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Maldonado J, Huang JH, Childs EW, Tharakan B. Racial/Ethnic Differences in Traumatic Brain Injury: Pathophysiology, Outcomes, and Future Directions. J Neurotrauma 2023; 40:502-513. [PMID: 36029219 DOI: 10.1089/neu.2021.0455] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Abstract
Traumatic brain injury (TBI) is a major cause of death and disability in the United States, exacting a debilitating physical, social, and financial strain. Therefore, it is crucial to examine the impact of TBI on medically underserved communities in the U.S. The purpose of the current study was to review the literature on TBI for evidence of racial/ethnic differences in the U.S. Results of the review showed significant racial/ethnic disparities in TBI outcome and several notable differences in other TBI variables. American Indian/Alaska Natives have the highest rate and number of TBI-related deaths compared with all other racial/ethnic groups; Blacks/African Americans are significantly more likely to incur a TBI from violence when compared with Non-Hispanic Whites; and minorities are significantly more likely to have worse functional outcome compared with Non-Hispanic Whites, particularly among measures of community integration. We were unable to identify any studies that looked directly at underlying racial/ethnic biological variations associated with different TBI outcomes. In the absence of studies on racial/ethnic differences in TBI pathobiology, taking an indirect approach, we looked for studies examining racial/ethnic differences in oxidative stress and inflammation outside the scope of TBI as they are known to heavily influence TBI pathobiology. The literature indicates that Blacks/African Americans have greater inflammation and oxidative stress compared with Non-Hispanic Whites. We propose that future studies investigate the possibility of racial/ethnic differences in inflammation and oxidative stress within the context of TBI to determine whether there is any relationship or impact on TBI outcome.
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Affiliation(s)
- Justin Maldonado
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia, USA
| | - Jason H Huang
- Department of Neurosurgery, Baylor Scott and White Health and Texas A&M University College of Medicine, Temple, Texas, USA
| | - Ed W Childs
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia, USA
| | - Binu Tharakan
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia, USA
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Reilly AS, Khawaja AM, Ali AB, Madsen T, Molino-Bacic J, Heffernan DS, Zonfrillo MR, Vaitkevicius H, Gormley WB, Izzy S, Rao SS. Disparities in Decompressive Cranial Surgery Utilization in Severe Traumatic Brain Injury Patients without a Primary Extra-Axial Hematoma: A U.S. Nationwide Study. World Neurosurg 2023; 169:e16-e28. [PMID: 36202343 DOI: 10.1016/j.wneu.2022.09.113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 09/24/2022] [Accepted: 09/26/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Decompressive craniectomy is recommended to reduce mortality in severe traumatic brain injury (TBI). Disparities exist in TBI treatment outcomes; however, data on disparities pertaining to decompressive craniectomy utilization is lacking. We investigated these disparities, focusing on race, insurance, sex, and age. METHODS Hospitalizations (2004-2014) were retrospectively extracted from the Nationwide Inpatient Sample. The criteria included are as follows: age ≥18 years and indicators of severe TBI diagnosis. Poor outcomes were defined as discharge to institutional care and death. Multivariable logistic regression models were used to assess the effects of race, insurance, age, and sex, on craniectomy utilization and outcomes. RESULTS Of 349,164 hospitalized patients, 6.8% (n = 23,743) underwent craniectomy. White (odds ratio [OR] = 0.50, 95% confidence interval [CI] = 0.44-0.57; P < 0.001) and Black (OR = 0.45, 95% CI = 0.32-0.64; P = 0.003) Medicare beneficiaries were less likely to undergo craniectomy. Medicare (P < 0.0001) and Medicaid beneficiaries (P < 0.0001) of all race categories had poorer outcomes than privately insured White patients. Black (OR = 1.2, 95% CI = 1.08-2.34; P = 0.001) patients with private insurance and Black (OR = 1.39, 95% CI = 1.22-1.58; P < 0.0001) Medicaid beneficiaries had poorer outcomes than privately insured White patients (P < 0.0001). Older patients (OR = 0.74, 95%, CI = 0.71-0.76; P < 0.001) were less likely to undergo craniectomy and were more likely to have poorer outcomes. Females (OR = 0.82, 95% CI = 0.76-0.88; P < 0.001) were less likely to undergo craniectomy. CONCLUSIONS There are disparities in race, insurance status, sex, and age in craniectomy utilization and outcome. This data highlights the necessity to appropriately address these disparities, especially race and sex, and actively incorporate these factors in clinical trial design and enrollment.
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Affiliation(s)
- Aoife S Reilly
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA; RCSI, University of Medicine and Health Sciences, Dublin, Ireland.
| | - Ayaz M Khawaja
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Neurology, Wayne State University, Detroit, Michigan, USA
| | - Ali Basil Ali
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA; RCSI, University of Medicine and Health Sciences, Dublin, Ireland
| | - Tracy Madsen
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Janine Molino-Bacic
- Department of Orthopedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Daithi S Heffernan
- Department of Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Mark R Zonfrillo
- Department of Emergency Medicine and Pediatrics, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | | | - William B Gormley
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Saef Izzy
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Shyam S Rao
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Neurology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Lu J, Gormley M, Donaldson A, Agyemang A, Karmarkar A, Seel RT. Identifying factors associated with acute hospital discharge dispositions in patients with moderate-to-severe traumatic brain injury. Brain Inj 2022; 36:383-392. [PMID: 35213272 DOI: 10.1080/02699052.2022.2034180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVE Identify sociodemographic, injury, and hospital-level factors associated with acute hospital discharge dispositions following acute hospitalization for moderate-to-severe traumatic brain injury (TBI) in the United States. METHODS The 2011-2014 National Trauma Data Bank data was used, including 466 acute care hospitals and 114,736 patients ≥16 years old who survived moderate-to-severe TBI. Outcome was acute hospital discharge dispositions: home with/without care (HC), skilled nursing home/other care facility (SNF/ICF) and inpatient rehabilitation/long-term care facility (IRF). Independent variables were patients' sociodemographic, injury, and hospital-level factors. Multilevel modeling was used to assess associations and compare likelihood of discharges. RESULTS Of all patients, 74.5%, 14.6% ,and 10.9% were discharged to HC, SNF/ICF ,and IRF, respectively. Intraclass correlation coefficients indicated that hospitals explained 14.3% and 14.8% of variations in probabilities of institution dispositions. Sociodemographic factors including older age, females, Non-Hispanic Whites, recipients of commercial insurance, and Medicare/Medicaid were significantly associated with higher institution discharges. Hospital-related factors including bed size, teaching status, trauma accreditations, and hospital locations were significantly associated with discharge dispositions. CONCLUSION Identifying factors associated with discharge dispositions after acute hospitalization of TBI is pertinent to ensure quality of care and optimal patient outcomes. Further research into hospital-related variations in acute care discharge dispositions is recommended.
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Affiliation(s)
- Juan Lu
- Division of Epidemiology, Department of Family Medicine and Population Health, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Mirinda Gormley
- Division of Epidemiology, Department of Family Medicine and Population Health, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Alexis Donaldson
- Division of Epidemiology, Department of Family Medicine and Population Health, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Amma Agyemang
- Center for Rehabilitation Science and Engineering (CERSE), Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Amol Karmarkar
- Center for Rehabilitation Science and Engineering (CERSE), Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Ronald T Seel
- Center for Rehabilitation Science and Engineering (CERSE), Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
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Hung YC, Wolf JH, D'Adamo CR, Demos J, Katlic MR, Svoboda S. Preoperative functional status is associated with discharge to nonhome in geriatric individuals. J Am Geriatr Soc 2021; 69:1856-1864. [PMID: 33780000 DOI: 10.1111/jgs.17128] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 02/23/2021] [Accepted: 02/28/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Discharging older individuals to rehabilitation facilities is associated with adverse outcomes, including readmission or increased mortality rate. As preoperative functional status is an important factor impacting patient outcome, we hypothesized that this would be associated with patient disposition to nonhome locations. MATERIALS AND METHODS A retrospective analysis was performed using data from the 2013-2018 American College of Surgeons National Surgical Quality Improvement Program, including targeted variables from the Geriatric Pilot Project. Patients aged 65 and older in 33 institutions across the nation were included (n = 44,219). Preoperative functional status was categorized as independent, partially dependent, and dependent. The primary outcome was home versus nonhome disposition. Nonhome was defined as rehabilitation facility and nursing home. Descriptive analyses were performed. Variables associated with postoperative discharge to nonhome were identified using logistic regression. RESULTS The largest percentage of operations was orthopedics (40.8%), followed by general surgery (29.2%) and vascular operations (10.0%). The majority of the patients were independent before operations (93.1% independent, 6% partially dependent, and 0.9% totally dependent). In regression analyses, patients who were partially dependent preoperatively had five times higher odds of discharging to nonhome, compared to patients who were independent (odds ratio [OR] 5.04, p < 0.01). Similarly, patients who were totally dependent had 3.2 higher odds of discharging to nonhome than patients who were independent (OR 3.22, p < 0.01). CONCLUSION Better preoperative functional status is associated with patient discharge to home in older adults. Preoperative interventions aimed at improving functional status, such as prehabilitation, may be beneficial in improving patient outcomes.
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Affiliation(s)
- Ya-Ching Hung
- Department of Surgery, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Joshua H Wolf
- Department of Surgery, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Christopher R D'Adamo
- Department of Family and Community Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jasmine Demos
- Department of Surgery, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Mark R Katlic
- Department of Surgery, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Shane Svoboda
- Department of Surgery, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
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Jacob L, Cogné M, Tenovuo O, Røe C, Andelic N, Majdan M, Ranta J, Ylen P, Dawes H, Azouvi P. Predictors of Access to Rehabilitation in the Year Following Traumatic Brain Injury: A European Prospective and Multicenter Study. Neurorehabil Neural Repair 2020; 34:814-830. [PMID: 32762407 DOI: 10.1177/1545968320946038] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Although rehabilitation is beneficial for individuals with traumatic brain injury (TBI), a significant proportion of them do not receive adequate rehabilitation after acute care. OBJECTIVE Therefore, the goal of this prospective and multicenter study was to investigate predictors of access to rehabilitation in the year following injury in patients with TBI. METHODS Data from a large European study (CENTER-TBI), including TBIs of all severities between December 2014 and December 2017 were used (N = 4498 patients). Participants were dichotomized into those who had and those who did not have access to rehabilitation in the year following TBI. Potential predictors included sociodemographic factors, psychoactive substance use, preinjury medical history, injury-related factors, and factors related to medical care, complications, and discharge. RESULTS In the year following traumatic injury, 31.4% of patients received rehabilitation services. Access to rehabilitation was positively and significantly predicted by female sex (odds ratio [OR] = 1.50), increased number of years of education completed (OR = 1.05), living in Northern (OR = 1.62; reference: Western Europe) or Southern Europe (OR = 1.74), lower prehospital Glasgow Coma Scale score (OR = 1.03), higher Injury Severity Score (OR = 1.01), intracranial (OR = 1.33) and extracranial (OR = 1.99) surgery, and extracranial complication (OR = 1.75). On contrast, significant negative predictors were lack of preinjury employment (OR = 0.80), living in Central and Eastern Europe (OR = 0.42), and admission to hospital ward (OR = 0.47; reference: admission to intensive care unit) or direct discharge from emergency room (OR = 0.24). CONCLUSIONS Based on these findings, there is an urgent need to implement national and international guidelines and strategies for access to rehabilitation after TBI.
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Affiliation(s)
- Louis Jacob
- University of Versailles Saint-Quentin-en-Yvelines, Montigny-le-Bretonneux France.,Parc Sanitari Sant Joan de Déu, CIBERSAM, Dr. Antoni Pujadas, Barcelona, Spain
| | - Mélanie Cogné
- University Hospital of Rennes, Rennes, Bretagne, France
| | - Olli Tenovuo
- , Turku University Hospital, Turku, Finland.,University of Turku, Turku, Finland
| | - Cecilie Røe
- Oslo University Hospital, Oslo, Norway.,University of Oslo, Oslo, Norway
| | - Nada Andelic
- Oslo University Hospital, Oslo, Norway.,University of Oslo, Oslo, Norway
| | - Marek Majdan
- Institute for Global Health and Epidemiology, Department of Public Health, Trnava University, Trnava, Slovakia
| | - Jukka Ranta
- VTT Technical Research Centre of Finland Ltd, Espoo, Uusimaa, Finland
| | - Peter Ylen
- VTT Technical Research Centre of Finland Ltd, Espoo, Uusimaa, Finland
| | | | - Philippe Azouvi
- Raymond Poincaré Hospital, AP-HP, Garches, France.,Université Paris-Saclay, UVSQ, Versailles, France
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