, women tended to be more vulnerable during the pandemic in developing symptoms consistent with various forms of mental disorders such as depression, anxiety and post-traumatic distress. However, they also were more likely than men to use a variety of adaptive coping strategies, including concentrating on doing something about the situation and getting emotional support from others. Conclusions: A high prevalence of mood symptoms was noted among women. In addition to meeting the physical health needs of the population, emphasis needs to be given to mental health and the prevention of psychiatric disorders, particularly in women.

Sex and Gender Issues for Individuals With Acquired Brain Injury During COVID-19: A Commentary.

Worldwide, the rehabilitation community has been affected by coronavirus disease 2019 (COVID-19). The effect of COVID-19 has been disproportionately devastating for individuals with disabilities, particularly those with acquired brain injury (ABI) owing to injury-related cognitive or sensory and physical difficulties. Many physical and psychological symptoms of COVID-19 are already well-known issues for individuals with ABI. Even in a fully functional social and health care system, post-ABI deficits can pose greater challenges to women and other marginalized groups, such as lesbian, gay, bisexual, transgender, gender-nonconforming, and queer or questioning-identified individuals. The restrictions and changes brought about by COVID-19 have the potential to broaden the existing disparities and limitations. This commentary highlights 3 key areas to attend to during this pandemic to help assuage such disparities and limitations.

An interview based approach to the anorectal portion of the International Standards of Neurological Classification of Spinal Cord Injury Exam (I-A-ISNCSCI): a pilot study.

STUDY DESIGN: Prospective, single-blinded study. OBJECTIVE: To design and evaluate the use of an interview based version of the anorectal portion of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) exam in the acute inpatient rehabilitation (AIR) setting. SETTING: AIR unit. METHODS: Participants admitted to AIR underwent standard ISNCSCI exams (S-ISNCSCI) as part of routine inpatient care within 3 days of being administered an interview version of the anorectal portion of the ISNCSCI (I-A-ISNCSCI). Agreement between the anorectal portion of the S-ISNCSCI (S-A-ISNCSCI) and the I-A-ISNCSCI was evaluated. RESULTS: Forty of forty-five enrolled participants completed the assessments. Agreement between the I-A-ISNCSCI and S-A-ISNCSCI was substantial for anorectal sensation to light touch (k = 0.71, 95% CI 0.52-0.90, N = 36), pin prick (k = 0.68, 95% CI 0.48-0.87, N = 38), deep anal pressure (k = 0.77, 95% CI 0.53-1.00, N = 37), and completeness of injury based on combined sacral sensory criteria (k = 0.72, 95% CI 0.47-0.97, N = 40); and fair for voluntary anal contraction (k = 0.29, 95% CI -0.01 to 0.59, N = 36). Responses of "I don't know" were excluded from agreement analyses. CONCLUSIONS: This pilot study was a first step in developing interview based tools such as the I-A-ISNCSCI in an AIR setting providing convenient access to individuals with SCI and their direct feedback. The study design introduces potential recall bias and may not match true clinical situations such as remote follow-up of neurological changes for chronic patients. The use of interview based tools for assessing individuals with SCI remains worthy of further study.

Factors associated with the remission of insomnia after traumatic brain injury: a traumatic brain injury model systems study.

Objective: To examine the factors associated with the remission of insomnia by examining a sample of individuals who had insomnia within the first two years after traumatic brain injury (TBI) and assessing their status at a secondary time point.Design and Methods: Secondary data analysis from a multicenter longitudinal cohort study. A sample of 40 individuals meeting inclusion criteria completed a number of self-report scales measuring sleep/wake characteristics (Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, Insomnia Severity Index, Sleep Hygiene Index), fatigue and depression (Multidimensional Assessment of Fatigue, Patient Health Questionnaire-9), and community participation (Participation Assessment with Recombined Tools-Objective). One cohort was followed at 1 and 2 years post-injury (n = 19) while a second cohort was followed at 2 and 5 years post-injury (n = 21).Results: Remission of insomnia was noted in 60% of the sample. Those with persistent insomnia had significantly higher levels of fatigue and depression at their final follow-up and poorer sleep hygiene across both follow-up time-points. A trend toward reduced community participation among those with persistent insomnia was also found.Conclusion: Individuals with persistent post-TBI insomnia had poorer psychosocial outcomes. The chronicity of post-TBI insomnia may be associated with sleep-related behaviors that serve as perpetuating factors.

Associations Between Insurance Provider and Assistive Technology Use for Computer and Electronic Devices 1 Year After Tetraplegia: Findings From the Spinal Cord Injury Model Systems National Database.

OBJECTIVE: To investigate the association between insurance provider and reported assistive technology (AT) use to access computers and electronic devices 1 year after sustaining tetraplegia. DESIGN: Multicenter cross-sectional study. SETTING: Participants enrolled in the Spinal Cord Injury Model Systems (SCIMS) National Database. INTERVENTIONS: Not applicable. PARTICIPANTS: Men and women with tetraplegia (N=498) enrolled in the SCIMS National Database were included in the analysis. MAIN OUTCOME MEASURES: The primary study outcome was the use of AT when operating a computer or other mobile electronic device. The primary predictor was the subject's principal health insurance provider, which was grouped into the 3 categories: government (Medicare, Medicaid, and other government), private (private insurance, private funds, and other), and workers' compensation. RESULTS: Overall, 34.7% of participants reported using AT to access computers and electronic devices. Results of logistic regression analysis revealed sex, injury level, injury completeness, self-perceived health status, and 12-month history of pressure ulcer were all significantly associated with AT use. After adjusting for these factors, participants with workers' compensation were more likely to report AT use than individuals with either government or private insurance. CONCLUSIONS: Despite significant technological advances, AT is not readily available to the people who might benefit most from its use. Findings from the present study are the first to shed light on AT funding sources and reveal that individuals with workers' compensation are more likely use AT than individuals with either government or private insurance. Additional work focused on AT use and functional outcomes is needed to assess the effect of barriers to use. Collectively, this work may inform insurers of the importance of having AT available for this unique population to potentially improve quality of life and participation.

Measuring Fatigue in TBI: Development of the TBI-QOL Fatigue Item Bank and Short Form.

OBJECTIVE: To develop a traumatic brain injury (TBI)-specific, item response theory (IRT)-calibrated Fatigue item bank, short form, and computer adaptive test (CAT) as part of the Traumatic Brain Injury-Quality of Life (TBI-QOL) measurement system. SETTING: Five TBI Model Systems rehabilitation centers in the US PARTICIPANTS:: Adults with complicated mild, moderate, or severe TBI confirmed by medical record review. DESIGN: Cross-sectional field testing via phone or in-person interview. MAIN MEASURES: TBI-QOL Fatigue item bank, short form, and CAT. RESULTS: A total of 590 adults with TBI completed 95 preliminary fatigue items, including 86 items from the Patient-Reported Outcomes Measurement Information System (PROMIS) and 9 items from the Quality of Life in Neurological Disorders (Neuro-QOL) system. Through 4 iterations of factor analysis, 22 items were deleted for reasons such as local item dependence, misfit, and low item-total correlations. Graded response model IRT analyses were conducted on the 73-item set, and Stocking-Lord equating was used to transform the item parameters to the PROMIS (general population) metric. A short form and CAT, which demonstrate similar reliability to the full item bank, were developed. Test-retest reliability of the CAT was established in an independent sample (Pearson's r and intraclass correlation coefficient = 0.82 [95% confidence interval: 0.72-0.88]). CONCLUSIONS: The TBI-QOL Fatigue item bank, short form, and CAT provide rehabilitation researchers and clinicians with TBI-optimized tools for assessment of the patient-reported experience and impact of fatigue on individuals with TBI.

A randomised control trial of walking to ameliorate brain injury fatigue: a NIDRR TBI model system centre-based study.

Fatigue is one of the most commonly reported sequelae after traumatic brain injury (TBI). This study evaluated the impact of a graduated physical activity programme on fatigue after TBI. Using a prospective randomised single-blind crossover design, 123 individuals with TBI, over the age of 18, were enrolled. Interventions included a home-based walking programme utilising a pedometer to track daily number of steps at increasing increments accompanied by tapered coaching calls over a 12-week period. Nutritional counselling with the same schedule of coaching calls served as the control condition. Main outcome measures included: the Global Fatigue Index (GFI), the Barrow Neurological Institute (BNI) Fatigue Scale Overall Severity Index Score, and the Multidimensional Fatigue Inventory (MFI). Step counts improved over time regardless of group assignment. The walking intervention led to a decrease in GFI, BNI Total, and MFI General scores. Participants reported less fatigue at the end of the active part of the intervention (24 weeks) and after a wash out period (36 weeks) as measured by the BNI Overall. The study suggests that walking can be used as an efficient and cost-effective tool to improve fatigue in persons who have sustained a TBI.

Factors associated with remission of post-traumatic brain injury fatigue in the years following traumatic brain injury (TBI): a TBI model systems module study.

Post-traumatic brain injury fatigue (PTBIF) is a major problem in the years after traumatic brain injury (TBI), yet little is known about its persistence and resolution. The objective of the study was to identify factors related to PTBIF remission and resolution. TBI Model System registrants at five centres participated in interviews at either one and two years post-injury (Y1-2 Cohort), or two and five years post-injury (Y2-5 Cohort). Characteristics of participants with PTBIF remission were compared to those with PTBIF persistence. Variables studied included the presence of and changes in disability, sleep dysfunction, mood, and community participation. The Functional Independence Measure did not differ significantly between groups or over time. In the Y1-2 Cohort the Fatigue Resolved group scored significantly better on the Disability Rating Scale and Pittsburgh Sleep Quality Index. In the Y2-5 Cohort the Fatigue Resolved group scored significantly higher on a measure of community participation. It was concluded that fewer than half of the sample in each cohort experienced a remission of PTBIF between time points. Persistence of PTBIF 1-2 years post-injury is associated with disability, sleep disturbance, and depression while persistence of fatigue beyond 2 years post-injury appears to be related to participation level, underscoring the potential impact of effective surveillance, assessment, and treatment of this condition in optimising life after TBI. Differences in fatigue progression may point to the presence of different types of PTBIF.

Trajectories of Life Satisfaction Over the First 10 Years After Traumatic Brain Injury: Race, Gender, and Functional Ability.

OBJECTIVE: This study investigated the influence of race, gender, functional ability, and an array of preinjury, injury-related, and sociodemographic variables on life satisfaction trajectories over 10 years following moderate to severe traumatic brain injury (TBI). SETTING/PARTICIPANTS: A sample of 3157 individuals with TBI from the TBI Model Systems database was included in this study. DESIGN: Hierarchical linear modeling (HLM) analyses were conducted to examine the trajectories of life satisfaction. MAIN MEASURES: The Functional Independence Measure, Glasgow Coma Scale, and the Satisfaction With Life Scale were utilized. RESULTS: Initial models suggested that life satisfaction trajectories increased over the 10-year period and Asian/Pacific Islander participants experienced an increase in life satisfaction over time. In a comprehensive model, time was no longer a significant predictor of increased life satisfaction. Black race, however, was associated with lower life satisfaction, and significant interactions revealed that black participants' life satisfaction trajectory decreased over time while white participants' trajectory increased over the same time period. Life satisfaction trajectories did not significantly differ by gender, and greater motor and cognitive functioning were associated with increasingly positive life satisfaction trajectories over the 10 years. CONCLUSION: Individuals with more functional impairments are at risk for decreases in life satisfaction over time. Further research is needed to identify the mechanisms and factors that contribute to the lower levels of life satisfaction observed among black individuals post-TBI. This work is needed to determine strategic ways to promote optimal adjustment for these individuals.

TBI-QOL: Development and Calibration of Item Banks to Measure Patient Reported Outcomes Following Traumatic Brain Injury.

OBJECTIVE: To use a patient-centered approach or participatory action research design combined with advanced psychometrics to develop a comprehensive patient-reported outcomes (PRO) measurement system specifically for individuals with traumatic brain injury (TBI). This TBI Quality-of-Life (TBI-QOL) measurement system expands the work of other large PRO measurement initiatives, that is, the Patient-Reported Outcomes Measurement Information System and the Neurology Quality-of-Life measurement initiative. SETTING: Five TBI Model Systems centers across the United States. PARTICIPANTS: Adults with TBI. DESIGN: Classical and modern test development methodologies were used. Qualitative input was obtained from individuals with TBI, TBI clinicians, and caregivers of individuals with TBI through multiple methods, including focus groups, individual interviews, patient consultation, and cognitive debriefing interviews. Item pools were field tested in a large multisite sample (n = 675) and calibrated using item response theory methods. MAIN OUTCOMES MEASURES: Twenty-two TBI-QOL item banks/scales. RESULTS: The TBI-QOL consists of 20 independent calibrated item banks and 2 uncalibrated scales that measure physical, emotional, cognitive, and social aspects of health-related quality of life. CONCLUSIONS: The TBI-QOL measurement system has potential as a common data element in TBI research and to enhance collection of health-related quality-of-life and PRO data in rehabilitation research and clinical settings.

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.

Global Outcome and Late Seizures After Penetrating Versus Closed Traumatic Brain Injury: A NIDRR TBI Model Systems Study.

BACKGROUND: If and how much dural penetration influences long-term outcome after traumatic brain injury (TBI) is understudied, especially within the civilian population. OBJECTIVES: Using the large TBI Model Systems cohort, this study assessed and compared penetrating TBI (PTBI) and closed TBI with respect to global outcome and late seizures 2 years after injury. METHODS: After performing unadjusted PTBI versus closed TBI comparisons, multivariate regression models were built and analyzed for both outcomes by including the following additional predictors: length of unconsciousness, posttraumatic amnesia duration, hospital length of stay, age, gender, race, marital status, education level, problem substance abuse, and preinjury employment status. RESULTS: The collapsed Glasgow Outcome Scale model (n = 6111) showed significant secondary effects of PTBI with employment status. When employed before injury, individuals with PTBI were 2.62 times more likely (95% confidence interval, 1.92-3.57) to have a lower Glasgow Outcome Scale category. The final model for late seizures (n = 6737) showed a significant main effect for PTBI. Adjusting for other predictors, individuals with PTBI were 2.78 times more likely (95% confidence interval, 1.93-3.99) than those with closed TBI to be rehospitalized for a seizure. CONCLUSION: This study empirically demonstrates that penetrating injury mechanism has important prognostic implications.

A home-based walking study to ameliorate perceived stress and depressive symptoms in people with a traumatic brain injury.

UNLABELLED: Abstract Objective: To determine whether a 12-week home-based walking programme can decrease perceived stress and depressive symptoms in persons with a traumatic brain injury (TBI). SETTING: Community- and home-based. PARTICIPANTS: Sixty-nine participants with a TBI. DESIGN: Comparative effectiveness cross-over design with random assignment to treatment sequence and blinded post-hoc assessment of outcome where participants completed a 12-week walking intervention and a nutrition education module. The walking intervention utilized pedometers to track the amount of steps each participant walked daily. With the assistance of an assigned coach, weekly goals were given with the intent of increasing the amount of walking that the participant was initially completing. The nutrition control group was created to offset the impact of the coaching calls. MAIN MEASURES: Measurement of perceived stress and depressive symptoms was completed through the use of the Perceived Stress Scale (PSS) and Center for Epidemiological Studies-Depression (CES-D). These measures were collected at three time points: baseline and following each 12-week intervention. RESULTS: RESULTS indicated that both perceived stress and depression symptoms significantly improved following the walking intervention. CONCLUSIONS: While limitations existed with the study, it is evident that walking can be used as an efficient and cost-effective tool to manage perceived stress and depressive symptoms in persons who have sustained a TBI.

Interdisciplinary communication and collaboration among physicians, nurses, and unlicensed assistive personnel.

PURPOSE: Historically, health care has primarily focused on physician, nurse, and allied healthcare provider triads. Using a phenomenological approach, this study explores the potential for hospital-based interdisciplinary care provided by physicians, nurses, and unlicensed assistive personnel (UAPs). DESIGN: This phenomenological study used a purposive nonprobability, criterion-based, convenience sample from a metropolitan hospital. THEORETICAL FOUNDATION: Malhotra's (1981) Schutzian lifeworld phenomenological orchestra study provided the theoretical basis for the conductorless orchestra model, which guided this study. In an orchestra, each member sees and hears the musical score from a different vantage point or perspective and has a different stock of knowledge or talent; however, members work together to produce a cohesive performance. Like the orchestra, individual talents and perspectives of physicians, nurses, and UAPs can be collaboratively blended to create a symphony: enhanced patient-centered care. METHODS: Qualitative semistructured face-to-face, individual interviews were carefully transcribed and coded with the aid of NVivo 9, a qualitative data analysis software program, to discover emergent patterns and themes. FINDINGS: The study suggests that most of the time physicians, nurses, and UAPs operate as separate healthcare providers who barely speak to each other. Physicians see themselves as the primary patient care decision makers. Many physicians acknowledge the importance of nurses' knowledge and expertise. On the other hand, the study indicates a hierarchical, subservient relationship among nurses and UAPs. Physicians and nurses tend to work together or consult each other at times, but UAPs are rarely included in any type of meaningful patient discussion. CONCLUSIONS: Since physicians, nurses, and UAPs each provide portions of patient care, coordination of the various treatments and interventions provided is critical to prevent errors and fragmentation of care. Tensions, misunderstandings, and conflicts caused by differences of opinions and interests can interfere with effective interdisciplinary communications and collaboration. Improving patient safety in the hospital requires addressing the current hierarchical professional structure inherent in healthcare delivery. A hospital patient care model based on the conductorless orchestra model would mitigate hierarchy; recognize physician, nurse, and UAP contributions to care; promote improved communication and collaboration; and enhance patient safety. CLINICAL RELEVANCE: Study results provide additional information supporting interdisciplinary communication and collaboration education and training among physicians, nurses, and UAPs to support positive patient care outcomes.

Predictors of follow-up completeness in longitudinal research on traumatic brain injury: findings from the National Institute on Disability and Rehabilitation Research traumatic brain injury model systems program.

OBJECTIVE: To identify baseline participant variables in the domains of demographics, medical/psychosocial history, injury characteristics, and postinjury functional status associated with longitudinal follow-up completeness in persons with traumatic brain injury (TBI) using the TBI Model Systems (TBIMS) National Database (NDB). DESIGN: Exhaustive chi-square automatic interaction detection was used to identify factors that classified participants according to level of follow-up completeness. SETTING: Retrospective analysis of a multi-center longitudinal database. PARTICIPANTS: Individuals (N=8249) enrolled in the TBIMS NDB between 1989 and 2009 who were eligible for at least the first (year 1) follow-up up to the fifth (year 15) follow-up. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Follow-up completeness as defined by 6 different longitudinal response patterns (LRPs): completing all follow-ups, wave nonresponse, dropping out, completing no follow-ups without formally withdrawing, formally withdrawing before completing any follow-ups, and formally withdrawing after completing some follow-ups. RESULTS: Completing all follow-ups was associated with higher levels of education, living with parents or others, and having acute care payer data entered in the NDB. Subgroups more vulnerable to loss to follow-up (LTFU) included those with less education, racial/ethnic minority backgrounds, those with better motor functioning on rehabilitation discharge, and those for whom baseline data on education, employment, and acute care payer were not collected. No subgroups were found to be more likely to have the LRPs of dropping out or formal withdrawal. CONCLUSIONS: These data identify subgroups in which retention strategies beyond those most commonly used might reduce LTFU in longitudinal studies of persons with TBI, such as the TBIMS, and suggest future investigations into factors associated with missing baseline data.

Racial/ethnic disparities in mental health over the first 2 years after traumatic brain injury: a model systems study.

OBJECTIVE: To determine whether racial/ethnic disparities occur in depression, anxiety, and satisfaction with life at 1 and 2 years postdischarge. DESIGN: A prospective, longitudinal, multicenter study of individuals with traumatic brain injury (TBI) participating in the National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems project. Medical, demographic, and outcome data were obtained from the Model Systems database at baseline, as well as 1 and 2 years postdischarge. SETTING: A total of 16 TBI Model Systems hospitals in the United States. PARTICIPANTS: Individuals with moderate or severe TBI (N=1662) aged 16 years or older consecutively discharged between January 2008 and June 2011 from acute care and comprehensive inpatient rehabilitation at a Model Systems hospital. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: The Patient Health Questionnaire-9, Generalized Anxiety Disorder 7-item scale, and Satisfaction with Life Scale assessed depression, anxiety, and satisfaction with life at 1 and 2-year follow-ups. RESULTS: After controlling for all possible covariates, hierarchal linear models found that black individuals had elevated depression across the 2 time points relative to white individuals. Asian/Pacific Islanders' depression increased over time in comparison to the decreasing depression in those of Hispanic origin, which was a greater decrease than in white individuals. Black individuals had lower life satisfaction than did white and Hispanic individuals, but only marginally greater anxiety over time than did white individuals and similar levels of anxiety as did Asian/Pacific Islanders and Hispanic individuals. CONCLUSIONS: Mental health trajectories of individuals with TBI differed as a function of race/ethnicity across the first 2 years postdischarge, providing the first longitudinal evidence of racial/ethnic disparities in mental health after TBI during this time period. Further research will be required to understand the complex factors underlying these differences.